Sunday 14 May, 2006

Gastroenteritis in children

Posted in Emergency Dept., General Practice, Michael Tam, Paediatrics, Resources at 22:41 by Michael Tam

Original article by: Michael Tam :: Printer friendly

Resources

Managing Young Children and Infants with Gastroenteritis in Hospitals

NSW Department of Health Circular (2002/26). Issued 28 June 2002.

Factsheet: Gastroenteritis

Children’s Hospital Westmead / Sydney Children’s Hospital

Oral rehydration protocol

Lyell McEwin Hospital Emergency Department

Infectious gastroenteritis in children is very common, more so during “gastro” season. For most children, the aetiology is a viral infection and the course of the illness will be relatively mild. They will not require medical investigation or in hospital management. For a minority of children, they may have severe symptoms and present with significant dehydration.

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IV fluid therapy in post-operative oliguria

Posted in Medicine, Michael Tam, Surgery, Wards at 20:54 by Michael Tam

Index: Intravenous fluid therapy :: Printer friendly

Original article by: Michael Tam

This is a common problem seen on overtime.

First step is to ensure that it is true oliguria. That is, make sure that the indwelling urinary catheter isn’t blocked or that there isn’t a post-operative urinary obstruction/retention (by physical examination of the abdomen and a ward bladder scan optimally).

“Low urine output” in a non-catheterised patient in the middle of the night is usually a furphy. My “urine output” is usually zero as well. Any patient with suspected oliguria needs an indwelling catheter and hourly urine output measurements.

Secondly, ensure that the patient doesn’t have pre-existing renal failure to explain the oliguria (look up the pre-op UECs).

Any urine output below 30 mL/h should be considered acute renal failure, but that doesn’t mean that a urine output of 40 mL/h is “okay”. Optimally, you should aim for a urine output of at least 1 mL/kg/hr.

Your target post-operative urine output is > 1 mL/kg/hr

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IV fluid therapy in post-obstruction polyuria

Posted in Medicine, Michael Tam, Surgery, Wards at 20:21 by Michael Tam

Index: Intravenous fluid therapy :: Printer friendly

Original article by: Michael Tam

Foley catheter

Urine output in these patients can be hundreds of millilitres per hour. This can lasts for a few days. Most commonly, these patients are post-operative urology patients.

The polyuria in these patients is partly physiological due to the expansion of the extracellular fluid during obstruction. A brief diuresis may not compromise fluid status as long as it is brief. The diuresis is generally electrolyte rich.

Nevertheless, there can be a substantial and huge loss of fluid leading to shock. These patients can literally lose their intravascular volume in a matter of hours. Given this is the case, these patients must have an indwelling urinary catheter and urine output measured on an hourly basis. Daily blood tests for electrolytes, urea and creatinine as well as serum calcium, magnesium and phosphate are a must.

Fluid choice: 0.9% NaCl (“normal saline”)

Rate: IV fluid rate (mL/h) = urine output of the past hour

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Antidepressants available in Australia

Posted in General Practice, Michael Tam, Psychiatry, Resources, Wards at 2:10 by Michael Tam

Original article by: Michael Tam

This is absolutely fantastic single page summary of the antidepressants available in Australia. It has been “liberated” from the GP Psych Support website.

It is basically a chart that compares efficacy, side-effects, advantages, disadvantages, drug interactions of the various antidepressants. Click here to download (in PDF format).

Small sample of the chart

GP Psych Support

Posted in General Practice, Good Websites, Michael Tam, Psychiatry, Resources at 0:48 by Michael Tam

Original article by: Michael Tam :: Printer friendly

GP Psych Support

As a general practice registrar, I have always found mental health interesting, though challenging. Perhaps more so than other specialities, one can often be stumped on exactly how to proceed with management. Add into the mix that community mental health services are relatively thin on the ground, it can be one big headache trying to give the best possible care (or even, adequate level of care).

There is, however, a fantastic service available for General Practitioners – the GP Psych Support.

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Friday 12 May, 2006

Standard post-operative fluid management in adults

Posted in Medicine, Michael Tam, Surgery, Wards at 17:07 by Michael Tam

Index: Intravenous fluid therapy :: Printer friendly

Original article by: Michael Tam

Not enough fluids?

Update (19 June 2011): This article is not consistent with current best evidence.  Please see the following comment. [Michael Tam]

Despite getting plenty of fluids intraoperatively, most patients are usually dehydrated after an operation. There are several reasons for this:

  1. Poor oral intake prior to fasting for theatre (e.g., due to anxiety)
  2. Prolonged fasting period pre-operatively (e.g., operating theatre delayed)
  3. Fluid and blood loss intra-operatively
    • direct blood loss
    • exposure of large internal surfaces to the heat and light of the theatre lights
    • fluid loss from respiration while intubated
  4. Post-operative ileus with third space losses of fluid into the bowel (especially after intra-abdominal and bowel surgery)
  5. Post-operative intravenous fluid therapy insuffient for maintenance and replacement.

Depending on the type and length of the operation, it is not uncommon for patients to be several litres “dry” in the post-operative period. In fact, unless you have specific knowledge otherwise, it is probably safe to assume that the patient is around 1-2 litres dehydrated. These patients would usually be otherwise asymptomatic. The aim is to rehydrate the patient to euvolaemia over a 24 hour period.

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Dummies guide to the mental health legal system (NSW)

Posted in Emergency Dept., General Practice, May Su, Psychiatry at 14:47 by May Su

Original article by: May Su :: Printer friendly

The Mental Health Act can be a headache

A legal framework for mental health in New South Wales, Australia is legislated in the Mental Health Act (1990).

A patient can be admitted either as a Voluntary or Involuntary patient. If they choose to be admitted as a voluntary patient, then they are choosing to be in hospital of their own free will. Essentially, no further paperwork. Just like any other admission into hospital.

The problem occurs if you feel that a patient has to be detained for their own safety, however they do not wish to be admitted. In most circumstances, the patient has the right to choose, provided they have the capacity to make an informed decision.

Remember that the law is in place to protect the patient’s rights, and we have to respect that. This all stems back to the bad old days of the institutionalised mental health system in which there were very few guidelines preventing patients from being incorrectly detained and/or treated.

The Mental Health Act (1990) in NSW is fundametally designed to protect the patient’s rights

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Thursday 11 May, 2006

Takedowns – Do not be a hero

Posted in Emergency Dept., May Su, Psychiatry, Wards at 10:28 by May Su

Original article by: May Su :: Printer friendly

Acute psychosis can be distressing
to both you and your patient

Remember that in a takedown it requires a minimum of five people to hold down an aggressive patient in order to safely restrain them from harm to themselves or others. Takedown of an aggressive patient means somebody holding the head, someone at each limb, and someone to administer medications (usually an intramuscular sedative +/- an antipsychotic). That is a minimum of six people.

If you feel that this may be at all necessary, then take the time to arrange the necessary number of people PRIOR TO SEEING THE PATIENT. Furthermore, if not in the same room as you, then they should be at least within close calling range for immediate assistance.

It takes a minimum of five people to hold down a patient in a take down. A sixth is needed to talk to the patient / administer medications.

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Monday 8 May, 2006

Index: Intravenous fluid therapy

Posted in Best Topics, Michael Tam at 21:45 by Michael Tam

Original article by: Michael Tam

This is an index page linking a series of articles on intravenous fluids.

Intravenous fluid therapy is the most common “prescription” written by a junior doctor. Paradoxically, however, it is a relatively poorly taught subject with most interns (very quickly) learning on the job. It is common to see the practice of simply “copying the last order”.

When I went through medical school, fluid management was taught – but from a physiological point of view and then by a renal physician. The first was enlightening though not easily translated into clinical practice. The second was simply above my level. And thus in clinical practice, I noticed initially in both myself and my peers that we had a reasonable grounding in fluid physiology but when it came to writing fluid orders on the run, they were based more on art than science… “my gut tells me that the next bag needs to run faster”. Sometimes we were right. Other times it did not matter. At times we were very wrong.

The following is a list of articles that give a practical overview on how to order and use intravenous fluids in most common settings.

Get a professional e-mail address

Posted in Advice, Michael Tam at 20:36 by Michael Tam

Original article by: Michael Tam :: Printer friendly

When you are contacting other health workers in a professional capacity, foxygirl@hotmail.com is not going to cut it any more.

Get a professional e-mail address.

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