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Hello, everyone and welcome to the last lecture of the surgical sessions run by mind the bleep. I hope you've enjoyed all the other lectures. Um If you haven't been able to watch them, you can catch them all on youtube, just search remind the Bleep Surgical Series. Uh So this lecture is on Perioperative Complications. Uh as mentioned previously in our lectures, this course is designed by four junior doctors were currently F twos. Um with an interest in surgery. We've created this surgical sessions course to prepare final year students in particular for their surgical rotations as F Y one doctors. So we're not focusing that much on path of physiology and sort of deep um surgical procedures, but rather than what you will see on the ward as surgical juniors. If you have any questions during the lecture, don't hesitate to comment on the Facebook chat uh or send us an email on webinars at mind the bleep dot com. If you have any questions you don't want to ask um during the lecture. So as mentioned, the general format is to prepare you as F Y one, um an F Y two doctors for your surgical rotations. We focus on the clerking, we focus on identifying diseases and an etiology and causes of different presentations. You might see as a surgical junior, uh investigations that you're expected to order, um, and identify and then the initial management as a junior doctor, then we'll try and uh, ask you some questions along the way as well to make it a bit interactive. This is me. My name is Frayer. I'm one of the fy two doctors with an interest in surgery. So for this lecture, the key learning points is optimizing the surgical patient, recognizing risk factors for operative complications, identifying common postoperative complication and understanding the management of common post operative complications. So you're going through intellectual, I just think that you're the fy one on take clerking a patient or on call being called by one of the nursing staff to see a patient that they're concerned about. So as mentioned, we're going to try and have some interactive questions along the way. So if you log in to pull E V dot com forward slash mind, the bleep 519, you should be able to get the questions up. This link will also come up during the question. So if you miss it on this slide, don't worry. So we'll start out with our first question. What is the most common cause? The question is supposed to say of post operative mortality globally. Is it sepsis, ischemic stroke, pulmonary embolism, major bleeding or ischemic heart disease. So you carry on and come back to the answer in a bit. So post operative complications are fairly common. About 20,000, 25,000 deaths occur yearly in the UK following surgery, 80% of the desks, uh the deaths are seen in high risk patients' and we'll talk a bit about what makes a patient high risk in the next couple of sites. Um, and 10% of surgical in patient's are classed as high risk. Postoperative complications can be classes either immediate. So less than 24 hours after surgery, they can be early which is within three days, post surgery, intermediate, which does anything from four days to two weeks after surgery and late complications, which is any complications after two weeks. POSTOP, it's a typical immediate post operative complications. Anything, um sort of in the hours after surgery often associated with, with anesthetic. So that can be anaphylaxis allergy from the anesthetic agents or the pain relief given POSTOP primary hemorrhage. So this is bleeding that's occurred during operation. So, continuing to bleed in the first hours after surgery, fever, we'll talk a bit about postoperative fever and later slides and renal failure and this is often due to pre renal failure. So, hypovolemia can be caused by either dehydration due to the surgery or from bleeding, early post operative complications, anything between 1 to 3 days, POSTOP atelectasis at Lexus. So collapse of uh part of the lamb or entire lobes can be caused due to pain. POSTOP patient's often tend to not take deep breaths, postop because of pain, especially after after inter abdominal surgery. And this can cause collapse, which can also lead to pneumonia, uh secondary hemorrhage. So this is bleeding post operatively, which can often be caused by an increase in blood pressure after surgery causing leakage or vessels that weren't previously bleeding. M I so any scheme, Ick heart disease is very common after surgery, nausea, vomiting and post operative Eilis are all common post operative complications. We'll talk about about all these later and sepsis. So, fever after surgery is very common, something you're often called to as a, as a surgical junior and this can be any hospital related fever and surgically related fevers. So, chest infections are very common as mentioned often because of the pain from uh intra abdominal surgery, meaning the patient doesn't take deep breaths, causing land collapse and therefore infections. Any urinary infections, patient's will often have catheters um either intra surgically or after surgery because of possibly know retention and wound infections. So this can be both from the ports, the small little wounds or from larger laparotomy scars um and um any cannulation. So any needles or plastic ing into the body can all be infected. So any uh complications a current in four and 14 days differ slightly from earlier causes of postoperative morbidity. Around around four days. You start running the risk of an anastomotic leak in clonic surgery. You also see collections starting to occur around four days. So before sort of 57 days, intraabdominal collections or any sort of surgical collection information is very unusual um wound infections as well. So, infections and and collections take some time to take a few days to start building up and start manifesting. Um and, and the same with pneumonias uti so you can see infections um of of the chest and um and UTIs prior to four days. But these are also more common after a little bit of time in hospital, post surgery. VT. So, patient's that around four days have often been um lying very still due to the pain, um, fatigue and just post operative immobility and this increases the risk of venous thromboembolism. So after 14 days, there is less risk of things like infection, but patient's may still be quite mobile and therefore run quite a high risk of vte um incisional hernias, quite common after intra abdominal surgeries, adhesive obstructions. So this can occur quite a while after surgery and often causes small bowel obstruction and an orthopedic surgery. Um, you might see delayed or non union or flashes, right? So what is the most chronicles of post operative mortality globally? And the answer which is actually quite a few of you've answered is ischemic heart disease. So according to and the lancet, the most common cause of postoperative morbidity is that will be within 30 days of the surgery is a scheme. It courtesy is accounted for as many as as 17.3% of surgical patient's stroke accounts for 10%. Um and COPD 5.4%. So they're the most common causes, right? So what constitutes a higher risk patient? So we have patient factors and then we have pre it's a single community. So patient factors includes factors such as increasing age. So any patient who is at an increased age will have many comorbidities, they will be frailer. Um they will have less of respiratory reserve and therefore run a higher risk of post operative complications. Smoking increases your risk um drastically um your baseline activity level. So in ability to perform activities of daily living, um we'll talk a bit about sort of the baseline assessment of a patient's um ADLs later and then obesity is a very strong risk factor for post optimal obesity. Pre existing mobility includes any pre existing infection. So a lot of patient's who are requiring surgery already have an ongoing infection, they're requiring emergency surgery, um any preexisting anemia. So to try and optimize the patient's hemoglobin before going to surgery, pre existing heart disease and ischemic heart disease um is quite a strong risk factor for postoperative morbidity, COPD and any respiratory disease in general diabetes. Um poor glycemic control, both before and during the operation increases the risk of morbidity mortality. Any immune suppression and malignancy, especially malignancy with ongoing chemotherapy or previous radiotherapy that renders um in particularly the bell susceptible to, to risks following surgery. So I'm sure a lot of you have seen the S A scoring system. So this is done for every surgery. Um and it classes the patient in a group in the category from 1 to 6 and based on their general state of health. So A S A class eight is a normal healthy patient. Class two as a patient with mild systemic disease, class three is a patient with severe systemic disease. And you'll often see the surgical patient's being either class two or three. Class four is a patient with severe systemic disease that is a constant threat to life. Any operative patient that is a class four will often need urgent surgical management rather than elective surgical management. Five is a patient that is requiring urgent surgery um and is not expected to survive without the operation. And six is a patient who is already dead and is requiring surgery for the removal organ for transplants. You might also see from the operation. Next that surgeries often classed according to their severity. So we have four different categories here. Grade one is classically operations or procedures such an endoscopy, breast biopsies or laproscopic surgeries. Grade two includes co quite common procedures, elective operations such as hernias, varicose veins, um idea tonsillectomies, knee arthroscopy, arthroscopies. Grade three includes things like hysterectomies, T U R P S and thyroidectomy. Is there a bit more invasive surgery and grade four other surgeries that run the highest risk of morbidity and mortality such as the total hip replacement or a taffy for a triple A uh clonic resection. So as an F one, you will be expected to see quite a lot of post operative patient's and some of the most common things you'll be called for our things like post operative fever, patient's with postoperative respiratory, depressed distress, hypertension, northern vomiting, any sort of room complications, whether it's bleeding redness or discharge. And a patient who is not opening the bells post operatively. So we're gonna go through some of these causes that you commonly will be called for as a surgical junior. So first we have our next question. So as a rule of thumb, one unit of red blood cells increases the hemoglobin by how much in grounds pelita. I'm sorry. We can't quite see the numbers. Let me just close that. So the uh the options are either 5, 10, 15 or 20. Let me just activate this question and you should be able to answer it now. So we'll carry on and come back to the answer in a little bit. Right. Let's move on to our first case. So you are called to review a 21 year old female with hypertension. She's about five hours post laparoscopic cholecystectomy. So you start off with your examination when you're called to see a patient on the ward and especially if you're not quite sure what to do. Always go through your A B C D's. It's quite a clear, concise, efficient way of examining a patient. And it also identifies um severe causes of disease and especially post operative complications. So you start with your a her airways, a patient. She's chatting to you going on to your breathing. So, a respirator bit high at 23 her saturations are 97% on room air on auscultation. Her chest is clear bilaterally. You can't hear any crackles. You can't hear a wheeze circulation. The heart rate is a bit high. 100 and 10. You feel her peripheries and they're cool bilaterally. Her BP is fairly low at 90/50 and she has a thready regular radial pulse. She has a good urine output of 30 minutes per hour. POSTOP with a catheter in situ and her heart sounds normal capillary refill time peripherally, however, is four seconds de she's GCS 15. Her pupils are equal and reactive bilaterally and A PM is normal and you do a quick abdominal examination and she has widespread abdominal pain but no bruising as far as you can see and her wound sites appear clean with no bleeding. So your initial management is patient. This is a post operative patient only five hours after surgery and she's already hypertensive. So some alarm bells should start ringing here. Um and you should start managing the patient as a surgical emergency. So the initial thing to do is in such a large ball cannulate while you're doing this, you want to obtain a V B G and formal bloods. So V B G is a very quick and easy way to get some important parameters. For example, hemoglobin in a surgical patient and a lactate. So in this case, her hemoglobin is only 90 to her preoperative hemoglobin was 125. And this is worrying, her lactate is 4.1 and this is also, but worrying as it's very high, you want to send off your routine bloods. The full blood count use needs LFTs, always sent off a cross match. And if you're worried about bleeding in any patient or it's an operative patient in general, send off a calculation screen in a young patient post operatively with high with tachycardia hypertension and a bit of a high rest rate also want to think about cardiac causes and VT. So send off a D dimer troponin addition. At this time, you should think about contacting your senior and you potentially already have bleeped your senior in order still at them of the fact that we have a POSTOP patient who is at risk of, of complications, for example, bleeding. And whilst you're waiting for your senior to come, you can assess the op notes. So anytime you're assessing your post operative complications, post operative patient, make sure you're familiar with the operation they underwent. So check whether there are any, any complications during the surgery, for example, anesthetic complications, um or any bleeding or any other complications of the operation. So in this case, it was uneventful operation with no unusual inter operative bleeding. You also want to perform common bedside investigations. And in this case, an E C G will be the most useful and you want to have a look for any sort of heart ischemia from hypovolemia. And in this case, all it shows is sinus tachycardia. So hopefully you've already contacted your senior. The questions you want to ask is confirm how they wanted to initially resuscitate the patient. And usually this will be in hypertension. A bolus of 500 mL of normal state line. Um There's no adverse effects of this and a young woman. Um and if there's any bleeding, this patient will need resuscitation before going to surgery. So give them a bolus, contact your senior and request for them to guide you as to any further imaging required. So, if you are worried about any post optic bleeding, the most especially abdominal surgery, the most important investigation will be a CT abdomen. Um This will be an urgent CT and you're required to, to call the radiologist and request this urgently. It's important when you have an emergency that like this, that you follow up on your radiology. So call the radiologist, request an urgent CT and then call the radiographer immediately and say that this has been vetted by the radiologist. And you require this patient to go down for imaging urgently in a young patient, post operatively or any patient really post operatively with tachycardia and hypertension. It's important to not think of, not become too focused on postoperative bleeding to remember other causes, for example, VT. So, a pulmonary embolus is common uh post operatively and it's important to think about this is one of the differentials. And if the CT abdomen is negative and there's no um postoperative bleeding, try to consider other causes and potentially across the CT P A. It's also important at this point when you speak to your senior whether to discuss the case with I T U. Um If this patient is having some sort of reaction to an a static or they're having bleeding that is going to require re operation, it might be worth speaking to I T U and alerting them of the patient. And you might want to request bed space for the patient post operatively. So post operative, post operative hemorrhage can be either primary. So this is any bleeding that's caused during the actual surgery, the reactionary. So this is often when the BP post operatively rises, uh comparatively to the BP during surgery. So during surgery, BP is often kept quite low um to prevent bleeding when it's then uh when it then goes up to its usual levels, postop activity, you might get new bleeding and previously nonbleeding vessels. Then we have secondary post active hemorrhage. So this is usually due to either collections or infections that cause damage to nearby structures that cause bleeding. And then this is often several days after surgery. Postoperative postoperative hemorrhage is a very high risk complication and requires urgent resuscitation, identification and senior alertness. So make sure any patient post operatively with hypertension, you do urgently escalate this to your senior. Um most uh intraabdominal postoperative bleeding will require a ct abdomen urgently. Um And often if bleeding is identified as the patient will require re operation. So, back to the question as a rule of them, one unit of red blood cells increases hemoglobin by how much in grams per liter and correctly it is 10. So if you have a hematoglobin of 90 inner bleeding patient, you want to request quite a few units of red blood cells because one unit will only increase the hemoglobin by 10. Okay. Moving on to our next question. Approximately how many patient's experience experience paralytic ileus, post intraabdominal surgery. So your options are 1% 10% 15% 30% or 50%. We will move on and look at the answers in a bit. So our second case, you're called to see a 54 year old man post laproscopic inguinal hernia repair. He's two days POSTOP, his abdomen is distended. A nurse reports one liter of vomiting. He's not passing any foetus or opening his bell's since the surgery. So again, you want to go through the A B C D E s? Um He's talking to you and his airways are clearly patent his rest breaks 18. So it's normal. His sats are 97% on room air. His lungs are equal bilaterally with no added sounds such as crackles or wheeze. His heart rate is 92. So he's not tachycardic, but it's sort of a little bit higher than normal. And his BP is 110. Over 82 it's warm and well perfused and it's strong radial pulses. His heart sounds normal and it's clinically euvolemic disability wise. His G C S is 15. His pupils are equal and his a fibril with normal Beyonce should do a quick abdominal examination. You can see that his abdomen is two standard and on percussion. It's can panic. However, he's not parasitic and there's some mild, well widespread tenderness but no local tenderness, no lumps felt, the wound site postoperatively is clean and you can't see any discharge or redness or bleeding. So your initial assessment, your bedside investigations includes an E C G. In this case, it showed nil abnormalities as this patient is postoperative. You can do a quick V B G as well to assess in particular lactate which in this case is normal. His hemoglobin is also normal. 125. You want to send off some formal bloods and all his bloods are completely normal and it's useful here to get a creatinine and potassium postoperatively as well to assess for any renal damage or any hyperkalemia from the anesthetic agent, which is quite common. A urea is also a good marker of intraabdominal bleeding or G I bleeding because blood um is metabolized in the gi system and um causes and a high urea. So because he hadn't opened his vows yet and he's in mild pain with an abdominal distension. You want to do an abdominal X ray. Um And this is the X ray you obtain and you can see dilated loops of bell. However, what you don't see is air fluid levels and this is seen in mechanical obstruction. So this is obviously obstruction, but it's functional and it's post operative. So this is what we call post operative or paralytic ileus. So this is a very common postoperative complication. See if we've managed to get some answers here, um which affects um as much as many as a third of operative patient's. No, we have a slight technical difficulty with the questions, but the correct answer anyway is 30%. So a bit of a disparity in answers here, but majority of you answered Factive cents. That's great. So, postoperative ileus is essentially transiently impaired propulsion of intestinal contents. Um And it is one of the most common courses of delayed discharge from hospital. We're not quite sure why this happens, but it's thought to be a combination of causes um including sympathetic hyperactivity from the abdominal surgery itself and inflammatory mediators from the abdominal contents being disturbed and the colon in particular, being mobilized during surgery. Opioid you uh opioid use as pain relief is a strong risk factor. We know opioid use causes constipation and it can also cause paralytic ileus and then electrolyte disturbances, especially hypochelemia can cause Eilis as well postoperatively. So, next question, which of the following is not a potential cause of post operative Adalius. So I mentioned a few of the risk factors. So it's a hypochelemia, opioids, dehydration or post operative mobilization. So the question is, which of the following is not a potential cause of postoperative ileus. We'll come back to the answer a little bit. So the clinical features of postoperative bias is a distended tympanic abdomen. Um You will hear that on auscultation and also see dilated loops of bells with uh patient's might experience abdominal pain. So they're not past stores or flatus post operatively and they might be in quite a lot of discomfort, they might experience nausea and vomiting. Um and on auscultation of the abdomen, you might hear an absence of bell sounds. So this is very common and it's often um not a dangerous complication of surgery, but it can cause quite a lot of discomfort. And as mentioned, it can cause delayed discharge. So the initial management is keeping the patient nil by mouth, especially if they're experiencing nausea and vomit, vomiting, you want to do a full assassin of the patient to identify any underlying causes. So for example, their electrolytes check they're not hypochelemia like and if they are, you want to make sure you replace their potassium. If they're on opioid algae, six, you might want to try and reduce their opioids or even stop them completely as these cause quite what these increase the risk of ileus, other drugs such as anti cholinergics. Oxybutynin Busk pan those sort of drugs can cause um I'll ius um they can also cause urinary retention and they're quite important to, to not just using William really post operatively. And if you have a patient experiencing alias, try and rationalize these medications and see if you can hold them temporarily whilst they're experiencing their, their obstruction, then make sure the patient isn't dehydrated. So, perform a full assessment of their hydration status, including their uh their ops and especially their postural BP, which is very good marker of dehydration. Um and um rehydrate them. If you think they are dehydrated. If the patient is vomiting and experiencing ongoing nausea, they might benefit from N G drainage until they're nausea and vomiting has settled until they've opened their bowels again. You want to make sure they're rehydrated um appropriately and encourage mobilization. So, mobilization is a really effective way of getting people to open a Bell's post operatively. Um And uh postoperative Eilis, as said, is most commonly uncomplicated and will resolve spontaneously with in three days. In most cases, if it doesn't resolve within sort of 3 to 5 days, you want to consider any imaging um to assess other causes of obstruction. So the question was which of the following is not a potential cause for POSTOP ileus. And the correct answer is POSTOP mobilization. So quite the contrary, postop mobilization, especially early mobilization is important and can often and resolve ileus, right. So the next question, not next question. Next case. Uh case number three, you are called to see a 70 year old man, four days post a hemicolectomy for perforation secondary to diverticulitis. Despite the temperature of 38.3, he complains of ongoing postop abdominal pain and a mild cough. So your main complaint here from a patient is a cough, abdominal pain and a fever. So again, you want to go through your eighties, make sure the airways are patent uh on breathing. His respirator is sort of on the brink of being high. His sats are slightly low on room air at 93%. He on auscultation, you can hear a right middle zone reputation. Um Otherwise he's a bit tachycardic. His BP is stable and his warmer welcome, perfused with strong radial pulses. His heart sounds normal and it's urine output is 20 minutes per hour satisfactory. It's clinically euvolemic. He's G C S 15 people's equal. It's got a fever is mentioned at 38.3 and his BM. So normal on abdominal examination, his abdomen is soft but he has widespread tenderness. His wound sites are clean and his carbs are soft and nontender. So the first thing you want to do is your bedside investigation. So make sure you obtain an E C G know patient with tachycardia. An easy assessment to do um in a patient with fever is a urine dip. Not only can you assess for um signs of infection or leukocytes and nitrites in the urine, but you can assess other things like blood and protein in the urine as well, which is important in other causes um of infections such as renal stones, causing, causing taps is because this patient is desaturating. On rumor. You might want to consider an A B G to assess his oxygen status as part of your septic screen, you can obtain your wound swab. And if the patient is experiencing diarrhea, you want to do a stool microscopy and culture as well and and include a see deaf in this investigation. So with any patient who's spiking a temperature, especially a post operative patient who's undergone um surgery and has cannulas and several sources of infection that possible you want to do a full septic screen. So you mentioned some of the bedside investigations you can do and make sure you send off a group and saving a coag because this is a surgical patient. You want to do cultures including blood sputum, urine, stool wound. And in this, this day and age, you want to do a COVID test as well and then do your investigations. You want to think for the sources of infection. So in our case, our patient had course crackles in the right middle zone. Um So you obviously want to do a chest X ray um in any septic patient postoperatively, even if you can't hear any crackles, it might be worth doing a chest X ray. Anyway, as post operative chest infections are very common as this patient is postoperative. You want to alert your senior to the fact that he's spiking temperatures. And you want to ask whether there's a need for further investigations such as the CT abdomen for a possible anastomotic leak, which can cause a raised temperature or whether you want to do a Doppler or a CT PA for a DVT. So it's important to remember that a cause of postoperative fever is also V T E and this can be the only sign of a pe postoperatively. So keep it as part of your differentials in any fevers, any patient spiking a temperature. So you do a chest X ray and this is your results. So as you can see, you have quite a nice middle lobe consolidation on the chest X ray. So your initial management of a patient presenting with a hospital acquired pneumonia will be immediate resuscitation including oxygen. This patient is slightly hypertensive in tachycardic, which might alert to the fact that he has become septic. So you want to resuscitate him with the fluid bolus, prescribes my antipyretic cells, for example, paracetamol and quite quickly prescribe empirical antibiotics and there will be empirical because you don't have any culture results. So in this case, you want to follow local policies and it's usually be broad spectrum Beetle Act um such as Comex Club in patient's any impatient, but especially surgical patient's who have a higher risk of morbidity and mortality. Make sure you always discuss the ceiling of care or assess ceiling of care with your seniors. So, is this patient ward based or will they be for further intervention such as non event, noninvasive ventilation or even I T admission for inotropes support or intubation and ventilation in any patient with sepsis is also really important to monitor urine output and a strict your strict fluid balance. So post operative pyrexia will be quite a common thing you're called for um immediate post operative pyrexia. So this is any fever within 24 hours of um of surgery is very common. It's usually low grade postoperative fever and it has uh in about a third of operative patient's. Um and this is sort of just a result of information, post surgery might be due to the medication or the blood products. And so assess what medications have had, assess the prophylactic antibiotics. They've had, assess whether they've had any blood transfusions and if they're having ongoing blood transfusions, um it's important to recognize that this may be a transfusion reaction. But in most patient's within 24 hours after surgery, they will have a completely non complex complicated low grade temperature just because of the fact that they've had surgery. And in this case, you can prescribe some paracetamol and monitor them and make sure they're high him oh, dynamically stable. You always want to do your septic screen, but you don't necessarily need to spend hours finding a source of infection. Um as mentioned, VTE is a cause of postoperative Pyrex. It, it can just cause a fever and no other signs. So this is important to keep as part of the differentials and the same goes for ischemic heart disease. So, michael infection can just cause a temperature as a an inflammatory response. So, acute postoperative Brexit is any fever occurring within seven days of surgery. Um This is usually due to infections. So whether that's of the surgical site uti this can often occur because patient's either have catheters in situ postoperatively or because they're experiencing urinary retention due to medication or opioid use, for example, uh pneumonia as mentioned because patient's don't take deep breath due to pain, um C diff. So any patient who is in hospital is unfortunately at risk of getting c diff. So any patient with diarrhea in hospital should be immediately moved to a side room and isolated and assessed for C diff we mentioned BT and M I and then blood transfusion reactions or medication reactions. Remember, pancreatitis is part of the differential as well. A lot of the medications we give um including steroids can cause pancreatitis. So keep that as part of your differential as well. So any fever between one and four weeks after surgery, you start thinking again about infections. But more commonly, this will be deep abscesses forming or infections of prostheses. In for example, orthopedic surgery patient's might still get UTIs pneumonia and VTS. But scheme eclipsys will be less likely in this time frame after surgery. As a rule of thumb in days, want to, you want to consider a respiratory source. So it's quite unlikely to get abscess formation or infection of a wound this close to surgery. So consider sort of respiratory um sources of infection. Um Day 3 to 5, you might consider urinary tract source and day 5 to 7, consider infections of the surgical sites or deeper abscess collection information. This is quite a gross rule of thumb, but it makes it a bit easier to identify possible causes. Um the five ws of post operative infections and put sorry, postoperative fever is also quite useful. So the first song we wind and this is respiratory sources of infection. So this is 1 to 2 days after surgery, water will be 3 to 5 days. Emsis would like classic would be UTI S walk. So this will be V T E. Um This will be 4 to 6 days after surgery, wound 5 to 7 days. So this includes abscesses and collections and then wonder about drugs, which is any time POSTOP activity. So that will be anesthesia or um antibiotics. Remember to identify patient's who you think might have sepsis. So, no, your servers criteria. The Q sofa criteria are quite easy to remember that any systolic BP below 100 or a spiritual 8/20 or GCS at um less than 15. And remember to identify this and act according to the sepsis six, within the first hour of identifying sepsis. Um When you want to escalate your patient with postoperative pyrexia, it depends on their clinical state, assess them for septic shock. So this is any patient who is still experiencing hypertension despite food resuscitation. If they're, if they have a lactate over four or no response to the antibiotics or fluids or oxygen, you've given them, you want to immediately escalate to um I T U or to your senior. And remember to in the days following the cultures from, to routinely assess the cultures and discuss them with microbiology for the treatment and as much as the culture and sensitivities. Um and it might be useful in a patient, for example, with the uti, it's useful to go back in the cultures and have a look at previous cultures as well to see whether there's any typical bug that Rikers, right. So we sort of missed this question a little bit. I'm not sure if you can see it. So just close the present of you. But the question is what percentage of patient undergoing surgery die during the same hospital admission in the UK? There's a bit of a morbid question, but it's just to alert you to the fact that the death rate during surgery is what I would say is fairly high. And the correct answer here is 1.6, which is what most people have answered. Um And this is obviously, uh this number is a lot higher in low income countries. Um But 1.6 is still unacceptably high. Okay, then we have the final question, which antiemetics should be used with caution in young adults. The IV metoclopramide, po cyclizine, IV Ondansetron or IV Don Paradyne. So we'll come back to the answer shortly. Ok. Case four, you're called to see a 23 year old lady eight hours post laparoscopic appendicectomy, complaining of severe nausea on examination and use zero. She's a federal and hemodynamically stable. Her abdomen is soft and she has mild localized tenderness over the wound sites, but the wound sites are clean and she's clinically euvolemic. She is passing places post operatively. So you want to do a couple of bedside assessments, assess her urine output and assess that gastric motility. So you've already asked her about her bells since she is passing Leitess and, and make sure you record her fluid balance, record an E C G um and assess her most recent blood's for any rising inflammatory markers or any electrolyte disturbances. Make sure she doesn't have an A K I post operatively to check her creation in her urea. You might want to do some new bloods, but her main complaint here is postoperative nausea. So this is quite a common complaint and something you are frequently called about when you're a surgical f one patient's very, very often experience nausea post operatively and there's a certain risk, a group of patient's are at higher risk of postoperative nausea and we'll touch on that in the latest slide. Um but the initial management will be to assess the operative notes, assess all the bloods her recent imaging and make sure there's no underlying cause of um of her nausea, vomiting. So any patient on opioids, um despite them being good pain relief, they do cause nausea. So it might be worth rationalizing these and reducing them or even stopping them if you can, if the nausea is caused by pain, make sure you do optimize her pain control. Um You might want to add in an NSAID rather than an opioid. Um If it's a combination of pain and opioid induced nausea, ensure that she's adequately hydrated, dehydrated, postoperatively can also cause nausea. Um If she's vomiting profusely or she can't keep anything down including fluids, you might consider N G tube decompression for the time being until her nausea is controlled, then you want to start prescribing an anti emetic. So this is when you've excluded any other causes of post of written nausea. So POSTOP nausea and vomiting affects about a quarter of patient's within the 1st 24 to 4, 48 hours post operatively and the patient's that are at high risk of POSTOP nausea are generally females, generally young females that anyone under the age of 50 anyone with previous postoperative nausea. So this is part of your preoperative assessment is asking about previous anesthesia and whether they've experienced nausea from this before. And patient's who are smokers will also be at higher risk and the cause of this is unclear, then we have operative risk factors. So anyone going through intraabdominal laproscopic surgery or laparotomy surgery will be at high risk of postdoc nausea, guy knee surgery in particular. Um This is slightly also unclear but it might be an autonomic response from the this sort of irritation of the vessel a during Gynie and inter abdominal surgery, any middle or in ear surgery, which obviously damages or um causes a disturbance of the vestibular system which can cause from almost emotion sickness. Poor pain control has mentioned O P analgesia and spinal injuries, algesia and then inhaled um pain relief, such nitrous oxide or isoflurane can also cause postdoc nausea. So, as mentioned, make sure you assess for any underlying causes before you just treat it as generalized postop nausea. So ensure they've opened their bells and they're not abstracted, ensure they've not got an underlying infection which often causes patient's become nauseous. Ensure their electrolytes are within normal ranges and check their BMS for DKA. Um stop any opioid if you can or reduce the opioid dozing if they're not in too much pain and just be conscious of the fact that antibiotics can also cause side effects. And if they're not necessary, just rationalize them. If they're causing nausea, patient's with raised intracranial pressure will, will also experience nausea. This is quite an uncommon cause of POSTOP nausea and vomiting and then just general anxiety can cause patient's to feel sick. So we won't go through all the path of physiology of nausea, but it's, it's quite useful to just be aware of the different causes and the different neurotransmitters. The anti emetics work on because this makes for a more effective management strategy. Um So with the different antiemetics, you have the main categories which are the dopamine antagonist. So this includes metoclopramide and um Paradorn. Um these are pro kinetic agents and are often avoided in abdominal g eye surgery. Um just because any pro kinetic agents in a bell obstruction will be quite detrimental. So try to avoid medical provides in particular as much as you can in the POSTOP patient, especially in general general surgery. Um Then we have um the serotonin antagonists on Dance Tron and this is quite useful and quite commonly prescribed antiemetic just because of the fact that this one cause constipation. So, in a patient who is experiencing nausea, because the constipation on Dansetron might not be the best option. And then we have a church one histamine receptor antagonists, which includes cyclizine. Cyclizine is important to avoid IV because it can cause a high and it can cause an addiction. Um So it always give it orally when you can. Um the other thing too because of the cyclizine is it does have anticholinergic properties. So just um just um administrate with caution in the elderly because it can cause urinary um obstruction and retention as well on Dan Strong, make sure you obtain an E C G four describing it as it can cause a long Q T C. Metoclopramide is important to avoid in young women, particularly because these patient's are at risk of extra pyramidal side effects from metoclopramide. Um And the other group of patient's who should avoid it in is anyone with Parkinson's disease or Parkinson's symptoms because of the anti doping magic effects? So the question which antiemetics should be used with caution and young adults, the answer is met metoclopramide because of the risk of extra pyramidal side effects. Okay. So final case, we'll go through this. You called to see a 65 year old lady four days post and nephrectomy for a right uh for a renal cell cast neighbor, she complains of shortness of breath only. So you go through your 80 again in age, she has a high respirator and oxygen saturations are 92% only on room air. Her chest sounds are however clear. She's tacky cardiac with a stable BP and she is warm and well perfused with the regular heart rates. Her heart sounds normal. She's a fibril and GCS 15 with normal BMS and pupils, abdomen is soft and nontender and her wound sites are clean and her calves are also soft and nontender. So you do your initial bedside investigations and this includes an E C G. So on your E C G, you can see she's clearly tachycardic. The other thing you can see is that she has some T T wave inversion, um particularly here in Leeds V one and V two. So these are the right precordial leads. In addition to this, you might see a right bundle branch block, um which indicates all these together indicate a right heart strain. So in any patient post operatively with tachycardia, um and low saturations just be wary of um any sort of VTS. Um in particular p severe initial investigations, send a few routine bloods and remember to include A D dimer and a troponin in these um as the patient's desaturating with a high breast rate, you might want to do an A B G to assess the their oxygen levels, um and their acid base balance. So your initial um investigation will always be a chest X ray, but make sure to contact your senior early and ask whether they would like any further imaging for for example of pe. So this will be a C D P A before you do a CT PA. It's important to assess the patient's renal status. So make sure they don't have a chronic kidney disease or an AKI that means that they are at risk or renal failure from contrast, CT PA. So just always have VTE in the back of your mind in a post operative patient. Um The management in post op patient's will be um something to discuss with your seniors because patient's are obviously at higher risk of bleeding post operatively, but they're probably at higher risk of morbidity and mortality from A P. So the the usual management will be low molecular weight heparin or unfractionated happen in patient's with renal failure. Um and the duration of oral anti regulation will depend on your local guidelines, but usually it is 4 to 6 weeks in patient's with temporary risk factors and 3 to 6 months for patient's with um no clear cause or lifelong for some patient's. So, so just make sure you adhere to your local guidelines when prescribing long term and calculation, but postoperatively often have quite clear cause and they will unlikely be on long term anti regulation. Okay. So whizzing through the last couple of slides there, but I hope that wasn't too fast paced for you. Um Suggest in summary, um, patient's who are operative, patient's must be thoroughly assessed to assess their surgical risk and try to identify patients that are in the high risk category. Ischemic heart disease, sepsis and POSTOP bleeding are all common causes of post operative mortality. Just make sure you keep them in the back of your mind when you invest in you and examine your patient's POSTOP. And remember to always escalate the postdoc patient early. So you might wanna alert your a lot of consultants will want to know uh any of their surgical patient's that are experiencing any POSTOP complications early on in the course, post operatively. Okay. So this was the last episode of our surgical sessions. I hope you've all enjoyed them. Please go on to the mind the mind, the bleed website for any further um further sessions on other medical specialties, well as surgical specialties um as mentioned, you can find all our lectures on youtube and we'd really like your feedback as always. So if you wouldn't mind using the QR code and just leaving us a little bit of feedback. Um If you want to ask a question, please email us on webinars at mind the blue dot com. Thank you all for watching. Hope you have a lovely Christmas and please follow the mind the bleep web page for any other resources.