Case 1 Bleeped by nurse Mr Anderson 56 3 days post op right hemicolectomy co abdo pain Case 1 Initial assessment A patent talking B Sats 98 on 2L RR 20 chest clear no CXR ID: 1048364
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1. Pre/post operative emergency
2. Case 1Bleeped by nurseMr Anderson, 56,3 days post op right hemicolectomyc/o abdo pain
3. Case 1: Initial assessmentA: patent, talkingB: Sats 98% on 2L, RR 20, chest clear, no CXRC: HR, 72, BP 120/82, U/O 60ml/hourD: GCS 15, coherent speechBloods: HB 10.6, U+Es normal, LFTs normal, WCC 10, CRP 250O/E right sided abdo tenderness, no massesAbdo drains have gradually reducedpassing wind, started oral fluids today, no vomiting
4. Case 1: planAnalgesiaRegular paractemaolPRN oromorphWean oxygenSit out/chest physio
5. Most surgical FY1s are bleeped about…PAIN RELIEF!So do we just prescribe better pain killers?
6. When post operative pain becomes serious…Abdo surgeryAnastamotic/bile leak – peritonitisObstructionVascular surgeryAcute ischaemia (re-occlusion/embolus)Ortho surgeryCompartment syndromeUrologyUrinary retention
7. Targeted post-op assessmentAbdo surgeryClinical: abdo tenderness/distension, drainsRadiology: USS, contrast study, CTVascular surgeryClinical: foot pulses/temperature, doppler, ABPI COMPARE WITH PREVIOUS DOCUMENTATIONRadiology: duplex (routine), angiogramOrthopaedic surgeryClinical: neurovascular status, compartment pressuresRadiology: Post op X-ray (routine)
8. Don’t forget other post op complications…A: not so much (more an issue in ENT surgery)B: atelectasis, pneumonia, PEC: dehydration, hypovolaemia, cardiac eventD: post-operative confusionE: electrolytes and glucoseInfection (line sepsis, collections, ANYWHERE)Wound dehiscenceHaemorrhage
9. Initial assessmentA: look listen feelB: RR, sats, chest exam, ?x-rayC: HR, BP, UO, drains, ?ECGD: GCSDrains/stomasOutput rateContentCheck drug chartThings to omit? Things to add?DVT prophylaxisBloods (previous and new set)Routine: FBC, U+E, LFTs, electrolytes (Mg, PO4)Targeted: ?VBG/ABG, lactateOther radiologyto look upto orderTreat as you go along!WoundWet/dry??dehisced
10. Case 2Bleeped by nurseMr Anderson, 56,3 days post op anterior resectionHypoxic and pyrexial
11. Case 2: Initial assessmentA: B: sats 93%, RR25, right basal creps, Temp 38.2C: HR 100, BP95/60, U/O: 10ml/hourD: GCS 14, confusedExamine Generalised abdo tenderness, guardingHyperactive bowel soundsDrainsAbdo drain increased in rate over late 2 hoursContent darkerBloodsHb 10.6, WCC 14, Cr 180 (70 pre-op) , CRP 400, ABG: pH 7.30, pO2 9.5, pCO2 4.3, lactate 0.5
12. Case 3: managementProblem:Unwell patient (pulmonary & circulatory compromise)High possibility anastamotic leakAcute renal failure?pneumoniaSupportive therapyOxygen, Fluids, pain reliefEscalate Need senior surgical opinion URGENTLY (SpR, consultant)?straight to theatre ?imaging first (CT)Call microbiology for Abx advicePrepare for theatreNBM, pre-op bloods (incl. G&S), call anaesthetist, call theatre coordinatorNeeds urgent exploration and repair of anastamosis
13. Anaesthetic workup(?ABG)Blood results, Blood productsCannula, CEPOD priority, (?CXR)Drugs (anti-platelets, warfarin)ECG (?Echo)Food (time last ate)Grade (ASA)History (Cardio-pulmonary)Angina, CCF, COPD, asthma, Exercise toleranceNB: this is all needed for less urgent cases pre-operativelyURGENT cases may not have time to have all these investigations!
14. CEPODGrade 1 - ImmediateRuptured AAA, compartment syndromeGrade 2 - UrgentBowel perf with peritonitis, critical limb ischaemia, fracture fixationGrade 3 - ExpeditedTendon/nerve injuries, obstructing tumourGrade 4 - ElectiveElective lap chole/AAA repair, joint replacement etc
15. Case 4Bleeped by nurseMr Anderson, 56,1 day post op right fem-pop bypasssevere leg pain, cold foot
16. Case 4: Initial assessmentA: B: sats 98% ON 2l, RR24, chest clear, Temp 36.5C: HR 90, BP120/705 U/O: 50ml/hourD: GCS 15Examine Cold right foot cf. left, absent pedal pulses, no doppler signalsABPI immeasurable12 hours post op: pedal pulses and biphasic doppler documentedDrainsAbdo drain increased in rate over late 2 hoursContent darkerBloodsHb 9.6, WCC 14, CRP 250
17. Case 4: managementProblem:Acutely ischaemic right foot?graft failureSupportive therapyOxygen, Fluids, pain relief, may need heparin infusionEscalate Need senior surgical opinion URGENTLYVascular SpR, consultantPrepare for theatreNBM, pre-op bloods (incl. G&S), call anaesthetist, call ODPNeeds urgent revascularisation
18. Case 5Bleeped by nurseMr Anderson, 56,2 days post op ORIF tibial fracturesevere leg pain and swelling despite opiate analgesiaPain out of proportion to expected
19. Case 5: Initial assessmentA: B: sats 98% ON 2l, RR24, chest clear, Temp 36.5C: HR 90, BP120/705 U/O: 50ml/hourD: GCS 15Examine Very tense anterior aspect of leg?impalpable pulse ?paraesthesiaPain on extending large toeBloodsHb 9.6, WCC 14, CRP 250CK 2000
20. Case 5: managementProblem:Compartment syndrome (pressure over 30mmHg)Supportive therapyIV Fluids, pain reliefEscalate Need senior surgical opinion URGENTLYOrtho SpR, consultantPrepare for theatreNBM, pre-op bloods (incl. G&S), call anaesthetist, call ODP
21. Remember…Any case of post op:Severe painObs deteriorationNeeds to:Be taken seriouslyHave a full assessmentHave suspicion of post op complication
22. The EndMany thanks,. Any questions?