Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Take some time usual. Ok, with life. Hi, everyone. So my name is Claire. I um the Education Officers for NSTS and one of the organizers for this er teaching series. So, welcome to the third um session of this series and this session will focus on focus on postoperative complications. Um If this is the first session you've been to for the series. Um Welcome. Thank you for joining us. Um The series is focused um um aimed towards final year or senior medical students and foundation and doctors in preparation for their first and surgical F one sho um It's hopefully going to give you a bit um a bit of a background into we've done sessions on what sort of things you can expect to see how to manage your own calls. Um And hopefully this will help you deal with some postoperative complications that you might see on the wards. So I will um hand over to ci to um deliver the session and then we'll do a little bit of feedback at the end. So over to you ci perfect. Thank you so much Claire. Um So, as you've already mentioned, this is a quick talk on postoperative complications. Um It is, there are a lot to cover. Um So it will be a sort of a brief overview on how to sort of have a systematic approach in managing um certain postoperative complications, especially the common ones and um more dangerous ones and to always sort of keep your composure basically. Um I've tried to do it as you're sort of getting bleeps. Um, we'll see if that works or not. So that's why I put the caption. Uh, welcome to the unluckiest surgical on call in the history. So, um, yeah, so before I sort of start, uh, going straight into the actual, um, nitty gritty of the, of the talk, just a little bit about me if anyone is at all interested, I don't know why. Um, as I said to my name is SI P. Um, I'm, er, currently working as a junior orthopedic clinical research fellow. Um, it's at the South West London Elective orthopedic center swe quite a mouthful. Um, and of course I also an education officer for a National Surgical Teaching Society for this year. So hopefully you'll see me around later on in the year, different tutorials. Um, one UCL did F one F two zone. Um, this is what I'm doing now. Future, I don't know. Let's carry on. It's a brief, brief overview, right? So what's the purpose of, um, today's talk? So, um, specific things that I want you to get out. I caught kind of already mentioned a few things. Um But what I want to really focus in on is developing a system, the last bullet points are developing a system to manage the uh following scenarios with differentials in mind. OK. So it will be things like postoperative, fever, postoperative bleeding and specific complications sort of by surgery. I have a few examples. OK. So that's the main objectives of today. So um my personal framework um before I go through it, um I keep emphasizing and I will keep emphasizing the um focus on being calm. So when you guys become F ones and your uncle, I, I want you to read this part of the top left corner of that slide, you know, very few scenarios are so demanding that the patient may die within seconds to minutes. OK. So um can you think of any, so if you guys can uh use that QR Code, pop it in, go on to men. Um And it should be a free, um you know, free words um that you can type in basically. So can you give me any few examples of um scenarios? Uh that would mean that the patient might actually deteriorate within seconds to minutes? Uh just to give you an example? Really? Ok. Um So that's what I'm saying. Not many are and especially not and they don't have to be surgical. OK. So any of them, you can either do that on me or you can pop them down in the chat as well. Um Either or so a anyone wants to just pop some stuff in also, by the way, this, the, these sort of webinars, obviously, the more you put in, the more you get out. So, yeah, just crack on, see if you can put some post anesthesia, mi aortic dissection, uh, some good stuff coming in. Hypotension. Yeah, I mean, that's not obviously a condition in itself, but I, I get it. Ok. Um Respiratory arrest, massive hemorrhage. Anaphylaxis. Yes, exactly. So these are exactly it. And that's enough for me to go off on. Ok. So, um anaphylaxis certainly. Ok. Massive hemorrhage. So where you can see it, you know, absolutely pouring, you know, um with blood coming out then that's obviously another one that can, um, you know, obviously if they're in cardiac arrest, that person is already technically dead, of course. So that doesn't count. But exactly. So those are the only kind of things that actually, you know, going to uh deteriorate within um that timeframe. The rest you have a lot more time than you realize. OK. So that's number one, then let's go through this framework. Um I put escalate about four times there because my entire aim is to say to you escalate at any point that you feel comfortable. OK? Um Or rather you don't feel comfortable. So if you get, you know, bleeped or cold about a patient that you just think what is going on? Goodness gracious. I've got no idea. Um, it's ok. The number, I can't tell you the number of times. Um, I've bugged my surgical registrar and, um, just as a heads up, you know, like I, I, you know, I, I, I'm literally a keen surgeon as well or wanna be surgeon. So, you know, uh, if I, if I can do it, like it's ok and anyone can do it like in a sense, bug bug them as much as you can if you don't feel comfortable. Ok? So that's number cool. So this is my framework. So you're called about a patient. Get a good SB R ok? So proper situation, background assessment recommendation, um get their observations that is crucial, you know, that tells you everything and that gives you a rough idea whether you need to do an in person review, you can wait a little bit or you can prioritize other things, ok? And when you do for an in person review, especially in the beginning, if you're not so confident, just start with your A two re assessment and I'm not going to go through that because it's not a talk on that but you know your airway, breathing, circulation, disability and everything else, ok? Everything else being things like drains, you know, external bleeding, any injuries, that kind of stuff, ok? Um but yeah, go through that then review their past medical history. The operation though is so crucial um you know, as medical students, I certainly remember. And as an F one as well, we don't understand the importance but, and it tells you exactly what was done in the operation, any complications that occurred and they have clear postoperative instructions. Sometimes the consultant even says if X and X, you know, happens directly, call me, you know, and so then you, you can, you can save yourself a lot of hassle when you go through the op node. OK. So that, and then obviously go through bloods and images if you have the time, obviously, otherwise your a three simultaneous resuscitation reassess and keep going through that. OK? Then the number one question that I think you need to sort of take away from, from this talk really is for you to decide you're in that scenario. Just imagine yourself there. You've done your A two E you've got, you got what you think is your provisional diagnosis of what's going on. You need to then decide roughly or you know, think about is this patient likely to have surgery or need to have surgery tonight? If the answer is yes, you've already reached what you can do. Well, in the sense that provided you stabilize them, um you've reached the limit. So you need to escalate to the surgical registration straight away and then they can guide you further. Um If you don't think that the patient is likely to have surgery, then, then you can think about, you know, can I or rather should I be managing this patient on my own if you are confident, um you know, go for it. But at the same time, I would always say obviously in the early stages, get verbal advice, at least just confirmation that could be from the sho or that could be from the registrar. Ok. And if you're not confident in managing that on your own, which is absolutely within your rights. Um because you should not be working outside of your competency request, an in person consult. Ok. Um That's a very mechanism I realize, but you know, just use it for the sake of uh ease. Um And you know, who depends on the presenting complaint or what you think the diagnosis is. If you think it's a primarily a surgical problem, your first port of call will be the surgical registrar and then they'll guide you. However, even if it is medical technical, the actual good practice would be though you seek the advice of the medical registrar, you should always let your surgical seniors know as well because ultimately, they're responsible for that patient that it's under your care as a surgical team. OK. Um In reality, surgical reg probably tells you to talk to the med reg. OK? But also remember you have the it registrar and other professionals as well within um that time period. OK. Good. So that's your framework. So simple things. So you get called, um, Sar and Abbs. Get that, that will allow you to go. Ok. Is this a priority? Do I need to go see them? You go see them, you two then get yourself a and look at their background, get yourself a provisional diagnosis. Think, do I need to, you know, does this patient need to go for surgery tonight? Yes or no. No. You've got more time, even more time. Um, and then you can go forward. Ok. Good. So that's the sort of background. Now we dive into it. Ok. So one of the most common, in fact, I think they did a study. Um I looked up studies for you guys as well. So one of the most common or in fact, the most common um POSTOP complication or presenting complaint rather was postoperative fever. Now, the differentials are broad and I'm using different little mini scenarios and we'll build on each scenario. I'll give you more information as we go to highlight the different possibilities, the different diagnoses that could be possible. OK, with a postoperative fever and you'll learn to distinguish it by timeline as well. So we've got scenario 12 and three. Scenario one, a 43 year old um lady postoperative day one. she's undergone a laparoscopic cholecystectomy, mild bit of pain controlled on oral analgesia and she spiked a temperature of 37.8. Ok. Keep that in mind. Scenario 2, 71 year old male um postoperative day six, undergone a sigmoid colectomy with primary anastomosis for colorectal cancer. They're in severe pain despite IV morphine and they spiked a temperature of 38.2 67 year old. Female scenario. Three. Now, postoperative day nine undergone a total hip replacement for a neck of femur frac neck of femur fracture. She had the fracture, they're short of breath despite two liters of nasal cannula, er two liters of oxygen via nasal cannula. Um and spiked a temperature of 37.6 barely a spike. But technically it is. Ok. So let's do the, let's go back to men who are you worried about the most? Uh can you rank? So which uh scenario if you, if you got those three ble bleeps at the same time, which would you be rushing off to first and put them in order? Ok. So I'll be having a quick. So let's see. Do you guys wanna have a quick? Yeah, just keep ranking. So which one are you most worried about the postoperative? Day? One lap coli the day six sigmoid Colectomy or the day nine tr or again, as I said, uh pop them in the chart either as well. OK. Feel free to. What about if someone can just pop in the chart, which uh if you just had to pick one, which did you go to first? Don't see too many um rankings don't be shy. Just go for it. Ok, fine. Let's put it there. Um Like I said, guys, if you, if you don't want to er, use men as well, feel free to use the chat function as well. OK. But um fine. So I think there were literally one or two be braver, there's literally no wrong answer, go for it. Um But um I think there will be one clear answer. Um, but I won't reveal it just here, you might realize later. OK. So let's go through the observations. Um So if you look at scenario one, look at the BP, heart rate, I'm not gonna go through every single reading. You can sort of see for it on your screen as well. OK? Um You can see sort of, you know who's hemodynamically stable, who's not, who's tachycardic, tachypneic, all that kind of stuff. OK. So given these observations, now, who would you be most worried about if you didn't vote before or again, if, if Menzies is not working for whatever reason, put them on, uh put them down in the chart as well? Good. Um There's some rankings coming through. Um So, yeah, exactly. Yeah. So people are slowly starting to go for seems like scenario two is the winner, correct? And you know, that's, you'd see the observations themselves speak for themselves, right? The hemodynamic instability with the BP, tachycardia, they're in severe pain. Despite IV morphine, the temperature itself is higher and uh the potential differential diagnosis here is also more worrisome. So remember our uh sort of framework I talked to you about before. So the nurse, you know, they might call you about with this bit of information only you would want to get up, you know, properly, even, even better as well than this, get the observations. Then you can decide uh where to go see them. In the scenario. You have, you've done a, a three for all of them. So in the first one, airway is fine, you know, breathing, you know, a bit of bibas crepitations. Otherwise ne of no, basically, um the wound side is a bit tender, nothing else. Scenario one sona too, the airway is fine, you know, breathing's ok, but they seem pale and clammy um and sweaty, diaphoretic, um abdomen is rigid. Um but the incision, the actual surgical scar is healing well. Ok. And scenario three, they've got moderate tachypnea. Um otherwise not much else uh in on your e um they've got eczematous skin rash over their hands and their legs. Um And they've also had diarrhea for the last three days as well. Ok. Just think, you know, these are obviously not like an SB a and not also representative real life, but it's more to guide you towards the um answers and think about what factors affect which diagnosis. Ok. And we'll come on to that in a minute. So let's try and get through the sort of diagnoses then. Ok. So what do you think might be going on? So we'll use the um, poll uh on. Ok. So what do you think is the diagnosis in scenario number one? And I will start the poll? Ok. So you can, you should be able to have a vote or pole rather and yeah, you can just start to vote. What do you think is the most likely diagnosis? Just choose one? Ok. OK. For you guys just um literally just go for, I can't see your names by the way, so you can vote. It's completely fine. All right. Give you a little bit more time. OK. Fine. So perfect. Um 32 responses um seems like most have gone for normal postoperative pain. Uh um That was the most popular um Bole league 9% atelectasis, 18% and perihepatic collection 3% fine. OK. Um If anyone's feeling brave enough, does anyone wanna write down why they thought it was normal postoperative or why they thought it was at? Is this so or shall I just go through the answer? Let's probably go through the answer for the interest of time. OK. So for this one, you know, I wrote atelectasis is the most likely answer. So, um but what you said about normal postoperative pain, um you're also not entirely wrong. OK. So it's one of those, it's very borderline tricky. OK. But if um you know, you're absolutely right in the sense that post-operatively in the first sort of 24 to 48 hours, you can expect a low grade pyrexia and that's because of the inflammatory response of surgery itself. Ok. Um, and it is described as mild pain as well. Um, but, um, but I suppose the addition of by basal crepitations on your A two e, um, changed things slightly for atelectasis. Now, what is atelectasis? Um, you know, hopefully you do know it, but if not just very quickly, obviously, you know, you're putting the patient through anesthetics, you know, their, their lungs are gonna be collapsed a little bit and with pain, they're not gonna be able to breathe and inflate those lungs fully. So you just get a little bit of, you know, er, airway collapse, small airways collapse and water gets trapped as well. So, uh, you don't recruit that uh, small airways in your breathing and again, through some long pathophysiology process that causes a bit of fever. Ok. But otherwise you guys are on the right line. What about scenario two then? So let's crack on. What do you think is a rather, no, that's, well, this was an obvious one. It's fine, er, technical glitch. I, we put it down to but I'll give you all the right answers. So this is the feared anastomotic leak. Ok. Um I might as well tell you that now rather than putting you through it. So, um, they've gone up, you know, it's postoperative day six, typical timeframe, uh, as a primary anastomosis, rigid abdomen, high temperature and they're hemodynamically unstable. Ok. So if we go through the other options collection, um, sort of tends to develop a little bit later, we're thinking sort of, you know, day nine, day 10, um, large bowel ischemia. Um, that's unlikely, um, you know, and it's unlikely to sort of also cause this constellation of symptoms as well. The other thing you got to think about is, you know, hopefully, um they're on um VT thromboprophylaxis which further on we'll get to. Um, so hopefully that wouldn't be the case. And this is definitely not the normal postoperative pain, is it because it's day six and they're still getting IV morphine. So that's that. Now, before I make the same mistake again, let's launch the poll er, for um the third one. Ok, so stop polling. So what do you think is the answer or the diagnosis for? Scenario number three? So let me see what people are putting down. Give you a little bit of time. Uh OK. There's only a few, few responses in, but it's also because I didn't give enough time. Keep coming. Keep coming, keep it coming. I'll give you a little bit more time. So again, remind a 67 year old female, um total hip replacement neck or femur fracture. Um Postoperative day nine, I think also I realized when I submit my answer, it locks it, but so my apologies. Um but yes, the vast majority of you went for pe um which is absolutely what I was getting towards. Um, note all the subtleties and uh my description. I don't know if anyone can appreciate that, but if we go back just here, you see our um in your at three assessment, they've had an eczema skin rash over their hands and their legs and also had diarrhea. So what might that, you know, what might be the significance of that? Um, again, if anyone's feeling brave, do you want to type down is a bit of an abstract, er, thought though. But it's a, it's a very common scenario in wars. Um, but I might as well say so, you know, with having a skin rash over your legs, the patient is unlikely to be putting on Ted Stockings. Ok. And with diarrhea, they're likely to have been immobile one and also too dehydrated. It's orthopedic surgery. Um, so, you know, you've got all the hallmarks of potential for causing a pee. Ok. And I suppose the main thing is day nine, you know, you have enough time for that to brew. Basically that ver triad to brew um, to cause a VT event. Ok. Good. Fantastic. Right. Management. So, um, of each of those. So do you wanna go onto men again? Um, how would you manage atelectasis? So, just have a little bash, right? It's open ended. Uh, words again. So how would you manage atelectasis? I told you sort of what it was so, feel free to put some concise um, responses. How would you manage that? So, you've come across this patient, you, you know, you're not overly concerned but you realize that, you know, it could represent some likely postoperative atelectasis and that's why they're spiking in temperature. Um How would you manage that? Go for it to anyone and again, also feel free on the chat to or would you like me to explain? What is the management? Yeah. Fantastic to hear some, some answers coming through. Yes. Yes, some good stuff. So, right. So supportive management. Absolutely. Option if required. Absolutely. Physio. Yeah, if you specified. Yeah, chest physiotherapy. Exactly. Perfect. Um And I really like the better pain relief. Ok. So that's really good stuff. So if we were to approach it, almost like your um almost like your poem, if you think about it because ultimately that is kind of what it represents. Just not the same path offi but you know what I mean? So set the patient up. Chest physio, saline nebs, ok. Um You oxygen titrates it to their requirement, you know, this patient, they were oxygenating. Ok? The SATS were fine. So you probably don't need to, but that's absolutely fine too. Absolutely better pain relief because they then are able to uh expand their lungs, take deep breaths in and also crucially cough. And that's part of, you know, um chest physio and also early mobilization. Ok. So that's fantastic. That's good stuff. All right, carrying on the next one. So this is probably far more important for you on call if you were ever have the misfortune of coming across an anastomotic leak um happening uh on your own call. How would you manage that then? So, um, also, um, I like the enthusiasm. Some are saying, Niv, you probably wouldn't go for NIV, for atelectasis. It's a bit too palmed. OK. Uh But good stuff. So next one, how would you manage um Anastomotic League? Hopefully your surgical registrar level by the end on step by step, go for it to give you a bit of time. Also, thank you for bearing with, by the way, the jumping back and forth from men. Um But yeah, it's a good way to hopefully get some uh interaction and for you to test out your answers as well and give you a little bit more time. Yeah, some things coming through. OK. Fluids, fine. OK. Antibiotics. Um Yeah. OK. Cool registrar. Good, good, stabilize the patient then back to theater. Yes. Absolutely good. Fine. So some good stuff coming through. Fine. Yes. So way we're gonna manage this. OK. Think about it like um this could be like in your sky, OK? That you say it, this could be in real life. You got to think about your immediate management and then your definitive management. OK? So one of you guys mentioned the definitive management um Yes. So which is essentially um the patient needs to go back to theater for repair of the anastomosis. Ok. So one of the answers was uh make a surgical referral. You are the surgical team, my friend. You are the surgical team. But yes. Correct. Um Someone's a born medic there. Um Fine. So um correct. So, you know, you, you wanna think about immediate management and definitive management, definitive management we talked about they need to go to theaters ultimately. OK? But there's everything before theater and that's your key task. OK? As A, as F one or F two on call, um that's, that's what, that's entirely your responsibility. OK. So you need to think about a two week scenario. So, you know, obviously, you know, airway is fine, breathing's fine circulation. You're right. Ultimately, these guys are septic. OK? So what you need to do is initiate the sepsis six pretty much. OK? Take three, give three, OK? Um And you know, can quickly go through it just for a recap, you know, purposes. Um You know, so take um you know, uh blood cultures, lactate urine output, give broad spectrum, antibiotics, fluids and um oxygen. OK. So that's your primary aim and that's going to stabilize the patient a lot more. OK? Make sure that they have a, a valid uh group and say it will cross match as well. OK. Um Your right, absolutely. Early senior escalation. Um and um you know, pain relief, as well. The these patients are in severe severe pain. Ok. Good. Um And then you can think about, you know, once you're even more advanced as in sho you think about then uh liaising with the surgical reg liaising with the anesthetics and theater coordinators to book them in for theater if you got the go ahead. Ok, realistically, the consultants getting involved too good stuff, right? Finally, uh scenario number three. So how would you manage this patient? So the pe how would you manage pe go for it again, think about immediate and then definitive management. OK. Again, also, by the way, guys put anything on the chart, if you think I'm going too fast, too slow. Um Any questions that you have, by the way, I, you know, doesn't need to even be said, just pop it in the chat. Um Don't put the questions onto men cos I won't be able to keep a track of them but on the chat and um we'll have a look. OK. Good. Um So do a yeah, seems to be a to confirm if not able to get in four hours and treat with a low moco a heparin fantastic stuff. Good. Um Absolutely correct. So, um yeah, you know, uh with a post operative patient whilst they're inpatient, you probably wouldn't go with AAA direct um oral anticoagulant. Um You would go for a low he um you would likely speak to the medical team as well in this scenario, by the way, but again, these are all definitive management and you're right. Uh We would confirm with the CCP um because why, why would we not do a d-dimer? Um Anyone wants to put on the chart, maybe why would we not do a d-dimer for this patient? Um You can type it very quickly. No worries, no judgment. Um Absolutely. Fine. OK. You can type if you do want to put anything on the either a sneaky way to get you guys on the chat. But um fine. No, so literally, um postoperative, they're postoperative. So the DD is going to be sky high anyway. Um OK, there are certain scenarios where A P would cause an increase on top of that, but you just can't tell. So instead of guessing you would go for a CT P. OK? But the immediate management again, I want you to always say in your osis, but also doing your real life a two approach, make sure they're hemodynamically stable. Um And that includes in a, in a pe setting, um you know, titrating option to um their requirements, um you know, and performing other um investigations like for example, an ECG which could show sinus tachycardia, um you know, even a chest x-ray, for example, to rule out other causes like a pneumonia go through blood results, all these kind of things. But yes, and then ultimate management would be with low molecular weight heparin after you've escalated. OK. Good, good stuff. So we've gone through um causes of postoperative fever. We've gone through three cases already. OK? And we vary it by timeline. So what day of postoperative uh day? They are basically OK. Now, the slide looks like a lot. Um but it's everything that I've gone through already. So why can you get a postoperative uh fever? I talked about body's inflammatory response. Next, most common thing is infection. So that could, and these are things that I mentioned obviously, but it could be, you know, chest infection, urine infection, surgical site, infection, anything like that. Ok. Um And then if we go through that timeline, early stuff is, you know, the body's normal response to atelectasis, then you get the infections coming through day 5 to 7 is when you think about that sort of, you know, anastomotic leak, er a bit later you get the uh collection and then tip typical. Even after that, you get the venous thrombo embolic events. OK? And you also want to think about infector lines as well. Ok. Good. And then we talked about immediate management using a three and sepsis six. and then definitive management while we went through each of those scenarios. Good. So that's presenting to plan number one. OK. We've got another one. couple more, well, three more scenarios for this and we focus on postoperative bleeding. Ok. So again, um take a minute to read and I'll read it out loud to same format as last time. Really good interaction wise. Um Yeah, let's go crack on. So, scenario one, I'm trying to choose a bit of variety here. Ok. So 64 year old male underwent an open iliac artery aneurysm repair 21 hours ago. Ok. Um Patient is in severe pain around the incision site uh with swelling around it and purplish discoloration locally as well. If it adds anything as well, that pain sort of started a a relatively suddenly, you know, 30 minutes ago. OK. Scenario one scenario 2, um 14 year old male underwent tonsillectomy eight days ago. Um Now has brought up some blood and some mucus and is feeling a little bit low in energy and he is not eating well either. OK. Sri two scenario that should say three apologies. So 67 year old male underwent a transurethral resection of the prostate uh procedure just arrived to recovery. Now, I literally just came out of the theater into recovery. Op note, uh estimates it was a great surgical core surgical trainee who wrote the op note straight away. Op Note estimates that the patient lost uh you know, 800 to and I think one of the other slides says maybe even 1.1 liters OK? Of blood. Um patient is short of breath and a bit dizzy. That's the background. OK. Good. So we're going to add what, what would you want to hear if you were called to review these patients. What would you want? So this was an SB a next thing you'd want would be according to the framework. OS OK. So that's what you're going to get. Uh But before you get the OS, you know, trick myself, um uh which scenarios would be, would you be most worried about before you even hear the ob observations? OK. So I want you to rank um So we've gone through this, gone through this. So rank which scenario worries you more. So very simple. 123, give you a vote to which one worries you the most. OK. A men that is, by the way, OK. Couple of responses. We've got a bit of a split vote but slowly but surely seems like do wanna give you guys a bit more time as well, but I'm also wary of trying to get through everything as well. So, apologies if you do feel a bit rushed. Ok? Uh You will hopefully have um this recording to watch back in your own time as well. So it seems like marginally, scenario one has uh one. And I would agree, but let's see, does the observations change anything? Let's see. OK. So again, you can read the observations for yourself. Uh You can see which one's more hemodynamically unstable going BP, you know, tachycardia, delayed cap refill, tachypneic. Um And also how alert or not they are. OK? So that might change something again, it should say scenario three. So based on these findings, now, which scenario wor worries you more. So go on to the next slide on your mental um and then give it, give it a bash should hopefully be very quick again just to, you know, keep it going. Basically as always any questions pop them down in the chart. OK. Few responses coming through. So seems like scenario one is still winning, but there's a little increase in scenario three though. Interesting. Yeah, keep it going. OK? I will keep it going, keep it going, keep it going. We're gonna have to be quick. So sorry guys. Fine. So yeah, scenario one still came out marginally on top over scenario three agreed, agreed simply because of the hemodynamics. OK? Look at their BP. Um So scenario three, I'll explain. So why I may not think so, but I understand why you guys might have gone for it. OK? So in scenario three, BP is a little low. OK? 98/73 we don't obviously know any of the normal BP. So you know that's true, but you don't always have that time or, or luxury as well either. But even then for just postoperative patient that's just come out of theater that 98/73 is not uncommon at all. OK? So that's number one. And then the other thing that you guys may have noticed and gone for scenario three is being more worried as well, is that they're now alert to voice, but why might that be the case in this scenario? Well, they're literally just coming off anesthesia. They're literally just coming off from being high as a kite, right? Um, with the ketamine, you know, coming out of sedation from propofol and all of that cocktail that they use. So, you know, they're going to be probably only alert to voice. So that's, that's fine. Um And that's probably also explains a little bit about, um that fact, little bit short of breath and a bit dizzy as well. Ok. Um But scenario one, you look at it's, it's truly, you know, hemodynamic instability, the the the pain started, you know, sudden onset, you know, um you know, it's 30 minutes ago, localized swelling, um, severe pain, everything is screaming in danger. So given these factors, um you've gone and done a, a two on all of them miraculously um simultaneously as well. So in scenario one patient is talking in full sentences, you know, nothing else but they look pale clammy. Um, you know, the observations are abnormal anyway. Um And around the wound site, it's what I've described to you. OK. That's it. So that's all you see. Scenario two. There's basically not much except for when you look in the mouth on e um there's a clot over the tonsilla fossa, OK? Otherwise nothing else. Um And in scenario three, you know, they're, they're talking words, they're not talking full sentences, they're talking words. Um And they're a little bit confused. Ok. That's it. Now, let's think about diagnoses then. So that's our framework, isn't it? So we've always said you get called, you get the observations, you then go do your A two E look at their background bloods and everything, which I know I haven't provided here, but I just want to do a quick rough overview. Um And then you think about your diagnosis, right? And then you think about whether or not they need surgery and that's how you manage them. So let's get to the diagnosis. So for scenario one, I'll run a poll again on, on a metal here. Ok? So POSTOP bleeding, scenario one, what do you think is the diagnosis? Ok. So let me POSTOP bleeding. Scenario one, stop polling. So I'll give you guys a bit of time. So sorry, it won't be too much time to see if you guys could get voting. Pronto. It's just so that we cover everything which I think hopefully will be good to cover and then I'll answer in maybe 10 seconds. Ok? And like I said, you know, don't take these answers as sort of SB A in not proper med school format. Sp A is ok. It's purely for learning purposes. That's all so well. I love how none of you have actually gone for. I don't know, show the results. Um, that definitely wasn't because I ran out of options to put. Ok, so, um, here we go. So I'll vote for mine and we'll end it there. Ok. Good. Fine. So we've got a good amount of answers. 27. Fantastic. Um, and we split exactly 33% 33% between reactive bleeding and then infected hematoma. Ok. So, um, fine, does anyone want to tell me why they went for infected hematoma? That is um you know one that I would want you to explain if you can um put it in the chart, anyone why they went for an infected hematoma? Perhaps because the more you, you know, you once you put it in there, then I can tailor like my, you know, feedback and thought process to you personally. So it's even more benefit but it's up to you. So the right answer would be um vascular injury or you know, reactive hemorrhage, reactive bleeding. That was the correct answer. So um why is it not infected? We'll go through what this, why, what this is and why that is. But why is it not infected hematoma? Well, look at the timeline, timeline is everything in this scenario. OK. So they underwent the operation, you know, 21 hours ago only. So it's probably not enough time for it to have been infected or one there to be in a hematoma at all because this pain only started about half an hour ago. Um And then not enough time for that to be infected basically. Ok. But you're right, that could also cause similar presentation but just over a delayed timeline. So that's, that's important. So everything that you see in spas, you do need to obviously then think about applying it into real life as well. And that's hopefully illustrates you a good example of what, you know, timeline makes a difference. Ok. So, so vascular injury or blood legal or reactive hemorrhage, what is that? Um Well, it's essentially bleeding within the 1st 24 hours in surgery, you might not notice it because the BP is a little low, you know, you, you put a clip on or something. But after within 24 hours, once they're out of uh you know, uh anesthesia and the BP goes up again. Um Or, you know, your technique in your surgery might not be adequate enough. The um osmosis might not be great. Ultimately, all that could cause leak of blood, ok? Um Once the BP goes up again. So that's essentially what it is, reactive hemorrhage as what we call it. Ok. Um And that's well an emergency as you can see because they're literally exsanguinating inside the body. Cool. Um Scenario two then. So, uh let me run the poll again. Um So POSTOP bleeding, scenario two, stop polling, give you guys a minute or two to get your responses in. So 14 year old male underwent tonsillectomy eight days ago. Um blood and mucus brought up low energy and remember on your, you saw a clot over the tonsilla fossa and that's it. That's all there was. Everything else was relatively normal observations um were relatively OK as well. I hope you remember those if you want, I can go back, but I'm just gonna answer now in five seconds or so. Ok. I mean, hopefully you see the theme of it anyway, but let's see. So, yes, exactly. Exactly. Um So secondary hemorrhage, so 23 of you guys managed to get in your answers, which is fantastic. Um Secondary hemorrhage, that's it. So this is fatal. All this can be fatal. Ok? It is a true emergency despite the fact that this boy, you know, appears stable. Um It is a true emergency. Secondary hemorrhage is essentially anything that happens after the 1st 24 hours. Um And it's usually because does anyone know why, what the cause of a secondary hemorrhage typically is? You can type it in the chart if you want for literally no reward except your learning. So secondary hemorrhage is typically due to infection. Ok. Um And that's what it is. So here it's, you know, going through the others essentially Quinsy. It's an infective process. It's a pre tonsil abscess or we've just taken out the tonsils. So it's unlikely to be that Ludwig and Joa does anyone know what it is? Again, you can have a little quick bash on the chat if you want, maybe give me a better explanation than I can essentially cellulitis of the floor of the mouth. Rapidly spreading. Very dangerous, very quick onset. Uh presents it completely differently. Ok. Um Not normal postoperative recovery because eight days after a simple procedure like tonsillectomy, they should not be bringing up any bits of blood whatsoever. Ok. Whatsoever. And they're systemically a little bit unwell as well. And that might be because of the infection. Ok. Good. And then, um finally, last scenario here we're getting hopefully towards the end, you guys are doing great. Um Let me run that poll. So was your scenario, um Scenario number three, isn't it? So started the poll. 67 year old gentleman lost 1.1 liters as I said, here of blood. Um They're a bit short of breath, bit dizzy. They'd just come out of theater, you know, a bit disorientated, talking words only, um alert to voice. Um What do you think the cause of this presentation is? What do you think the diagnosis is his observations of BP, slightly low, slightly low, not much. Ok. I'll give you another 10, 15 seconds or so and I will answer it myself. So that locks in the results. Um Good. Fantastic. Yeah. So again, 24 response is fantastic. So you got split exactly one third, two, third split. So two thirds of you went for the, you know what I was getting out the right answer to due to intraoperative blood loss. Ok. Um, essentially is, well, how I framed it as iu primary hemorrhage. I didn't want to just give you that. Um, that's why, um, and I hope that didn't confuse anyone. And then also, um, the guys you went for post anesthetic state, you're absolutely correct in the sense that that could be, but the shortness of breath and the dizziness, um you know, typically you may be dizzy following an, you know, anesthesia, but you typically shouldn't be short of breath. So what might this be because of what am I getting at? Well, it's acute blood loss, uh acute blood loss and 1.1 liters is quite a bit. And as we will see, we'll go through um you know, the shock classification index very briefly, I assure you. Um And so you'll see that's quite a bit and then therefore they will, despite heavy anesthesia, they will respond in some way. Ok? And um it's because of primary hemorrhage and primary hemorrhage is essentially all the blood that you lose within the operation itself, ok? Um And that should be sorted out. So this should hopefully not be a bit big problem at all for you. So when you come to your management, you'll understand. OK. So, um I'm not gonna go through individually the management. Uh but I, I'm sure you can recognize that scenario number one here. That is hopefully you realize um what's the definitive management? Does anyone wanna say on the chat? You can say it in one word. What's the definitive management for? Scenario? Number one, you'll be coming across this in your vascular rotations for sure. Theaters. Ok. So that's def definitive scenario. Definitive management, definitive management scenario number two. Potentially. Also one word. What did I say about secondary hemorrhage? Is it serious or not serious? Will they need to go to the theater or not? That's your decision, isn't it? And the answer is yes, they would need to go to theaters. So that's definitive measurement is theaters as well. And finally, scenario number three. well, they've just come out of theaters. We've just explained, it's because of the loss of blood that they did have. So all you might want to do is give a blood transfusion after doing an at v of course. So we'll go through quickly. Um The uh POSTOP bleeding essentially. OK. So I already talked to you about the classification. So if it's intraoperative, it's primary hemorrhage within 24 hours, that's a reactive hemorrhage um within, well, it technically you should say anything after 24 hours is a secondary hemorrhage. OK. But typically presents within say uh 7 to 10 days of uh dates of surgery. OK. And it's usually because of infection um classification score uh or index of shock essentially is that of acute hemorrhage. Um That's a lot of numbers you don't necessarily need to know all of them. You just need to think about the blood loss. Ok. I always remember tennis score. So 15, 30 40. Um, and then we'll go from there, um, for the classes. Um, and then also again, don't worry too much about the, you know, the observations at your level. Um, you'd need it in something like a TLS or something, but, you know, think about percentage of blood loss or ML of blood loss and then think about their mental status. Look at how they would present. Ok. So if it's just under 750 ML or under 15% right. Look at the last row, um, they'll be slightly anxious, then they become mildly anxious and they become properly anxious and confused and then fourth class of shock, er, they'll be confused and very much lethargic. Ok. So, yes, how would you manage it? Well, it's the same as any bleeding. You know, if you think about a, a, you know, ruptured AAA A, um, you know, um, upper G, I bleed all of these things that you've managed. Um, you've gone through for your OS and your scenarios as you've gone through clinical years in medicine. It's the same thing. Ok. Always a, to make sure airways patent, you know, if they're pers, you think they're per s call the crash team, that's, that's what you need to do. Ok. Um, and the crucial thing with these, uh, kind of patients is simultaneous stabilization and resuscitation. And for that, that's pretty much blood like for like so blood for blood. Ok. So if you need to activate the major hemorrhage protocol, go for it. Um make sure that, that, you know, you take blood for value group and save and cross match. You know, if, if you know that they're going for theater like scenario one and two, you'd want to cross match the bigger the vessel, the more you want to cross match AORTA six IA at least four. Ok. Tonsils, er, 2 to 4. Ok. That kind of uh you know, you need to be thinking about that essentially. Ok. And obviously, you know, along in this a two week scenario, you'll always what uh when we go through it, it's doctors ABC DS and it, so, you know, after response, you always, for sort of senior, you always escalate uh early on. Ok. And I want to touch up on two specific scenarios. I obviously don't have enough time to go properly in on them, but think about post thyroidectomy. Ok. Um, now you've removed the thyroid um and you've closed that skin off uh or you've closed the layers and you've put skin clips or, you know, suture it, whatever. Ok. Now what happens if you start to get bleeding there? Um might be slow, might be a lot, if it's a lot, symptoms will be quicker. If it's slow, they'll become a hematoma, they'll be they'll clot up and then you get s uh symptoms. What kind of symptoms would you get? Is anyone wanna write on the chat? You can use the chat function? I promise. Ok, fine. Um, clear up, that's fine. So, Airway, Stridor, OK. Airway compromise because you're literally having a compressive effect with the blood or the clot pushing onto the airway. And so this is the one scenario. So you might come across this in your general surgery rotation. Ok? And that's why I want to mention it. Um, you know, certainly in Basildon, we had, um, thyroidectomy patients. Thankfully, this never happened, but you don't wait for theater, you don't wait for theater to remove the skin clips and remove the sutures, ok? You do it on the ward because it's airway compromised, comes before everything, ok? And you wanna get the crash team straight away, including your sur senior surgeon. Ok. Good. So that's that, um, post laparoscopic bleeding. It's not so relevant. It's quite rare. I won't touch upon it for now. But essentially the principles are the same. If you see any external bleeding, you always want to apply pressure, ok. Um, onto the area like real pressure for a long time whilst you get help. Ok. Good. That's basics of it. Anyway, so last sort of 10 minutes or so. Um, apologies if you guys have to go. Um, but hopefully this will be interesting again. Well, let's begin your night shift as such Ok. And this is a very, very brief, um, scenario. Not too long. Don't worry your jobs. Look, you know, your, you're 8 to 8 p.m. you just started your night shift. Your jas list is looking kind of heavy already. Um, day team and on call, team evening on call didn't do a great job just to dump it on to you. Ok. Um, there's prescribing fluids for overnight. There's prescribing antibiotics. Pen cannulas, repeat your VBG. Um, you know, prescribe pain relief for a 67 year old male who's post femoral popliteal bypass. Day one nurses have called three times. Um, because the previous painkillers, the day team we've given haven't worked so far. Ok. Uh So, um, then you've got antiemetics because, uh PV is postoperative nausea and vomiting. Um Someone's complaining about itching, ok. Uh And amongst all of this, um, and then another one, a nurse noted some oozing of midline wound. Um, they day eight midline laparotomy. Ok. Uh They want you to review as well and the last one is the sh is, you know, bogged down in A&E they're saying, can you please chase this report for, for bowel obstruction as well? Ok. Uh But they've taken care of the management. I know that's a lot, but I've given you only a few options. I hope. Uh, which of these would you prioritize first? Ok. So, um, it's a pole on here. Ok. So I'll start the pole on here. So, have I start at the pole? No, that's not it. Return to cue I will. Yeah. Which task would you prioritize first? Let me start pulling this. OK. So give you literally 10, 15 minute seconds or not, definitely not minutes. So it's a little run in behind, but we're nearly there. So you're gonna go do the BBg. Are you gonna do the painkillers? Are you gonna do s of the midline wound? Or you're gonna chase the report for the up to you? And I answer pretty much knelt so that we don't run out of time. Ok. So good. Ok. We've got quite a few responses and the majority did go for the um, femoral popliteal bypass. You might have gone for that because I told you, uh I hinted at it anyway. But yeah. Um Absolutely. Um And we'll talk about why you might want to. Ok, in a minute. So it depends because of the diagnosis that we have in mind. Ok. So this is a vascular patient who's gone through that, the operation one day ago. And now they've got a lot of pain, previous painkillers aren't working. You've then remember you then get the Os, don't you? So given you the OS you can see for yourself, they're a bit tachycardic, otherwise not so different and they're quite a bit tachypneic as well. Respirator 27. So, what would you do then? Ok. So, um, what would you do? Um I think this poll is. Oh, yeah. So, stop polling again. I don't know if anyone answered this one actually or if you could. Um, let's see, it's, it's, you know, given the fact that you're worried enough, it's pretty much, you know, makes sense. You're going to do an in person review, aren't you? You're worried the fact that they're in so much pain and they haven't, uh, you know, the painkillers haven't worked. So you arrive onto the scene. Those are the observations, the airway is patent. They're screaming in pain, tachypneic, shallow breathing. Um They're sweating a lot. Um And they've got dressing, um you know, wrapped all around the lower leg otherwise, uh Nilo notes where they had their surgery, obviously. Ok. So what is your diagnosis? So let's quickly start up all for that too. So that's what is the diagnosis for this patient? What do you think? Give us a start guys? Last few, literally, last few slides. So, do you think it's ad VT that's causing their pain that's locally um within their leg? Do you think vascular surgery is quite painful anyway? So this is, you know, they are only day one. So it's normal postoperative pain. Do you think it's compartment syndrome in this vascular patient or do you think it's a surgical site infection? Um or will anyone go for, I don't know, show me the results. Who knows? Let's see. So I'm going to close the answers in like five seconds. Ok. Yeah, uh barn storming, correct. Uh So going for compartment syndrome um good. So um DVT again, you know, they're only day one. So it's unlikely um time frame wise, same with the infection and definitely not normal postoperative pain because they're requiring such strong painkillers and nothing is working. So, um compartment syndrome. Well, you know, the typical case that we come across in compartment syndrome, we're always taught in medical uh medical school is always that classic high energy road traffic accident, tibial shaft fracture. And then they develop compartment syndrome, don't they? But actually vascular patients can very typically develop compartment syndrome. And in fact, I've seen it myself. Um and yeah, we had to do an urgent, well, we'll see what the management is. So back to many if you can um this is a bit long, I appreciate. But uh what would be the order in which you would do your management then? So you know it's compartment syndrome. But what is the order in which you would manage? So see if you can go two that, ok, put it in order. So will you be giving IV fluids and IV analgesia first? Would you will you first escalate to surgical? See urgently? Um Would you ensure that systemically stable and resuscitate if required by an A two E, would you keep the leg, neutral, removable dressing or would you who knows some of you might be brave, book a fasciotomy by informing the theater coordinators and the anesthetist. How would you go for it? So, we've got ensure patient is systemically stable and resuscitate by a three escalate to senior urgently second. Ok. Keep leg uh neutral uh removal, dressing IV, fluids, IV, analgesia and book for a fasciotomy as that. And that is spot on guys. That is perfect. Pretty much. That's what I would do. Ok. So resuscitate always number one first, they seem hemodynamically stable. Ok. So that's good. I would take that off. I had called the con er registrar already being like, hey, look, I'm worried that this is Compartment syndrome. Um You know, my plan is to remove all the dress and keep the leg neutral. Give IV analgesia and fluids. Uh Do you agree? They'll tell you yes or no. And then they'll also may tell you, you know, I wanna see for myself or they'll say no, no, no, I trust you to go um book in theaters as well. Ok. Fantastic. As that was spot on, it's a little bit on the path of phys of compartment syndrome. Unfortunately, just running a little bit short of time, but the slides are there, you can keep a look at it, but essentially, you know, for whatever reason, high energy vascular injury, rhabdomyolysis, you know, or just us putting on too tight dressing or splints, um essentially cause lots of inflammation, edema within the restricted area. It can't expand and so it starts to die off. Ok? Um, this is the most important part of that slide. OK. Is just pain, OK. That is the most important clinical feature you think about, you know, other six pieces of ischemia. Well, by the time they set in it's far too late. OK. It's far, far too late. Cos I've explained the path of phys here. You can go through it in a minute, um, once you have the recording but you can see ischemia results right at the end. OK? Right at the end. So all your other piece, your you know, er pa pulse paralysis, all of that, even the nerve injury, which comes a little bit earlier but still very late paresthesia is all late signs, pain, pain, pain, pain, pain, OK? And it's passive stretching of the compartment. OK? So say for example, this is your foot or lower leg and this is your foot. If you've got compartment syndrome, the anterior part of your lower leg here, it's not dorsi flexing it, that will cause pain, it will be stretching that compartment, stretching the muscles. OK? So it will be plants are flexing it passively, so passively you doing it, OK. And the management we went through perfectly fantastic. Last scenario, literally last scenario to go through. Um Remember the midline news. Yeah, we'll come onto that. This is one of those surgical complications. People don't talk to you about enough and that I wanna mention on because I again, I've seen it, OK? So you go to review the wound and that's what it looks like. OK. Um You've got the observations there. Um So BP is OK. Heart rate is OK. Temperature is OK. On inspection, I'm just gonna describe what you can see hemos fluid uh discharging from the wound, abdomen is rigid and the patient himself is in severe pain. OK. So what do you think is the diagnosis last, literally last one or two polls? Ok. So in fact, this is the last poll. So run it and I will stop very, very shortly. I hope this has been useful as well. Uh We'll get near the end. So give you 10, 15 seconds. Apologies to rush. So do you think this represents the fact that they're in pain? And there, there's a bit of fluid oozing up from the wound. Um They day seven post laparotomy. Remember a midline laparotomy? Do you think it's a superficial wound is? Ok. Do you think it's a bit of normal postoperative ooze can happen? Um Maybe, you know, the s closed up and they didn't, you know, put some sutures perfectly in some places who knows? Um Can't be me. Um Joking. Do you think it's secondary hemorrhage? So we talked about that timeline. Remember? So anything after 24 hours, do you think the secondary hemorrhage started to build up again? Um Or do you think it's a full thickness wound dehiscence? Ok. So I'll submit my answer now, and we'll lock the poles and we'll see what you guys come up with and I'll explain. OK. So fine as expected, we've got a real split, exact tie between full thickness and superficial thickness, wound dehiscence. OK. So first, correct, it is wound dehiscence. OK. It's, it's seven days later, it's probably not enough for me to justify a hemorrhage because they're not hemodynamically unstable, right? That's the key thing. OK. So now what, what might make this more uh so official or more deep? What things, what characteristics about it might make it that? So the answer is actually, well, I didn't put the answer there but the answer is um full thickness. OK. Um And the thing that key, the key thing that points out is the hemos here is discharge and the fact that the abdomen is rigid and tender and that implies that there's a burst of the abdomen and there's stuff coming through. And if you open that dressing, you may well see omentum and bowel coming out. Ok. Which I have seen? Ok. Um Cool. So final one onto many um how would you rank in order? How would you manage the wound ooze patient? Ok. Um So last thing really? Ok. Say gi book a relic procedure by informing the theater coordinator and the an test because you know they need to go to the theaters given that it's a full thickness first, abdomen. Would you keep the abdominal cons covered using a sterile gauze and soaked in saline first. Um Would you do an, a two week, would you escalate first or would you do sepsis? Six first? What would you go for? So, hey, three guys, you've my most important message of the day, which is fantastic. Unfortunately, three's popping up again. I don't want. Yeah. No, cool. Sorry about that. So, um good. That's fantastic. Then you'd escalate again, which is exactly what you need to do. This is a case that needs to be met by a senior. Yeah, absolutely. In between the what you want to do. Well, you want to keep the abdominal conta safe by keeping them sterile, which is exactly what you said. Um And in the meantime, you know, whilst you're doing that or someone else is doing that, you can go make sure get sepsis six ready. Ok? And also prep them for theater. So that would be ensuring the group and say is valid and all of that and coordinating. Ok. So that's ruined the adherence. I talk through what you know, the difference is superficial and uh full thickness. Um superficial means that the rectal sheath is mostly relevant to middle and laparotomies. Rectal sheath is intact. It's only the fascial or the skin that rips apart full thickness. The rectal sheath itself is gone through and that's why you get protrusion of abdominal contents. Uh clinical diagnosis, sometimes they do do ac t though. But if you can't see you know, organs coming out straight to the theater. Um and then, you know, management wise, superficial where you just treat it like an underlying infection because that is usually the cause of it and let it heal by secondary intention, you just bring the edges together. OK. Full thickness, uh theater exploration, OK? Sometimes you can put a negative pressure or not a negative pressure, a Bogata bag, they say um but you know, that's a bit too niche, but for your understanding, that's what you need to do. OK. Summary, keep calm, systematic approach. I think I've have it in the framework tons of times now, prioritize accordingly. And obviously, but the biggest tip I can give you is before you start your rotation, learn some specific POSTOP complications that you're likely to see within that rotation. So for example, if you're doing ent you might see that tonsillectomy otherwise you won't need to, right. Um If you're doing um you know, Jen said you'll see this kind of stuff. If you do an author, you might see pe S or compartment syndromes. So that kind of stuff. OK. Perfect. And here's the um feedback. I'd be very grateful if you could er give me some feedback guys. Um I appreciate um it was a lot to take in. Uh Sorry if I was too fast. Um There's just a lot to cram in. Um I hope that was helpful um And I'll hand it over back to Claire for any closing remarks. Thanks very much. That was excellent. Um Is there any final questions for sci, we'll watch the chat for a minute, but thank you all for coming. Um So our next session is on Thursday evening, seven o'clock again. Um, and this is going to be on postoperative care. So we've got a bit of a POSTOP week this week. Um I'm just going to focus a bit on some nutrition and wound care, which are often the things I think we, we forget about and we're quite poor at managing particularly as an left one. When you, what what do I do? I'm going to try to help you with that. Um and talk through some uh common as you might come along, come across on the wards. So again, thank you very much. Um and the rest of the links to our talks are in um on our medal page and I'll share the link for Thursday's talk with you now in the chat. Mm mm. Yeah, you should all have that. Now, there you go. So I'll give you a few minutes to finish that feedback. Um And any questions as well, feel free to use my email as well. You can email me any questions that's absolutely fine as well. Yeah, I hope it was useful guys.