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Yeah, that's the three weekly, um, been on Syria's you've been doing every Tuesday and Thursday and hopefully to help you. Better about starting your surgical on cools. So just up a minute, passage open so we can start. So today speaker is I'm talk to Alice Garden. She's one of the committee members off STDs and being with us from the start. And she was recently, which is not a way to actually recently secured a plastic surgery thing to call surgical training job on phenomenally become coming 38 in the country and rankings. And that's a Georgia London. But should we start to taper on? She's really keen about surgical education on D is actually on a branch of the committee at the moment. That's helping with the virtual here to curriculum on becoming out in September. So stay tuned and have the pleasure of going Teo, you never city with Alice and I nations that's deliver a fantastic lecture. And is that further day I'm gonna handle able to at this. Hello? Can you hear me? Yeah. So yeah. My name's Alice. Thank you, Jennifer. The introduction today I clicked too many buttons, but we're going to go through a few. Um, as with all the other lectures common on core scenario bleeps that all of you, I think most of you are about to become f ones. So how you approach the patient with a high temperature, including recognizing sepsis, a patient with low BP on a patient with confusion. So three common bleeps that you might get when you're in F one. So hopefully you feel a bit more confident at the end of this feel free to put questions in the chat the whole way through. Jen's gonna be monitoring. It is a really sunny day, so thank you all for turning up. Well, hopefully we'll be done before eight o'clock so you can all have enjoy the rest of your evening. So, first of all, you've been bleeding and this is you. You with your f Y one badge on doctor. One of your patients has a temperature, so don't panic. That says it on a lot of science scenario number one. So 65 year old male he spiked a temperature of 38. So this is a temperature is always worth checking with the nurse on the phone. If he's actually spiked a temperature or not, because sometimes they haven't. Most nurses will have given them paracetamol tried to, anyway. But if not, it's always worth. You can say, Check that they've got paracetamol prescribed, and then you can ask them to give some paracetamol before you even get there. Um, but what else will you be thinking when you're on the phone? What else you need to find out if you're ah hospital, that's lucky enough to have virtual notes. You can ask for the patient's hospital number. Um, have a look at their notes. You can see their observations throughout the day. Um, have a little look at whether they how many days POSTOP they are. Have they got paracetamol prescribed already? If so, the nurse can give it. Obviously, if you haven't got Elektronik notes, you need to go to the ward Any way to take a look? So, as a practical point, blood bottles, blood culture sets can actually be really difficult to find when you're on call. If you're tracing around a really big hospital, I used to know a cupboards in like an opposite wing was the only place I knew that had blood cultures. So if I had to find them myself, then I had to go there before the ward. So it's useful to ask the nurse to get an up to date set of observations and a blood culture set ready for you. So as you're heading over to the patient, you can kind of be thinking about differentials in your head. So, have they had recent surgery? If you're the surgical F one on call, most likely they have had recent surgery or they're going to be having surgery. Um oh, what drugs might they be on? So drugs such as ever had a recent blood transfusion that might have caused they're temperature to spike. Gonna be thinking about antibiotics as well. Money dose? Is that the heart? Is it doing? It's job. Um, obviously, with the temperature, your first thought is usually when my first thought is, Have you got an infection brewing? Are they hemodynamically stable? So this is where you start thinking when you're prioritizing your patients on call. How sick is this person? How quickly do you need to go see them? Have they? Despite a little temperature, they already on the right treatment Or are they really young? Well, so links onto this. Is this serious? Is it? Think of your prioritizing. How quickly do you need to see this patient on? So you're starting to think about things as you're walking over. So here you are. You're tired already. Apparently, Um and you have asked all the important questions You're on the way for the ward and always ask for a full set of observations to be repeated before you go uncheck that the moment is working because some houses no. So this is where I going to see. The patient is the most important thing, because does this patient have a temperature that's worrying or not? And that's that What you need to figure out when you're on call by yourself. So this man, he's 65 year old man. He's two days POSTOP for peptic ulcer emergency repair. You have a look at his notes and you notice that on the ward around that morning, they've already suspected he's developed a chest infection and he's been started on two biotics. So you're looking at him. You do. You write Teo, you go. These his observation. So he's got a temperature, those 7.6. Otherwise, he's pretty stable. He has not started decompensating. Other what? Like Hemodynamically, his heart rate's 85. His blood pressure's still 100 35/80 is saturating well, but the end of the body looks a bit sweaty. So you might be thinking here on this temperature might be appropriate for the fact that he's already developed a chest infection. He's probably on the right treatment. He might not have had many doses of his antibiotics yet, So what can you do in order just to reassure him on B Do? Obviously you do your full assessment, but you might not actually to intervene for this patient, however. Scenario number two. So this time you've got a 65 year old male. He's seven days POSTOP for the same operation on Do your Walking into the ward and you don't even need to before even starting your 80 examination, you just think he looks horrendous on D. That's one thing that you developed really well throughout your first year is just being able to see a patient. Do they look ill, or do they not looking sick or not sick? It's most important thing toe figure out. So this guy you do again, you do the 80 examination, which I'm not gonna talk through because you're all finding a medical students, you know what to do. His temperature is 38.4, otherwise looking his observation. So he's slightly borderline tachycardia 104. But he has also dropped his BP. 80/40 her 65 year old male. That's definitely low. So this patient Europe you're already worried about. He's starting to decompensate in other ways, not just the temperature. So I'll give you a second. Think about your differentials. So there's a second, Um, when a patient has a temperature. Obviously, most people go straight for the effective cause because, I mean it could be a wound. The patient's having operation. He's got wounds side my vertical ecti in obviously chest in your in the most common sources for POSTOP infection. But you need to also think about it. So I always think about when I see a patient with the temperature infective and noneffective causes. People obviously cast dries them in their own way. But I find this is the most logical way to do it, so they might have developed. Atelectasis is they might have a P or a DVT on depending on how close they are. Like a drug reaction might have been anaphylactic reaction that have had a reaction to anesthetics If it's, um, the prosthetic, if it's near the end of the operation or they might have a recent blood transfusion so effective and noneffective causes. So this is a former, I think it's been used in most of the lectures of this Siris, but it's really useful in real life has a way of thinking through things. So what you can do at the bedside. So that's your 80. Your observations. What blood? So you're thinking about taking, what imaging might you want and then probably less relevant. When you're the search, wear one on call but special tests. They're gonna help you with the diagnosis. So let's say in this 65 year old male, both of them, that it's an infected cause. So we're thinking about you as the F one on call. What are you going to do on that's gonna be your your septic? Six. Your sepsis. Six. So I think of this is Buffalo. But That's just because it's how I was taught at university. And when you're panicking, it's, um I mean the letters layout. You can remember them from the letters, as opposed to trying to remember the septic sepsis. Six. When you're panicking. So they're the exact same thing, though, so do it the way you know how. But you've got your six things that you need to do. Three and three out. You got blood cultures, urine output. Um, has it been tapering off throughout the day? Have they got no urine output? Have they got fluids prescribed? You're going to think about giving him a bolus. We'll go into that with management What antibiotics they need. What's their lactate on? Be starting on oxygen if you're worried about them, so the sepsis six or buffalo are all things that you can initiate as the F one. Even if the patient's really sick and you think you need senior help quickly, you should be able to do all of these, and you should feel confident in being able to do all of these things. Sometimes septic patients are really difficult to bleed, so you never feel bad about having to ask somebody else to come and give you a hand even though you're Shor something. So initial management for patient infective cause of high temperature. So in that first scenario, you do You're 80 assessment now that they identified on the ward round that this patient they thought had a chest infection. But he's had a couple of doses. So So you're the evening or the night F one. He's had a couple of doses of his antibiotics now, so you can have a listen to his chest. Do you agree? Have a look. A chest X ray. Has he been started on the right antibiotics? You can definitely send a repeat PSA blood since, um, repeat cultures, which would be useful for the day team. But if you're happy, that is on the right. Antibiotics? You think he's fairly stable? Then you could just document that you've assessed him. You've identified he had a temperature. You've seen the patient. But you're happy that he's on the right management, so that would be four or less. The patient we were less worried about. However, the second patient he was sick. I mean, you saw that he looks sick from the end of the bed. So you're going to do your 80 assessment that you'll know your buffalo, this patient. So, as I said, the buffalo they are the six things that you conducive F one on dure. Really slick. If you I mean, if the patient's really really deteriorating, then of course, you can escalate very quickly. You can put out a medical emergency. Cool. But if the patient septic is doing your case chatting to you, you can get started on this buffalo sepsis six. And then you can escalate your registrar if you're in your registrar going. Look, I've taken some blood cultures sent off the lactate I've done, uh, VBG. I know the lactate. I've given him a fluid bolus on, but he's on oxygen. What do you want me to do now, or can you come and see the patient with me? I'm still worried about them. Then you just look great that you've already done those six things, cause otherwise you're gonna bring your register and go. There's a patient with a temperature. He looks really unwell. What do I do on? They'll tell you to do the sepsis. Six. So if you've initiative started initiating it first. You just look quite competent. Um, this patient six. So you're definitely gonna be thinking about handing over to the 19 for review and again document. Clearly, that's obviously good practice for everything. Uh, this is from teach me surgery website. That if you haven't come across is really useful way to think about where. I mean, it's not bible of what Each day, um, POSTOP is three. Infection will be, but it's quite a good indication. So day one to consider postop considering a respiratory source and patients in PE, and they're not taking deep enough breaths properly. Eso They're not a rating the bottom of their lungs. Very well. And so they're really high risk of getting a respiratory infection date. 35. More likely you're on resource on daily on later on. More likely an abscess because it takes a bit of time to form collection, which is gonna mount a temperature, um, or a surgical site infection. So you want to look at that wound even though the nurse says they've only just redressed it? You need to have a look at it yourself. Of course. Consider all lines, including cannulas, a possible source any day. So antibiotics in the sepsis six or buffalo? I'm not gonna list off antibiotics for you because you will be revising it for your finals or you've passed. Congratulations. If you're past, um, and you will have trust guidelines, so it will be different throughout the country. What's the first line for chest infection? Urine infection. So the most important thing is to know where your hospital guidelines are. There's always a microbiologist on call that you can speak to, but usually if it's a simple chest infection, it's detailed in the guidelines. You don't even need to speak to them. If you were worried about that patient that you've given two doses, too, and you don't think it's working, then that's that's what they're really useful for. Considering another source or telling you to send off a few, um, atypical screens etcetera, and they're usually available by a switch or, if you haven't done loaded it already in your starting your job in August. This isn't that, um, the induction at I use every day at work. It's brilliant. You can set it to your this was my hospital last. Yes, that Mary's you consent. It's your hospital, and it means you can call directly from your phone. You don't need to find a phone if you get bleeped. You can also call through your phone as opposed to finding a phone. So if you've nipped cost A. You can return a bleed easily. Um, so definitely done with the induction app. If you're starting in August, Um, but usually most things are covered pretty well on the treatment. Got on guidelines except for this, um, specific things like orbital cellulitis, etcetera. That's when you always speaks the microbiologist. So always check allergies on a few patients still spiking as we covered. After a few doses of antibiotics, you need to review it the source and another cause of the higher Xia. Okay, Jen, are there any any questions from the first case? But most people, I think that's probably one that's quite well managed. Yeah, absolutely. I just, um, I'm going to see if any questions. That was one question on just about talking about different causes off the va as to what drugs can cause fever. So, yeah, I mean, it's a difficult one. There's obviously blood transfusions, really common for a patient to develop a fever. It doesn't immediately mean you need to stop the transfusion. You might just need to slow it down and give him some fluids. Any drug allergy usually causes a inflammatory response. And you get fever associated with that. Some pain killers can cause patients to develop a fever. Um, obviously not processing all process more helps that. And then the side effects of some drugs. So, for example, if you have a patient is taking a lot of codeine, they might become constipated. Constipation can cause a fever. Onda. I think some anesthetics can assess well, Jen. Yes, I have. I think most general anesthetic are as you mentioned in your time frame. And also, I think I had a patient, actually. Quite, Um, interestingly, that develops a fever after having antibiotics just because it makes a little bit funny, which is a bit counterintuitive, but yeah, some people react, manage different. Um, especially IV's. Yeah. Thank you for that. That was old. So probably keep keep going. Unless anybody else has got any questions. Yeah. So, Carrie, Sudden Okay. Yeah, I know. Um, the drug one's almost is something you need to think about later on if the patient doesn't have a clear sign of infection or um doesn't have a V T. It's just another thing to think about. So another scenario. Theft one looks like Hispanic and again. But don't panic. You get bullied by a nurse doctor. This patient's got a BP of 80/50. So I got blue about that on my first day and asked like Oh, no, that sounds disastrous. And so I did panic. But there we go. Let me just bring it back to it again. How we went through the first one. So what else do you need to find out? So again? Really useful. If you got Elektronik notes, you can put the patients number, and I have a little quick read. If if the nurses really worried, it's often useful to go and have a look at them first. So when they look whether they look on well again, I'll reiterate that again. It was talked to me, but also read again. Just look at the patient, sick or not sick, and that's a very good way of how to prioritize things went on call. So of course you're thinking When did they come in to hospital. Are they POSTOP? Or they might be pre op. Do they? Look on. Well, where you going? So, yeah, if you he's feeling a bit better already, cause he's thought about all these things. You've also the important questions, and you're now on your way to the ward. You obviously will ask the nurse to do a full set of observations. Lost your in your way. So again what? Your initial thoughts that you're going to see this patient, You got a patient with a low BP. What? What could you be thinking about? Have they had recent surgery? Was it that morning? Have they been in hospital for a while? Have they been know by mouth? Um, have they been given, prescribed their maintenance fluids by the day team? Or has this poor patient been know by mouth all day? Missed his operation, not drunk or anything. And then the day team have forgotten to prescribe many fluids. So coming onto that are the hemodynamically stable? We've touched on that in the first one. Had they mounted a tachycardia to make up for this, or do they sit quite happily? 80/50 urine outputs are really, really important. One for lots of things, especially BP, because it gives you an idea about end organ perfusion. Um, is the BP so low that the kidneys are drying out of it and said, I'm not producing any urine? Um, what's their normal BP? Be careful with this one, because patients could be on medications that alter this, uh, patients on beat blockers sometimes don't mind attack it more, more so tachycardia on when they're sick. But on gum times, people like, Oh, they're they usually sit around that back But it could be bleeding. So that one's one. We are gonna touch it in this scenario, but that is one to be wearing off in real life on again end organ profusion. Are they alert today? Chatting? Is that a GCS 15 15? Or if they started to become more confused? So your first scenario is a 59 year old male. His blood pressure's 80/50. Let's say post are for a hernia repair. He's confused. Hey, looked. He's got a low urine output and he looks on Well, so of course you've gone to see him. I mean you can see from this before you've done your assessment, he looks sick. So you do you write Teo on his abs. I heart rate 117 BP 89 50. Saturating fine on room air. But he looks confused. I mean, you don't know what he's like A baseline, but he looks confused. This is a Pyrex hell. So you're a bit worried about this chap, cause he's not only hypertensive, he's also tachycardia now, whereas say, in the bed next door you've got a 19 year old female. Her blood pressure's also 80/50. She's got a normal urine output. It seems like her blood pressure's been 80/50. I know, I said to be wary, but it's been like this. The whole of her admission on no one else has seemed to have done anything about it. Um, she's on lots of analgesia POSTOP for her. Appendicectomy on Budgie says it's 15 15. So when you're looking at this girl from the end of the bed, when you're doing your before you do your 80 examination, so her arms, her up heart rate is 60. Her blood pressure's 80/50. She's saturating beautifully on room air. She's a pirate show, and she's absolutely chilling. Sat watching some Tic Tac's and her phone. So you can tell these two scenarios just completely different from looking at the patient at the end of the bed and doing some observations. It's going to completely change how you're gonna manage on Prioritize, went on call. So differentials for a low BP. I'll let you all have, Ah, 12th. Think about what you might think. Okay, so differentials again. Infections always up there at the top. Have they got an infection? Are they in septic shock? Have had a drug reaction on a flat. It can cause you to have a profoundly low BP. Are they bleeding? They had an operation. They could have come back from theater that could be leaking, and that's causing their BP to drop. Um, other kinds of shock. Cardiogenic shock. Neuro cardiogenic shock on D. Could it be a normal variant? That patient, If she's got a good urine output normal GCS then it's far less concerning. Okay, so again, we touched on this and it might seem a bit repetitive, but this has got me out of a lot of germs that work. Just going through your, um, systematic approach. So you're at the bedside. That's your 80 assessment your observations with a low BP, you want to see what their heart rate's doing as well. So whether they've mounted a tachycardia want to do any see GI on the urine dip? Uh, full blood count. Using these LFTs coag group and saving a lactate, you can get your quickest way to get a lack tape for your septic patient or yellow put pressure is, um BBg. But you can send off a formal one. A swell emerging. Think about chest X ray ultrasound, maybe less so in this one. On if your patient s o say POSTOP abdomen so they have a collection that's causing them to become septic. Do they need a CT A P or they bleeding? This is where you're gonna be getting senior in put down here. So initial management for a patient with low BP back to the basics again Is that patient well or unwell? Do your 80 look at the observations and I am for output chart. Are you worried about this patient that that lady, that 19 year old sat chilling on the phone watching picked up. So I don't think you're very worried about her. Maybe tell her toe, have a drink and then see what it does. Have a walk around it. Is she okay or you're not too worried? Where is that other gentleman he's on? Well, he's gonna need some kind of fluid resuscitation. Intention. So little pressure. Give fluids. I always ask the nurses to encourage oral intake. It's on everybody's plan when you're enough. One so you can get fluids or or IV 500 million bolus normal saline. You are not going to go wrong doing that in anyone. Really? Um, maybe a very fragile elderly lady with really fragile heart failure. You give the 2 50 bolus. But realistically, in real life of 500 bolus is the same as putting someone's feet in the air in terms of venous return. And someone said to me once it's basically a counter Diet Coke, and you probably aren't going to kill a lot of people with a can of Diet Coke. So 500 mile bolus, normal saline, and then importantly, is monitoring their response to that. So did the BP improve? So those we call responder did the BP improved, then immediately fall again a transient responder? Or did the BP stay the same Or, in fact, get worse? A non responder? So think about how we manage each of those. So the responders brilliant. You've given the 500 more bolus. Their blood pressure's come up to 130 over 70 on day, so most likely they're dry past that. 18 forgot to prescribe their maintenance fluid. Perhaps they were know by mouth for a real long period. Perhaps they've gone off their food. There's all sorts of reasons patients are really dry postop commonly. So the best thing to do for this patient, you know that they're responding to fluids, prescribed them some maintenance fluids, encourage role and taking less than old by mouth on. Then get the nurses to call you back if it drops or there's any further concerns, obviously document what you've done. You've seen the patient even to beaned, um, then the transient responder so you can give another bonus and then track again. Because the BP did pick up a bit. It might be that they're really, really dry, and they just need some more fluid. If it's still transient, you want to think of other causes, so maybe bleeding. So if you think of the patient as a bathtub with the plug is open, you can keep filling up the patient with 500 mils. But if they're leaking from somewhere, it's going not really do much that needs fixing on do if they're really septic. It might be that everything you're putting into the intervascular space, they've got leaky vessels, and it's just going going straight out and get extra visiting so they might need some of those people that might see it needs circulatory support. So you probably wouldn't be speaking to I to use the F one. So those people you have a chat, your Reg or your asset show they might need some input from seniors, then your non responder. So if someone's absolutely not responded, the blood pressure's still tanking. Then they're the ones that you should be immediately escalating, especially if it's that patient you're worried about. So any questions from that one, Jen Yes, we do have a couple of questions about fluid, so to quite similar. Insensitive on how soon after you give that bolus, You measuring the BP again to determine whether they respond to it on similar, you know, But would you expect the response to have happened? And what you thinking that queen when they're not responding? Yeah. So a response to, ah fluid bolus should be pretty, pretty instantaneous. I mean, usually it goes in, they say stat, but usually takes, like, 515 minutes for 500 mils to go through. So then you're just gonna check it after that? As soon as the fluids in it should have taken an effect. The quickest way to see if someone is a responder is to lift their legs up into the air and check the BP straight away. But lots of our ladies don't don't like their legs feel lifted in the air. So it's quick. It's getting over 500 mile bolus. No, that's not enough. I guess you worried that that blood pressure's dropping serial blood pressure's good. You want to bring a nurse in with you on by the bedside so that you have a seat, it's going. You can put them on your abs machine, and most of them have a circulating, like every 5 10 minutes, depending on how worried you are. Absolutely. And someone's just asked. I think it was a bit Edith. Um, could you quickly flip back to the differential sides? We could just split back to me. Oh, and discussing other questions. Just Yeah. So that's Ah, differentials. Yeah, it's a pretty useful causes unfinished in there. So that's useful on be someone mentioned about. Would you mind explaining a little bit more about the intravascular interstitial spaces and just briefly, just really, really slowly for somebody, He never quite got it, which is understandable. Yeah, No, I mean, this is something that I have struggled with that university as well. I wasn't that interested in where Fluid waas, but it actually is quite important. So the reason we check for like, peripheral edema is if the blood, if the fluid is pooling and someone's ankles, that just is a clinical sign that the fluid is not in the right place. If the fluid is not in your blood vessel, then that's why you've got a low BP and those people. So those different causes for fluids going out on did It's I'm not gonna go into like osmotic movement because it's really boring. And you should. You don't do surgery. Just go do it to you. They septic patients get really leaky blood vessels, so when you give him fluids, it just kind of leaves Thiebaud vessels and therefore it's sitting in the except that extra vascular space. And so that's why you can feel it. As a Dina, I might check my own edema at the same time, but I don't have any time on. That's why I picked up. These patients need basic presses, cause that stops the blood vessels being leaky and then that keeps all the fluid in the right compartment. Same happens with anaphylaxis is bleeding is because there's a natural source of bleeding, so that's why it's leaving by itself on. But I think that's basically all the detail you need it to be and be. Is the fluid in the right place? Is it in the blood vessel or is out of the blood vessel? If it's out of the blood vessel, how do we get it in? And that's either by a base oppressor most commonly or fixing the source. Absolutely Just really useful to know that thinking have to treat it so that was very good cranky. And And if you want to go into more detail, recommend looking up like a cheap It is on how it works. But they're useful. Frankly, Thea other one is a again slightly more complicated. But last one on fluids for questions, for now, basically is talking about medications that you could give for hypertension in a specific scenario s so basically, if a patient has a K and pulmonary edema, but their BP is dropping rapidly and you don't want to exacerbate it, can you give would you give me call to say, you know, mid it three And then I was a sick patient with pulmonary edema on D. Okay, I So you're doing an A T E assessment and you've come across pulmonary edema in your B. Your patient is sick. Correct me if I'm wrong, John, your patient is sick. You worry about the kidneys. Later. You give that patient cruise mind to stop them dying from their respiratory condition. The patient's going to rather they not drown to death from having fluid on their lungs and then worry about their AKI later, then have Christine kidneys. Andi, have you dead because they died of pulmonary edema? I think what I would say that this question is that he's a definitely kind of big worries and things that you think manage. But if you're ever trying to manage a do this balancing act, you want you're gonna want speak up, getting help from seniors to make this decision. Definitely. Yeah, that was one of the West. Things is a tough one. Is changing someone's bruise on my dose when you're looking at their potassium on, Did you just change it every day, depending on help, Help that potassium is and how bad the breathing is. But that's not something you know. You wouldn't be managing partner. You do more by yourself out of hours on D. If that patient was sick, it's likely they're gonna need to go to I t. U um and then I'll get that for his mind, but that also be putting a filter to save that kidneys. But in the acute scenario is an F one. If you were worried, that patient told me a demon you had no help on the way you wouldn't be in trouble for giving 40 mg bolus of fruits mind sedate me? Um, one more about near a cardiogenic shock. What do you do about patient with a low BP? If it's been, you're a genotype. So I guess this is kind of a swell going into slightly mawr your left. The related scenarios that I appreciate. These are effect like and relevant early. If you have diagnosed a neurogenic shark up extremely impressed that they kind of tend to be in distributive shock on D. Their heart rate doesn't MTA's well, you get. It's like a sympathetic out flow issue on. But those are the patients that will need some kind of circulatory sport on, but you're definitely be discussing them with this with the senior, you wouldn't be managed in them by yourself. This is where you probably be getting critical care, outreach or idea involved. If you're worried that someone's really shut him down and haven't got a a urine output or yeah, showing signs of neurogenic shock on there, maybe pay. This is where you're calling for help. Basically Mayan implants that does that. Is that Okay, so we move on to the next year we'll come back to it at the end if you won't discuss it in more detail. Yeah, so you know you're panicking again because you think you just diagnosed a neurogenic. Shock and critical care outreach aren't on the way, but But you given your flow bolus and you've got a bleep, doctor, this patient seems a bit confused. This one, my least favorite bleeps to get as an f one because it's so vague. So back to the start, what else do you need to find out? So what did they come in with? Our They POSTOP preop what they being treated for you again can have a look on your You know, tsps, if you have them and have a little read through before you go. But then you're heading over. Yeah, you've asked all the important questions and you're on your way to the ward for confusion and be really useful to get an upstate set of observations anyway, So you can ask the nasty that while you're on your way So here's your scenario. Three got 79 year old male. He's 12 hours post a complicated hemiarthroplasty. It was much longer operation than expected. He shouting at the nurses, He's trying to leave the ward. His trying a pill is catheter out. He seemed really upset, and he's really confused on what's really useful is the nurses are with your patients all day. They have a much better idea about the baseline of your patients than you do just because you spend less time with them. Um, the nurses tell you this is completely out of character for him. He was doing his crossword this morning, chatting away to the man in the bed next to him, so they're really worried about what's going on. So initial thoughts, surgeons love ordered thinking. So here's Ah, pinch me for confusion. That's really useful. The surgical save. If you haven't heard of the surgical save, um, it's a way to think about differentials for every presentation you have, like vitamin A, B. C. D. Um, you can just google the lows and those different ones and find the one that works for you. So pain. Uh, patients have had an operation that bound to be in pain if they haven't got propranolol easier, this condensed it, Lee cause confusion. Infection comes up time and time again. If you're infected, you could have a low BP, which is causing a low brain perfusion, which could be causing your confusion. Infections, one of the most common causes you guys for confusion in the elderly. Acute delirium. So it's definitely got to be top of your differentials. Uh, nutrition. Not really going to go into this, but it has been shown that malnutrition can increase the risk of POSTOP delirium. Constipation really, really common in your POSTOP patients. It puts a lot of stress on the body, and the body tends to slow down a little bit in terms of gut transit so that patients are bundle up and not appropriate laxatives. They can become constipated, and you're in retention. Most common cause of a low urine output POSTOP is a blocked catheter, which could cause the patient to go into urinary retention. This patient that we've seen in the scenario he's tugging at his catheter. Has it been draining? Have a look. It might be that is blocked. He's an acute retention. He's really confused and upset. Who wouldn't may hydration again? We've obviously touched on this in the last scenario low BP. Have they been a prescribed, appropriate maintenance fluids? Are you drinking enough POSTOP? Is that what's causing them? A low BP and low end organ profusion and causing them to be confused medications again. So opioid toxicity that can cause you to be confused on D lots of anesthesia is Candace. Well, you get all sorts and finally, you want to be checking those electrolytes. Any kind of abnormality and electrolytes can manifest itself as confusion on easily corrected. So again, going through our what? You're gonna do it the bedside as the F one. So you're 80 assessment sort of observations, ECD and urine dip because the patients infected do bloods. Full blood count. Use knees. Lft is coag group, and saving a lactate lactate again would point towards maybe an intra abdominal source or uninfected in think of patients confused. Might need a chest X ray. Ultrasound. This would be worth chatting to. The nurses has a sustained an injury. Perhaps he needs a CT head. Maybe he had a fall on the wart on do. If you especially was on anticoagulants, then you could have a bleed which could be causing his confusion. So going through these is a good way on Finally, Yeah. Your CT abdomen owner as I mentioned you, t ct head. So, um hey, confused patients can be really difficult to manage, and it's actually not their fault. And it's very easy to become quite annoyed with them. But most of the time, they have a reason to be confused and agitated and upset on D. Um, quite tricky. You can work with the nurses to see what you can do. So back to the basics. Look at your patient. Are they well or unwell? It might be that the patients just, um, got known dementia. Andi. He does this every night. And in fact, if you Chatham get his daughter on the phone, then he settles down and he's very calm. So it's useful to speak to the nurses about his base patient baseline. But it might be that he's really, really sick. He's got a new infection, and you need to resuscitate and intervene. So, yeah, you're gonna be investigating those organic causes and correcting them as possible. So thinking through your pinch, me and managing them is appropriate that I'm sure you're really which is 50 years. So, yeah, for the confused patient, if possible, try trying to get family members on the phone is really good, because it's nice. It orientated patients, even if it's Ah, organic cause for their delirium kind of settles them down, and it means that you're able to get that cannula and to give them some antibiotics means you're able to get the urine dip or flush their capita. Do avoid using further sedation because, uh, it is. Sometimes it's unavoidable because of risk to staff and other, um, patients on the patient themselves. If he's a risk of him, for example, and I to you, we had a patient who was really, really confused. This was encoded, actually, and he was on up to flow, which is kind of like CPAP, but just with a nasal cannula. On day he had, um, intensive care delirium. He was trying to get up early in Canada's out, trying to pull the oxygen off Onda because he kept pulling his oxygen off his saturations with Covic. We're going down to 60 50. It was really dangerous, so we had to use a bit of sedation to get him to keep his oxygen on and but on the ward, it's good practice to try and do everything you can first, before sedating somebody on, of course, escalated concerns not only to your sexual your registrar, but if you're worried about the safety of a patient or other patients, you can speak to the onsite security team who are really useful. Um, in these kind of scenario that the management do you rate it, you first go back to the basics observations, think about causes on, then just being safe and documenting. So oh, there we go. Well, we've come to that. Let's do the questions for that one first, Jen. And that was our last scenario. Gyn sorry, I should need t o. The first question is on for confusion is how can constipation cause urinary retention? Oh, so constipation, uh, for this slide, I actually meant constipation can cause confusion. And because kind of bowel and bladder are nearby, urinary retention can also cause confusion. But constipation can actually cause urinary retention. If you've got a patient that so fecal reloaded, they can cause pressure on the bladder. And it can cause, like, a post obstructive pattern so that the urine conk out if a patient's that constipated actually can happen. Yeah, forget the other side Tenement years up? Yeah, definitely can. Very common, actually a cause of urinary retention. So urology is always good to do a d r e on. But if you got some gene, your your attention, worry about things like prostate post post renal causes fantastic on. But I was a question here, just briefly to speak for what has included in a confusion screen. So, yeah, confusion screen is usually it's less so done on, uh, I think it's last done on a surgical ward, but it's confusion. Screen includes checking all your electrolytes, checking someone's thyroid function, checking their hematinic so they're B 12 and folate on D, actually doing a syphilis screen as well. Um, I guess your full blood count would be included, but I get usually after every day anyway. But that's your main confusion screen. Yeah, I guess anything that investigates the cause is that we looked into the attic and is what? Is there any difference between confusion and delirium? Um, I guess confusion is the symptom on delirium is one of the causes off confusion, eyes kind of I guess I've used it a little bit intimate interchangeably. They're probably incorrectly confusions. The symptom delirium is one of the causes of it. Absolutely Degree. So I'm just doing the image of the depression that you love isn't really cold and a key confusional state as well, so they are sometimes used interchangeably on. But you had a very, um, tends to be an acute thing. Um, which is amazing, Thank you. That's very clear. And continue to ask questions to sell you guys if you want on this and never go on. And this next question is just would you know what? What do you need to involve a senior If you wish to sedate someone, um, this comes down to your experience. Um, every drug that you prescribed and give you need to be comfortable prescribing and giving that drug. So if you've never given a diazepam or lorazepam or a haloperidol before then we could be completely within your right toe. Ask your senior, because if something goes wrong, for example, you give too much of a benzo and your patient kind of conks out a bit. Then you need to I think it's just work within your incompetence always. And you can always ask for seeing your help. Ah, I don't think I would've sedated someone in my first couple of months without seeing your help. Uh, if a patient is known to get a bit aggressive, Um, this is a really tricky one in terms of sedating sometimes that we had a patient that would always get aggressive at the same time every night, and they have a little bit of haloperidol before bed and the nurses knew about it was on the P R N. Then I'd be much more likely to kind of authorize it as opposed to a new delirium, that you think there might be something else going on. Nothing. That's a pretty good onset. Brady, which reiterate just only other, prescribe what you feel comfortable describing. Don't just barely have to prescribe something. We have a natural was going to say I think will be covered in the prescribing lecture, but you get a nautical of the time is an F one. You get asked to prescribe things and just be wary that it's your name, your signing against that. So if you're not comfortable, you need to just have a quick check, and it was normally hostile guideline on safe sedation as well. But that's the question bluntly. I would always involve a senior from sedating Anyone is is basically where it go. Just watch, even if they're not senior. I just discussed it with somebody who's more experience than me is probably the safest thing to do if you're not sure happiness on. But I mean, sorry, there might be some other question. In summary, we've come try to approach the pyrexia well, the hypertensive and the computer patient as the f I want out of hours, we've covered a structured approach for assessing, investigating and managing these patients on. By achieving these, we've hopefully increase your confidence. So you feel better prepared to go on to be the best F ones in August. And then I guess I'll give you opportunity of any general questions. So, I mean, if you miss the intro, I'm in London as an F two. I'm doing CST in October, so if anyone has any lecture related or general questions, I'm happy to answer any. If you give me an email, I believe you need to follow this QR code for your feedback on day food back for me, which would be really appreciated on the certificate. Were there any other general questions? Let me know, Jennifer. They come through, but, um okay, um, I just haven't taken the things that Yeah, I just thank you so much, Alice, for that lecture. Really, really concise and useful scenarios that you'll get called to time and time again on day. So really good to have a framework just to reiterate that all of our webinars will be posted on our website, which is and just type in national surgical teaching side to interview girl or follow the website which we posted on the chats on. So they all got loaded tears. You can go back and have a look back at the slides on a say It's the really, really useful thing for Alice Toe have the feedback on do for her portfolio, but also it's deep useful for us to know what you find useful on what you'd like to hear in the future of compare the webinars on So just five minutes of your time, or less than it's so use up that muscle to know how you find this lecture series of what's going on on the next upcoming lectures will be on Thursday again. That's looking at's, um, and other scenarios if you got anything else that you guys would really like to become of it on. As things go one just I type it here on it too soon. Your feedback. We can try and and get that in its some point in the series for you. You just have a quick look on things around for tuning in on your Tuesday evening, Tuesday have lost track. Okay, just someone just asking me quickly. Share the slide if the management of the confusion, you know? Yeah, of course. But one of the sides will be available online. So something where you feel that you've missed things. A tool. Okay, so we'll give everyone a minute. I'll put it back on the feedback slide for a minute and then well, that you will golf in mice. My email. If anyone One set, then everyone could go and enjoy the evenings. You see, my knowledge? It's him. Perfect. I think that just looking through the questions I could see the now they're fine. Okay, so thanks, everyone. I'll go away. Thanks very much. Other