Don Zhang General surgical registrar Post operative complications Can happen in all surgical specialties Have to have a basic understanding of the surgery to look for specific complications Key is to recognize early and start basic management to prevent deterioration ID: 656960
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Slide1
Assessing critically unwell patients
Don Zhang
General surgical registrarSlide2
Post operative complications
Can happen in all surgical specialties
Have to have a basic understanding of the surgery to look for specific complications
Key is to recognize early and start basic management to prevent deterioration. Slide3
Take home points
Recognise
unwell patient?
How to manage the patient?Slide4
Common post operative problems
Cardiopulmonary
Atelectasis
P
ulmonary
oedema
AMI/CCF
Arrhythmia
Infective
Fever
Line infection
Chest
Urinary
Wound
Surgical site
Venous embolism
DVT
PE
CNS
Stroke
Delirium
Renal
Oliguria/anuria
Urinary retention
Haematuria
Electrolyte disturbance
ARF
Endocrine
Hypo/
hyperglycaemia
hypocalcaemia
Slide5
Categorisation
of potential post operative complications
Related to procedure
Ileus after major abdominal surgery
Leak or collection after bowel resection
Lost of blood flow to reconstruction flap
Related to patient’s co-morbidities
Bleeding with coagulopathy
Wound infection on diabetics
Sepsis in immunosuppressed patient
General problems
cardiopulmonarySlide6
Different way of raising concern
Pre
–
MET calls
MET calls
Code bluesSlide7Slide8
How would you assess the patient
CCRISP
Care of the Critically Ill Surgical Patient
Developed in UK after Hillsborough Soccer disaster
Taught around the world, in Australia by RACS
Teaches prompt, simple actions save lives AND prevent complicationsSlide9Slide10
Immediate management
Airway
Breathing
Circulation
Dysfunction of GCS
ExposureSlide11
End of immediate management
Immediate steps taken to preserve life
Ongoing monitoring established
Pressing investigation
organised
Stable/improved vitals
Called for help?
Move to HDU/ICU or OTSlide12
Full patient assessment
Chart review
Respiratory
RR, FiO2, SaO2
Circulation
HR and rhythm
BP
UO
IV/oral intake
Fluid balance/Weight
CVP
Surgical
Temperature
Drains
Special requirement of the operationSlide13
Full patient assessment cont
History and systematic examination
History: HOPC,
PMHx
, operation detail, daily progress
Systematic examinations: hands, neck, chest , abdomen, peripheral
Available results
Biochemistry profile
ABG/VBG
Glucose
Haematology
Blood count
Clotting
Crossmatch
Microbiology
Radiology
ECGSlide14
Full patient assessment cont
Available results
Biochemistry profile
ABG/VBG
Glucose
Haematology
Blood count
Clotting
Crossmatch
Microbiology
Radiology
ECGSlide15
Stable patients –
Daily plan
Medication
Analgesia
Prophylaxis
Routine medication
Communication
Patient
Nursing staff
NotesSlide16
Unstable patients
Involve senior and consider HDU/ICU/OT
When unsure, consider
Review priorities
Is resuscitation required before you begin investigations?
Does it need to be continued simultaneously with proposed investigations?
How will you achieve that?
Begin any treatment or support that is obviously necessary at once
Does the patient need a higher level of care?
Investigation
Definitive treatmentSlide17
Example
86
yo
man D3 after laparoscopic right
hemicolectomy
for
caecal
cancer
PMHx
IHD, NSTEMI 2012, hypertension,
hyperlipidaemia
, T2DM on orals
Been progressing well post operatively, tolerating diet, has not passed wind
Now pre MET for tachypnea, RR of 26Slide18
Back to Patient
Airway: own, no stridor
Breathing: RR 26, O2Sats 89% on RA
Circulation: well perfused, HR 105, BP 100/70
Disability: GCS 15, orientated to T/P/P
Exposure: distended abdomen, wound covered with dressing
What to next?Slide19
Back to patient
Chart review
Obs
chart
RR has been stable below 20, increase since early morning now to 26. HR between 90~100, SBP between 95~120. afebrile
Fluid Chart
Had 4Ls of CSL since operation, currently has 5
th
liter going at 12/24
Bowel chart
empty
Fluid balance Chart
No daily weight
Urine output 30mls per hour on average since midnight, 1.2 L yesterday
+
ve
1.5 L yesterday and +
ve
3
Ls
since operationSlide20
History and Systematic examination
Non obstructing
caecal
cancer,
PMHx
as mentioned, D3 post op, been uneventful apart from no flatus
Examination findings
Abdomen distended,
generalised
tenderness, no
peritonism
, no hernias, PR empty rectum
Chest: 2HS + nil, decreased air entry
bibasally
with coarse crackles.
Peripheral: pitting
oedema
to ankle, nil sacral
oedema
, nil calf tendernessSlide21
Available results
Hb
102
110
WCC 15.9
17
, CRP 150
170
Cr 150 (at baseline)
LFTs N
No recent imagingSlide22
Decide and Plan
Stable
vs
Unstable?
Differencial
diagnosis
Investigations
Repeat bloods
ECG
CXR
AXRSlide23Slide24
Definitive management
NGT
Checking and correcting electrolyte disturbance
Careful fluid management
Chest physiotherapySlide25
The next day
After morning ward round, MET call on the same patient with tachycardia of 120Slide26
Back to Patient
Airway: own, no stridor
Breathing: RR 30, O2Sats 89% on 4L NP
Circulation: HR 120, BP 85/60, peripherally shut down
Disability: GCS 13, orientated to T/P/P
Exposure: distended abdomen, wound covered with dressing, NG has 500mls of gastric content
What to next?Slide27
After Immediate management
Pressing
investigation
organised
ECG
Bloods
Called
for help?
MET callSlide28
Back to patient
Chart review
Obs
chart
RR has 24 to 30 for past 24hours, HR between 100 to 120, SBP between 90~110. afebrile, gradually increasing O2 requirement
Fluid Chart
Having 7
th
liter of CSL going 12/24
Bowel chart
empty
Fluid balance Chart
Gained 4kg comparing to pre op weight
Urine output 30mls per hour on average since midnight
-500mls yesterday, 2L NG outputSlide29
History and Systematic examination
Felt better after NG has been inserted, still not passing wind, ongoing abdominal pain which is worsening, no chest pain.
Examination findings
Abdomen distended,
generalised
tenderness, low abdominal
peritonism
, no hernias, PR empty rectum
Chest: 2HS + nil, decreased air entry
bibasally
with coarse crackles.
Peripheral: pitting
oedema
to ankle, nil sacral
oedema
, nil calf tendernessSlide30
Available results
Hb
98
102
110
WCC 19
15.9
17
, CRP 190
150
170
Cr 170150 (at baseline)
LFTs N
No recent imagingSlide31
Decide and Plan
Stable
vs
Unstable?
Differencial
diagnosis
Investigations
Repeat bloods
ECG
RAP
CT
later showed collection Slide32
How to prevent it?
Be Vigilant
Recognise
unwell patient
Recognise
common complication early
Know and understand specific complication to your surgical unit
Know your patients well
Escalate care and involve seniors earlySlide33