1. Cover Shifts part 3 - Dr Carol Chong
Constipation
Warfarin Orders
Oliguria
Hypoxia
Tachycardia

2. Constipation
What meds are in your armamentarium?

3. Dr Chong’s armamentarium
1/7 of constipation
Coloxyl and senna 2 tablets b.d +
Lactulose 20mls o b.d prn
2/7 as above but lactulose is strict now
3/7 as above but add in movicol 2 satchets o b.d strict and microlax enema 1 pr daily prn
(lots of other options pt’s might have their own) eg. Metamucil, fybrogel, glycerine suppository

4. Constipation for 4/7 – big guns
Have all of the previous cocktail plus
Movicol (jug) 6 satchets of movicol in mls of water to be drunk over 1-2 hours (if not on fluid restriction or
Fleet enema 1 pr daily prn
Or both!
Usually works!

5. Dosing of Warfarin - Some scenario’s
We need a warfarin order… Mr Clay’s INR is 2.3, how much warfarin shall we give him tonight? What other questions do you want to know before you dose?

6. Warfarin Orders Common ward call on cover Need to know
(1) Reason why the patient is on warfarin
(2) Target INR – usually , could be higher for prosthetic valves
(3) Need to know usual warfarin dose …
(4) Previous warfarin doses given and INRs

7. Case 1 72 y.o admitted for NonSTEMI and dehydration 4/7 ago.
Usually on warfarin for A.F. Aiming INR
Last INR yesterday INR 2.1 given 5mg warfarin.
Any more info to know?

8. Case 1 INR 2/7 ago was 2.1 given 5mg warfarin
Has actually been on 5mg warfarin prior to admission
How much warfarin to give him tonight? And when to recheck INR?

9. Warfarin rule – takes 48hours to affect the INR
INR Bang on target so 5mg warfarin is fine.
Note – INR is reflective of the dose of warfarin given about 48 hours ago! (so the warfarin dose charted yesterday will affect the INR tomorrow)

10. Case 2
“I need a warfarin order”.
INR is 3.2

11. Case 2 INR 3.2 On warfarin for pulmonary embolism
In hospital for pneumonia, on IV anti’s for 3/7
INR 1/7 ago was 2.9 given 6 mg warfarin
INR 2/7 ago was 2.8 given 7 mg warfarin
INR 3/7 ago was 2.1 given 10mg warfarin
Usual dose warfarin 10mg
How much warfarin to give?
Aim for INR?
Why is warfarin dose lower now?

12. Case 2 INR 3.2 On warfarin for pulmonary embolism
In hospital for pneumonia, on IV anti’s for 3/7
INR 1/7 ago was 2.9 given 6 mg warfarin
INR 2/7 ago was 2.8 given 7 mg warfarin
INR 3/7 ago was 2.1 given 10mg warfarin
Usual dose warfarin 10mg
How much warfarin to give? Definitely less than 10mg, (7mg warfarin affected the INR 3.2 result (from 48 hrs ago), so give less than 7mg warfarin preferable eg. 5 or 6mg
Aim for INR?
Why is warfarin dose lower now? On iv antibiotics

13. Case 3 INR 3.7 On warfarin for mechanical aortic heart valve
Aim for INR
In hospital for 2 weeks with bowel obstruction.

14. Case 3 Warfarin dose date INR 4mg 27/1/19 3.5 3mg 28/1/19 3.6
?? /1/

15. Case 3 Warfarin dose date INR 4mg 27/1/19 3.5 3mg 28/1/19 3.6
?? /1/
Best to give less than 3mg warfarin as 3mg on 28/1/19 has caused INR 3.7 on 30/1/19 (48 hrs later) – so 1 or 2 mg

16. Case 4 INR 5.0 On warfarin for mechanical aortic heart valve
Aim for INR
In hospital for 2 weeks with bowel obstruction.

17. Case 4 Warfarin dose date INR 4mg 1/1/19 3.5 4mg 2/1/19 4.0
?? /1/
Reasons why INR is elevated?

18. Case 4 Warfarin dose date INR 4mg 1/1/18 3.5 4mg 2/1/18 4.0
?? /1/
Reasons why INR is elevated? Drugs, malnutrition etc.
INR 5 from warfarin dose from 2/1/18 4mg best to give less than 4mg – ie. Withhold, 1, 2 or 3 mg ok as long as INR tested daily. Withholding might be best until the result of 2mg from 3/1/18 known (ie. Tomorrows INR will help)

19. Case 5 INR 1.9 On warfarin for mechanical aortic heart valve
Aim for INR
In hospital for 2 weeks with bowel obstruction.

20. Case 5 (aiming INR 2.5-3.5) Warfarin dose date INR 4mg 1/1/19 2.8
4mg /1/ not tested
4mg /1/ not tested
?? /1/
What dose of warfarin to give?
Why is INR lower?
What else should you consider?

21. Case 5 (Aiming INR 2.5-3.5) Warfarin dose date INR 4mg 1/1/19 2.8
4mg /1/ not tested
4mg /1/ not tested
?? /1/
What dose of warfarin to give? More than 4mg. Eg. 5, 6, 7 mg
Why is INR lower? Could be from drugs, not eating
What else should you consider? Anticoagulating until therapeutic INR

22. Subtherapeutic INRS
If you get this call, just consider if the patient needs therapeutic anticoagulation. May need to check the patient’s history.
If renal function normal – clexane 1mg/kg s/c b.d until INR therapeutic

23. Case 6 INR 1.7 A.F on warfarin. In hospital for gout, can’t walk
Warfarin usually 7mg o daily.
1st day of admission
How much warfarin to give?
Do you need therapeutic clexane?
How about prophylactic clexane?

24. Case 6 INR 1.7 A.F on warfarin. In hospital for gout, can’t walk
Warfarin usually 7mg o daily.
1st day of admission
How much warfarin to give?
Not lower than 7mg and probably no more than 10mg.
Do you need therapeutic clexane?
No. Doesn’t have a current thromboembolic problem nor mechanical valve
How about prophylactic clexane?
No, INR 1.7 is like having prophylactic clexane.

25. Case 7
Mrs AS in hospital for UTI. Usually on warfarin for A.F. Has been on ceftriaxone for UTI for the last 5 days.
INR today is 3.2

26. Case 7 Mrs AS Warfarin dose date INR 8mg 11/1/19 2.0 8mg 12/1/19 2.7
???? /1/
Reasons why INR is elevated?
How much warfarin to give?

27. Case 7 Mrs AS Warfarin dose date INR 8mg 11/1/19 2.0 8mg 12/1/19 2.7
???? /1/
Reasons why INR is elevated?
Probably from the antibiotics
How much warfarin to give?
Less than 7 or 8 mg. eg. 5 or 6 mg.

28. TIPS Know indication for warfarin Know INR range for the patient
Previous warfarin and INR results help guide new dose
**Have a plan for re-testing. Really important – document in the file and also handover verbally if necessary. Don’t forget to put in the INR slip for the next day if needed.

29. Low urine output Mr AC has not passed urine for the last 4 hours.
What are you going to do?

30. Low urine output Mr AC has not passed urine for the last 4 hours.
What are you going to do?
Determine the CAUSE!

31. Low urine output Causes of Oliguria? Easiest to break up into:
Pre-renal
- Dehydration/ Hypovolaemia, too many losses eg. Vomiting, diarrhoea,
- pump failure – cardiac failure,
- Sepsis – causing renal impairment
Renal
– ATN, glomerulonephritis etc
Post-renal
– obstruction, starting at the ureter – bilateral calculi, tumours, bladder, prostate a common cause.

32. Low Urine Output
What Key Questions will you ask the nurses over the phone?

33. Questions you should ask over the phone
Is there a catheter in situ?
What is the trend in urine output – eg. Suddenly dropped off versus tappering off
Have they done a bladder scan?

34. Low urine output
Easiest to rule out obstruction first and look into pre-renal causes (not much you can do about renal causes on cover shift)
Ask if the patient has a catheter?
Need to rule out obstruction first – you can ask the nurses to do a ……………..
If urine retention is present – catheter needed.
What else do you want to know?

35. Low urine output
Need to rule out obstruction first – you can ask the nurses to do a ……………..
Bladder scan – noting the Post Void Residual Volume (PVR)
(Ideally it should be less than 250mls).
Can accept up to mls – depends on the patient.
If urine retention is present – catheter needed BUT ASK PATIENT TO TRY AND PASS URINE FIRST!!

36. Low urine output
If bladder scan shows <200mls post void residual, now look for.
Pre-renal causes – very common in hospital
How to assess fluid status?
Treatment – try fluid bolus first
Often need catheter for fluid balance and careful fluid monitoring

37. Low urine output
If bladder scan shows <200mls post void residual, now look for.
Pre-renal causes – very common in hospital
How to assess fluid status?

38. Assessing Fluid status
History – not eating or drinking? In severe CCF ? O/E – the key. Grab the fluid input and output chart. What’s their weight? Obs b.p, pulse JVP, Mucous membranes, skin turgur Ix – U+E’s key – look for evidence of dehydration and renal impairment. Look at other bloods ?septic.

39. Low urine output Bolus fluids first unless overloaded.
If overloaded try frusemide (start low iv and go up slowly).
How much frusemide?!
Depends on whether they are already on etc…
Lasix 20mg iv if never on it before
Or roughly usual dose iv or double
Inform the registrar – patient may not do very well at all (oliguric and renal failure)

40. Hypoxia Must see the patient.
Nurse rings “Mr JS is short of breath and has sats of 84% - what should I do?
What else do you need to know?
What can you ask the nurse to do before you see JS?

41. Hypoxia Ask to put oxygen on until sats are over 90% at least.
Ask for all the other obs (RR etc) and how the patient looks well versus unwell
MET call! You should call one – he fulfils the criteria – it is in his best interests for a team approach.

42. Hypoxia – oxygen equipment
If mildly hypoxic = nasal prongs
Upgrade to face mask 10-15L then
50% oxygen – humified oxygen then
CPAP or BIPAP then
Intubation

43. At the Met Call – Stabilise and why is pt hypoxic?
DRABC
Examine the patient – DRA good
B – breathing - aim to get sats into range and examine chest.
Sitting up leaning forwards – best to listen posteriorly for crackles.
Other – fluid status
Someone should look through folder for history (you can do this if reg examining)
Possible causes …

44. Causes of hypoxia Lung problems
pneumonia, atelectasis, COPD (inf exac), asthma, P.E, lung cancer, aspiration, metastasis, obesity hypoventilation/ OSA
Cardiac
CCF, pleural effusions
Other
Chest wall disorders (flail chest)
Neuromuscular disorders (GBS, Myasthnia gravis crisis, othere rarities)

45. Hypoxia on cover – looking for the cause and severity so you can treat
Investigations
Radiology – may need portable CXR at MET call if very unwell.
CXR
ABG
Bloods

46. Treatment Treat hypoxia first – patient can die from this.
(rather than worrying about CO2 in COPD)
Treat cause –
CCF – diuretics, CPAP - eg. Lasix 40mg iv stat
Pneumonia – reconsider antibiotics (upgrade)
P.E – anticoagulate – order tests
Asthma – consider HDU/ICU if hypoxic despite high flow O2
COPD –can accept at slightly lower levels of SpO2 if known CO2 retainer. Beware CO2 narcosis. Aim SpO % - ie. Don’t want them to have 100% sats if known Co2 retainer!

47. Treatment
How to give nebs – patient has been admitted acute exac of asthma
Ventolin 5mg/ Atrovent 500mcg /N Saline 5mls neb 4-6/24 strict
Can give 5ml N/Saline neb prn if thick sputum and struggling to bring up
Ventolin 5mg neb prn.
Don’t forget steroids eg. Prednisolone 1mg/kg eg. 50mg o stat or hydrocortisone iv

48. Tachycardia
Worrying.
Need to see the patient.
Common causes…

49. Tachycardia – Common Causes
In hospital we worry about
Pain
Sepsis
Arrhythmia (sinus versus other – eg. Rapid AF), SVT, (ask for an ECG!)
Dehydration
P.E

50. Tachycardia – Associations
Other vital signs. Think about them all together. What might you see -
Pain
Sepsis
Arrhythmia (sinus versus other – eg. Rapid AF), SVT,
Dehydration
P.E

51. Tachycardia – Associations
Other vital signs. Think about them all together. What might you see -
Pain – raised b.p
Sepsis – low b.p (so tachycardia is compensatory – you Don’t want to lower the pulse)
Arrhythmia (sinus versus other – eg. Rapid AF), SVT, - high bp would be better than low (in shock)
Dehydration (tachycardia is compensating for low b.p)
P.E (Sats could be low)

52. Tachycardia - treatment
Think carefully before treating.
You really need to determine the cause first.
You might cause more problems if you simply try and slow the pulse without thinking (eg. Give a beta blocker and eliminate the compensatory tachycardia in the setting of sepsis or hypotension)

53. Rapid A.F Not uncommon in hospital Common causes Determine cause
Investigations and
Treatment in hospital