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Peri-operative and post-operative care Chim Wing JoeLearning Objectives Recall peri- Group and Peri- Measures Basic Classification Importance of operative Save & Cross operative taken to sequence of of analgesia drug matching procedures enhance events during anaesthesia post- management and protocols patient surgical and its operative, •Corticosteroid in emergency recovery anaesthesia mechanism WHO pain and diabetic case of action ladder medications •stop/alter/startLearning Objectives Significance of post-operative Common post- nausea and vomiting(PONV) & operative medications used to counteract complications it intra and post-operatively Re-starting drug regimes post- Use of catheters intra- operatively operatively and trial without operativelyOC) post- Post-surgical review of patient Types of nutritional support available post-operatively & methods to calculate nutritional Post-operative VTE need of an individual prophylaxisPeri-operative medication management • The peri-operative period extends from the pre-operative day through the operation and into the post-operative recovery • Proper peri-operative management helps to prevent or minimize complications, to reduce post- operative pain, and to accelerate recoveryPeri-operative medication management Components of peri-operative medication management • Accurate documentation of pre-operative medication • Established decisions on stopping medications prior to surgery • Monitoring of appropriate chemistry study results to determine dosages and the occurrence of adverse effects • Appropriate management of pain • Administration of adjunctive medications • Use of appropriate formulations and alternative products when needed • Review of discharge medications to ensure discontinuation of surgery-specific drugs (e.g., anti-coagulants, analgesics) to avoid polypharmacyPeri-operative management of diabetes • Patients with diabetes are at higher risk for perioperative complications. In a study of 1042 patients who underwent total hip replacement, researchers compared the incidence rate of post- operative infection in persons with diabetes (11%) and in persons without diabetes (2%) • Adequate glycaemic control is essential prior to an elective surgery. Primary goal of peri- operative control is to avoid ketosis and to maintain glucose levels • Aim of blood glucose levels for peri-operative period: 6-10 mmol/L(4-12 mmol/L is acceptable) • HbA1C monitoring(NICE guidelines; individual context is important) • >69 mmol/mol • Refer to team who manage their diabetes for optimization • Surgery may proceed with caution • >85 mmol/mol-inadequate control • Refer to diabetes team and only proceed if surgery is urgent or they feel patient’s control is as good as it can bePeri-operative management of diabetes • Peri-operative management of blood-glucose concentrations depends on factors including: • required duration of fasting • timing of surgery (morning or afternoon) • usual treatment regimen (insulin, anti-diabetic drugs or diet) • prior glycaemic control • other co-morbidities • likelihood that the patient will be capable of self-managing their diabetes in the immediate post-operative period • All patients should have emergency treatment for hypoglycaemia written on their drug chart on admission (NICE Guidelines)Peri-operative management of diabetes Drug Day Before Day of Surgery During Surgery After Procedure Surgery Oral Discontinue Omit dose Insulin (SC or IV) Insulin until hypoglycaemics patient is no longer NPO Insulin Usual dose Usual dose Omit dose Insulin (SC or IV) Usual dose on Restart the dose Thyroxine Usual dose morning of when patient is surgery with sip no longer NPO of water Table 1: Perioperative Medication Management for Patients With Diabetes and HypothyroidismPeri-operative management of steroids • A common issue that arises in patients who are on long-term corticosteroid therapy is the peri-operative supplementation with stress doses. Several studies have shown that a stress dose is needed only when the hypothalamic- pituitary-adrenal axis (HPAA) is suppressed. • The time to recovery of normal adrenal function after stopping corticosteroids varies from a few days to several months. • When using peri-operative corticosteroid supplementation, doses should parallel the physiologic response of the normal adrenal gland to surgical stress, providing only very short-term supplementation Combined hormonal contraceptives Herbal medicine Lithium Drugs that Angiotensin-II should be Monoamine receptor stopped oxidase inhibitors antagonists (MAOIs) before surgery Angiotensin- converting Tricyclic enzyme (ACE) antidepressants inhibitors Potassium- sparing diureticsRisk Assessment for Venous Thromboembolism(VTE) • pre-operative evaluation that determines a patient's risk of developing a blood clot • When? • Upon admission to hospital; Reassessment done within 24 hours of admission and whenever clinical situation changes • For elective procedures, the assessment is usually done at a pre-assessment clinic appointmentVenous thromboembolism(VTE) prophylaxis • anaesthesia should be used over general anaesthesia ifal possible • Type of prophylaxis • Mechanical prophylaxis • should be offered to patients with major trauma, or undergoing cranial, abdominal, bariatric, thoracic, maxillofacial, ear, nose, and throat, cardiac or elective spinal surgery • Prophylaxis should continue until the patient is (or for 30 days in spinal injury, elective spinal surgery or cranial surgery • Choice of mechanical prophylaxis depends on factors such as the type of surgery, suitability for the patient, and their conditionVenous thromboembolism(VTE) prophylaxis Anti-embolism stockings Intermittent pneumatic compressionsVenous thromboembolism(VTE) prophylaxis • Pharmacological prophylaxis • should be considered in patients undergoing general or orthopaedic surgery when the risk of VTE outweighs the risk of bleeding • The choice of prophylaxis will depend on the type of surgery, suitability for the patient, and local policy • Low molecular weight heparin is suitable in all types of general and orthopaedic surgery • Heparin (unfractionated) is preferred in patients with renal impairment • Fondaparinux sodium is an option for patients undergoing abdominal, bariatric, thoracic or cardiac surgery, or for patients with lower limb immobilisation or fragility fractures of the pelvis, hip or proximal femur • Pharmacological prophylaxis in general surgery should usually continue for at least 7 days post-surgery, or until sufficient mobility has been re-established • Pharmacological prophylaxis should be extended to 28 days after major cancer surgery in the abdomen, and to 30 days in spinal surgeryPoll Question Which of the following medications should generally be continued in the peri-operative period for a patient with chronic hypertension? A) ACE inhibitors B) Diuretics C) Beta-blockers D) Antiplatelet therapy (e.g., aspirin)Poll Question(with answer) Which of the following medications should generally be continued in the peri-operative period for a patient with chronic hypertension? A) ACE inhibitors B) Diuretics C) Beta-blockers D) Antiplatelet therapy (e.g., aspirin) Rationale: Beta-blockers are commonly continued perioperatively for patients with chronic hypertension, especially if they have a history of cardiovascular disease or are at risk for perioperative cardiac complications. Beta-blockers help prevent arrhythmias, manage blood pressure, and reduce the risk of myocardial ischemia during surgery. ACE inhibitors and diuretics may need to be adjusted or temporarily withheld before surgery, as they can affect kidney function, fluid balance, or cause hypotension in the perioperative period. Antiplatelet monotherapy such as aspirin is usually continued if surgery is not high- risk for bleedingGroup & Save and Cross-Matching Guidelines Group and Save(G&S) Crossmatching Determines the patient’s blood type (ABO Final step of pretransfusion compatibility and RhD) testing Screens for atypical antibodies Involve mixing the patient’s blood with the donor’s blood Recommended if blood loss is not expected Determine if there is an immune reaction between the patient’s blood and the donor’s blood Takes about 40 minutes Takes about 40 minutesPoll Question Which of the following is the primary purpose of performing a crossmatch before a blood transfusion? A) To determine the donor's blood type B) To ensure compatibility between the donor's and recipient's blood C) To assess the recipient's overall health status D) To identify any existing infections in the donor’s bloodPoll Question(with answer) Which of the following is the primary purpose of performing a crossmatch before a blood transfusion? A) To determine the donor's blood type B) To ensure compatibility between the donor's and recipient's blood C) To assess the recipient's overall health status D) To identify any existing infections in the donor’s blood Rationale: The primary purpose of performing a crossmatch is to ensure compatibility between the donor's and recipient's blood. This test involves mixing a small sample of the donor's red blood cells with the recipient's serum to check for any reactions that could indicate incompatibility, such as agglutination or haemolysis, which could lead to a transfusion reaction. Group and save tests help identify the recipient's blood type and screen for unexpected antibodies, but the crossmatch specifically assesses compatibility. While donor blood is also screened for infections, this is a separate process from the crossmatchPeri-operative procedures & protocols in emergency cases Peri-operative diagram of patient’s homeostasis in elective and emergency general surgeryEnhance Recovery After Surgery(ERAS) • Initiated by Professor Henrik Kehlet in the 1990s, ERAS, enhanced recovery programs (ERPs) or “fast-track” programs have become an important focus of perioperative management after colorectal surgery, vascular surgery, thoracic surgery and more recently radical cystectomy. • These programs attempt to modify the physiological and psychological responses to major surgery,and have been shown to lead to a reduction in complications and hospital stay, improvements in cardiopulmonary function, earlier return of bowel function and earlier resumption of normal activities • Key principles of protocol: • Pre-operative counselling • Pre-operative nutrition • Avoidance of peri-operative fasting and carbohydrate loading up to 2 hours preoperatively • Standardized anaesthetic and analgesic regimens (epidural and non-opioid analgesia) • Early mobilisationSequence of events during anaesthesia Triad Stages unconsciousness Induction Maintenance Emergence General anaesthesia analgesia relaxationCommon techniques Spontaneous ventilation with a laryngeal mask airway (GA LMA SV) • Generally used for elective or emergency surgery in patients who have been fasted and where there is no risk of aspiration of gastric contents • Common risk factors for aspiration include: • history of reflux or hiatus hernia • intra-abdominal pathology • Pregnancy • Can be used for patients in the supine or lateral position • Not recommended for use in very long cases.Common techniques Intermittent positive pressure Rapid Sequence Induction ventilation with an • To protect the airway if there is a risk of endotracheal tube (GA ETT soiling from gastric contents (RSI GA IPPV) ETT IPPV)Stages of anaesthesia(Guedel's Classification) • “Induction stage” Stage 1 • Patients are sedated but conversational • Breathing is slow and regular Analgesia/Disorientation Stage 2 • hypertension, and tachycardiarium, uncontrolled movements, loss of eyelash reflex, • Airway reflexes remain intact during this phase and are often hypersensitive to Excitement/Delirium stimulation • Hallmarks: Ceased eye movements and respiratory depression Stage 3 • Airway manipulation is safe at this level Surgical Anaesthesia • Occurs when too much anaesthetics agent is given relative to the amount of surgical Stage 4 stimulation →worsening of an already severe brain or medullary depression Overdose • Begins with respiratory cessation and could end with potential death • Skeletal muscles are lax, and pupils are fixed and dilatedStages of anaesthesia(Guedel's Classification)General Anaesthesia • Primary goal: render a patient unconscious and unable to feel painful stimuli while controlling autonomic reflexes IanaestheticsV) Neuromuscular Inhalational blocking drugs anaesthetics Classes of anaesthetic agents Synthetic opioids IV sedativesMechanism of Action of General Anaesthesia GABA reAeptors and anaesthetic action (A) GABA is released at inhibitory synapses and binds to postsynaptic GABA reAeptors. This allows chloride to enter the postsynaptic neuron. (B) The influx of chloride hyperpolarizes the neuron, generating an inhibitory postsynaptic potential (IPSP). The IPSP is enhanced by anaesthetics binding to the GABA receptor. A (C) The GABA reAeptors are pentamers of closely related subunits. (D) The membrane topology of a single subunit is illustrated. The amino acid residues thought to contribute to an isoflurane binding site are illustrated in (C) and (D) by red balls. (E) A schematic representation of a GABA receptor, illustrating that in A addition to binding sites for the physiologic neurotransmitter GABA, GABA reAeptors have distinct modulatory binding sites for benzodiazepines, barbiturates, neurosteroids, etomidate, propofol, and halogenated anaesthetics.Intravenous(IV) Anaesthesia Propofol • Phenol agent with rapid onset and short duration of action • Can be used for induction and maintenance of anaesthesia • Induction dose can cause profound respiratory depression • Offers advantage of effortless awakening with minimal residual sedation, even with prolonged infusion • Has anti-emetic properties • MOA: positive modulation of the inhibitory function of the neurotransmitter gama-aminobutyric acid (GABA) through GABA-A receptorsInhalational Anaesthesia • Liquids at ambient temperature and pressure • Transformed by vaporization into gas for rapid absorption and elimination by pulmonary circulation • Medication absorbed in alveoli and anaesthetic concentration in brain directly related to alveolar concentration • Commonly used for maintenance of anaesthesia • Key measure: Minimal alveolar concentration(MAC)-concentration that will prevent movement in 50% of patients in response to a painful stimulus(e.g. surgical incision)IV Anaesthesia VS Inhalational Anaesthesia Intravenous anaesthesia Inhalational Anaesthesia Specialized equipment are not necessary for their Special equipment's are necessary for their delivery/expensive facilities for the recovery and delivery/expensive facilities required for recovery disposal of exhaled gas and disposal of exhaled gas Onset of action of drugs(Propofol, Thiopental) are Most have a onset of action slower than IV faster than newer inhaled drugs(Desflurane, Anaesthetics Sevoflurane) Faster rate of recovery Slower rate of recovery Extensive use in outpatients Less use in outpatients Used most of the time as provides a quick, Can be utilised in patients with difficult IV access, smooth induction of anaesthesia which bypasses severely needle-phobic, paediatric patients the ‘stages’ of anaesthesia (tolerate mask better than IV cannulation) Can be used solely to conduct anaesthesia in short surgical procedures(Thiopental, Propofol, Ketamine)Poll Question Which of the following is the most common side effect associated with the use of inhalational anaesthetics? A) Hypertension B) Nausea and vomiting C) Bradycardia D) HyperthermiaPoll Question(with answer) Which of the following is the most common side effect associated with the use of inhalational anaesthetics? A) Hypertension B) Nausea and vomiting D) Hyperthermia Rationale: Nausea and vomiting are common side effects of inhalational anaesthetics, and desflurane. These side effects are often referred to as "postoperative nausea andurane, vomiting" (PONV). They can occur due to a variety of factors, including the type of anaesthetic used, surgical procedures, and the patient’s individual susceptibility. While hypertension and bradycardia can occur, they are not the most common side effects of malignant hyperthermia, which is triggered by certain anaesthetics but is not a commonike side effect.World Health Organization(WHO) Analgesic LadderPost-operative nausea and vomiting(PONV) • affects approximately 20-30% patients within the first 24-48 hours post-surgery • Consequences: • Increased recovery time and hospital stay • Metabolic alkalosis • Aspiration pneumonia • Surgical complications Female gender Patient Age factors Previous PONV/motion sickness Intra-abdominal laparoscopic surgery Risk Surgical factors Prolonged operative times factors Poor pain control post-operatively Anaesthetics Opiate analgesia/spinal anaesthesia factors Inhalational agents(e.g. : isoflurane, nitrous oxide) Prolonged anaesthetic timeThe pathways and neurotransmitters involved in the control of vomitingPerioperative urinary catheter use • Urinary catheters (commonly known as Foley catheters) are frequently placed in patients undergoing surgical procedures • serve to prevent bladder distention or incontinence in the anaesthetised patient, as well as facilitate the measurement of urine output during and after surgeryPerioperative urinary catheter use Infectious and non-infectious urinary catheter complications. CAUTI, catheter-associated urinary tract infection.Trial without Catheter (TWOC) • Catheter which has been inserted previously into bladder via the urethra/abdomen is removed for a trial period to determine whether patients are able to pass sufficient urine spontaneously as before • Once the catheter comes out patient will be asked to drink plenty of fluids approximately a glass every 30 to 45 minutes • Patient will be asked to stay until they have passed urine satisfactorily, a minimum of 3 times. Patient’s urine will be measured each time they void, and a bladder scan will be performed after the third void to determine the volume of urine remaining in their bladderPost-Operative Nutrition • Surgical procedures induce a hypermetabolic response on the body increasing protein and energy requirements • Development of post-operative malnutrition is dependent on the patients pre-existing nutritional status, the surgical procedure and the degree of hyper-metabolism • Post-operative malnutrition can impair immune function, increase mortality, increase length of stay, compromise wound healing and increase complication rates • Early enteral nutrition post-surgery reduces the risks of wound infection, pneumonia, intra- abdominal abscess and anastomotic dehiscence.Hierarchy of Feeding If unable to eat sufficient calories Oral nutritional Supplements (ONS) If unable to take sufficient calories orally orNasogastric tube feeding (NGT) dysfunctional swallow If oesophagus blocked/dysfunctional Gastrostomy feeding (PEG/RIG) If stomach inaccessible or outflow Jejunal feeding (jejunostomy) obstruction If jejunum inaccessible or intestinal failure Parenteral nutrition (IF)Calculation of an Individual’s Nutritional Needs The Eatwell Guide • divides the foods and drinks we consume into 5 main food groups • On average, women should have around 2,000 calories a day (8,400 kJ) and men should have around 2,500 calories a day (10,500 kJ) • does not apply to children under the age of 2 because they have different nutritional needsRole of MDT in Post-Operative Care • Refer to dietician • liaise with both patients and the MDT to identify a suitable dietetic plan to improve nutritional status considering patients' individual dietary preferences and clinical factorsCommon post-operative complications Delirium • Likelihood of post-operative complications is influenced by the type Post- of surgery, the patients pre-existing Atelectasis operative comorbid state and peri-operative haemorrhage management General post- • Post-operative complications can be complications general or specific to a particular operation and can also be classed Deep vein Sepsis according to their time of onset: thrombosis immediate, early and late IleusAtelectasis • Collapse of areas of the lungs and may result in post-operative pulmonary complications such as hypoxia • Clinical examination may show reduced basal air entry with reduced lung volumes on chest x-ray • Prevention and treatment includes humidified oxygen, good quality analgesia to allow deep respiration, coughing and sitting up, early mobilisation, chest physiotherapy and continuous positive airway pressure (CPAP)Post-operative Haemorrhage bleeding that occurs within the intra-operative period Primary • occurs within 24 hours of operation • Due to ligature that slips or a missed vessel Haemorrhage Reactionary • can often be missed intra-operatively due to intra-operative hypotension and vasoconstriction Secondary • occurs 7-10 days post-operatively • often due to erosion of a vessel from a spreading infection, such as when a heavily contaminated wound is closed primarilyClassification of Haemorrhagic Shock Class I Class II Class III Class IV Blood Loss(ml) <750 750-1500 1500-2000 >2000 Blood Loss(%) <15 15-30 30-40 >40 Heart Rate <100 100-120 120-140 >140 Blood Pressure Normal Normal Decreased Decreased Respiratory Rate 14-20 20-30 30-40 >40 Urine Output (mL/hr) >30 20-30 5-20 <5 The American College of Surgeons Advanced Trauma Life Support (ATLS) Haemorrhagic Shock ClassificationPost-Operative Haemorrhage Risk factor Cause Drugs Heparin, warfarin, non-steroidal inflammatory agents(NSAIDS), anti-platelet drugs Congenital bleeding disorder Haemophilia, von Willebrand disease Acquired bleeding disorder Sepsis, liver disease, disseminated intravascular coagulation(DIC)Delirium impairment Type of Age surgery Risk factors Medications Pain acute confusional state which can Sleep occur post-operatively in any disruption Dementia patientReduced bowel function Reduced • Constipation may occur post-operatively due function to opioids or anti-cholinergic • Management involves adequate hydration, appropriate nutrition and laxatives Reduced • Post-operative ileus may be caused by intra- absorption Features Abdominal operative bowel manipulation, pain, of oral of ileus distension immobility, hypokalaemia and opioids drugs • Ileus usually resolves within 24-36 hours and management involves insertion of a naso-gastric tube, analgesia and reduced oral intake Naanda vomitingPoll Question Which of the following is the most common cause of post-operative fever in the first 48 hours after surgery? A) Surgical site infection B) Deep vein thrombosis (DVT) C) Atelectasis D) Urinary tract infection (UTI)Poll Question(with answer) Which of the following is the most common cause of post-operative fever in the first 48 hours after surgery? A) Surgical site infection B) Deep vein thrombosis (DVT) C) Atelectasis D) Urinary tract infection (UTI) Rationale: Atelectasis, or the partial collapse of the lungs, is the most common cause of postoperative fever in the first 48 hours after surgery. It occurs due to shallow breathing and reduced lung expansion after surgery, especially in patients who undergo abdominal or thoracic procedures. The fever is usually low-grade and is often associated with mild respiratory symptoms such as cough or difficulty breathing. Surgical site infection (SSI) is a more common cause of fever beyond the initial 48 hours. Deep vein thrombosis (DVT) can lead to fever but is less likely to be the cause in the first 48 hours. Urinary tract infections typically cause fever later in the postoperative period and are more common in patients with prolonged catheterization.Poll Question Which of the following is a key risk factor for the development of post-operative delirium? A) Advanced age B) High body mass index (BMI) C) Use of regional anaesthesia D) Long duration of surgeryPoll Question(with answer) Which of the following is a key risk factor for the development of post-operative delirium? A) Advanced age B) High body mass index (BMI) C) Use of regional anaesthesia D) Long duration of surgery Rationale: Advanced age is one of the strongest risk factors for the development of postoperative delirium. Older patients are more susceptible due to factors like cognitive decline, multiple comorbidities, polypharmacy, and changes in brain function. Delirium is a common postoperative complication, particularly after major surgery or in the presence of other stressors such as infections or metabolic disturbances. While a high BMI, regional anaesthesia, and long surgery duration may also influence postoperative recovery, they are not as strongly linked to delirium as advanced age.Post-Surgical Patient Review Summarise patient’s case • Patient’s demographics: Full name & age • Operation: • Days Post-Operation • Type of operation • Reason for operation • Planned management: • Check operation note to ascertain post-operative plan Investigations results review • Latest bloods and their trends • Inflammatory markers (WCC, CRP) – may rise for first 2 days post- operatively but should fall after that • Haemoglobin • Electrolytes • Other new investigation results Post-Surgical Patient Review Any Fluid Drain Focused symptoms/is Pain Mobilising? Observation balance Stool chart Food chart Tubes in-situ quantity and Wounds system sues? controlled? s chart output examination Planandmedicationsreview Clerking Nursing charts Examination Patient AssessmentReferences 1. NICE. Diabetes, surgery and medical illness [Internet]. NICE. 2023. Available from: https://bnf.nice.org.uk/treatment-summaries/diabetes-surgery-and-medical-illness/ 2. Blood Products - ABO - RhD - Administration [Internet]. TeachMeSurgery. Available from: https://teachmesurgery.com/perioperative/preoperative/blood-products/ 3. Aspirin [Internet]. UKCPA Handbook of Perioperative Medicines. UK Clinical Pharmacy Association; 2023 [cited 2025 Jan 26]. Available from: https://periop-handbook.ukclinicalpharmacy.org/drug/aspirin/ 4. NICE. Anaesthesia (general) [Internet]. NICE. 2023. Available from: https://bnf.nice.org.uk/treatment- summaries/anaesthesia-general/ 5. Stages of Anaesthesia - General Anaesthetics | Pharmacology [Internet]. pharmacy180.com. Available from: https://www.pharmacy180.com/article/stages-of-anaesthesia-1125/ 6. Siddiqui BA, Kim PY. Anesthesia Stages [Internet]. PubMed. Treasure Island (FL): StatPearls Publishing; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557596/ 7. Royal College of Anaesthetists. Basic anaesthetic techniques [Internet]. The Royal College of Anaesthetists. 2019. Available from: https://www.rcoa.ac.uk/documents/novice-guide/basic-anaesthetic-techniquesReferences 8. Pergolizzi J, Raffa R. The WHO Pain Ladder: Do We Need Another Step? [Internet]. www.medcentral.com. 2015. Available from: https://www.medcentral.com/pain/chronic/who-pain-ladder-do-we-need-another-step 9. Post-Operative Nausea and Vomiting - TeachMeSurgery [Internet]. TeachMeSurgery. 2015. Available from: https://teachmesurgery.com/perioperative/general-complications/nausea-vomiting/ 10. Meddings J, Skolarus TA, Fowler KE, Bernstein SJ, Dimick JB, Mann JD, et al. Michigan Appropriate Perioperative (MAP) criteria for urinary catheter use in common general and orthopaedic surgeries: results obtained using the RAND/UCLAAppropriateness Method. BMJ Quality & Safety [Internet]. 2018 Aug 12;28(1):56–66. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6365917/ 11. Trial without Catheter (TWOC) [Internet]. University Hospitals Sussex NHS Foundation Trust. 2022. Available from: https://www.uhsussex.nhs.uk/resources/trial-without-catheter-twoc/ 12.BNF is only available in the UK [Internet]. NICE. Available from: https://bnf.nice.org.uk/treatment- summaries/venous-thromboembolism/#venous-thromboembolism-prophylaxis 13. Owen S. Post-operative general surgical patient review [Internet]. OSCEstop. 2022 [cited 2025 Jan 26]. Available from: https://oscestop.education/learning/post-operative-general-surgical-patient-review/