- The Hands-on Guide to Practical Prescribing
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Most local anaesthetics are in the form of a base combined to a hydrochloride.
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There are a number of considerations when choosing a local anaesthetic agent. A long duration of action is not always desirable as this may delay patient mobilization or discharge. Lidocaine has a rapid onset of action and moderate duration of effect. By contrast, bupivacaine has a slower onset but a longer duration of action. For example, lidocaine is available in 0. To increase the duration of action of local anaesthetics, vasoconstrictors, usually adrenaline 1: This reduces the rate at which the local anaesthetic is taken up into the circulation.
The maximum dose of adrenaline is micrograms 1: Topical local anaesthesia is useful for skin and mucous membranes. In general, cocaine, lidocaine and prilocaine are the most useful for this purpose. The onset of action is usually 5—10 min and lasts for up to 1 h. It should be applied 1 h in advance and is commonly used prior to taking blood or the placing of intravenous cannulae.
An occlusive dressing will stop it being rubbed off. Maximum doses and toxicity Maximum doses are given for each local anaesthetic in Table Maximum plasma levels of local anaesthetics usually occur at around 30 min. Signs of toxicity include mild sedation and circumoral paraesthesia. At higher levels, convulsions, cardiovascular collapse and rhythm disturbances may be seen. Local anaesthetics with or without opiates are used to give spinal and epidural anaesthesia Table This percentage is slightly lower for females, as they tend to have more body fat.
Water moves across the cell membrane if there is a difference in osmolality between the sides. The number of particles determines osmolality, not their size: It is useful as the basis for providing basal replacement as it has 30 mmol of sodium and chloride with the glucose being rapidly metabolized leaving water. Hyponatraemia may occur with overuse of dextrose saline. Thus, normal saline tends to distribute throughout the extracellular space without any net movement of water into the cells.
Colloids These include albumin, starches and gelatins. The capillary membrane is impermeable to colloid and so the solution remains within the intravascular compartment for longer. Most of these carry a high salt load and this must be considered when planning therapy. This is in health and takes into account losses in sweat, faeces and urine. The very presence of a patient in hospital suggests that basal replacement alone may not be adequate to keep pace with increased losses.
Additional requirements One of the most common examples of a patient with additional requirements occurs in bowel obstruction, vomiting or in those with a high nasogastric output. High-output stomas can lead to losses in bicarbonate, potassium, chlorine, sodium, water and protein. Bleeding will cause a proportionate loss of everything. A spot assessment of urinary biochemistry, including pH, may help to guide replacement.
It will buy you time to assess the patient further and plan therapy. Colloids stay in the vascular space for longer and may be more appropriate after the initial stage. Further information may be obtained from blood tests and assessing renal function and haematocrit. In special cases, total urine output of electrolytes may need to be measured. However, if some other intervention is planned, it may need to be faster. One such example would be the patient who needs a laparotomy for peritonitis. Fluid replacement must be as rapid and effective as can safely be achieved before peritonitis and sepsis supervene.
Alternatives to central lines include femoral lines. These can be used to measure central pressure trends but are more prone to changes in intraabdominal pressure compared to an internal jugular or subclavian line. This may be true in health and for the walking wounded, but for a considerable number of in-patients this is not the case. It is easy to imagine a scared old lady in a busy accident and emergency department with tepid water in a plastic jug, just out of reach.
She may be scared to drink as she is worried no-one will be able to take her to the toilet. Sadly, this happens every day. Fluids should be prescribed with any additives clearly indicated and the rate to be given noted. Supplements Maintenance of plasma potassium levels is important and this can be achieved using oral or intravenous supplementation. The quantity of potassium that may be given intravenously over 24 h depends on the type of access. These are maximum values and if there is a need to give more potassium than these amounts, then a central line is appropriate and a more thorough review of the case may be 36 CHAPTER 11 Table Calcium supplements may be given as chloride and gluconate salt.
Both come as mL ampoules and calcium chloride also comes as a minijet. Magnesium replacement is dependent upon indication. The initial dose is 8 mmol over 20 min for rhythm disturbances and 72 mmol over 12—24 h is the usual replacement rate Table Nutrition Up to half of patients in hospital may show evidence of malnutrition as a result of their underlying disease or their social situation.
Malnutrition may be compounded by the process of hospital admission and treatment such as surgery. Poor nutritional status is associated with a number of problems including poor wound healing, reduced muscle strength, unbalanced electrolyte compositions and dehydration. The dietetic services in hospitals should be considered an integral part of the team and their advice sought early.
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Assessment of nutrition is not simple. Some of the methods are shown in Table Therefore, it is good practice to assess all patients coming into hospital. Perhaps the single most important issue in nutrition is that patients with a normal or near-normal gastrointestinal tract should be fed via the enteral route.
In general terms, the process by which a patient is fed may be based on the following factors: Giving more than the necessary energy requirement may result in hyperlipidaemia and hyperglycaemia. Malnutrition in patients with normal gut and able to eat normally These patients should be encouraged to eat.
Note that the examples may be affected by many factors other than nutrition. Method Example Anthropomorphic measurement Triceps skinfold thickness Dynamometric measurement Hand grip strength Biochemical measurement Serum albumin Immunological measurement Lymphocyte count an adequate nutritional intake. It is useful to ask nursing staff to keep a chart of food intake both food ordered and amount of each meal eaten.
Favourite meals can be brought in by the family but there are reheating rules to be followed, so seek out local policy. There is a large range of cartons of liquid supplements available. One of the most commonly used is Ensure, which has kcal in mL volume and contains Juices, powder supplements and milk shakes have all been formulated.
It is the policy of certain units to supplement routinely the calories in a standard hospital meal. This is especially true in elderly care wards. These are individualized food packets. The exact contents vary but include a selection of fruit, biscuits, crisps, yoghurt and sandwiches.
This is designed as a snack and should not be used repeatedly in lieu of a meal. These do not need to be prescribed. Malnutrition in patients with normal gut but unable to take an oral diet Routes of access Many patients have a relatively normally functioning gut but have an impaired ability to take in food. This may be because they have swallowing problems e. In such patients, enteral feeding via a nasogastric or nasojejunal tube, percutaneous gastrostomy or feeding jejunostomy is appropriate.
Apart from simplicity and avoidance of venous line-associated morbidity, this approach has several advantages over parenteral nutrition. Fine-bore tubes are more comfortable for longer term use. Feeding is commenced at a slow rate e. Sometimes, gastric stasis may hinder enteral feeding and this manifests as abdominal distension, high-volume nasogastric aspirates or vomiting. In such circumstances, promotility agents such as erythromycin mg b. For any surgery after which prolonged postoperative enteral feeding is anticipated, a feeding jejunostomy is often placed at the time of surgery.
This has the advantage of being less irritant to the patient. Furthermore, after surgery the colon and stomach take the longest time to recover motility. The small bowel, by contrast, often recovers almost immediately. Many upper gastrointestinal surgeons also favour jejunostomies because they allow feeding distal to the site of anastomosis.
The overwhelming majority of patients can be adequately managed using a polymeric diet. In a small number of patients e. The nitrogen source in these feeds is from free amino acids or oligopeptides and carbohydrate is supplied in the form of glucose polymers of less 39 than 10 glucose molecules. If using a nasally placed tube, the position is normally checked by an X-ray prior to starting feeding.
There is a trend towards early aggressive enteral feeding in patients. In wellnourished patients in whom oral or enteral feeding is not anticipated within 7—10 days of surgery, consideration should be given to early parenteral nutrition see below. Malnutrition in patients with abnormal or inaccessible gut These patients require total parenteral nutrition TPN.
Some of the issues associated with parenteral nutrition are considered below. Routes of access The intravenous supplements are high osmolality and should be given through a dedicated cannula in a large vein. Some can be given peripherally but thrombophlebitis and line failure commonly occur. If prolonged use is envisaged, central access is needed.
This should be clearly labelled and preferably isolated from the other lines. Lines can be tunnelled so that the exit point through the skin is remote from the site of venepuncture to reduce line infection risks. Composition of total parenteral nutrition TPN bags are normally 2. They usually contain around kcal, provided approximately equally by carbohydrate and lipid emulsions. They also contain electrolytes, trace minerals and vitamins.
The hospital pharmacist may adjust the proportions of each of these to take account of the daily electrolyte results. Morbidity associated with total parenteral nutrition There is considerable morbidity associated with the central lines commonly used for TPN. These are immediate complications associated with insertion, including arterial puncture, haemothorax and pneumothorax. There are also delayed complications, including linerelated sepsis and venous thrombosis. There are also metabolic complications associated with TPN, including hyper- and hypoglycaemia.
Insulin regimens may be needed at the same time. Abnormalities of plasma potassium, sodium, calcium and phosphate are also seen. Regular monitoring of electrolytes and liver function is essential. It is common to see deranged liver function predominantly cholestatic in pattern amongst patients on long-term TPN. Giving drugs via enteral feeding tube route It is not enough to just prescribe drugs to be administered via the nasogastric route or similar.
Most tablet or capsule forms of drugs can be crushed and given via the tube. Drugs that are slow- or controlledrelease preparations are unlikely to retain this quality as crushing often disrupts the delivery system. Naturally long-acting agents can be used normally.
Prescribe suspensions when possible and replace slow-release drugs with short-acting agents given at increased frequency and comparable replacement doses.
This is bound to disrupt established pharmacokinetics and closer monitoring may be needed for clinical effects and therapeutic plasma levels. Absorption of drugs will be affected by the feeding regimen. Details of such drugs are beyond the scope of this book and once the treatment intentions are clear, a discussion with your local pharmacy to select the most suitable drugs in the relevant classes is advised. Once normal feeding commences, previous medicines can be reintroduced with vigilance regarding effects and levels.
Early enteral feeding, compared with parenteral, reduces postoperative septic complications: Ann Surg ; The subjective pain a patient feels may be compounded by anxiety and fear and it is important that these aspects are addressed. A regimen that on paper looks ineffective may have been providing good control of symptoms in the community. It is often useful to ask patients to score their pain on an analogue scale of 0—10, with 0 representing no pain and 10 the worst pain they have ever felt.
This is useful in assessing the response to analgesics. The basic principles of analgesia are: Acute intervention to regain control is called rescue analgesia and provision should be made for this whenever treating a painful condition. Types of analgesic drug Simple non-opiate analgesia Paracetamol This is a very good analgesic and also has antipyretic properties. It is particularly effective when prescribed as a regular medication. It is generally safe but should be used with caution in patients with liver impairment.
It is a dangerous drug in overdose. The resultant severe liver damage may not manifest itself for several days. Doses of — mg can be given with a maximum dosage of 4 g in 24 h. It also has antiplatelet activity. Its mechanism of action is through cyclo-oxygenase inhibition. They are very useful drugs for the treatment of pain and are being increasingly used in the perioperative period to reduce pain and 41 42 CHAPTER 13 Table Analgesic mg Numbers needed to treat Ibuprofen 1.
Diclofenac and ketorolac are just two examples of NSAIDs that can be given by injection intravenous or intramuscular. However, the incidence of upper gastrointestinal irritation or ulceration is lower with COX-2 inhibitors see below. It can cause angio-oedema and urticaria and also has an important interaction with warfarin, increasing bleeding risk. Upper gastrointestinal side-effects Gastric irritation or ulceration has been reported for aspirin and the other NSAIDs. These drugs should be taken with food. Enteric formulations of aspirin are available which should cause less gastric irritation, but at the expense of a slower onset of action.
Arthrotec contains diclofenac and misoprostol a prostaglandin analogue. The misoprostol provides gastric protection in elderly patients with no gastric symptoms who need NSAIDs on a regular basis. COX-2 inhibitors have slightly more restricted licensed indications for use, which differ for the various preparations now available, although these are constantly being changed.
Of importance, COX-2 inhibitors are associated with a lower incidence of side-effects — although they are still contra-indicated in the presence of peptic ulceration. It has been suggested that COX-2 inhibitors should be reserved for those patients at high risk of gastrointestinal side-effects previous history of ulcers, perforation or bleeding. COX-2 inhibitors should also be considered in older patients or in those who are taking other medications known to increase the risk of upper gastrointestinal ulceration.
There is no merit in combining COX-2 inhibitors with aspirin. The newer intravenous COX-2 inhibitors, such as Paracoxib, are marketed for use in acute pain and have a prolonged therapeutic window up to 24 h. However, this is an uncommon problem. Patients who have well-controlled asthma and have previously taken NSAIDs without problems should be unaffected. It is inadvisable to start an NSAID in a patient with poorly controlled or an exacerbation of asthma. They can dramatically worsen renal function. It is often used in combination therapies with drugs such as paracetamol.
It is rapidly going out of favour. Dihydrocodeine and codeine These drugs have similar pharmacology. By themselves, they provide limited analgesia and should not be used as a rescue alternative. They are mostly used in combination with paracetamol or aspirin. Strong opioids These drugs are effective for the treatment of moderate to severe pain, especially that of visceral origin. Along with analgesia, euphoria and dependency can be seen. Respiratory depression can be fatal. Morphine and its more soluble cousin, diamorphine remains the gold standard of therapy. Its versatility, reproducibility of action and ubiquitous availability have contributed to its widespread use.
There are faster acting opioids , with shorter half-lives, less dependence on renal clearance and fewer side-effects. They are becoming more fashionable but still largely remain in the realms of specialist use, probably because of expense. Morphine can be given via any route. When used to control true continuous pain, there is little danger of addiction or tolerance.
Respiratory depression is seen if excess opioids are given for the amount of pain experienced. There is no ceiling effect. Constipation with morphine is severe, so laxatives can be used early. Intravenous preparations give high plasma levels rapidly. Initial doses should be given in 1-mg increments over 30 s until control is achieved. Opioids can be given via the intramuscular route. In cases where there is hypoperfusion of muscle groups e. It does have a role in the postoperative stable patient see Postoperative analgesia below.
Do not give intramuscular injections to suspected cases of myocardial infarction as thrombolysis can lead to a nasty intramuscular haematoma. Subcutaneous administration is possible and is used widely in the palliative care setting. Diamorphine is chosen as it is more soluble. Rectal preparations also exist. Of the other opioids, pethidine has weaker effects but releases less histamine than morphine and so has a use when patients suffer from any form of atopy, including asthma symptoms.
Pethidine is largely used intravenously or intramuscularly. Fentanyl is a synthetic opioid which is times more potent than morphine at the same dosage. It is used in surgical analgesia and the transdermal route is especially favoured in the palliative care setting. They last for 72 h and can be combined to give the necessary quantity.
The Hands-on Guide to Practical Prescribing
At very high doses of opiate analgesia, methadone can be considered. Opiates can be reversed by naloxone, micrograms given intravenously. Naloxone has a shorter half-life than morphine and so this dose may need to be repeated or given as an infusion. It ascends from mild pain at the bottom of the ladder to moderate to severe pain at the top of the ladder. At each level, the ladder suggests the consideration of adjunctive therapy. Adjunctive therapies also encompass non-pharmacological treatments, such as transcutaneous electrical nerve stimulation TENS.
The WHO analgesic ladder is widely employed and regarded by many as the best approach to the management of pain from whatever aetiology. These strong analgesics may be less effective in certain pain conditions, including neuropathic pain see below.
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It is not enough simply to have written a prescription for a patient, you also need to check that the patient has been requesting it if it is written as a p. Other sources of help Many hospitals have specialized pain teams, which often include an anaesthetist. They are often an invaluable source of help and may advise on analgesia and other techniques, such as nerve blocks and epidurals. These are listed in Table Postoperative analgesia The pharmacological agents used for postoperative analgesia are the same as for the management of any acute pain. Regional blocks and epidurals are also used in the immediate postoperative period.
Good postoperative analgesia is vital to reduce the extent of complications, aid healing and promote recovery. Pain can be helped with physical supports, such as a pillow across the abdomen when coughing after abdominal aortic aneurysm repair or a support trough after a knee replacement. Your ward physiotherapist will be able to help. Muscle spasm and anxiety should be attended to as needed. As with analgesia for any indication, it should be regularly given with drugs for breakthrough pain readily available.
Drugs to act on the side-effects of the analgesics, such as antiemetics and opiate reversal agents, should be provided. The oral route may not be as predictable in the immediate postoperative phase because of nausea or the type of procedure and so intravenous, intramuscular or regional blockade is preferred. Oral medications should be introduced soon after operation using combinations of simple agents, NSAIDs and opioids given regularly.
There must be cardiovascular Table Check the clinical situation Yes Hypotension may be due to drugs or surgical complications. Use morphine whenever possible in a bolus dose of 7. The need for analgesia should be assessed at least every hour Fig. Patient controlled opioid analgesia and epidurals The principle is the same for these two modalities.
A drug is administered via a regulated syringe driver. For patient controlled analgesia PCA , any of the opiates can be used commonly morphine or pethidine. For epidurals, local anaesthetic and opiate mixtures are used, although single agent versions are common. Patient controlled analgesia Patient controlled intravenous opiate analgesia is widely used in all branches of medicine to provide a consistent level of pain relief. Any opiate can be used although morphine still remains the agent of choice.
Pethidine is more appropriate if histamine release could be a concern. The following should be undertaken in the patient requiring PCA. Some systems then require a maximum dose over 4 h to be set as a further safety feature against opiate toxicity. There is usually a separate area on the drug chart for the prescribing of PCA. Some departments require every new syringe to be prescribed separately. While inconvenient in some respects, this does ensure a regular review. For PCA to be successful, the patient must have had instructions preoperatively and have been able to understand them.
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There should be no physical limitation to activating the system e. An intravenous loading dose of morphine should be given at the start of the process and provision made for a review of use a number of times a day. Naloxone should be readily available. Do not prescribe regular opiates for use at the same time as a PCA or opiatecontaining epidural.
Rescue analgesia should be available, which is best given as small increments of intravenous opiates until control is achieved once more. The reason for poor control can then be assessed Table This will allow you to test the rest of the kit at the same time. Excess dosage may result in opiate toxicity. Assess the patient and reduce the opiate or stop it for a while. Stopping and reversing opiates fully results in pain that may be much more of a problem than the mild drowsiness.
Clearly, if the patient is compromised, then you should resuscitate as usual, including the use of reversal agent micrograms naloxone as a bolus followed by further doses or infusion if needed. Epidurals and patient controlled epidural analgesia If your patient is to have a regional or epidural block, it is useful to know who is responsible for the prescription and, if there are any problems, who to call.
You should familiarize yourself with the kit. Epidurals or patient controlled epidural analgesia, PCEA involve a G catheter inserted into the epidural space under aseptic technique. It is conventional for epidural tubing to be coloured yellow in the UK. Bupivacaine is a common local anaesthetic used. Combining with opiates does improve the quality of the block but can lead to respiratory depression.
If opiates are to be used, fentanyl is relatively short acting and is a preferred agent, although diamorphine is also commonly chosen. If opiates are included in an epidural infusion, regular opiates should be avoided by other routes and great care taken to ensure close observations. In many cases, the pharmacy department will make up standard concentrations in syringes or bags.
A typical epidural concentration: In a mL syringe this is equivalent to A min lockout should be used. If the block is poor but present, higher doses and greater volumes may be needed. This can be given as a rescue bolus followed by an increased hourly rate. If the epidural itself is not well placed the block may be patchy or non-existent.
Unless you have been instructed in the care of this kind of kit, do not try to reinsert or manipulate it as you may do more harm. Seek assistance and if appropriately trained staff are unable to come, then cap off the lines, remove the catheter making sure the tip is seen and discard the syringe drivers for safety. Provide analgesia through conventional means. Motor block can be seen with epidurals and this usually indicates a deep block. Possible causes are damage to the spine unlikely or a spinal block. A spinal anaesthetic is usually quite safe in experienced hands.
As long as no further agent is given, it should wear off within a few hours. Try to sit the patient up to keep the block as low as possible. Problems occur if the block ascends and respiratory muscles are affected. Close observation and pulse oximetry are needed. A good marker for deep blocks or spinal blocks is a drop in blood pressure as peripheral vasodilatation occurs.
It is important to closely monitor blood pressure, pulse, saturations and respiratory effort. Ephedrine predominantly alphaagonist given in 2—3-mg doses it comes as 30 mg in 1 mL which should be diluted up to 10 mL of saline can rescue profound hypotension caused by such vasodilatation. It will lead to a tachycardia as it is not selective. Respiratory depression can be seen with opiate toxicity and is dealt with in much the same way as in traditional PCA. The solution should be changed to a single agent local anaesthetic only and restarted once the patient has been resuscitated and after a full clinical review.
Continuous regional blocks These have a similar sized G catheter placed in a nerve sheath or near a plexus. A solution of local anaesthetic is infused at a set rate. As yet there is no consensus on colours or identifying markers for these catheters or attachments so they should be clearly labelled at every port and connection.
References 1 Hawkey CJ. Publication that described management of cancer pain. These conditions may affect a range of intraabdominal organs. Some of the more common conditions are dealt with in more detail below. General principles Analgesia As soon as a diagnosis has been achieved, analgesia should be commenced. The timing of analgesia is one of the controversies of surgical practice, with some practitioners maintaining that it interferes with the accurate assessment and monitoring of clinical signs. However, there is little evidence to support this in the literature .
Oral analgesia is often avoided in this group of patients, as many will be undergoing surgery. Fluid resuscitation Fluid balance must be optimized as far as reasonably possible, especially if surgery is being contemplated. This should include correction of dehydration and electrolyte disturbances, both of which are commonly seen in this patient group. Treatment should be instituted and monitored on the basis of clinical signs including pulse, blood pressure and urine output.
Antibiotics These may be appropriate in certain cases and are considered in more detail below. In general terms, the acute abdomen may be managed surgically or non-surgically. The choice of antibiotic is determined by the site and type of pathology. The stomach and duodenum have low bacterial counts and perforation of these organs causes a peritonitis that is predominantly chemical in nature. Bacterial counts are also low in the small bowel. By contrast, large bowel perforations may cause considerable Gram-positive and Gram-negative bacterial contamination.
Acute appendicitis The treatment of acute appendicitis is almost invariably by appendicectomy, with minimal delay. However, in patients in whom surgery is delayed for reasons of need for resuscitation or availability of theatre time, some surgeons advocate the use of broad-spectrum antibiotics such as cefuroxime mg i.
However, most surgeons would agree that resolution of symptoms and signs on this antibiotic treatment should not prevent planned appendicectomy. In all cases of appendicectomy, anti51 52 CHAPTER 14 biotics should be given as a single preoperative or perioperative dose as this reduces the incidence of postoperative wound infection .
A recent Cochrane review has supported this and suggested that the incidence of intra-abdominal infection may also be reduced . In cases of perforated or gangrenous appendix at surgery, between 2 and 5 days of postoperative antibiotics should be given. The treatment of uncomplicated appendicitis with antibiotics alone has been advocated .
This has not been widely adopted as appendicitis may progress to perforation. A relapse may also be seen in the medium term that will then require surgical intervention. There are three notable exceptions where medical therapy should be preferred over surgery: This should be combined with regular clinical assessment and ultrasound if available. An associated abscess requires drainage and evidence of progressive increase in size of the mass, generalized peritonitis, persistent pyrexia and tachycardia may necessitate surgical intervention. Interval appendicectomy is usually performed some 2—3 months after the acute presentation.
In older patients, this is usually preceded by a barium enema to rule out caecal carcinoma mimicking appendicitis. The gold standard for diagnosis is laparoscopy, although treatment is often based on a clinical diagnosis and vaginal swabs which may be normal even in laparoscopically documented PID. The most common causative organisms in PID are Chlamydia trachomatis and Neisseria gonorrhoea, although other organisms are commonly involved. Inevitably, empirical treatment is often instituted with a quinolone orally and metronidazole mg t. PID is associated with risks of tubal occlusion and infertility.
Oral and rectally given metronidazole has very high bioavailability and is much cheaper than the intravenous route. In the acutely ill patient, especially if there is gastrointestinal upset, gut absorption is unpredictable and so the intravenous route is preferred. Cholelithiasis and biliary colic Gallstones are common, although in many patients they will cause no symptoms. Gallstones may be treated by dissolution therapy, commonly ursodeoxycholic acid or chenodeoxycholic acid. Patients should be advised to adopt a low- fat diet and they need to be monitored radiologically.
The pain is typically severe and usually lasts less than 12 h. If the duration of attack extends beyond this, then cholecystitis is a more likely diagnosis. Many cases can be safely managed at home by administration of opiate analgesia. Vomiting often accompanies the attack. If the patient fails to settle then hospital admission may be necessary. Acute cholecystitis The overwhelming majority of cases of cholecystitis are caused by gallstones or gallbladder sludge becoming impacted in the gallbladder neck and causing blockage of the cystic duct.
Bacterial infection with enteric organisms, most commonly Escherichia coli, Enterococcus and Klebsiella may occur. The management of acute cholecystitis is a balance between conservative measures and operative intervention. It is appropriate to institute conservative measures in all patients presenting acutely and in the majority of cases the stone or sludge will fall back from the gallbladder neck. Such management includes nil by mouth, intravenous rehydration and analgesia.
Analgesia might include morphine and an antiemetic. A single dose of 75 mg diclofenac i. If the patient has systemic evidence of infection temperature, raised white 53 cell count or is failing to settle, intravenous antibiotics should be started. This should usually be a second- or third-generation cephalosporin, such as cefuroxime mg—1. In some centres, conservative management is continued until symptoms settle and the patient is discharged with a view to interval cholecystectomy some 6—12 weeks later.
However, not all patients will settle with conservative measures and urgent surgery will be mandated. This condition, or suspicion of it, requires emergency cholecystectomy. Gallbladder perforation presents with biliary peritonitis, although sometimes the perforation may be contained by adherent viscera and an empyema develops. After appropriate resuscitation, surgery is indicated. It usually results from infection with clostridia or anaerobic streptococci, recognized by gas within the gallbladder wall, visible on plain X-ray or ultrasound. It can occur in the absence of gallstones.
After appropriate resuscitation and broad-spectrum antibiotics, emergency surgery is usually performed as a high percentage proceed to perforation. The issue of whether to opt for interval cholecystectomy or immediate surgery is contentious. However, there is evidence that those patients operated on within 72 h of the onset of symptoms have fewer complications and a lower conversion rate to open cholecystectomy than those patients operated on during the acute admission but after 72 h and those offered an interval cholecystectomy some 2—3 months after acute presentation .
However, there are further studies in direct contradiction to this, showing that conversion rates and morbidity are higher in patients operated on in the early less than 3 days phase of acute cholecystitis . Relieving the obstruction is an essential part of management after initial medical therapy. This is most easily performed by endoscopic retrograde cholangiopancreatography ERCP and sphincterotomy but, if this fails, then percutaneous transhepatic drainage should be tried.
Surgical drainage is a last resort. The most common organisms involved are E. An antibiotic regimen such as cefuroxime 1. Such treatment is a temporary bridge to biliary tract decompression. Acute pancreatitis The treatment of uncomplicated pancreatitis is medical and essentially supportive in nature. Furthermore, the vomiting that often accompanies the condition may exacerbate the problem. Oral intake may be recommenced when pain and the associated ileus are settling. Early commencement of TPN should be considered. Antibiotic use The use of prophylactic antibiotics in pancreatitis is controversial.
However, a further trial showed a reduction in mortality with no effect on pancreatic sepsis . The choice of antibiotic is unclear. Imipenem has been suggested on the basis of good penetration into pancreatic tissue, while cefuroxime prescribed early in the attack has been shown to reduce the incidence of infective complications and mortality. The duration of use remains unclear. Platelet-activating factor antagonists In patients with severe acute pancreatitis, there is some evidence that 3 days of treatment with a platelet-activating factor PAF antagonist reduces the severity of organ failure.
However, more recent trials have thrown doubt on the effectiveness of this therapy and further studies are awaited. These include anticholinergics, glucagons and somatostatin. However, because the incidence of stress ulceration in these patients is known to be high, these seem to be reasonable therapy. Chronic pancreatitis Chronic pain is a major feature of chronic pancreatitis.
If possible, nonsteroidal drugs should be tried as opiates may cause constipation and exacerbate abdominal pain. Fentanyl patches may be a useful alternative for patients poorly controlled with non-steroidals. These patients should be encouraged to reduce fat intake. Pancreatic supplementation pancreatin can be given. As these preparations are inactivated by stomach acid, they should be taken with food or, alternatively, a proton-pump inhibitor or H2-receptor antagonist should be given.
Broad-spectrum antibiotics should be employed. The main causative organisms are aerobes, such as E. Many treatment regimens are based on metronidazole and a cephalosporin or gentamicin. These may be given intravenously if the patient requires in-patient care or orally if out-patient treatment is considered appropriate. Many clinicians regard computerized tomography CT of the abdomen as the gold standard investigation in diverticulitis. This may accelerate recovery with conservative management. Surgery is reserved for the complications of diverticulitis or in patients failing to settle or deteriorating with conservative management.
Some authors advocate that elective surgery usually sigmoid resection should be undertaken in any patient with two documented episodes of diverticulitis. Perforated peptic ulcer When the diagnosis has been made, a nasogastric tube should be inserted to minimize intra-abdominal contamination. Antibiotics should be started: After resuscitation, most patients will be taken to theatre for oversewing of the peptic ulcer and suturing of an omental patch to the defect.
At the time of surgery, these perforations have often sealed themselves; the critical aspect of surgery is the peritoneal lavage. Prompt use of a nasogastric tube and intravenous antibiotics also minimizes the intra-abdominal contamination. Many surgeons also prescribe ranitidine 50 mg t. After surgery, most would agree that patients need to be on either an H2blocker or a proton-pump inhibitor. The duration of this treatment depends on local policy, although some advocate lifelong treatment.
As soon as reasonably possible, Helicobacter pylori should be sought and treated as necessary see Chapter A proportion of patients are suitable for conservative management. Ranitidine 50 mg t. Some surgeons advocate the wider application of this non-surgical management to acute peptic ulcer perforation , although this has not been adopted widely. If the conservative approach is to be adopted, then regular clinical assessment is mandatory.
The principles of management of some of these conditions are covered above. However, antibiotic therapy should be instituted as soon as the diagnosis of peritonitis has been made. This will probably need to be continued for several days postoperatively. The causative organisms are both anaerobes, such as Bacteroides, Fusobacterium and Clostridium, and aerobes, such as E. A cephalosporin and metronidazole are commonly employed. The cephalosporin may be substituted by an aminoglycoside such as gentamicin.
Gentamicin had fallen out of favour in recent years because of the risk of nephrotoxicity and the need to monitor serum levels. The evolution of a once daily dosage has resulted in a resurgence of its popularity. In some centres, where the patient is very unwell or the degree of contamination is severe, monotherapy with a very broad-spectrum antibiotic, such as imipenem, is preferred. Safety of early pain relief for acute abdominal pain.
Ten year computerised audit of infection after abdominal surgery. Br J Surg ; Antibiotics versus placebo for prevention of postoperative infection after appendicectomy. Cochrane Database Syst Rev ; 2: Eriksson S, Granstrom L. Randomized controlled trial of appendicectomy versus antibiotic therapy for acute appendicitis.
Gall stones and mortality: Treatment of biliary colic with diclofenac: The impact of patient delay and physician delay on the outcome of laparoscopic cholecystectomy for acute cholecystitis. Am J Surg ; Surg Endosc ; Glazer G, Mann MV. United Kingdom Guidelines for the management of acute pancreatitis. A randomised multicenter clinical trial of antibiotic prophylaxis of septic complications in acute necrotizing pancreatitis with imipenem.
Surg Gynecol Obstet ; Prophylactic antibiotics in treatment of severe acute pancreatitis. Early treatment with antibiotics reduces the need for surgery in acute necrotizing pancreatitis: J Gastrointest Surg ; 5: Early antibiotic treatment in acute necrotising pancreatitis: Role of antibiotics in acute pancreatitis: J Gastrointest Surg ; 2: A randomised trial of nonoperative treatment for perforated peptic ulcer. N Engl J Med ; In those patients with incomplete acute ischaemia, medical therapy may result in limb salvage. If the limb is irreversibly ischaemic, amputation is required.
Otherwise, immediate amputation is required. The two most important features of complete ischaemia requiring emergency treatment are paraesthesia and paralysis. Urgent referral to a vascular surgeon is required. Rarer causes, such as aneurysm, dissection and trauma, should be considered. The aetiology of the ischaemia has implications for its management. Immediate management for complete and incomplete acute vascular occlusions General resuscitation and optimization of medical status should, as always, be the goal.
Stop all vasoconstricting agents. In particular, heparin is contra-indicated in aortic dissection or if there is a history of multiple trauma, head injury or actual or recent intracerebral bleed. Acute limb ischaemia is painful and analgesics should be prescribed. Opiates are probably best.
In cases of complete arterial occlusion, the patient should be taken to theatre for embolectomy or thrombectomy. Most surgeons would agree that thrombolysis is not an option. In cases of incomplete arterial occlusion, embolectomy or thrombectomy is rarely successful. This will image the distal vessels and provide information about possible surgical reconstruction and the state of distal run off vessels, which is of particular interest if thrombolysis fails.
Thrombolysis is a specialist procedure in which streptokinase or recombinant tissue plasminogen activator is infused into the thrombus down a 59 60 CHAPTER 15 cannula placed into the clot or thrombus. It is a specialist procedure that should only be undertaken by appropriately trained staff in specialist units. Prostacyclin analogues are sometimes used for the treatment of critical limb ischaemia. These drugs do not have a licence for this indication and should only be used with specialist advice as the resultant vasodilatation may cause severe hypotension.
Subsequent management Patients with an embolic cause of acute limb ischaemia should restart heparin after surgery immediately or with a short delay of around 6 h thought to reduce the risk of haematoma formation. Lifestyle factors Smoking cessation is important. Patients who smoke heavily are approximately three times more likely to develop intermittent claudication, and peripheral artery disease is related to the amount and duration of smoking.
Nicotine replacement in the form of patches, sprays and gums approximately doubles the rate of people stopping smoking. Patients should be encouraged to walk to a point close to the maximal level of pain for around 30 min at a time, at least three times a week and for at least 6 months. Reduction in cholesterol Patients should be encouraged to eat healthily, and reduce in particular the amount of saturated fat in their diet. Cardiovascular complications are reduced by about one-quarter in patients who have peripheral vascular disease and have their cholesterol reduced by one-quarter . This appears to be independent of sex, age and baseline cholesterol level.
Patients at risk of peripheral vascular events should be offered aspirin 75 mg o. ISCHAEMIA While there is evidence that clopidogrel is marginally superior to aspirin in preventing vascular complications and death in patients with overt atherosclerotic disease, the number needed to treat for 1 year to prevent one event was The substantially greater cost of treatment with clopidogrel compared to aspirin means that clopidogrel has not been widely adopted. It should be considered in those patients with peripheral arterial disease who cannot take aspirin.
There is no evidence to support the use of oral anticoagulants in the management of peripheral vascular disease. Antihypertensive drugs Patients with hypertension should be treated even though, in the short term, a reduction in blood pressure may worsen their symptoms. The choice of antihypertensive is probably between a lowdose thiazide diuretic or an ACE inhibitor. ACE inhibitors should be used with caution monitoring of renal function as there is a high incidence of renal artery stenosis in this group. A selective beta1-blocker or a calcium antagonist would be second choice.
There is a theoretical concern that beta1-blockers may unmask claudication in previously asymptomatic patients or worsen the symptoms of peripheral vascular disease. Carvedilol has some intrinsic sympathomimetic properties which may make it useful in this setting. Good glycaemic control reduces the microvascular complications of overweight people with diabetes and metformin reduces large vessel complications . Peripheral vasodilators Oxpentifylline, naftidrofuryl oxalate, cinnarizine and inositol nicotinate are licensed for peripheral vascular disease.
They have been shown in small studies to produce small increases in pain-free walking, but these improvements are not dramatic and these drugs are therefore not widely used. Lifestyle changes, especially stopping smoking, are vital. Some relief is obtained from using nifedipine 5 mg t. Management of peripheral arterial disease in primary care. Exercise for intermittent claudication. Collaborative overview of randomised trials of antiplatelet therapy.
Maintenance of vascular graft or arte- rial patency by antiplatelet therapy. Intensive bloodglucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes UKPDS Breast problems Endocrine therapies in breast cancer Some breast cancers depend on oestrogen for their growth. Depriving tumours of this driving force is an established treatment for breast cancer. In postmenopausal women, androgens, mainly from the adrenals, are converted into oestrogens by the enzyme aromatase, which is present in a range of breast tissues, including about two-thirds of breast cancers.
Tamoxifen Tamoxifen has a complex pharmacology and is metabolized to a number of different compounds that have different activities. However, its most important role lies in stopping the proliferation of breast cancer cells that express oestrogen receptors. Tamoxifen also has partial oestrogen agonist activity in some other tissues. This translates into providing protection against osteoporosis in postmenopausal women. Less helpfully, tamoxifen also causes endometrial proliferation that results in a time- and dose-dependent increase in the risk of endometrial cancer .
Prompt investigation of patients with vaginal bleeding is required. Patients on tamoxifen also have an increased risk of thromboembolism. It concludes that looking at randomized trials of tamoxifen taken for variable durations of time, the risk of recurrence and death is reduced. Aromatase inhibitors These are a class of drugs that inhibit the synthesis of oestrogen from androgens in postmenopausal women. Further long-term data are required before the place of these drugs in relation to tamoxifen becomes clear.
There is some evidence that anastrozole may be superior in ER-positive patients with early breast cancer in terms of disease-free survival and contralateral breast cancer. Anastrozole use was also associated with 63 64 CHAPTER 16 a lower incidence of endometrial cancer, stroke and thromboembolic events, although the rate of fractures was higher . This class of drugs probably should, at present, be considered in patients at high risk of deep venous thrombosis, pulmonary embolus and endometrial cancer.
Breast pain Breast pain is common. There are two broad categories of breast pain: They tend to complain of pain often associated with lumpiness and swelling in the breast. Patients with non-cyclical mastalgia tend to be older. The pain may come from the breast itself but also from other areas, such as the chest wall, incorrectly interpreted by the patient as being within the breast.
Treatment Many patients with pain are worried that they have cancer. This is an extremely unusual presentation and patients should be reassured after clinical examination. Some centres advise patients to avoid certain dietary substances, including caffeine and chocolate, although the evidence of causation with these agents is unclear. First-line therapy for cyclical breast pain is usually evening primrose oil containing gamolenic acid , up to six or eight tablets per 24 h. In patients still complaining of severe symptoms, it is reasonable to try either danazol mg o.
The majority of patients should obtain relief after this algorithm of treatment. In those with persistent symptoms, there are other options, including tamoxifen and gonadotrophinreleasing hormone agonists, although these drugs are not currently licensed for these indications. The true origin of pain in patients with non-cyclical breast pain needs to be elucidated as this determines treatment.
In those patients with breast wall pain — often little more than costochondritis — analgesics, particularly NSAIDs, should be prescribed. Beginning with the general principles of prescribing and basicsof writing a prescription form, the book guides you through topicssuch as using the BNF, drug interactions and monitoring toxicity,before moving on to cover both surgical and medical topics such aspreoperative and postoperative patients, prophylaxis, organ failureand diabetes. The hands-on guide to practical prescribing is a problem-basedbook that covers the common problems and questions a house officermight encounter, and will be an invaluable guide to life on thewards.
The authors are specialist registrars in medicine andsurgery, have undertaken SHO and registrar posts in the majorspecialities and also write and teach regularly on clinicalpharmacology. This new addition to 'The hands-on guide' series brings togetherthe core The Hands-on Guide to Practical Prescribing.