Post Operative Pain Management and Encephalopathies

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Post Operative Pain Management and
Encephalopathies

• Is it their baseline or drug-related and
• do they return to normal?
• Royal M. Becker, M.D.
• Lead Hospitalist, TMFHS

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• Take a History and do a good Physical.
• What is their baseline?

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Encephalopathies

• Competence
• Surrogate Decision Marker
• Mini Mental Status Exam

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Competent

• Having suitable or sufficient knowledge, skill,
  experience for some purpose
• Properly qualified
• Adequate, but not exceptional

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The Dirty Dozen
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1. Anesthesia

• Long Half Life/ Breakdown of by-products
• Fat Soluble
• Fever
• Anesthesia
• Other Meds
• Atelectasis

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2. Narcotics

• The 5th Vital Sign
• Parenteral Narcotics
• Oral Medications
• Transdermal Medications

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3. Pre-Existing Conditions

• Dementia
• Mood Disorder
• Encephalopathy
• Hypoxic Brain Injury
• Previous CVA

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4. Shock

• Hemorrhagic
• Hypotensive
• Septic

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5. Medications(other than anesthesia or
narcotics)

• Phenegran/Reglan
• Antibiotics
• Benzodiazapines
• Pepcid/ Zantac
• Clonidine

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6. Hyponatremia

• Anesthesia (especially females)
• CHF
• Medications (SSRIs, HCTZ)
• Pulmonary/ SIADH
• Psychogenic Polydypsia

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7. Withdrawal

• ETOH
• Benzodiazapienes

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8. Respiratory Failure

• Over-sedation
• Obstructive/ Restrictive

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9. Obesity
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10. Renal Failure

• Mechanism
• Pre/ Post Intrinsic
• Increases Half Life of nearly everything

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11. Hypertensive Encephalopathy
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12. Sleep Deprivation
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Do they recover?

• Identify problem
• Less is more
• History and Physical
• Time, Fluids and Patience

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CASE STUDIES
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Case 1

• 90 yo female
• Lives with daughter
• Hip facture
• Hypotensive
• Respiratory Failure Post op
• Hyperkalemia
• Renal Failure

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Further History

• Dehydrated due to nausea vomiting
• UTI- given Septra
• Familys wonder drug The Blue Pill

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Case 2

• 70 yo with hx of Diabetes, hx of Renal Failure
• Bilateral TKA, woke up post-op, then into coma
• Intubated, Trached, PEG, comatose for a month.

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Case 3

• 68 yo female
• Avid golfer
• Community leader
• Hernia surgery- 2 days post-op is febrile,
  confused, agitated, paranoid, BP148/102

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Case 4

• 61 yo construction worker
• Prostrate surgery
• Never smoked
• Unarousable- Post-op Day 1 on 3 Liters, sat. is
  92

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What is our PURPOSE?

• Is medicine worthwhile?
• Can you make a difference?
• Know patients history
• Know their anxieties
• Listen to their family

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First, Do No Harm-

• To cure sometimes, diagnose often, TO COMFORT
  ALWAYS!

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Questions Responses