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We'll just give everyone else um a couple more minutes to join and we're gonna use Ment two today just to um help go through and um make it as interactive as possible. So if you guys want to um join that way, I'll also keep an eye on the chart on my phone if there's any problems. So just let me know. That's good. I can see some um answers coming through to the first question already. So if you guys want to just pop in, if you got any ideas of what complications might be in POSTOP patients or patients that are on the surgical ward sort of waiting um theater and then we can obviously go through them. Um As the presentation goes ahead. Yeah, we'll get started. I'm just having a quick look at what you guys have put as your answers. Um There's some really good ones in there, bleeding, infection. Um Iatrogenic complications. Yeah. Adhesions. Yeah. Um We've got wrong operation done. Hopefully that's done a lot less frequently with all the checklists and things we have to go through, but obviously it is something that does occur. It's not something that I've personally seen, um, sepsis dvts. Yeah, some really great suggestions there guys stop. So I think we'll get started with the rest of the presentation as well. And then obviously as people join, they can just, um, join in with us as we get along. So, does anyone know what causes are of POSTOP fever? It's something that you'll get called to see all the time that someone has spiked temperature on, um, like on a, a ward after they've had surgery. Um, and so what are the causes of those, or what is it that you'd be looking out for resp infection? Yep. Very good. Particularly a problem with abdominal infe uh, abdominal surgery, bleeding. Yep, sepsis, infection. Yep, cellulitis. Yeah. Pneumonia. Yup. Uti S. Yup. Very good. Ok. So often when you're thinking about POSTOP temperature spikes, you can sort of break it into early causes, which is in sort of the first five days or later causes, um, sort of after five days. So, straight away you're thinking of like, is it a response to something that we've given them? So, is it a reaction to the drugs that we've given them? Sort of the anesthetics? Is it, have they had a blood transfusion while they've been with us? Is it a response to that? Um, having a look at the, obviously, when you're doing a full, a two assessment, have they got any lines in? Have they got any drains in? What does the wound look like. Is it possible that it might be a bit of cellulitis? Um UTI S. So getting a good history and thinking if they got a catheter in, have they had a catheter in um, and things like that, you can also get a physiological systemic inflammatory reaction which um often will show in the bloods as well. So if someone's been to theater, they will get um raised white cells and raised CRP, it doesn't necessarily mean they've got any infection or complication. It's just the body's reaction to going through something traumatic like surgery. Um, and then atelectasis also can be a, an early cause of, um, POSTOP fever. Then there's the later causes. So things like BT S pneumonia, a wound infection. Um, is it possible that they might have a anastomotic leak or a collection developing? Um, so yeah, the next question I've popped on. It's just a good way to sort of think about the different causes of, um, what might cause POSTOP fever and you can use it using the Five Ws. Um, so yeah, we've got wind wound and water, which are really good ones. Um, anyone got any other ideas, what the other two might be for? Wunder drugs. Yup. Me about and we'll go through it. So the five Ws are wind such as the problems with the lungs, including Atis and pneumonia, water such as UTI S walking, which is like BTP, um, wound and wonder drugs or I've seen that. So, like anesthetics, blood products, allergies, you can also think of that as, as wonder about what we've done. So, thinking about what have we done to this patient that might be causing, um, POSTOP fever there, we'll move on to, um, going through them. So we're gonna go through drug, a drug reactions and anaphylaxis first. Um, something I get called to see all the time. I've not seen anything as bad as anaphylaxis. Um, but you often get called, this patient has had this and they've got a rash or they've got a bit of a fever after having this or they've been having a blood transfusion. Can you just review them to see if we're safe to give the second unit? Um, so does anyone know what common causes of anaphylaxis are not just in, um, in terms of surgical, just in general as well? Penicillin? Yes. So, antibiotics are a really common cause of anaphylaxis. Um, so you want to make sure you've got a really good, um, drug history and, um, allergy history from a patient because we really don't want to be giving them something that they're allergic to. And it's also making sure, you know, is it the group that they're allergic to, is it just one specific drug that they're allergic to? Thinking about the sensitive, like the cross reactivity of the different drugs? Yeah. Insect stings. Um, anesthetics. Um, food is a big one. especially in Children, obviously, just because they, we've given them things such as an antibiotics, blood transfusions, anesthetic drugs. It could be that they've quite simply had, um, peanuts in their dinner and they weren't aware about it also really considering, um, the fact that it's, it doesn't just have to be medications and things. Does anyone know how anaphylaxis might present, um, in a patient or what would trigger you to be worried that someone might be having an allergic reaction? Yeah, acute breathing problems, throat closing up, um, swelling if they've got any rashes or hives. Yeah. So, I think, um, to be honest, it's always something definitely in an a, to e scenario that I'm always considering, um, have they been given something, have they gone for a CT? And they've had contrast, um, and then if you go to that patient and they've got a problem with their airway, um, it's very possible that this could be anaphylaxis. Um, often the patient will be, you know, really, really anxious, get any fear of sort of impending doom. Um, so it's just having that sort of always in the back of your mind, um, in a patient that's got that we've given stuff to and, um, especially if they've got known allergies as well. And does anyone know how anaphylaxis is treated? What is the mainstay of, um, there is other things we can give but there's one thing that we do. I am adrenaline. Yeah. Very good. So it was initially um steroids and antihistamines and salbutamol were all in the algorithm, but they were finding that because people are more comfortable with giving salbutamol steroids, that kind of thing. It was actually delaying, giving the lifesaving adrenaline. Um So they've currently, all we give at the moment in the immediate resuscitation is um im adrenaline. Obviously, you're going through a two, you might stabilize other parts as well. So I'll just show you a little table. So, yeah, risk factors. So, have they had a blood transfusion antibiotics, anesthetic drugs? Have they got IV fluids running? Um, what have they eaten? I've had several patients on the ward that have been bitten by bugs not to the point where it's being anaphylaxis, but we have had wasps N and things in the hospital to really thinking out of the box. It might not be something that has happened to them because of their condition. It could be that a wasps come in and stung them and we need to be thinking about that as well. So contrast medium. Have they been in for a CT and have they had any vaccines? So you could have a patient that's had a splenectomy and they've um had to have loads of postoperative vaccinations. I've had a patient today that's been given the flu vaccine. Um So there's lots of different things that go on with your patients while they're in hospital. Um, so just keeping it quite broad. Um So yeah, immediately when you approach a patient, they might have, have a look in their mouth, even if their airway seems patent in terms of their talking to you. I would definitely have a look in the mouth uh to see if there's any tongue swelling at all. And obviously, at that point, personally, I'm not an airway expert. Um I would, if I'm worried about an airway, I want people there that immediately that can help me with that. So that's probably popping out a peri arrest call. Um saying we've got a potential loss of an airway. We need some urgent anesthetic and senior doctor support. Um If you're thinking at that point, it possibly could be anaphylaxis. I would say that um and then as the f one there, I would just try and um do anywhere, any airway maneuvers that I feel comfortable with. So that's the head tilt, chin lift, jaw thrust, either depending on the level of consciousness of the patient, either put in it or pharyngeal airway in and nasopharyngeal airway or put in an eye gel in. Um All very much depends on the patient you've got in front of you. Uh You might also hear a stridor due to sort of airway um the airway closing up. Um moving on to be, it's not always that you're gonna get sort of an obvious anaphylaxis straight away. Um So you might um get sort of increased respirate with lower SATS, they might be um quite wheezy, quite obviously breathing quite hard using their accessory muscles moving on to see you get um hypertension and tachycardia. So with these patients, you can give them fluid challenges. Um but you might notice that this does not become responsive to fluids. Um you can also get sort of decreased GCS, anxiety, panic, syncope. Um Obviously, if they get in a decreased G CS, that's when you're definitely gonna be wanting to make sure you've got some sort of airway um impending uh because you've got an impending sort of airway obstruction. Um They often say the phrase of GCS less than a bit as an F one. It's not something um that I would do, but I would definitely get some sort of airway in there so that when the anesthetist comes, they can sort out getting a more definitive airway if that's necessary. Um And then obviously you're going to want to completely expose the patient, see if there's any rashes, any sort of redness. Um that might point you towards that. They might be having sort of an allergic reaction. So, yeah, doing a full a toy assessment of them, obviously, observations about one at the ECG um full blood count us LFT S um CRP ABG or BG. That's just because I would want to, when I'm doing a full A to a assessment of a patient, even if I'm pretty sure it's anaphylaxis, I also want to make sure that I'm considering, is it sepsis? Is it, um, a stemi, is it like making sure you're fully thinking of, what is the other reasons that this patient could be having reduced sats, um, that kind of thing and also getting a mast cell trip to his level as well. Um, honestly, if you're thinking it's anaphylaxis, you just need to make sure that you're getting that adrenaline I am in as soon as possible, making sure you're removing that trigger. So if they've got antibiotics running, take that out, um, take the cannula out, get them in, um, you know, too big, um, sort of, uh, Cannulas, um, making sure that you're giving them fluids lying, the patient down, lifting the legs up, do not stand the patient up because that can lead them to go into cardiac arrest. Um, and just making sure that everyone's aware that you've got a Perret situation. It can very quickly deteriorate and you want senior people there as soon as possible, giving them 15 L, non rebreathe and make sure you time in when you've given that first adrenaline so that you can repeat it. We can also give IV adrenaline. Um, but that's something that has to be done by experts. It's not something that you would make the decision on. Um, it's making sure that you've given them, um, that I am adrenaline first and then when the more senior people arrive, they can make that decision. You can also, once the patient is sort of stabilized in terms of hemodynamically you. But if they're still quite wheezy, you can think about giving them some salbutamol nebs hydrocortisone chlorphenamine. But it's just making sure that you've done the initial resuscitation with the I adrenaline. That is what is on the algorithm nowadays. So adrenaline, um it's really useful to know that does honestly, they will have a um a policy for it at your trust. So it's not something that you 100% need to know and it does need to obviously be correct depending on the um sort of the ratio of it because it's different than in cardiac arrest. So you give um one in 1000 I am adrenaline in adults. It's 500 mcg, Children, more than 12, it's 500 mcg, 6 to 12 is 300 less than 6, 100 and 50. Um I know there is a lot of questions on this um on sort of past me and things. So it is a good one to sort of have in your head, but I even did a s on this a couple of um weeks ago and I was like, I'm pretty sure I know what it is, but I'm just gonna have a quick glance at the um the guidelines just so that I'm not given the wrong dose. So yeah, moving on if there's any questions about anaphylaxis or anything um pop that in the chart. Um it's something that I've not been called to it, but, you know, it's very, very scary thing. It can go very badly, very quickly. Um, so it's something that you need to, if you think it's anaphylaxis, get as many experienced people there as possible in case, because it might just be that, that first adrenaline and need them feel much better, but it very quickly can deteriorate into cardiac arrest. So, yeah. How does the opioid odo present? Yeah, decreased G CS and decreased respirate, uh pinpoint pupils, respiratory distress. Very good. So it's something that happens a lot in um sort of on the ward because we're obviously giving our patients a lot of pain relief because especially um in general surgery, they've had big laparotomies, they've had hernia repairs, which is very, very painful. Um, so it's something that, that does happen a lot. And does anyone know how we might treat an opioid of naloxone? Yep. Very good. Yeah, well done. Um So obviously in terms of opioid overdose, it's not just your classic comes into A&E and they've been recreationally using um heroin. It can also be um obviously intentional. So there's all the um holistic mental health care that you might need to put in place and it could be unintentional overdoses such as on the board if we're trying to um control the patient's pain. Um, if a patient has chronic pain and they've been sort of increased the dose of morphine or they've accidentally took too many, um, tablets at all in palliation. Um, we obviously give regular morphine to keep the patient as comfortable as possible knowing that it could actually bring about their death, um, more sooner than they would have died naturally, but it's something that we do to keep them comfortable. Um, we're not obviously intentionally shortening their life but it's something that we understand, um, does happen. Um, if the patient's got a PC and they've pressed it several times, I've had that as a simulation as 1/5 year. Um, you get called to someone on the orthopedic ward who just had enough repair and they've got a PC up. No one really knows anything about the patient other than you can see, they've got a PC up. Um, and then when I went to obviously examine them, the respirate was like four and they had pinpoint pupils. Um, also if a patient's got hepatic or renal impairment, so we always, when we're prescribing morphine, um, you want to have a look at, um, the dosing for that patient, um, to make sure that you're not given too much based on their, um, current so renal impairment. A lot of people on surgical wards all have achy eyes either because of why they've come in. So they might be vomiting and sort of very unwell or if we took them to theater, we've not given them enough fluids. And so, yeah, it's just making sure that you're considering all that. So yeah, doing your full air to e of the patient, it might have decreased consciousness and snoring. So again, it's that classic lesson debate. So if you're worried about that airway, I would definitely want to get someone more seeing you there to help control the airway. Um So even if it's just doing that head tilt, chin lift, getting some sort of airway in, um the respirate will be less than 12, you might get shallow breathing, you might like stop breathing might also get bradycardia and hypotension, um decreased level of consciousness, confusion, pinpoint pupils when you examine yawning and then obviously, when you're assessing the patient fully might get rhinorrhea or watering eyes and then looking for any signs of um abuse, uh needle track marks. I always like to have a look in the notes. What is it they've been given? Um Were they given that more in A&E that we weren't aware of? Were they given more in the, that we weren't aware of? Do they have a PCA? What is their dose? Is it wrong for them? Look at their weight, look at the user, you want to look at the LFT S. Um And then obviously, if they've got um sort of breathing problems, might want to do it ab G as well to see if we're gonna need any more um sort of advanced breathing support. Um So when you know, when you suspect that this might be an opioid overdose. You can give uh naloxone 400 mcg. And then if there's no responders, you can give 800 mcg for up to two doses and then 2 mg for one dose. So the half life is actually quite short, 60 to 90 minutes. So it might be that you give someone naloxone and they sort of pretty much come back to life and then um it happens again and then you have to either give sort of repeated doses or infusion. So it's definitely something that I would, if I'd, you know, stabilized the patient, I would sort of either ring, the med reg ring, the surgical reg say, look, this patient has um had opioid overdose. I've given naloxone, they're much better. Now. Um, you know, you've suspended the opioids. Is there anything else you want me to do for them? Um, or it's just, you know, going back and checking on them, making sure you tell the nurses, um, you know, if this is to happen again, bleep me immediately and I'll come and see them whether it's prescribing some naloxone for the, the, the sort of nurses to give as a um, a preemptive um in case that they might need it also, you obviously always wanting to check, making sure, you know what the glucose is. Um because it could be that they're hypoglycemic and that's why they're presenting this way. So this is just an example of pinpoint pupils. Ok, So, does anyone know how cellulitis might present or what we're looking for in terms of cellulitis? Yeah. So systemic symptoms, redness, fever, hot swelling. Yeah. Warmth. Very good. Ok. So we'll go through cellular just a bit. So what obviously kind of increases the risk of cellulitis is diabetes, obesity, immunosuppressants. Have they got cannulas in lines in drains in, have they got large wounds? Have they got several different wounds and it's gonna be most likely staph aureus that is causing the infection. You want to be super, super careful with anyone, especially with all the big risk factors, diabe diabetes, immunosuppression, obesity, if they have signs of cellulitis or a skin infection and they're very unwell. Um You also want to be in the back of your mind thinking, could this be necrotizing fasciitis? Um There's been quite a few cases that I have seen um at um Doncaster and it's just if you are all suspecting that you need to make sure you're speaking to someone a lot more senior and getting them reviewed by them and get some urgent IV antibiotics and getting them down for debridement because it spreads very, very quickly and it does not have good outcomes. Um So yeah, it obviously presents temperature, redness, heat, swelling, pain, an indistinct border that's poorly defined, could be purulent discharge and then you could also get sort of more systemic symptoms like confusion, tachycardia hypertension classic, like high news scores. Um So yeah, you want to have a look at all the wounds, all the lines have a look at the cannulas. Have they got pic lining central line and just looking at any possible place that the infection could be. Um I would also want to make sure that when you're obviously doing the examination of it, draw around where you think the cellulitis is and then you can monitor how fast it's spreading. Um So you'd obviously want to do observations, ECG urine MC NS to see if there's any other sources of sepsis. I'd want to do FBC s using these LF TSC R PVV G or A G to see if there's any obviously raised lactate. Um And see if it's how poorly this person is. Um I want to do blood cultures. So if they've got a line in and you think it's possibly a lyme infection, we do peripheral blood cultures and also cultures from the line as well. Um It's definitely something a really useful skill to learn is how to take ly bloods. Um It's not something that I personally got taught at medical school specifically, it's just something I saw on the wards and learned to do on the wards and then it's something I probably use once a day at least. Um And it just makes it so much easier if you know how to do it. Um because normally people that have lines in either it's for TPN or it's because they're extremely difficult to get access from. Um So you can also do things like wound swabs, strain cultures and obviously just doing a full screen. So that's getting your urine dip, getting your chest X ray, doing your bloods, doing your blood cultures, getting your lactate. Um If the patient is unwell, we obviously wanting to resuscitate them. So that's, you know, activating the sepsis six, giving them fluids, oxygen, um antibiotics, doing a lactate urine output and blood cultures. So, trying to get the patient a catheterized, they potentially won't accept it, but try and convince them they will definitely benefit them if they have um a catheter in. If they've got less, you can give them 15 lis non rebreath, depending on what the SATS are. Um If the shots are only slightly low, you might think more along the lines of giving them a nasal cannula, but you can always put 15 L on um, in an unwell patient and then wean them down using a vur or put them onto a nasal cannula. Um So if they've got potentially a collection or a sort of deeper infection, you can get um radiology to put a drain in. Um, so that would be either sort of ultrasound guided or um, you can get CT guided drains. I'd wanna have a look at the line and probably move the cannula and try and reset the cannula if it's a more permanent line such as a Picc line. Um, I would want my senior to come and see it before we would consider taking it out. So, just some pictures of cellulitis, I'm sure you guys have probably already seen it before. So atalopsis. Does anyone know what atelectasis is? Yeah. So it's a partial lung collapse of small airways due to either airway compression, alveolar gas resorption, interrupted interoperatively or impairment of surfactant. So it reduces airway expansion and predisposes to infection. That's why we're so worried about um POSTOP pneumonia and things in patients with um like big abdominal surgery or patients that have been um having a lot of um gasses and things while they've been in theater, very common after surgery. Most people, if they have a chest X ray after surgery will have some sort of ATS. Um risk factors are age smoking, use of G a duration of the surgery, preexisting lung or neuromuscular disease, prolonged bed rest and poor postoperative pain control. So, thinking about those risk factors, does anyone know how we might sort of treat or prevent atelectasis or prevent it becoming a more serious problem? Yeah. So patient repositioning analgesia. Yeah, early mobilization. Yup. Yeah. A patient will present with sort of um problems breathing, let us that you might get fine crackle and auscultation. Um If this is happening, you'll want to obviously do bedside observations, potentially an ECG. Um And then you'll wanna do depending on how unwell the patient is full, full, full blood count. E LFT CRP, see if there's any sign of infection at all. Um We might want to do an ABG as well and potentially some cultures and a chest X ray. So, yeah, essentially the treatment is ensuring you get really good pain management if you can't um control it, sort of on paracetamol, a weaker opioid and then a stronger opioid as of the P RN. Um You might want to speak to your pain team as to whether they have anything that they would like to give. Um, the pain team are really good at making sure that we get patients pain under control. Um, making sure that they're doing deep breathing, coughing, chest phys. Um, it's really important to get your post operative patients engaged in chest physio. So giving them incentive spirometry, making sure they're sat out of bed and mobilizing around the ward. Some of the worst outcomes that I've seen have been people that have just really not engaged, um, with the POSTOP care and it hasn't been actually a problem with the surgery. It's been that they've got a horrible pneumonia afterwards. The BTA big thing that we worry about while they're in hospital, especially when we're doing surgery on them. Anyone know any risk factors for VTE big one is, um, obviously what I say all the time. A lot of the reason why patients are on a general surgery ward first stop PM is a risk factor. What operations might a person have had, or conditions might we be treating that might increase the risk, bed rest, long periods of travel. Yeah. Abdominal surgery. Yeah. Yep. So, cancer increases the risk as well. So that we have so many patients in our wards that have had, um, either lap, um, laparotomy or la, uh, la la laparoscopies for, um, removal of, um, cancers. So, it's, they've not only have they been to surgery and they're laid up and they're not very active, they've also had either they still have a big malignancy or it's been just being removed. Um, anyone know what investigations we do for a patient that we're worried, um, might have a clot whether that's, um, either, um, peripheral or a PE D and CTP. Yeah, very good. Does anyone know what we might do differently if the patient were to have renal impairment? A scan that can be done? Not that I've ever seen it be done, but it's a big question that comes up on past med BQ scan. Yep. So, yeah, make sure when you're doing past of questions, try not to be caught out by the fact that, um, you know, patients might be very clearly having a pe but then they might have, you know, an AK or, um, a really low G fr, yeah, risk factors are increase in age. So, any hypercoagulability disorders, malignancy, inflammatory conditions. So, most of our patients that come into the hospital are at higher risk of um any clots, like even patients with cholecystitis because of their inflammation, family history, obesity, anesthesia. If we've had picc lines, put in central lines, put in that can increase the risk patients with heart failure if they're on um combined or contraceptive pill or hormone replacement. Um, if they're on tamoxifen, um signs of DVT, you might get pain tender, swelling, redness, warmth. So if you're thinking that could be sort of a differential for someone with cellulitis or vice versa. And then obviously, always making sure you're feeling the coughs while you're doing an E two E assessment. Um And then if you're thinking pee it might be some chest pain, hemoptysis, cough, um trouble breathing and I've dropped the sats quite suddenly. Um classically when you listen, they'll have a, a clear chest. Um So obviously, I want to do fully assessment on them. Um observations, you can do an E CG, which is the most common finding is sinus tachycardia. But you can also get the S one Q three T three, which is a large S wave in lead, one, a large Q wave in lead three and invert at wave in lead three. So then um make sure you calculate the well score because when you are requesting um a CTPA, at least on our system, they want to know that you calculate the well score and what is the well score so that when the radiologist gets it, they can decide how urgent this CTPA needs to be done and if it needs to be done at all. Um I also want to do you know in any unwell patient FBC S obviously, do you need to see if they can have contrast at that time? LFT CRP? Just to see how the patient is doing, is it possible that this could be a sepsis or a chest sepsis? Instead, ABG um do ad dimer, obviously not that useful either if a patient's got malignancy, if they're pregnant or if they are post surgery because these can and sepsis can also raise it as well. Um The radiologist might request that you do a chest X ray um prior to a CT PA. Um And then obviously you can do a VQ scan if you're thinking more, um DVT, you can do an ultrasound Doppler, Doppler. So prophylaxis is really, really important, making sure that unless there's any contraindication that all your patients have Ted Stockings on and they get delta or whatever low, low molecular heparin and your trust users as prophylaxis, making sure that those patients are getting out of bed, getting them walking around. Um Obviously, if they're unwell, you can give them um resource of fluids, 15 L, non rebreath, weaning that down with a V. Um And then in our, we give treatment, do par. Um And then obviously, once they're out of surgery, we can out of hospital or not likely to need um further surgery, we can convert it to a doac. Um, if they're unstable, you can consider thrombolysis. Um, so if it's provoked, so if you've got any of the sort of risk factors such as surgery, cancer, that kind of thing, you keep on it for three months. If it's unprovoked, then, um, it's six months. Um, and then when we discharge our patients, if they've had, um, a laparotomy or they've had some hemicolectomy where they've had a bit of bowel removed or if they've had, um, a cancer surgery, they have 28 days of adults power in from the day of operation unless they're on, um, a doac or something like that. This is just a picture of, um, what it might look like if a patient's got a DVT, I've only seen one patient with a confirmed DVT and they were in a lot, a lot of pain. Um, it had been a query cellulitis, but when I went to see them, I just didn't think it really looked very cellulitic and they were just in that much pain that I was really quite worried. It was a DVT. So, with discussion with the vascular surgeons because it was a vascular patient, we started them, um, on some treatment before we'd even got it confirmed because we had such a high clinical suspicion of it. Um, and then this is just the wells for a PE. So I don't know this off the top of my head every time I need a patient. I just will Google well score and, um, calculate that way. I think it makes it easier and it reduces the risk of error. So, any know anyone know any risk factors for hospital acquired pneumonia? Immunocompromised. Yeah. Very good. Yeah. So, intubation and ventilation, old age. Yeah. And how might it present if someone was to have pneumonia? What are the signs and symptoms that you would be, um, worried about thinking that a patient might have pneumonia? Yeah. So they might have a spike in a fever. They might suddenly have dropped their sacks or have increased respirate cough. Um, yeah, just any sort of signs of sepsis. Yeah. Risk factors are intubation, immunocompromise, smoking, COPD can be due to sort of, um, staff hygiene, contaminated equipment. So, it might be aspirational. So, either they've not been fasted for theater or it's emergency surgery and that they don't have time to fast for, um, poor pain management after surgery. So, as we were just talking about in terms of atelectasis, if there's not Deb breathing, not mobilizing and there's atelectasis, it just creates sort of a perfect breathing ground for bugs to grow and then for patients to get quite unwell. Um, so if it's ho for it to be hospital acquired pneumonia, it has to be 48 hours after admission. Often the air will pay, you might have increased respirate, lower sats, accessory muscles, you might be able to hear crackles or gravitation, um decreased expansion, that's dull percussion, cough, oxis, pleuritic chest pain. You might also find that the tachycardic hypertensive um pill refill and obviously, you might be quite confused, quite septic. So you obviously wanted to do a full assessment of ecg, full sort of septic screen. So, urine dipstick sputum sample, chest X ray blood cultures doing all the normal bloods also doing an ABG to see if they're in a sort of respiratory compromise. What is the lactate? And then you also might want to on sort of discharge or if they're still in six weeks later, think about repeating that chest X ray just to check the consolidation is resolved and check if there's potentially any underlying problems such as malignancy, which might have made um chest infection more likely to like sort of give an area for a chest infection to be if a patient is um sort of presenting to GP with recurrent pneumonia in the same lobe, that might be indicative that there is some sort of malignancy there. Um So obviously you want to resuscitate them and do sepsis six. So start them on if they've got less and start them on 15 L, give them some IV um give them antibiotics as, as per guidelines. Um At Doncaster, it's either you can give Comox clav or if they've had a recent course of Comox or they're elderly or if they're very unwell, you can give um tazocin. So you might want to think, do they need um, sort of noninvasive ventilation and what is this patient? Do they, are they appropriate to be escalated to critical care or HD? Um, do they have a respect form, sort of, what is the level of care that this patient should be expecting? And so are they for ward based? Do they want um, any, um, do they want to be intubated? So it's an important conversation to have with patients. Does anyone know how either hemorrhage or POSTOP bleeding might present? So we'll move on to hemorrhage and things next. So yet hypertension and confusion. Very good tachycardia. Yeah. So often if a if a person is losing blood tachycardia presents first and then they might develop hypertension afterwards. And does anyone know how we treat hemorrhages? Um especially quite bad ones? What it is you can do is um what kind of things we can do? Yeah, blood. Is there any protocols that anyone's aware of or? Yeah, major hemorrhage protocol? Very good. So she's a picture of some pneumonia as I'm sure you'll have all seen loads and loads of um chest x rays in your time. So yeah, reverse anticoagulants. Very good hemorrhage. So we can either classify it as primary, which is intraoperatively reactive within 24 hours secondary within 7 to 10 days of POSTOP. So, aversion of blood vessels from spreading infections, you might get um wound um adhes breaking down of the wound So in terms of classification, you classify it as 1 to 4. Um quite difficult to remember. I know there is quite a lot of questions on pass med. Um I know the way I always used to remember it was like one was less than 15%. No tachycardia. No. So everything was kind of normal other than they were losing a bit of blood then going up to it, it's then 15 to 30% and there's a bit of tachycardia capillary refill is a bit prolonged, things are sort of starting to increase. Um And then the next one up is 35%. They've then got a low BP. Um you know, urine output is decreasing. So obviously, the more blood you use lose, obviously, the worse it is, it's quite difficult to um remember and it's not something that you will need in practice, but it might be something that you get quizzed on um in terms of examinations. So, yeah, presentation. Um you might have very possibly a patient airway. It possibly, you know, if there's um hematosis or decreased level of consciousness that might affect the airway, um get increased respiratory rate. Patients probably quite panicked, especially we've had a couple um in the hospital that the patient has been very, very unwell hematemesis melena and they're obviously very panicked because they can see just how much blood they're losing. Um tachycardia and hypertension with a prolonged capillary refill time might feel peripherally cool. So if you can feel a radial pulse and then likely the BP is above 80. If you can feel um carotid and a feer, it's 70 to 80 systolic. And if you can just feel a carotid, then it's 60 to 70 um you might get decreased G CS and confusion. Um And obviously, then when you're having a look, um you might see obvious bleeding and that's why it's really important to fully expose your patient, including doing APR exam PV exam. Um Having a look after they got a vomit ball, it's full of six somewhere and it's got a bit of blood in it. Having a good feel of the tummy. Is it tender? Is it distended? Is it peritonitic? Is there potentially some bleeding inside the tummy? Um Having a look at what the urine output is and you can also get Collins and greater a sign as well. Um So the a good way people remember where they're thinking about where the blood might be coming from. A hemorrhage is one on the floor. So can you see blood or is there obvious bleeding coming from somewhere and fall more? So in that's the chest, abdomen, pelvis and then the limb from a broken bone. So, complications, you get something called the lethal triad, which is what causes a hemorrhage to get worse in a patient that's already hemorrhaging. So, hyperthermia, if we're giving them lots of fluids, um that can then cool them because they can be, the fluids can be quite cold. Um So it can then impair platelet and enzyme function within the clotting cascade um acidosis because of hypoperfusion because of the bleeding, then can lead to lactic acidosis and impair clotting and then coagulopathy which is dilutional and or consumptive. So either because they're losing so much blood, they're trying to clot, they're not clotting. So they're using all these clotting factors or dilutional in terms of um we're giving them that much fluid that is diluting their blood. Um So you can also get hypocalcemia, hyperkalemia and transfusion reactions. They obviously want to do observations, ecg glucose. Um If you've got a decreased level of consciousness, obviously wanting to do FP CE LFT S group and save um getting CRP doing the clotting, seeing if there's anything can um change in an acute situation. I definitely want at least a VBG, probably an ABG. So we can have a look at the hemoglobin as fast as we can. Um You might want to do a CT angiography or a fast scan um and potentially an OGD if you're suspecting an upper gi bleed. So treatment for it and if it's a major hemorrhage, I would probably again put out a per call because you want, you need hands there ASAP. Um And you need, because putting out the major hemorrhage protocol call, it's, it's quite an involved. Anyone can put it out, but it's quite an involved protocol, which uses a lot, a lot of resources. So you want to make sure that you're putting it out appropriately. So at least, you know, is there a senior around that you can be like this is pretty bad. There's the hemorrhaging. I think we need to activate the major hemorrhage protocol and get, trying to get someone more so you need than yourself to do it. So you can obviously start resuscitation, Um obviously giving them some fluids because of hypertension, we can do this thing called damage control resuscitation. So that's given permissive hypotension which allows tissue perfusion but decreases the risk of dilation or coagulopathy and clot distribution. It's much better to obviously give them what they're actually losing some, make sure they're having blood. Um But you know, if you're the first person to get to a patient that is actively hemorrhaging with a low BP, there's absolutely nothing wrong and MS definitely sure you do giving them um some IV fluids just to try and get that BP up. Um So trying to make sure they've got two wide ball cannulas in their A FS or essentially just as many lines as you can. We did this one as a simulation and in the acute resuscitation, you cannot get enough lines in these people because the amount of stuff you're putting in them all the cannulas blur. So it's essentially they were saying in sort of a major hemorrhage, it's normally just one person's job to just continually put cannulas in because they keep blowing. Um So applying pressure if there's any obvious source bleeding or wounds, um you can give Vitamin K obviously activating the major hemorrhage protocol. If you don't think it's potentially as fair as that, you can just order some blood from the blood bank. Um They might either need to go to theater or return to theater and then just thinking, is there anything that is helping the patient bleed? So, are they on Warfarin Heparin? Like any wax Warfarin you can reverse with VCA and prothrombin complex Heparin, you can reverse with protamine sulfate and di di di you can, I'm not even good at, I'm not very good with pronunciation and but it's a really good like you need to, there's a lot of questions of this on passed and um on exams. So just knowing how you can reverse each anti anticoagulant is good and also give Tranexamic acid, which is a 1 g bolus and then 1 g of eight hours. So different transfusions that we can give um red blood cells. So each unit should increase hemoglobin by 10 per unit. Um So you can give statin emergency 90 to 100 and 20 minutes or 2 to 3 hours of co morbidities. Um So platelets um because obviously when people bleed and it's not, they're not just um slowly using red blood cells. So we will also give platelets. Um which have the highest risk of bacterial contamination of all the products that you can give. Um obviously, there is different um levels of which indicates uh platelet transfusion. Um So it depends on the levels. Um If it, there's no active bleeding, it has to be bl 10 times 10 to the nine, if it's um significant bleeding, less than 30. And if it's um you're worried about any bleeding at critical sites such as sort of head injuries, um less than 100. So F FP, you can give um which contains clotting factors, albumin immunoglobulin, and which can be used to collect clotting deficiencies and then cryoprecipitate which is formed from F FP, which contains factor eight and fibrinogen used in D IC and liver failure. So this is just an example of the major hemorrhage approach called Doncaster. Um gives you the numbers gives you what it is you give and just um a way of working through it. So leaks anyone, any risk factors for leaks. So, anastomotic leaks, we're talking about colon surgery. Yeah. So I'll give you guys to think some time to think about that and we'll go on what it is. So it's a leak of Luminal contents from a surgical joint. It can result in significant contamination of abdominal cavity with Luminal contents leading to severe sepsis, multi organ failure and death. It's quite common. There's, there's quite a lot of it on the surgical ward. Um So yeah, smoking can increase the risk, previous adhesions and infections. So you can break it into patient factors or surgical factors. So, patients um on medications, steroids or immunosuppressants if they have smoking or alcohol excess, diabetes, obesity, malnutrition. So is the albumin really low nsaids if the male increases the risk, um, any history of radiotherapy or increased age. Um So surgical factors can include emergency surgery, extended operative times, peritoneal contamination such as um if they've got perforated appendix or perforated viscous, um where the anastomosis is also increases the risk if they've got a stoma which diverts feces away from the anastomosis that decreases the risk. And then obviously surgical surgeon factors such as like knot tying and things like that also affect the risk. Anyone know how a leak might present. It's quite important. Um, if you're gonna be on a surgical ward to be quite aware of leaks, um because it might be that you're the patient, you're the one that's seeing the patient every day. You might just notice um sort of how they're presenting and you might, you know, mention to the red on ward round. I'm a bit worried this patient might have a leak pain and distension. Y. So it's normally on POSTOP day 3 to 5. Um, but it can occur at any point. So you get worsening of the abdominal pain, clinical features of sepsis, a prolonged ileus. So like an essentially non improvement after having surgery. So they're not progressing um new af. Um So it's important in all your patients to get an ECG. And then if they've got a tender abdomen with either localized or generalized signs of um peritonitis, anyone know how we investigate um leaks. Yeah, imaging. Anyone know what kind of imaging we might do. So, obviously, you want to do your classic observations also want to do an ECG um because it might be a lot of the time it's new tachycardia, potentially af that might lead you towards it being anastomotic leak. Um So you can also send, you know, do a full septic screen. You might do urine samples, wound swabs, um sputum cultures, that kind of thing to see if there's any other potential cause of sepsis. So you'd wanna do bloods. Um So all the normal bloods including cultures, lyme cultures, CR PVG. Um because it could be that they've got an increase in lactate. If their inflammatory markers are increasing, they've still got raised white cells, raised CRP, that's not either, either not improving or increasing. Um So we do a CT scan with oral and IV contrast. Um And if there's any presence of gas or enteric contents outside the lumen at the side of the anastomosis, anastomosis is suggestive of a leak. And if you're given oral contrast, if there's any contrast that's outside the bowel, that also suggests a leak, does anyone know how we manage a anastomotic leaks starting from the basic to you know, potentially maybe taking them back to theater. Yeah, back to theater is what we essentially do with some of the patients. Not every patient with a leak has to go back to theater. Um, some of them can be managed conservatively it, so it's very much depending on the patient you've got in front of you. So, resource fluids, pain relief, antiemetics, get them a catheter in. Keep them all by mouth, get them, make sure if they're not already on anti antibiotics, get them on some, if they've got a minor leak. So they're quite well. Um, we've got a patient on the ward at the minute who has evidence of a leak, but he's very well in himself. News zero, all of his inflammatory markers are improving. So at the moment we've just kept him nil by mouth, kept him on bowel rest. He's got on antibiotics and you can also potentially put a drain in. Um, if they're systemically unwell, um, you might want to pop them, um, back to theater, do a wash out refashion, the anastomosis or form a defunctioning, er, and proximal to the anastomosis to protect those anastomosis um, from the feces. Ok. So that was a very well, um, thing of leaks. I think the most important thing is to just make sure you're considering it in any patient with several anastomosis. And if they've got new af or they've got anastomosis and they're not improving or they're how much markers are raising, it's always a leak until proven. Otherwise, things you can do as an F one is, as soon as you're worried about it, just keep them nil by mouth. You can always feed them when you've spoken to the reg. Keep them nil by mouth, get them on some antibiotics, resuscitate them if they need it and then speak to your reg and say, I'm a bit worried this person has a leak. What do you think about doing a CT and get them a CT done? Anyone know what an eye is moving very swiftly on? Yeah. So functional um, obstruction. So it's a reduction in intestinal motility following surgery. Um very common. Lots of our patients go into ileus, um particularly after abdominal pelvic surgery. So risk factors. Um So patients age electrical electrolyte derangement if they've got any, no neurological disorders such as dementia or Parkinson's, you use any anticholinergics and they're not getting up and moving around. Um, the bowels just go to sleep really. So it's always making sure you're checking those electrolytes um and replacing them if required. So, surgical factors such as use of opioids, pelvic surgery, extensive intraoperative intestinal handling. So they run in the bowel when they're doing a laparotomy um to check if there's any dead bowel, that kind of thing. Um If there's any peritoneal contamination such as pus or feces, for example, in perforated appendix or perforated, um if you've got a perforated obstruction and if there's been any resection of the intestine. So we, we have gone over bowel obstructions before. So I'll just quickly talk about the presentation of ili failure to pass or feces, blur and distension, nausea and vomiting. Or if they've got already got an I AN NG tube in, they might have high output of the NG tube and absent bowel sounds because this is a functional obstruction in a mechanical obstruction. You get those, um, tingling bowel sounds. So investigations, obviously, observations check they're stable, do an ECG because as well as affecting the bowel, obviously, we know electro abnormalities can also affect the heart. Um Obviously you wanted to check the electrolytes, um check the, um, have her do a burn profile and check the calcium and phosphate, check the magnesium. Um because if the magnesium is low as well, no matter how many times you try and replace the other electrolytes, they're gonna stay low. So if you've got, um, say a potassium that's low and even though you start treatment, it's still not improving, think about starting some magnesium replacement as well. You can also do an abdominal X ray to see dilated bowel loops and you can use gastrograph in to see how far it might get down. Um, CT abdomen and pelvis can help out help to look at the dilated bowel loops and can also look for other complications such as collections or leaks. And obviously, we'll show dilated bowel loops, failure of contrast or gastrograph and to progress that just shows you, um, some evidence of dilated bowel loops. So they should be uniformly dilated because there's not, um, an obstructing point. Um, like there would be in a mechanical bowel obstruction. The treatment of ili is very similar to, um, obviously other bowel obstruction, for example, in an A A I keep the nail by mouth with fluids and strict, put input output on it, monitoring, put them in A R tube, left them free drainage with regular as aspirations. Obviously, as it gets better, we can then start to think about um space in the NG tube, um increasing oral intake and then taking the NG tube out daily bloods. Um because we wanted to check electrolytes and obviously replacing any electrolytes, encourage mobilization, meaning making sure you've got the pain under control. So it might be one that you speak to the pain team about because you're obviously gonna want to reduce any opioids because that might cause constipation and then just making sure you're letting patients know that when it does settle and their bowel does start to work again. Um You will um likely have quite a lot of watery stools. So we are very nearly finished. We're just gonna um run through a case if people are happy to, I appreciate it's probably just gone over the um time I said I was going to run it. If people would like to um do the case let me know if not, we can leave it here. So, um I think I have already sent you guys um the feedback form. Um So I see if you guys could complete that. Um But we'll just run through this case quickly. Um So you bleed to the surgical ward whilst on call, they have a male patient age 55 who they are worried about. He's come back from 30 to 3 days ago. He had elective reversal apartments. They had previously had a perforation. He has um known Crohn's disease. Um The nurse has called you doesn't know much about the patient just as only just start looking after him. All she knows that um the day team reviewed him earlier due to a temperature spike, but she doesn't know what the day team did. So what are you worried about in terms of his patient that um had a temperature spike during the day, day three POSTOP? Is there anything that you guys are worried about there cause infection sepsis? BT leak hemorrhage drug reaction would be worried about to go and see this patient. So airway, nothing of not the patient is talking to you. Um So you move on. There's not really anything you can find now where breathing respiratory rate is 29. So that's 82. It's widespread wheeze with crackles on the lower left lobe, um decrease expansion and dull percussion on the left lobe. So what do you want to do about um how they're presenting in terms of breathing. They've got low SATS and potentially have got signs um found on respiratory exam. Yeah. X-ray, very good. So I would wanna do 15 L non rebreath because obviously this is quite low saturations. Um And then depending on that, I would wanna keep a close eye on the saturations and wean down with a ventura. Um because of this, I'd also want to make sure I was doing an ABG just to make sure they're not um co BD or a returner and get a chest X ray as well. So, circulation low BP heart rate which is irregular, irregularly, irregular capillary refill is less than two seconds. Do you feel per peripherally warm? What would you want to do about um circulation? It's really important to know the difference between maintenance and resuscitation fluids. Um Unfortunately, I've seen quite a lot of um dodgy fluid prescribing. So it's important to, yep, ecg. Very good. Obviously want to resuscitate with 500 mils and start repeat it if required. Um If they've got a history of heart failure, you can give 250 MS or if they're elderly. Um two wide ball Cannulas FP CS using these LT CRP blood cultures and an ECG GIS 15 out of 15 and the patient is very anxious. Glucose is normal, pupils are equal and reactive and movement of all limbs is normal. Um abdomen is soft and tender the bowels are open and the plasty in flatus, they do have a rash that's extending over the abdomen and you know that the patient is already um has a cannula that's cooked up to Comox clave drip that is still running through. So your f one colleague saw them in the day. They ordered a um all the bloods we spoke about and a chest X ray. Um they are showing um increase in inflammatory markers. Blood cultures are not available yet and a chest X ray shows left basal consolidation. Your co your f one colleagues start Comox as purchase guidelines. The ECG of order shows fast atrial fibrillation. As you were reading, the nurse calls you back to um to tell you that the fluid challenge is finished, the BP remains the same. So it's non fluid responsive and you now notice that the patient is struggling to breathe. What would you do now? But I would restart the A two E um You notice that the patient's tongue is swelling. So what do we want to do about this? Obviously get some airway management in, put a Perret call out um as you want, seeing your doctors there as soon as possible, likely in this case, there's multiple things ongoing. I think likely it's anaphylaxis on the background of sepsis, most likely um due to chest sepsis. So you're gonna wanna give some urgent im adrenaline per arrest team arrive. What do we do now? So, you do an sbar. So you would say I'm surgical F one on call. I have this 55 year old gentleman with hypertension, non responsive to fluids and loss of airway due to airway spelling. He had reversal heart 13 days ago with known Crohn's. He has received do Comox and has a chest X ray showing left sided consolidation, an ECG showing fast af all inflammatory marks are increasing blood cultures have been taken and he has received one dose of iron adrenaline. So then you say, I think this patient has an anaphylaxis on background of chest sepsis. And I need um urgent support with the management of this patient including airway support. So leave those questions. So yeah, obviously just making sure that you consider all possible causes of why a patient is presenting in the way that they are um have they been given. So, so in that case, yes, they do have chest sepsis, but also they've been given some antibiotics that are slightly allergic to um the anaphylaxis is going to kill them faster than chest sepsis. So making sure you take that antibiotics down, give them adrenaline and then um get them to HD and switch in their antibiotics so that we can treat the chest sepsis. It's really important that when you're speaking to um your seniors, you can give them a good concise history and know what you want from your seniors. Is it that you just want a bit of advice or is it that you want them to come and see this patient immediately? And this patient I had on Friday that I had to get the to ring. Um the med Reg and I said, I don't want advice. I want you to come and see them immediately because I'm very, very worried about this patient. Um So just making sure that you know what it is you want from the, from the senior that you want to speak to and make sure you're um speaking to the appropriate senior for that particular thing. Yeah, thank you so much for joining. I hope it's been useful. Um This is the last episode in the series. Um So if you guys could fill it in, I'll, I'll follow up with um an email, um probably this week and then potentially next week as well, I'll get your certificates out as soon as I can. Um And I hope it's been useful and you guys all have my emails. If there's anything that you need, please do message me and I will try and um reply as soon as I can and thank you guys so much for joining.