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Transcript of post op f1
7/23/2019 post op f1
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Dr Tom Hampton
(CT1)
Dr Simon Bellringer
(CT1)
Post Operative Care and
Surgical Ward Based
Emergencies
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Aims
Cover common post-op surgical problems and
develop a logical approach to them.
- 1. Hypotension
- 2. Oliguria
- 3. Hypoxia
- 5. Sepsis and temperatures
- 6. Nausea and vomiting
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Assessment of any patient
Airway - Patent, speaking?
Breathing - Sats, RR, Resp Exam
- CXR, ABG
Circulation - BP, HR, examine i.e JVP, odema,HS, mucous membranes
- ECG
Disability - GCS, pupils, movement of limbs
Expose - abdominal examination
Assess other information available; including - DrugCharts, Fluid Balance Charts, Observation Charts(for patterns ), Bloods Folder/WinPath.
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Management of any patient…
l Manage according to what you find on your
assessment of ABCDE.
l Escalate to SHO/SpR if appropriate.
l Make a plan to review whether youmanagement plan has worked!!!
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Managing your time…
l This is particularly important when on call
where you need to be as efficient as possible
l
Make use of your team – From SpR to HCA!l What could be done for the patient before
you get there?
and
l What will make you assessment easier?
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1. Hypotension
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Assessment of hypotensive
patient
l A and B…
l C – LOW BP!
Tachycardia
Low/unseen JVP Cap refill >2 seconds
Dry mucous membranes
Pallor
l D – GCS reduced, AVPU (this is what is on mostObs charts)
l E – Negative fluid balance or poor urine output
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Causes of Hypotension
• Hypovolaemia or Haemorrhage
• Epidural
• Sepsis
• Cardiac
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Hypovolaemia
There are lots of reasons surgical patients become
hypovolaemic:
-Blood loss
-Sepsis/SIRS
-GI losses i.e. diarrhoea, vomiting, high stoma output,
ileus
-Low albumin reducing osmotic pressure and increasingfluid leak out of vessels
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Epidural
l Epidurals block sympathetic nerve fibres
l Decreases systemic peripheral resistance
l Increased pooling of blood in peripheries
mimicking hypovolaemia.
l Treatment:
l Elevate legs only
l Small boluses fluid
l Slow infusion and d/w anaesthetist if stopping
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Treating hypotension
l Try to identify cause!
l ABCDE approach
l Fluid boluses 250-500mls
l Give blood if indicated
l Reassess response to ‘fluid challenge’
l (Even if it means asking to be called back!!)
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2. Oliguria
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Oliguria
Minimum acceptable urine output (adults):
0.5mls per kg per hour
i.e. 70 kg man 35mls per hour.
N.B. Be aware of haemodialysis patients on
Surgical Wards!!
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Oliguria
• Pre-renal
- Hypotension/hypovolaemia
• Renal• Nephrotoxic drugs
• Intrinsic renal pathology e.g. ATN, CKD,
Nephritis
• Post renal
• Blocked catheter
• Ureteric blockage (extrinsic or intrinsic)
• Urinary retention (drugs/prostate)
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Managing Oliguria
l Identify cause if possible
l ABCDE approach
l Check renal function
l Fluid challenge
l Stop nephrotoxic drugs – NSAIDs, ACE inh,
Gent (levels).
l Flush catheter/check position
l Discuss with seniors
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3. Hypoxia
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Causes of hypoxia
l Surgical Causes;
l Atelectasis
l PE
l Non Surgical Causes
l Pneumonia (inc Aspiration)
l Pleural effusion
l CCF
l COPD
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Atelectasis
Exacerbated by pain and
immobility
Signs:
-Decreased air entry in bases-Crackles at bases
- éRR and low sats
Management:
- Sit up- Analgesia
-Chest Physio – in mean time
encourage deep breathing and
coughing.
-O2 if required
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Pulmonary emboli
Risk factors:
- Surgery
- Cancer patients
- AF
- Prev VTE
Signs/Symptoms:
- Sudden SOB
- Pleuritic chest pain
- Low sats (not always!)- Mild pyrexia
- Check calves for signs of DVT (often absent)
- ECG – Tachy, R Heart
Strain, S1Q3T3.
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P.E.
Investigations:
- ECG
- ABG
- CXR to ensure no other causes!
l Treatment dose heparin (LMWH normally) started only after discussion with the medical team and seniors as these patientsmay have had recent major surgery.
l CTPA is of value to confirm the diagnosis but should notchange your immediate management.
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ECG Changes –P.E.
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Pulmonary effusions
l Patients may complain of shortness of breath and pleuritic chestpain.
l On examination, they will have:l reduced breath sounds at the bases
l stony dull percussion
l decreased vocal fremitus
l Management:l Improve nutritional status
l Monitor clinically
l If very symptomatic discuss with seniors re. therapeutic tap.
l NB – BTS guideline state Respiratory Team should be doing this.
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Pleural effusions
lIn relation to surgery, pleural
effusions are usually notpathological butreactive/physiological.
lPost gastro-intestinal surgery,
patients tend to have aconsiderable drop in their albumin levels.
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Pneumonia
High risk are those with
underlying resp
disease.
Findings:
- Low sats
- Tachypnoea
- Focal signs
- Fever - Productive cough
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Pneumonia Management
-Bloods (bloods cultures if T >38.0)
-CXR
- ABG-Sputum MC&S
-Empirical ABX as per policy (HAP vs CAP)
-Mobilise and chest physio
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Post Operative Hypoxia -
Summary
l Ask nurses to give O2 to get Sats above 96%.
l Give O2 even to COPD patients.
l Regular review however to ensure not becoming narcosed
from hypercarbia.
l Investigations: - CXR
- ABG
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4. Sepsis andtemperatures
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Temperatures
l Post operative temperatures are a common occurrence and do
not necessarily mean that there is infection on board.
l A temperature of < 38.0ºC within the first 48 hours after surgery
can simply be a physiological response to injury.
l A temperature of ≥38ºC should be considered pathological
and investigated accordingly.
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SIRS and SEPSIS
l SIRS
l Temperature >38 or < 36
l HR > 90
l RR >20 or PaCO2 <4.3kPa
l WCC >12 or <4
l Sepsisl SIRS plus identifiable organism (+ve culture)
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SIRS cont.l Severe Sepsis
l SEPSIS + organ hypofunction-skin mottleprolonged cap refillDecrease urine outputLactate >2
confusionplts <100 ARDSECHO
l Septic Shockl Severe Sepsis + MABP <60mmHg after challenge
l DOPAMINE…
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Approach
l Systematic approach
l ABCDE
- Culture everything (urine, sputum, wounds as
baseline)
l Common sources
l Pneumonia
l Urinaryl Wound infections
l Collections (intra-abdominal)
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Post Operative Temperatures – Post
Operative Collections
l Patients often complain of increasedabdominal distension and pain.
l On examination there abdomen may be non-
specifically tender or locally peritonitic.l Further imaging is usually required in the
form of an Ultrasound Scan or CT.
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Post Operative Temperatures –
Anastomotic Leak
Anastamoses have the
potential to leak,
especially in high risk
patients, e.g. smokers,
high BMI, diabetics,
Jaundice etc.
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5. Nausea andvomiting
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Nausea and Vomiting
l Causes:
l Drugs (opiates and anaesthetic drugs)
l Obstruction or ileus
l Ileus:
l Ensure electrolytes normal. Aim K+ 4.5
l Consider imaging if prolongedl Question nutritional supplementation i.e. TPN on day
3 of NBM
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Management
l Assess patient and take history
l ABCDE
l Look at charts (especially drug chart)
l Management:l Trial anti-emetic – try to choose an
appropriate one.
l If concerned about obstruction:
l Sips or NBM
l AXR and erect CXR
l NGT if vomiting or grossly obstructed
l Inform senior
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Scenarios
For these we will require
some audience
participation
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Example Telephone Call – Mr P
l S
l B
l
Al R
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Example Telephone Call – Mr P
l S – I have a patient on L8Tower with a low
blood pressure.
l B – 80yr old man with a background of T2DM
and PVD who had a below knee amputation
yesterday evening.
l A – Very Sleepy, BP 85/60, HR 110bpm,
Sats 96%OA.
l R – Can you come and review the patient??
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Mr P
What can you ask for before you get
there??
Notes and Charts?
Bedside tests?
Any intervention?
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Mr P
A - Patent
B - Increased RR, R=L with no addedsounds.
C – Cool Peripherally, CRT 3 seconds,
Pale, BP and HR as previously mentioned,
JVP not seen, thready pulse.
D – Drowsy (Responsive to Voice)
E – Dressings stained around BKA site.
How will you assess the patient?
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Mr P
What is you management?
A
B
C
D
E
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Mr P
What is you management?
Post Operative Hypotension secondary to
blood loss.
Give Fluids/Blood.
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Example Telephone Call – Mr R
l S
l B
l
Al R
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Example Telephone Call – Mr R
l S – Patient on L9AW with a temperature of
38.6C
l B – 75yr old man with a background of an MI
8 years ago. Admitted with diverticulitis 3
days ago and is on IV ABX (Co-Amoxiclav)
l A – Temperature 38.6, RR 22, HR 105, BP
120/60mmHg, Sats 93% OA.l R – Can you come and see the patient???
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Mr R
What can you ask for before you get
there??
Notes and Charts?
Bedside tests?
Any intervention?
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Mr R
A - Patent
B - Increased RR, R=L with no addedsounds, decreased chest expansion
(shallow breaths)
C – Warm to touch, CRT 4 seconds, BP and
HR as previously mentioned.
D – Drowsy (Responsive to Voice)
E – Globally Peritonitic Abdominal
Examination.
How will you assess the patient?
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Mr R
What is you management?
A
B
C
D
E
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Mr R – Erect Chest Radiograph
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Mr R
What is you management?
Perforated Diverticulum – Needs an
operation; so prepare the patient for theatres!
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Example Telephone Call – Mr D
l S
l B
l
Al R
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Example Telephone Call – Mr D
l S – I have a patient on L8Tower who hasn’t
passed any urine for 6 hours
l B – 65yr old man who was admitted with
frank haematuria yesterday.
l A – All his obs are fine but his NEWS score is
now 5 because he is on Oxygen and he
hasn’t passed an urine for 6 hours.l R – Can you come and review the patient?
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Mr D
What can you ask for before you get
there??
Notes and Charts?
Bedside tests?
Any intervention?
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Mr D
A - Patent
B - Normal, R=L with no added sounds.
Sats 100% on 2L.
C – Haemodynamically stable. No urine
output despite being catheterised
D – Alert and in no pain.
E – Some ‘rose’ coloured urine in the
catheter bag beneath the urometer.
Abdomen SNT.
How will you assess the patient?
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Mr D
What is you management?
Blocked Catheter secondary to blood clots.
Likely to require bladder irrigation if catheter has been blocked once already.
Example Telephone Call
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Example Telephone Call
– Mrs W
l S
l B
l A
l R
Example Telephone Call
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Example Telephone Call
– Mrs W
l S – Patient on L9AE who is vomiting
l B – 66 year old lady who had a Hartmanns
Procedure 4 days ago but had been fine
since then.
l A – BP 100/60, HR 110, Sats 92% OA,
Temperature 36.5C.
l R – Can you come and see the patient??
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Mrs W
What can you ask for before you get
there??
Notes and Charts?
Bedside tests?
Any intervention?
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Mrs W
A - Patent
B – Decreased air entry at both bases.
C – CRT 2 seconds, BP/HR as previous,
UO 15ml/hr for last 4 hours.
D – Alert, vomiting.
E – Distended abdomen, Soft and mildly
tender.
Assess other information available to you
How will you assess the patient?
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Mrs W
What is you management?
A
B
C
D
E
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Mrs W
What is you management?
Ileus/Obstruction
NGT
NBM/Sips
Inform senior
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Any Questions??