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NATIONAL SURGICAL TEACHING SOCIETY Post Operative Complications Welcome to the unluckiest surgical on-call in history… 19 September 2023 Mr Sai PendyalaLittle Bit About Me Mr Sai Pendyala Junior Orthopaedic Clinical Research Fellow, SWLEOC Education Officer for NSTS 23-24 The Timeline So Far o Medical School - UCLMS o Foundation Training – Basildon & Thurrock University Hospitals (MSE Trust) o F3 – JCRF at South West London Elective Orthopaedic Centre (SWLEOC) The Future? o CST ? ACF ? USMLE ?KEY LEARNING OBJECTIVES Aims o Recognize post-operative complications and understand the management; immediate and definitive alike o Become confident in what you can manage alone, with supervision/advice and which need to be escalated/managed by seniors o Developing a system to manage the following scenarios with differentials o Post Op Fever o Post Op Bleeding o Specific complications by surgery My Personal Framework Keep Calm Called about a postop patient Very few scenarios are so demanding that the patient ESCALATE may die within seconds- minutes –can you think of some? SBAR+ Obs? Review PMH/Op A-E Note/Bloods/Images Reassess ESCALATE Is this patient likely to ESCALATE need surgery tonight? Yes. No Surgical Reg Can I or, rather, SHOULD I ESCALATE be managing this on my own? Yes. No Request In-Person Consult Verbal Advice Who? Surgical Reg ITU Reg Med Reg Post Op Fever Scenario 1 Scenario 2 Scenario 3 • 43F POD1, undergone Lap Chole. • 71M POD6, undergone Sigmoid Colectomy • 67F POD9, undergone THR for NOF. • Pt in mild pain (controlled on oral analgesia) with primary anastomosis for CRC. • Pt in SOB (despite 2L Nasal Cannula) • spiked a temperature of 37.8. • Pt in severe pain (despite IV morphine) • spiked a temperature of 37.6. • spiked a temperature of 38.2. Post Op Fever Scenario 1 Scenario 2 Scenario 3 • 43F POD1, undergone Lap Chole. • 71M POD6, undergone Sigmoid Colectomy • 67F POD9, undergone THR for NOF. • Pt in mild pain (controlled on oral analgesia) with primary anastomosis. • Pt in SOB (despite 2L Nasal Cannula) • spiked a temperature of 37.8. • spiked a temperature of 38.2. morphine) • spiked a temperature of 37.6. Who are you worried about the most? Rank Post Op Fever Scenario 1 Scenario 2 Scenario 3 • 43F POD1, undergone Lap Chole. • 71M POD6, undergone Sigmoid Colectomy • 67F POD9, undergone THR for NOF. • Pt in mild pain (controlled on oral analgesia) with primary anastomosis. • Pt in SOB (despite 2L Nasal Cannula) • spiked a temperature of 37.8. • Pt in severe pain (despite IV morphine) • spiked a temperature of 37.6. • spiked a temperature of 38.2. • BP: 113/67 • BP: 108/68 • HR: 98bpm • BP: 93/64 • HR: 106bpm • CRT <2s • HR: 117bpm • CRT: <2s • RR: 21 • CRT 4s • RR: 24 • Sats: 95% on RA • RR: 22 • Sats: 97% on 2L via NC • AVPU • Sats: 97% on RA • AVPU • AVPU Post Op Fever Scenario 1 Scenario 2 Scenario 3 • 43F POD1, undergone Lap Chole. • 71M POD6, undergone Sigmoid Colectomy • 67F POD9, undergone THR for NOF. • Pt in mild pain (controlled on oral analgesia) with primary anastomosis. • Pt in SOB (despite 2L Nasal Cannula) • spiked a temperature of 37.8. • Pt in severe pain (despite IV morphine) • spiked a temperature of 37.6. • spiked a temperature of 38.2. • BP: 113/67 • BP: 108/68 • HR: 98bpm • BP: 93/64 • HR: 106bpm • CRT <2s • HR: 117bpm • CRT: <2s • RR: 21 • CRT 4s • RR: 24 • Sats: 95% on RA • RR: 22 • Sats: 97% on 2L via NC • AVPU • Sats: 97% on RA • AVPU • AVPU Who are you worried about the most now? Rank Post Op Fever Scenario 1 Scenario 2 Scenario 3 • 43F POD1, undergone Lap Chole. • 71M POD6, undergone Sigmoid Colectomy • 67F POD9, undergone THR for NOF. • Pt in mild pain (controlled on oral analgesia) with primary anastomosis. • Pt in SOB (despite 2L Nasal Cannula) • spiked a temperature of 37.8. • Pt in severe pain (despite IV morphine) • spiked a temperature of 37.6. • spiked a temperature of 38.2. • BP: 113/67 • BP: 108/68 • HR: 98bpm • BP: 93/64 • HR: 106bpm • CRT <2s • HR: 117bpm • CRT: <2s • RR: 21 • CRT 4s • RR: 24 • Sats: 95% on RA • RR: 22 • Sats: 97% on RA • AVPU • Sats: 97% on RA • AVPU • AVPU • Airway: patent, talking in full sentences • Airway: patent, talking in full sentences • Breathing: mod tachypnoea, otherwise nil. • Airway: patent, talking in full sentences • Breathing: nil of note • Circulation: Nil of note. • Breathing: bibasal creps, nil otherwise • Circulation: Appears pale, clammy and • Disability: BM 6.7, AVPU, PEARLL • Circulation: nil of note. diaphoretic, otherwise nil apart from obs. • Everything else: Has eczematous skin rash • Disability: BM 6.7, AVPU, PEARLL • Disability: BM 6.7, AVPU, PEARLL over hands and legs and has had diarrhoea • Everything else: wound site mildly tender, nil • Everything else: Abdomen rigid, incision well for last 3 days. else of note. healing. Post Op Fever Scenario 1 Scenario 2 Scenario 3 • 43F POD1, undergone Lap Chole. • 71M POD6, undergone Sigmoid Colectomy • 67F POD9, undergone THR for NOF. • Pt in mild pain (controlled on oral analgesia) with primary anastomosis. • Pt in SOB (despite 2L Nasal Cannula) • spiked a temperature of 37.8. • Pt in severe pain (despite IV morphine) • spiked a temperature of 37.6. • spiked a temperature of 38.2. • BP: 113/67 s ? • BP: 108/68 • HR: 98bpm • BP: 93/64 s e • HR: 106bpm • CRT <2s • HR: 117bpm n o • CRT: <2s • Sats: 95% on RA • aRR: 22 • Sats: 97% on RA • AVPU D • Sats: 97% on RA • AVPU • AVPU • Airway: patent, talking in full sentences • Airway: patent, talking in full sentences • Breathing: nil of noteg in full sentences • Circulation: Nil of note., otherwise nil. • Breathing: bibasal creps, nil otherwise • Circulation: Appears pale, clammy and • Disability: BM 6.7, AVPU, PEARLL • Circulation: nil of note. diaphoretic, otherwise nil apart from obs. • Everything else: Has eczematous skin rash • Everything else: wound site mildly tender, nil • Everything else: Abdomen rigid, incision well for last 3 days.egs and has had diarrhoea else of note. healing. Post Op Fever Scenario 1 Scenario 2 Scenario 3 • 43F POD1, undergone Lap Chole. • 71M POD6, undergone Sigmoid Colectomy • 67F POD9, undergone THR for NOF. • Pt in mild pain (controlled on oral analgesia) with primary anastomosis. • Pt in SOB (despite 2L Nasal Cannula) • spiked a temperature of 37.8. • Pt in severe pain (despite IV morphine) • spiked a temperature of 37.6. • spiked a temperature of 38.2. DDx DDx DDx 1. Normal post-operative pain 1. Collection 1. ARDS 2. Bile Leak 2. Anastomotic Leak 2. PE 3. Atelectasis 3. Large Bowel Ischaemia 3. Pneumonia 4. Peri-hepatic Collection 4. Normal post-operative pain 4. Anxiety 5. Idk, show results 5. Idk, show results 5. Idk, show results Scenario 1 ? Post Op Fever Scenario 1 Scenario 2 Scenario 3 • 43F POD1, undergone Lap Chole. • 71M POD6, undergone Sigmoid Colectomy • 67F POD9, undergone THR for NOF. • Pt in mild pain (controlled on oral analgesia) with primary anastomosis. • Pt in SOB (despite 2L Nasal Cannula) • spiked a temperature of 37.8. • Pt in severe pain (despite IV morphine) • spiked a temperature of 37.6. • spiked a temperature of 38.2. DDx DDx DDx 1. Normal post-operative pain 1. Collection 1. ARDS 2. Bile Leak 2. Anastomotic Leak 2. PE 3. Atelectasis 3. Large Bowel Ischaemia 3. Pneumonia 4. Peri-hepatic Collection 4. Normal post-operative pain 4. Anxiety 5. Idk, show results 5. Idk, show results 5. Idk, show results Scenario 2? Post Op Fever Scenario 1 Scenario 2 Scenario 3 • 43F POD1, undergone Lap Chole. • 71M POD6, undergone Sigmoid Colectomy • 67F POD9, undergone THR for NOF. • Pt in mild pain (controlled on oral analgesia) with primary anastomosis. • Pt in SOB (despite 2L Nasal Cannula) • spiked a temperature of 37.8. • Pt in severe pain (despite IV morphine) • spiked a temperature of 37.6. • spiked a temperature of 38.2. DDx DDx DDx 1. Normal post-operative pain 1. Collection 1. ARDS 2. Bile Leak 2. Anastomotic Leak 2. PE 3. Atelectasis 3. Large Bowel Ischaemia 3. Pneumonia 4. Peri-hepatic Collection 4. Normal post-operative pain 4. Anxiety 5. Idk, show results 5. Idk, show results 5. Idk, show results Scenario 3? Post Op Fever Scenario 1 Scenario 2 Scenario 3 • 43F POD1, undergone Lap Chole. • 71M POD6, undergone Sigmoid Colectomy • 67F POD9, undergone THR for NOF. • Pt in mild pain (controlled on oral analgesia) with primary anastomosis. • Pt in SOB (despite 2L Nasal Cannula) • spiked a temperature of 37.8. • Pt in severe pain (despite IV morphine) • spiked a temperature of 37.6. • spiked a temperature of 38.2. DDx DDx DDx 1. Normal post-operative pain 1. Collection 1. ARDS 2. Bile Leak 2. Anastomotic Leak 2. PE 3. Atelectasis 3. Large Bowel Ischaemia 3. Pneumonia 4. Peri-hepatic Collection 4. Normal post-operative pain 4. Anxiety 5. Idk, show results 5. Idk, show results 5. Idk, show results Post Op Fever Scenario 1 Scenario 2 Scenario 3 • 43F POD1, undergone Lap Chole. • 71M POD6, undergone Sigmoid Colectomy • 67F POD9, undergone THR for NOF. • spiked a temperature of 37.8.n oral analgesia) • Pt in severe pain (despite IV morphine) • spiked a temperature of 37.6.annula) • spiked a temperature of 38.2. DDx DDx t ? DDx 1. Normal post-operative pain 1. Collection e n 1. ARDS 3. Atelectasis 3. Large Bowel Ischaemia 3. Pneumonia 4. Peri-hepatic Collection n 4.a Normal post-operative pain 4. Anxiety 5. Idk, show results M a 5. Idk, show results 5. Idk, show results Post Op Fever Scenario 1 Scenario 2 Scenario 3 • 43F POD1, undergone Lap Chole. • 71M POD6, undergone Sigmoid Colectomy • 67F POD9, undergone THR for NOF. • Pt in mild pain (controlled on oral analgesia) with primary anastomosis. • Pt in SOB (despite 2L Nasal Cannula) • spiked a temperature of 37.8. • Pt in severe pain (despite IV morphine) • spiked a temperature of 37.6. • spiked a temperature of 38.2. DDx DDx DDx 1. Normal post-operative pain 1. Collection 1. ARDS 2. Bile Leak 2. Anastomotic Leak 2. PE 3. Atelectasis 3. Large Bowel Ischaemia 3. Pneumonia 4. Peri-hepatic Collection 4. Normal post-operative pain 4. Anxiety 5. Idk, show results 5. Idk, show results 5. Idk, show results Scenario 1 ? Post Op Fever Scenario 1 Scenario 2 Scenario 3 • 43F POD1, undergone Lap Chole. • 71M POD6, undergone Sigmoid Colectomy • 67F POD9, undergone THR for NOF. • Pt in mild pain (controlled on oral analgesia) with primary anastomosis. • Pt in SOB (despite 2L Nasal Cannula) • spiked a temperature of 37.8. • Pt in severe pain (despite IV morphine) • spiked a temperature of 37.6. • spiked a temperature of 38.2. DDx DDx DDx 1. Normal post-operative pain 1. Collection 1. ARDS 2. Bile Leak 2. Anastomotic Leak 2. PE 3. Atelectasis 3. Large Bowel Ischaemia 3. Pneumonia 4. Peri-hepatic Collection 4. Normal post-operative pain 4. Anxiety 5. Idk, show results 5. Idk, show results 5. Idk, show results Scenario 2? Post Op Fever Scenario 1 Scenario 2 Scenario 3 • 43F POD1, undergone Lap Chole. • 71M POD6, undergone Sigmoid Colectomy • 67F POD9, undergone THR for NOF. • Pt in mild pain (controlled on oral analgesia) with primary anastomosis. • Pt in SOB (despite 2L Nasal Cannula) • spiked a temperature of 37.8. • Pt in severe pain (despite IV morphine) • spiked a temperature of 37.6. • spiked a temperature of 38.2. DDx DDx DDx 1. Normal post-operative pain 1. Collection 1. ARDS 2. Bile Leak 2. Anastomotic Leak 2. PE 3. Atelectasis 3. Large Bowel Ischaemia 3. Pneumonia 4. Peri-hepatic Collection 4. Normal post-operative pain 4. Anxiety 5. Idk, show results 5. Idk, show results 5. Idk, show results Scenario 3?Post Op Fever Aetiology Very common, inflammatory mediators released as part of the body’s response to surgery will already cause low-grade fever within 24 hours. Otherwise, the most common cause is infection. Apart from this, a venous-thromboembolic events, atelectasis could also cause this. Timeline (Guidance Only) •Day 1-2 – Either normal response or atelectasis •Day 3-5 – Infection - ?Urine ?Chest •Day 5-7 – consider a surgical site infection or abscess/collection formation (anastomotic leak tends to be earlier than collection) •Day 7+ - typically consider VTE •Any day post-operatively – consider infected IV lines or central lines as a source Investigations/Work Up As the on-call, you’d want to consider an A-E response if appropriate, with likely initiation of the sepsis 6, considering their PMH, Bloods, imaging and Venous/Arterial Blood Gas. Management 1. Atelectasis – Sit up, titrate O2 to requirements, chest physio, saline nebs, Abx if indicated from bloods/clinically 2. Infection – treat as you would a medical patient – sepsis 6 (Abx as per trust policy, fluids, O2, and take blood cultures, lactate, U/O) 3. Leak/Collection – A-E approach, escalate to senior surgeon early, resuscitate simultaneously, definitive Mx in theatre/IR 4. VTE – A-E approach, escalate to medical and surgical teams, using senior support/advice can start anti-thrombotic medications Post Op Bleeding Scenario 1 Scenario 2 Scenario 2 • 64M underwent an open Iliac artery • 14M underwent tonsillectomy 8 days ago, • 67M underwent a TURP procedure, just aneurysm repair 21 hours ago. brought up some blood and mucus and is arrived to recovery. Op note estimates that • Pt in severe pain around incision with low in energy without eating well. the patient lost 800mL of blood. Pt is SOB swelling and purplish discolouration locally and dizzy. Post Op Bleeding Scenario 1 Scenario 2 Scenario 2 • 64M underwent an open Iliac artery • 14M underwent tonsillectomy 8 days ago, • 67M underwent a TURP procedure, just aneurysm repair 21 hours ago. brought up some blood and mucus and is arrived to recovery. Op note estimates that • Pt in severe pain around incision with low in energy without eating well. the patient lost 800mL of blood. Pt is SOB swelling and purplish discolouration locally and dizzy. Who are you worried about the most? Rank Post Op Bleeding Scenario 1 Scenario 2 Scenario 2 • 64M underwent an open Iliac artery • 14M underwent tonsillectomy 8 days ago, • 67M underwent a TURP procedure, just aneurysm repair 21 hours ago. brought up some blood and mucus and is arrived at the recovery bay. Op note • Pt in severe pain for 30 minutes, around low in energy without eating well. estimates that the patient lost 800mL of incision with swelling and purplish blood. Pt is SOB and dizzy. discolouration locally • BP: 83/57 • BP: 124/78 • BP: 98/73 • HR: 137bpm • HR: 120bpm • HR: 104bpm • CRT 6s • CRT <3s • CRT <2s • RR: 24 • RR: 23 • RR: 14 • Sats: 96% on RA • Sats: 99% on RA • Sats: 97% on RA • AVPU • AVPU • AVPU Post Op Bleeding Scenario 1 Scenario 2 Scenario 2 • 64M underwent an open Iliac artery • 14M underwent tonsillectomy 8 days ago, • 67M underwent a TURP procedure, just aneurysm repair 21 hours ago. brought up some blood and mucus and is arrived at the recovery bay. Op note • Pt in severe pain for 30 minutes, around low in energy without eating well. estimates that the patient lost 800mL of incision with swelling and purplish blood. Pt is SOB and dizzy. discolouration locally • BP: 83/57 • BP: 124/78 • BP: 98/73 • HR: 137bpm • HR: 120bpm • HR: 104bpm • CRT 6s • CRT <3s • CRT <2s • RR: 24 • RR: 23 • RR: 14 • Sats: 96% on RA • Sats: 99% on RA • Sats: 97% on RA • AVPU • AVPU • AVPU Who are you worried about the most now? Rank Post Op Bleeding Scenario 1 Scenario 2 Scenario 2 • 64M underwent an open Iliac artery • 14M underwent tonsillectomy 8 days ago, • 67M underwent a TURP procedure, just aneurysm repair 21 hours ago. brought up some blood and mucus and is arrived at the recovery bay. Op note • Pt in severe pain for 30 minutes, around low in energy without eating well. estimates that the patient lost 800mL of incision with swelling and purplish blood. Pt is SOB and dizzy. discolouration locally • BP: 83/57 • BP: 124/78 • BP: 98/73 • HR: 137bpm • HR: 120bpm • HR: 104bpm • CRT 6s • CRT <3s • CRT <2s • RR: 24 • RR: 23 • RR: 14 • Sats: 96% on RA • Sats: 99% on RA • Sats: 97% on RA • AVPU • AVPU • AVPU • Airway: patent, talking in full sentences • Airway: patent, talking in full sentences • Airway: patent, talking words • Breathing: Nil of note • Breathing: nil of note • Breathing: nil of note. • Circulation: Pt pale, clammy, obs abnormal, • Circulation: nil of note. • Circulation: Obs apart, nil of note. otherwise nil • Disability: BM 6.7, AVPU, PEARLL • Disability: BM 6.7, AVPU, PEARLL • Disability: BM 6.7, AVPU, PEARLL • Everything else: Clot over the tonsillar fossa • Everything else: Nil of note, pt mildly • Everything else: wound site swollen, on examination, otherwise NAD. confused. severely tender and tense, purplish discolouration Post Op Bleeding Scenario 1 Scenario 2 Scenario 2 • 64M underwent an open Iliac artery • 14M underwent tonsillectomy 8 days ago, • 67M underwent a TURP procedure, just aneurysm repair 21 hours ago. brought up some blood and mucus and is arrived at the recovery bay. Op note • Pt in severe pain for 30 minutes, around low in energy without eating well. estimates that the patient lost 800mL of discolouration locally and purplish blood. Pt is SOB and dizzy. s ? • BP: 83/57 • BP: 124/78 s e • BP: 98/73 • HR: 137bpm • HR: 120bpm n o • HR: 104bpm • RR: 24 • aRR: 23s • RR: 14s • Sats: 96% on RA D • Sats: 99% on RA • Sats: 97% on RA • AVPU • AVPU • AVPU • Breathing: Nil of noteg in full sentences • Breathing: nil of noteg in full sentences • Breathing: nil of note. words • Circulation: Pt pale, clammy, obs abnormal, • Circulation: nil of note. • Circulation: Obs apart, nil of note. otherwise nil • Disability: BM 6.7, AVPU, PEARLL • Disability: BM 6.7, AVPU, PEARLL • Everything else: wound site swollen, • on examination, otherwise NAD. tonsillar fossa • confused.g else: Nil of note, pt mildly severely tender and tense, purplish discolouration Post Op Bleeding Scenario 1 Scenario 2 Scenario 2 • 64M underwent an open Iliac artery • 14M underwent tonsillectomy 8 days ago, • 67M underwent a TURP procedure, just aneurysm repair 21 hours ago. brought up some blood and mucus and is arrived to recovery. Op note estimates that • Pt in severe pain around incision with low in energy without eating well. the patient lost 1.1L of blood during swelling and purplish discolouration locally procedure. Pt is SOB and dizzy. DDx DDx DDx 1. reactive bleeding 1. Quinsy 1. Post-anaesthetic state 2. Surgical Site Infection 2. Ludwig’s Angina 2. Opioid overdose 3. Infected Haematoma 3. Secondary Haemorrhage 3. Due to intraoperative loss 4. Reperfusion Syndrome 4. Normal post-operative recovery. 4. PE 5. Idk, show results 5. Idk, show results 5. Idk, show results Scenario 1 ? Post Op Bleeding Scenario 1 Scenario 2 Scenario 2 • 64M underwent an open Iliac artery • 14M underwent tonsillectomy 8 days ago, • 67M underwent a TURP procedure, just aneurysm repair 21 hours ago. brought up some blood and mucus and is arrived to recovery. Op note estimates that • Pt in severe pain around incision with low in energy without eating well. the patient lost 1.1L of blood during swelling and purplish discolouration locally procedure. Pt is SOB and dizzy. DDx DDx DDx 1. Surgical Site Infection 1. Secondary Haemorrhage 1. Post-anaesthetic state 2. Infected Haematoma 2. Quinsy 2. Opioid overdose 3. Vascular Injury – blood leak – reactive 3. Ludwig’s Angina 3. Primary Haemorrhage haemorrhage 4. Normal post-operative recovery. 4. PE 4. Reperfusion Syndrome 5. Idk, show results 5. Idk, show results 5. Idk, show results Scenario 2? Post Op Bleeding Scenario 1 Scenario 2 Scenario 2 • 64M underwent an open Iliac artery • 14M underwent tonsillectomy 8 days ago, • 67M underwent a TURP procedure, just aneurysm repair 21 hours ago. brought up some blood and mucus and is arrived to recovery. Op note estimates that • Pt in severe pain around incision with low in energy without eating well. the patient lost 1.1L of blood during swelling and purplish discolouration locally procedure. Pt is SOB and dizzy. DDx DDx DDx 1. Surgical Site Infection 1. Secondary Haemorrhage 1. Post-anaesthetic state 2. Infected Haematoma 2. Quinsy 2. Opioid overdose 3. Vascular Injury – blood leak – reactive 3. Ludwig’s Angina 3. Primary Haemorrhage haemorrhage 4. Normal post-operative recovery. 4. PE 4. Reperfusion Syndrome 5. Idk, show results 5. Idk, show results 5. Idk, show results Scenario 3? Post Op Bleeding Scenario 1 Scenario 2 Scenario 2 • 64M underwent an open Iliac artery • 14M underwent tonsillectomy 8 days ago, • 67M underwent a TURP procedure, just aneurysm repair 21 hours ago. brought up some blood and mucus and is arrived to recovery. Op note estimates that • Pt in severe pain around incision with low in energy without eating well. the patient lost 1.1L of blood during swelling and purplish discolouration locally procedure. Pt is SOB and dizzy. DDx DDx DDx 1. Surgical Site Infection 1. Secondary Haemorrhage 1. Post-anaesthetic state 2. Infected Haematoma 2. Quinsy 2. Opioid overdose 3. Vascular Injury – blood leak – reactive 3. Ludwig’s Angina 3. Primary Haemorrhage haemorrhage 4. Normal post-operative recovery. 4. PE 4. Reperfusion Syndrome 5. Idk, show results 5. Idk, show results 5. Idk, show results Post Op Bleeding Classification •Intraoperative = Primary haemorrhage – Bleeding that occurs during the surgery, should be dealt with and mentioned in the op notes •Within 24hrs = Reactive haemorrhage – Bleeding that starts once BP normalises (post anaesthetics) or a ligature/clip loosens •Within 7-10 PODs= Secondary haemorrhage – Usually due to Infection. Clinical Features Management 1. A-E as always. Approach as you would for any major haemorrhage protocol 2. Simultaneous stabilisation and resuscitation with planning for theatre (if required) (e.g. blood for blood, X-Match for 2-6 units Specific Scenarios 1. Post-thyroidectomy – remove all skin clips/sutures ON THE WARD – do not wait till theatres 2. Post laparoscopic bleeding – inferior epigastric artery bleeding – apply pressure on the area. https://thetraumapro.com/wp-content/uploads/2016/10/classes_of_shock-500x375.jpgThe Night Shift Begins … Your Current Jobs List… 1. Bed 23 WH ward – prescribe fluids overnight bag; pt pre-op 2. Bed 14 Lister ward – prescribe 2 ABx as per op note instructions 3. Bed 36 SRU ward – insert cannula to give IV fluids for tomorrow’s surgery and to get G&S x 2 4. Bed 7 Bulphan ward – repeat VBG at 12am to monitor K+ (prev. level 7.1, treatment ensued at 7:30pm) 5. Bed 4 Horndon ward – prescribe pain relief for 67M patient post femoral-popliteal bypass D1- nurses called x3 as previous painkillers haven’t worked so far 6. Bed 13 Bulphan ward – prescribe anti-emetics as PONV [Day 2 post lap-chole] 7. Bed 8 Laindon ward – patient c/o itching – prescribe antihistamines? 8. Bed 5 Laindon ward – nurse noted some oozing of midline wound [POD 8; midline laparatomoy] please ?review 9. Cubicle 23 ED – chase CTAP report for ?bowel obstruction as per SHOWhich one will you prioritise first?Bed 4 Horndon ward – prescribe pain relief for 67M patient post femoral-popliteal bypass D1- nurses called x3 as previous painkillers haven’t worked so far Obs BP – 102/63 HR – 127bpm Temp – 37.2 CRT - <2s RR - 27 Sats – 99% on RA AVPU - A What will you do then? 1. In person review 2. E-prescribe pain meds & reassess 3. Verbal consult of SHO 4. Demand in-person review by the Vascular reg 5. Idk, show me the resultsYou arrive onto the scene Airway Patent but screaming in pain Breathing Tachypneic and shallow breathing, otherwise nil Obs of note BP – 102/63 HR – 127bpm Circulation Nil of note except pt profusely diaphoretic Temp – 37.2 CRT - <2s RR - 27 Disability Sats – 99% on RA Nil of note AVPU - A Everything Else Dressing adhered onto lower leg, otherwise nil of note.What is the diagnosis? 1.DVT 2.Normal Post-operative pain 3.Compartment Syndrome 4.Surgical site infection 5.I don’t know, show me the resultsWhat is the diagnosis? 1.DVT 2.Normal Post-operative pain 3.Compartment Syndrome 4.Surgical site infection 5.I don’t know, show me the resultsYour Management? Rank in order 1. IV fluids and IV analgesia 2. Escalate to surgical senior urgently 3. Ensure patient systemically stable/resuscitate if required via A-E 4. Keep leg neutral, removing all dressing 5. Book fasciotomy by informing the theatre coordinators and the anaesthetistCompartment Syndrome https://teachmesurgery.com/wp-content/uploads/2022/04/Screen-Shot-2022-04-18-at-08.39.20.png.webpCompartment Syndrome Definition Critical pressure increase within a confined fascial compartment Leg > thigh > forearm > foot > hand > buttock Pathophysiology Following high energy trauma (fractures, crush injuries) or vascular injury/surgery, rhabdomyolysis or even iatrogenic splints/casts. Initial Inflammatory response à oedema à pressure increase à venous outflow obstruction à further increase in hydrostatic pressure à Further fluid leakage into compartment à traversing nerve compression à once DBP reached = arterial inflow obstruction = ischaemia Clinical Features – Clinical Diagnosis PAIN. Everything else (paresthesia, pallor, pulselessness, paralysis etc.) comes very late (i.e., once ischaemia sets in). Pain is marked on passive stretching of compartment. Management 1. Keep limb neutral 2. Improve O2 with high flow O2 3. IV Fluids to improve perfusion (only transient) 4. Remove all dressing/splints/casts down to skin + analgesia 5. Perform fasciotomy (go for re-look in 24 hours) Your Current Jobs List… 1. Bed 23 WH ward – prescribe fluids overnight bag; pt pre-op 2. Bed 14 Lister ward – prescribe 2 ABx as per op note instructions 3. Bed 36 SRU ward – insert cannula to give IV fluids for tomorrow’s surgery and to get G&S x 2 4. Bed 7 Bulphan ward – repeat VBG at 12am to monitor K+ (prev. level 7.1, treatment ensued at 7:30pm) 5. Bed 4 Horndon ward – prescribe pain relief for 67M patient post femoral-popliteal bypass D1- nurses called x3 as previous painkillers haven’t worked so far 6. Bed 13 Bulphan ward – prescribe anti-emetics as PONV [Day 2 post lap-chole] 7. Bed 8 Laindon ward – patient c/o itching – prescribe antihistamines? 8. Bed 5 Laindon ward – nurse noted some oozing of midline wound [POD 8; midline laparatomoy] please ?review 9. Cubicle 23 ED – chase CTAP report for ?bowel obstruction as per SHONew Bleep… Obs BP – 112/63 HR – 94bpm Temp – 37.2 CRT - <2s RR - 23 Sats – 99% on RA AVPU – A On inspection you can observe, haemoserous fluid discharge from the wound. The patient’s abdomen is rigid https://i.ytimg.com/vi/5gVy0HQb4DM/maxresdefault.jpg and patient himself is in severe pain.What is the diagnosis? 1. Superficial wound dehiscence 2. Normal Post Op ooze 3. Secondary Haemorrhage 4. Full thickness wound dehiscence 5. I don’t know, show me the results https://i.ytimg.com/vi/5gVy0HQb4DM/maxresdefault.jpgYour Management? Rank in order 1. Book re-look procedure by informing the theatre coordinators and the anaesthetist 2. Keep abdominal contents covered using sterile gauze soaked in saline 3. Ensure patient systemically stable/resuscitate if required via A-E 4. Escalate to surgical senior urgently 5. IV fluids and IV Abx – sepsis 6Wound Dehiscence Definition Reopening of the wound following surgery after failure to heal, can happen to any wound but typically seen in midline wounds. Can be divided into Superficial – rectus sheath intact, fascia/skin fails Full thickness – rectus bursts too, leaving for protrusion of abdominal organs/contents (i.e. burst abdomen) Pathophysiology Superficial – usually due to infections/poor nutrition/DM Full thickness – usually due to increased intra-abdominal pressure/poor technique Various factors can increase the risk (pre-operative, intra and post-operative) Clinical Features – Clinical Diagnosis Superficial – visible opening of the wound, with surrounding erythema, usually secondary to an SSI Full Thickness – haemoserous discharge with new bulging = full thickness wound dehiscence until proven otherwise Management 1. Superficial – Treat underlying infection, let it heal by secondary intention 2. Full thickness – A-E approach, cover with saline gauze, IV ABx, urgent theatre explorationSummary Keep calm – you can’t go wrong Get the SBAR à Obs à A-E Prioritise accordingly Read up on specific with a systematic approach assessment à R/v PMH/Op complications for your surgery note/Bloods à Make decision if (e.g. if any they likely to need surgery or not plastics/ENT/cardiothoracics etc. à Escalate to appropriate senior rotations) THANK YOU! ● QR code and survey link ● Stay tuned for… upcoming lectures ● Follow the link to NSTS website for further learning resources ● Any Questions: sai.pendyala3@nhs.net