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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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Acutemanagement
Riskassessment
Involving the MDT, formulate a risk management plan based on your risk assessment. Takeintoaccountadvanceddirectivesandconsiderwhatmeasuresandapproacheshave helpedinthepast.
De-escalation
Takethefollowingapproachwithpatientsatriskofaggressionorviolence:
Separateagitatedpatientsfromotherswheresafetodoso.Useadesignatedquietareaoftheward forthisifpossible Onestaffmembershouldtaketheprimaryroleincommunicatingwiththepatient,butdonotisolate asinglestaffmemberwiththepatient Seekclarificationfromthepatient Negotiatetoresolvethesituationnon-confrontationally Bemindfulofyourownnon-verbalcommunication(avoidexpressinganxietyorfrustration—tryto appearcalm) ConsiderofferingPRNmedications(e.g.promethazine25–50mgPOorlorazepam1–2mgPO).
Restraint
Only use restrictive interventions (e.g. seclusion, restraint) if the above-listed measures failandthereisariskof harm tothepatientorothersifthisactionisnottaken.Ensure thatrestrictiveinterventionsare:
Proportionatetothelevelofrisk Theleastrestrictiveoption Usedfortheshortestpossibleduration Usedinaccordancewiththepatient’spreferencesifpossible Appropriatetothepatient’sdevelopmentalage,physicalhealth,andfrailty.
Mechanical restraint (e.g. handcuffs) should only beused in high-securitysettings, and onlyasanoptionoflastresort.
Seclusion
Seclusion means confining a patient within a room for the protection of others. If necessary,itshouldtakeplacewithinadesignatedroom,andthepatientshouldbeunder continuous observation. It should take place for the shortest duration possible and reviewsshouldtakeplaceatleastevery2hourstoconsiderwhethertheseclusioncanbe terminated.
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Legalstatus
Use of restrictive interventionsshould promptanurgentreview of the patient’s legal status.Forinformalpatients(voluntaryadmission)whoaresecludedasanemergency, the need to use powers to detain under the Mental Health Act should be assessed urgently.
Rapidtranquillization
Thisistheuseofparenteral(usuallyIM)medicationforurgentsedation.
Foradultsuseeitherlorazepam1–2mgIMorhaloperidol5mgIM+promethazine 25–50mgIM.
Whenchoosing,considerthepatient’spreferences,physicalhealthproblems,possible intoxication, previous response, possible interactions, and total daily dose (including regularmedications).Ifthereisinsufficientinformation,uselorazepam.
Avoid haloperidol and promethazine if there is no ECG available(risk of dangerous QTprolongation)orifthereisevidenceofcardiovasculardisease.
Reviewafterthefirstdose.Ifthereisapartialresponse,considergivinganotherdose. If thereisno response, consider usinganother agent (e.g. if no responseto lorazepam, thenconsiderhaloperidol/promethazine).
A daily medicationreview bya senior doctor is necessary if the patient is requiring rapid tranquillization. For patients whodo notrespond torapid tranquillization,geturgent senior advice.
Followingrapidtranquillization,ensurethatthefollowingaremonitoredatleastevery hour: pulse, blood pressure, temperature, hydration level, level of consciousness, and side effects, until there are no further concerns regarding the patient’s physical health. Theseshouldbemonitoredevery15minutesifanyofthefollowingapply:
DosesofmedicationaregivenexceedingBNFlimits Thepatientisasleeporsedated Thepatienthasalsobeenusingdrugsoralcohol Thepatienthasapre-existingphysicalhealthproblem Thepatienthasbeenharmedbecauseofarestrictiveintervention.
Treatmentafterstabilization
Pharmacological
Thereshouldbeanagreed‘pharmacologicalstrategy’forpatientsatriskofviolenceand
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aggression,includingtheuseofregularandPRNmedication.Thisshouldbeformulated assoonaspossiblefollowingadmission.
Review this strategy at least once a week. If rapid tranquillization is being used, a seniordoctorshouldreviewthisatleastonceaday.
Whenreviewingmedication,considerthefollowing:
Whatisthetherapeuticaim? Howlongshouldthemedicationtaketowork? Whatisthetotaldoseofmedicationprescribedandadministered,includingPRN? Haveanydosesbeenmissedandwhy? Hastherebeenatherapeuticresponse? Arethereanysideeffects?
WhenprescribingPRNmedication:
Ensurethatthe MDT(particularlynursingstaff)agreeunderwhichcircumstancesthe medication shouldbeadministered Ensurethatitisnecessary(PRNmedicationsshouldnotberoutinelyprescribed,althoughtheywill benecessaryformanypatientswhoareatriskofaggressionandviolence) CheckthatthetotaldoseofregularandPRNmedicationdoesnotexceedBNFlimits,especiallyif aregulardailydoseisalsobeingused(BNFmaximumdailydoseforhaloperidolis20mg/day) ConsiderstoppingPRNmedicationthatisn’tbeingused.Reviewatleastweekly.
DosesabovetheBNFmaximumshouldonlybeprescribedfollowingdiscussionwithasenior doctor.Clearlydocumenttherationaleforthisdecisioninthepatient’snotesandbeawarethat thesepatientswillrequireclosermonitoring.
Psychosocial
Consider offering a psychological intervention to enable the patient to develop skills aimedatreducingtheriskoffutureviolenceandaggression.
Observation
Theobservationlevelisthefrequencywithwhichstaffwillobservethepatienttoensure theirsafety.AgreethelevelofobservationforeachpatientwiththeMDTaccordingtothe risk assessment. The following observation levels are usually found on psychiatric inpatientwards:
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Low-levelintermittent(30–60minutes):forlower-riskpatients High-levelintermittent(15–30minutes):forpatientsat↑butnotimmediaterisk Continuousobservation(i.e.‘oneto one’):keptateyesight orarm’s lengthofa designatedstaff member—forpatientswhoareatcontinuousrisk Multiprofessionalcontinuousobservation(e.g.‘twotoone’):thesepatientsareathighestriskand requirecontinuousobservationfrommorethanonememberofstaff.
Specialconsiderations
Emergencydepartments
Violence or aggression as symptoms of a known or suspected mental health problem shouldbemanagedasapsychiatricemergency.Referurgentlytothementalhealthliaison teamwhoshouldassesswithin1hour.
Furtherreading
1.OgloffJR,DaffernM(2006).Thedynamicappraisalofsituationalaggression:aninstrumenttoassess
riskforimminentaggressioninpsychiatricinpatients.BehavSciLaw.24:799–813.
2.WoodsP,AlmvikR(2002).TheBrosetviolencechecklist(BVC).ActaPsychiatrScand.106:103–5.
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47
48
Part7
Nephrology
Acutekidneyinjury
Chronickidneydisease
Hyperkalaemia
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Chapter46
Acutekidneyinjury
Guideline: NICE NG148 (Acute kidney injury: prevention, detection and
management):https://www.nice.org.uk/guidance/ng148
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Acutekidneyinjury(AKI)isdefinedasanabrupt(within7days)lossinkidneyfunction, whichmayoccurinthecontextofpre-existingkidneydiseaseorcompletelynormalrenal function.
Diagnosis
History/diagnosticcriteria
Factors knowntoprecipitateAKIincludeacuteillness,surgery,and receivingiodinated contrast. Particular care should be taken in patients with underlying risk factors for developingAKI,whichinclude:
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CKD Heartfailure Liverdisease Age≥65years Diabetes HistoryofAKI Hypovolaemiaorsepsis Use of drugs that can cause or exacerbate kidney injury (including diuretics, ACE inhibitors, ARBs,NSAIDs,andaminoglycosides).
AKIcanbedetectedandstratifiedaccordingtoseverityusingthecriterialistedinTable
46.1.
Table46.1AKIseverityclassificationcriteria(fromRIFLE,AKIN,andKDIGO systems)
AKI stage
Serumcreatininecriteria Urineoutputcriteria
1
Creatinineriseof≥26μmol/Lwithin48hoursOR Creatinineriseof1.5–1.99×baselinewithin7days
Urineoutput<0.5mL/kg/hourfor>6hours(in adults)
2
Creatinineriseof2–2.99×baselinewithin7days Urineoutput<0.5mL/kg/hourfor>12hours
3
Creatinineriseof3×ormore frombaselinewithin7 daysOR Creatinineriseto≥354μmol/LOR Newrequirementforrenalreplacementtherapy
Urineoutput<0.3mL/kg/hourfor>12hours
AKIN,AcuteKidneyInjuryNetwork;KDIGO,KidneyDisease:ImprovingGlobalOutcomes;RIFLE, Risk,Injury,Failure,Lossofkidneyfunction,andEnd-stagekidneydisease.
AKIitselfwillnotcausesymptomsunlessverysevere.Inthiscase,patientsmaypresentwith nausea and vomiting, fatigue, shortness of breath (due to pulmonary oedema), peripheral oedema, and symptoms of uraemia (e.g.itch, chestpaindue to pericarditis, or behavioural disturbancesduetoencephalopathy).
Examination
AKIexaminationfindingsarelistedinTable46.2.
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Table46.2AKIexaminationfindings
B
Bibasalcoarsecrepitations
C
Coolperipheries Prolongedcapillaryrefilltime ↑JVP Tachycardia
D
Drowsiness
E
Pittingoedema Palpabledistendedbladder Renalangletenderness
Investigations
InvestigationsthatshouldbecarriedoutinAKIarelistedinTable46.3.
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Table46.3CausesofAKIandappropriateinvestigations
Type Causes Investigations
Prerenal (reductionin bloodsupply tokidneys)
Dehydration Sepsis (see
Chapter122)
Shock
ECG Bloods including FBC, U&E, LFT, bone profile, CRP, blood cultures, VBG ChestX-ray
Intrinsic(direct damageto kidneys)
Acute glomerulonephritis Drugs Toxins including iodinatedcontrast Reduced blood supply Pyonephrosis (infected and obstructed kidney) Myeloma Rhabdomyolysis
Urinalysis—checkfor(proteinuriaand/orhaematuria) FBC Serumelectrophoresis,immunoglobulins,serumfreelightchains Creatinekinase Vasculitis screen if blood/protein on urinalysis or otherwise unexplained AKI (ANCA, complement C3/4, ANA, anti-glomerular basement membraneantibodies,antistreptolysinOtitres)
Postrenal (obstructionof urinaryflow)
Obstructing renal calculi Bladder malignancy Enlargedprostate Retroperitoneal fibrosis Pelvicmalignancy Urethralstricture
Ultrasoundofurinarytract
Start with simple investigations to identify a cause before considering performing a vasculitis screen or electrophoresis/immunoglobulins/serum free light chains, unless there are particular reasonstosuspectspecificconditions. Ultrasoundisnotrequiredifthecausehasbeenidentifiedandtreated. IfthecauseofAKIisnotidentified,considerarenaltractultrasound. Ifpyonephrosisissuspected,ultrasoundshouldbeperformedwithin6hours.
Management
Themanagementof AKI largelydepends on theunderlyingcause. Callfor helpfroma senior clinicianif there are anyclinicalconcerns or a high earlywarningsystem score.
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Generalprinciplesinclude:
Acutemanagement
IVfluids:ifthepatientishypovolaemic Monitor:U&Eandurineoutput.Urinarycatheterizationmayberequired Antibiotics:ifsepsisissuspected.Ensurechoiceofantimicrobialagentanddoseareadjustedto
renalfunctionasperlocalguidelines/BNF/RenalDrugDatabase. Medications review: stop nephrotoxics if indicated and antihypertensives if the patient is hypotensive. Note that some drugs that are metabolized by the kidney may require dosage alterationsaccordingtoeGFRorcreatinineclearancetoavoidtoxicity,e.g.digoxin Renalreplacementtherapy: should beconsideredimmediately ifany ofthe followingare not respondingtomedicaltherapy:
Hyperkalaemia(seeChapter48) Metabolicacidosis Symptomaticuraemia(e.g.tremor,cognitiveimpairment,coma,fits) Fluidoverload Pericarditis Pulmonaryoedema Anuria.
Treatmentafterstabilization
Referraltotheurologyteamisindicatedincasesofupperurinarytractobstruction.
Refer immediately if suspecting pyonephrosis, obstructed solitary kidney, bilateral upper urinary tract obstruction, or complications of AKI caused by urological obstruction. Nephrostomy or stenting should be undertaken as soon as possible, and within12hoursofdiagnosis.
Referral to the nephrology team is indicated if considering renal replacement therapy, in patients with a renal transplant, where the cause of AKI is uncertain or if specialistmanagementofthecauseisneeded.Ifanyofthefollowingarepresent,discuss withanephrologistassoonaspossible,andwithin24hours:
Adiagnosisrequiringspecialisttreatment(e.g.vasculitis,glomerulonephritis,myeloma) AKIwithnoclearcause Inadequateresponsetotreatment ComplicationsassociatedwithAKI Stage3AKI Renaltransplant Pre-existingCKDstage4or5.
Once the AKI has resolved, consider a referral to nephrology if eGFR remains <30mL/min/1.73m2.
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