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Um Once again, I'd like to thank our sponsors and this will follow up follow on from our preoperative care talk. Um As you can see the sponsors on the slide um that hopefully most of you have attended already, I'll now hand over to Isha and um and a reminder that if you fill out the feedback, you can get an attendance certificate. Hi, everyone. Hopefully you can all hear me. Um Thank you for the introduction. Yeah, my name is Aisha. I'm 1/4 year medical student as well. Um And I'm just taking the postoperative care talk just hopefully running through the main learning outcomes for today, looking at basically any postoperative complications. Um looking at how we can optimize postoperative care as well using adequate analgesia and the importance of this as well. Um We'll go through in depth and um a lot of the common um complications and more of the severe ones and how we can manage those. And from that, we can understand the whole picture of post operative care, which is really important for any sort of surgical specialty or any anesthetics knowledge that you guys want to have. Um So, yeah, Um Hopefully you guys can see everything. If you can go to the next slide, we'll just start looking about um sort of the principles of enhanced recovery. So this is mainly for sort of elective surgery. Um And this is kind of why we want to have good recovery. Obviously, it seems quite self explanatory. You wanna make sure that the patients are adequately kind of prepared um pre and postoperatively as well. But also why is it that we want that to have enhanced recovery? Why do we wanna um ensure that the preoperative care process is all sufficient and then having um a good postoperative care? Well, we wanna have that preparation for surgery. We want it to be minimally evasive and and provide adequate analgesia and this is all to reduce any complications in the postoperative period. So how we can do that is by providing good nutritional support around the surgery, making sure that postoperatively they have an early return to oral diet. And so they reduced kind of support on any other sort of nutritional aids. Um and ensuring that they have adequate fluid intake, POSTOP as well. Early mobilization, obviously, that reduces the risks of any clotting and avoiding drains and NG tubes. Ultimately, it's reducing the reliance on a lot of the other medical interventions, making sure the patient can sort of recover themselves, having early catheter removal and early discharge as well. All of these are optimizing the patient's recovery in the long term, not only in the short interim period, POSTOP, but actually, in the long term, reducing any complications and any further need for any of the further surgeries or reliance on medications. Um So if we go to the next slide, we can see, um if you just click once and then forward, just sort of the aims for the analgesia, then so we've established that we want to enhance the patient's recovery. Obviously, it's the patient's best interest. One of those points and how we can enhance recovery is to make sure the patient's got adequate pain relief. They've just undergone perhaps an intense or an invasive procedure or even if it's minimally invasive, there is going to be that sort of associated pain. So why do we want to have that analgesia? The whole aim of it is to encourage the patient to mobilize, to ventilate their lungs fully. And that's preventing any risks of chest infections and any lung collapsing and making sure that they can have the adequate oral intake. If the patient's in pain at the end of the day, they're not gonna be inclined to take that food and that's just gonna slow down the whole recovery process. Obviously, adequate nutrition is important for the healing stages. So making sure that we can kind of monitor their um pain and manage their pain fundamentally is going to kind of relieve them if any um sort of complications further down. So if we just go click back one button, we'll just go through this slide just looking at POSTOP analgesia. So there are loads of different options in how we can um provide this pain management for these patients. Um So if you're aware of the who pain ladder, we'll start by looking at how you can cope with mild pain. So most patients will start on this sort of rung of this um pain ladder and work up it as the pain doesn't get managed. So mild pain can be um sort of controlled by non opioid analgesics. These include paracetamol and nsaids. So this is recommended first line for mild to moderate pain. Um And then as we go up that rung of the bladder, we can start adding on weak opioids or adjunctive therapies. Um So the weak opioids that we can look at are stuff like our codeine traMADol compresses that as well. And then we go into our final rank when we've got our moderate to severe pain. So these are our strong opioids. Um So that's what we've got to kind of consider when we're looking at um pain relief. So the opioid analgesics, we'd want to use these as few as, as we can at the end of the day, a lot of the patients are going to need them, but we want to reduce reliance on these medications. So we can use them um in conjunction with non opioid analgesics as well. For the severe pain. So we can use that with and without those um, paracetamol and nsaids. Um And then we've got this um point about patient controlled analges and so we can talk about that a little bit more on the next slide, but this is allowing the patient to kind of administer controlled, obviously, um and monitored by any physicians but allow them to self administer pain relief, depending if and when they need it. Um So if in case the next slides, thank you. So, just a little bit more about um these analgesics in effect. So first we have paracetamol. So this is our bottom rung of this h pain ladder. So, paracetamols action is to inhibit prostaglandin synthesis, therefore reducing any pain and it gets metabolized in the liver. A couple things to note obviously is paracetamol toxicity. So it does take quite a lot to overdose or take too much paracetamol. But actually, if you're doing it long term postoperatively and it's not controlled regularly or the patient is in a lot of pain, that risk of toxicity increases. And the reason that you get toxicity is because you get um acute of the N A PQ I metabolite in the liver and that can lead to acute liver injury. How do we manage this toxicity? Well, you can take either activated charcoal but it has to be within the hour of all ingestion. So, post that hour, the activated charcoal is not gonna really have effect. And the way that they activate the charcoal works is almost like soaking up that excess paracetamol. Um And then you can also use N acetylcysteine. Now, you can use this within the first eight hours. Technically speaking, you should be using it regardless. Um They also say you have to wait four hours post um ingestion to, to kind of monitor the levels of toxins. But if the patient has severe liver damage, regardless if that's the history or due to the toxicity, then it's just important to use the um N acetylcysteine within any time period, post ingestion. Um So then we've got nsaids. So these are um medications. So they're non steroidal anti-inflammatories. So these are stuff like ibuprofen aspirin, um diclofenac. So the action of these are cox two inhibitors. They also work on cox one as well because they can be nonselective. There are specific cox two inhibitors that can be used as well, but they work in the prostaglandin synthesis pathway. So the way that they work is an analgesic and antiinflammatory effect based on the prostaglandin synthesis as well. Um they can have their risks and side effects. Um As most of you are aware, they do increase the risk of peptic ulcer and peptic bleeding. So you have to prescribe a PPI such as omeprazole alongside it to prevent that risk um of any peptic ulcer formation. It can also be contraindicated in those with renal impairment and coronary heart disease. Um, coronary heart disease is a relative contra indication depending on sort of what nsaids you're taking. So, it's taken with a pinch of salt and again with asthma, although it's contra contraindicated in those with asthma, sort of in a exam, sort of mindset. Actually, what you'll find is only 1% or less than 1% of asthma. Asthmatics will actually be affected by nsaids. But again, it's important to err on the side of caution. But I think what you'll find in practice is as long as they've tried it and they tested it in a monitored sort of condition. Most asthmatics are fine taking nsaids. Um And then finally, just a point to mention if you've got patient with any sort of neuropathic pain rather than providing them with paracetamol nsaids, that neuropathic pain can be particularly targeted using these neuropathic medications such as amitriptyline, DULoxetine, gabapentin and pregabalin. So, next slide. Thank you. So again, just a couple more of these uh medications just to go through. So these are looking more about opioid analgesics. So we've got codeine and morphine. So the difference between codeine and morphine is just about how they get metabolized in the body. So codeine is, you can almost think about it as an inactive form of morphine that gets activated or converted to in the body. So you use um a larger dose per se of codeine in comparison to morphine as less of that codeine gets metabolized into the body. Except for those, um you can get super metabolizes of codeine as well, but also you can get poor metabolizer. So these are the people that although they might experience some of the negative side effects of the opioid analgesics, what they actually can't do is convert that codeine into morphine. So that enzyme cyp two D six converts that codeine into morphine in the body. And that allows that to have that analgesic effect. So these poor metabolizer that have inactive copies of this enzyme can't metabolize that codeine into morphine. Therefore, they'll get all the negative side effects, but actually won't have the benefit of that pain relief. So when we have um morphine, so in terms of its half life, it's got quite a medium half life. So it's quite good for sort of long term pain. Um medication, especially in that postoperative period, you can kind of have it uh have fewer doses within that day. Um Examples of some medications that have shorter half lifes. So you can kind of have that comparison is um opioid medications like fentaNYL and a fentaNYL. Um that's why they use alfentanil. Hopefully, as you learn in the preoperative care because it kind of wears off quicker post um operative period. Again, it's metabolized in the liver. And this time if you do have a morphine overdose or you have any morphine toxicity, you can get uh you can manage that with Nalox. Um the side effects that you get with morphine. And these are relevant to codeine as well as nausea and vomiting, constipation. That's why it's always recommended that an opioid medication gets co prescribed with a laxative. And you can also get respiratory deer depression. And that tends to be when you've got more of that opioid toxicity. Um, and you can develop a to, uh, tolerance to these medications. So you could either titrate them up or have to consider stopping to a different sort of opioid um if just click button. So some of the signs of opioid toxicity and that's when you've obviously taken a bit uh either overdosed or the calculations and the toss haven't been wiped out properly. Some of the signs of this opioid toxicity can be uh pruritus. So having that itch any myoclonic jerks, pinpoint pupils, it's quite a notable sign confusion, having that decreased G CS respiratory depression, going to respiratory failure and again, nausea and vomiting. So again, how do we monitor and manage that opioid toxicity? It's prescribing that Nalox. Ok. Lovely. Ex excited. Yes. So a couple of things that I wanted to just say that were relevant to sort of anesthetics as a whole is like I mentioned that PCA. So that's that patient controlled anna analgesic. So this is when you've got an IV infusion normally of a strong opiate. So that could be a morphine attached to a patient controlled pump and you're administering bonuses if and when and as required. So, although this is really good for the patients, if they're in that sort of pain, they can use um kind of bonuses of morphine to act as sort of that breakthrough pain. It does require careful monitoring. What's good about it is you can't really um take too much. There is that safety device feature on the on the pump. So it does prevent any um sort of toxicity, but you have to have that rapid access to naloxone because things happen and obviously you want to be able to reverse any negative effects. So other sort of analgesics that you could use either in the operative period itself or postoperatively, that sort of would happen within theater, but would have that analgesic effect for several hours after. Um the theater is use of local anesthetics. So this is an example, the most common being beer, bupivacaine, that's a long acting local anesthetic and it provides that analgesia for several hours. So they might use that within the surgery and it would have that long lasting effect. So it can be used as a nerve block for selective analgesias. Uh um and it can be useful when a sympathetic block is needed to improve postoperative blood supply. So we can always say use an epidural anesthetic. So this tends to be the gold standard for abdominal or bilateral lower limb surgery and they are administering um an anesthetic sort of into the spinal cord. So if you um block the, if you administer the block above T four, you can get some autonomic um, symptoms or side effects as a result. So you can get associated hypertension. And if you do have that, you should uh stop the infusion for around 30 minutes, restart it at a lower rate. So it's not just a sort of single shot. You can use a, um a, an IV infusion as you're administering this epidural anesthetic or you can use vasopressor to counteract that hypertension. You can monitor the block via the bromage score. We're not gonna go into too much detail about that, but it's just a way of monitoring any of the adverse effects and looking at any reducing any of these risks post um administrating this epidural anesthesia, uh anesthesia. So the risks that um can occur a hematoma, a postural puncture headache and um failure. So what I mean by failure is obviously the anesthetic not working, which is not quite good come some other things as well. And so the risks are quite rare. So the risks for hematoma are only 100,000. You do have a higher risk of postural puncture, headaches, that's one in 100. So that's basically just saying that there might be that risk of the headache, post it, but actually weighing the risks. But the benefit during the surgery happy to take it. What's surprising to know is that the failure of it working is actually a one in 10 statistic. So it's, it's important to ensure that the patient is aware of the risks of it not working and that there's adequate analgesia in place to cope. Um post administration, there is risks of nerve injury as well. And the common, more common um risks with the epidural are nausea, vomiting and itching. What's important and exciting to know is that there is no evidence of chronic back pain, post epidural. So a lot of patients do have that sort of fear. I guess it comes with the psyche of getting a needle in your back that you'd have any chronic back pain or any long lasting effects. But there's no evidence to suggest that there would be a link with that. Um ok, lovely, please. So a couple of things to mention, um just in that postoperative phase is being aware of urinary tension. So this is um the inability to pass urine despite a despite it accumulating in the bladder. So this can lead to an AK I which as we've said is a decrease in the normal volume of urine. So, and your urine output is less than naught 0.5 mL. What's important to know is that what sort of a here it is, is dependent on why we've got that urinary retention. So it might be an obstructive course, there might be um things within the surgery that have caused an obstruction. Um But it also might be due to some of the medications having a nephrotoxic effect on the kidney. So, as long as, uh, when we're thinking about urinary retention in the postoperative phase, we tend to be thinking about an obstructive course because that means the bladder is filling up with the urine, but it's just not having it. Um, there's no ability to pass. But if we're thinking more of the renal causes of AKI, then it's important to understand which sort of medications have been administered recently in the, in the um admission of the patient. And then looking at the effects on whether they're nephrotoxic at all. So how do we investigate this urinary retention? It's doing a bladder scan and looking at the um, prevoid or if the patient hasn't gone to the bathroom yet, obviously, then looking at the volume within that bladder and seeing how much has been retained. Um So if the patient has gone into that, um AK I, there are other things that we can do. So we're obviously going to measure and monitor that urine output, do urine analysis to see if there's anything that would be suggested of, say an acute interstitial nephritis due to any nephrotoxic medications perform using these monitoring the creatinine and urea levels. And if it's really unsure about the cause of this AK I, if it presented as an AK I picture doing an ultrasound of the kidneys, the ureters and the bladders would either suggest there's an obstructive cause later down the line. So how do we manage this urinary retention? Well, we correct the fluid and electrolyte imbalances if there was a renal cause, or we're going to stop any of the medications that were nephrotoxic, if the reason was that we're not generating the urine. But actually, if it's an obstructive course, it's monitoring that obstruction, removing it if possible or catheterizing the patient when necessary, important thing to be aware of in the postoperative phase is obviously, once you've administered the catheter, you have to take it out at some point. Um And being aware that you have to do this in a controlled and monitored state, you don't want to just remove the catheter and just allow the patient to be discharged immediately. You'd have to have this t which is the trial without the catheter. Um And in doing so, you'd check again with bladder scans or just by speaking to the patient, you'd monitor the urine output, post catheter removal. Now, if this isn't adequate and the patient is still retaining urine, the catheter might need to be reinserted. And if you have this a lot of times this, I think it's around twice, you might need a long term catheter in place. And that can be reviewed periodically to see whether not the patient can then be um without that catheter long term, just on the next slide, there's some more things about this. AK I so there is that thing stop just looking for the causes of AKI especially. So I just wanted to bring your attention to this because it's important to be able to identify when patient is in AK and being able to manage it as well because you do want to prevent any signs of hypervolemic shock and septic shock as well. And also an AK is important to manage, like I said, due to those complications. So we've got our staging of our um A KS. Um looking at either the creatinine or the urine output, the common causes being sepsis, hypervolemia toxicity. So those tend to be due to the medications, obstructions that can be stones could be um prostatic diseases and parenchymal diseases as well. But this management, as mentioned before stopping any nephrotoxic medications, aim for fluid resuscitation and remove any obstructions where possible. Ok. This next cycles. So um another common thing that you'd have to monitor and manage postoperative is nausea and vomiting. Now, this can be due to many different things. It could be due to the procedure itself. It could be due to the anesthetic and reaction to the anesthetic prior to any pain that the patient is experiencing. And then when trying to manage the pain side effects to the opiate. So it tends to be kind of a double edged sword, this nausea and vomiting. A lot of patients will experience it for very many different causes. And unfortunately, it's one of those that either you just have to monitor and manage after or adequately explain to them in the preoperative check and when consenting the patient that there is a high risk of nausea and vomiting. So to be classed as nausea and vomiting in the postoperative period, it has to be 24 hours after the operation. There are some factors that can increase your risk of getting nausea and vomiting. So, being female or having a history of postoperative nausea and vomiting or motion sickness in the past being a nonsmoker surprisingly increases the risk using those um opiates postoperatively as a common side effect with these having a young age and using the volatile anesthetics. So, instead of using IV any propofol that's actually gonna reduce your risk of um nausea and vomiting, but using inhaled. So your um iso fluorane, those are gonna all increase your risk. So, how do we manage nausea or vomiting? Well, first we can prevent it from actually happening. So you in the preoperative period, um especially in induction with anesthetics. Hopefully, this has been mentioned before. So you guys are experts. Um you can take prophylaxis. So the um an anesthetist will administer either a Dansetron um dexamethasone or cyclizine to prevent any further or prevent severe sort of nausea or vomiting when the patient wakes up POSTOP. So, Ondansetron is a five HT three receptor antagonist, that's a serotonin receptors. Um and it should be avoided in patients with prolonged QT as it can cause long Qt syndrome, dexamethasone can also be administered which acts as a corticosteroid. And again, as its action as a steroid, you should caution with those with diabetes or those that are immunocompromised. And finally, we've got cyclizine, which is a H one. So a histamine receptor antagonist and so precaution for those with heart failure and those in the elderly can cause an increased uh risk of falls as well. Um So if in the case that the prophylaxis hasn't done adequate sort of prevention of nausea and vomiting and the patient is still sort of feeling quite unwell with it. You can use Ondansetron cyclizine again in the postoperative phase, but you can also use prochlorperazine. Thanks. Thanks, as mentioned, in order to enhance recovery for patients postoperatively, it's important that they have adequate nutrition. So the aim is to optimize their pain and their management so that they have oral um eating or eating via their gi tract. And that's enteral feeding where possible. So that's gonna ensure healthy wound healing and overall recovery. So, if that can be um kind of kept to as long as possible, that is sort of the aim. But if not, if the patient isn't able to um sort of feed themselves, they're not able to get that gi feeding, you can use NG tubes. So um you can use feeding um assistance. So you can also use a peg tube which is a per percutaneous endoscopic gastrostomy. So an NG tube is going through the nose peg, it's more of an external tube that can help with nutritional support. But again, it's important that you just try and encourage eating where if and where possible. So you can also, if the NG tube and the peg tube are contraindicated or not viable for this patient, you could also have total parental nutrition. So that's what TPN is. So instead of going via the GI chart in said, you're giving an IV infusion of all the nutrients that the patient um is requiring. So that's your carbs, your fats, your proteins, your vitamins and minerals. Now, the problem with this is because obviously you're administering your IV. First of all, you'd need like a large ball cannula in place um or in, into a central line. And that's because you've got a high risk of thrombophlebitis. If you think about it, it's a large IV infusion and it's not a sort of gentle things. These are nutrients that you'd normally get through your gut. So if you're giving that IV, it's going to have sort of that inflammation. Another thing to um bring your eyes to is this must tool. So this is to look at um the nutrition in patients. Um elderly patients tends to be, but it's looking at just overall nutrition for all those patients and whether they're at high risk or low risk of malnutrition. Excellent. Thank you. Ok. So, yeah, now we're just gonna look at some of the main postoperative complications. So we'll be going through um some of them in a bit of detail, but I just wanted to pop this little slide here. So this is a table just showing you the complications and what's actually going on physiologically to sort of arise these complications. So things like arrhythmias tends to be due to um potassium levels in the blood and any arrhythmias due to disorders, potentially high or low cal um potassium levels, looking at other electrolyte disturbances, they can be due to either inappropriate ADH excretion or just as a general stress response is a common complication as well. And we'll go through that in a lot of detail. And what's going on here again, is a loss of electrolytes really be resolving in a gastric immaturity. So we'll be going through um e see an antic leak but also that looking at the risk of having um an M I event. So a heart attack, post surgery and this just um is due to the decreased cardiac output that you get during the operative stage. So obviously the patient is um on total anesthetics and a lot of the kind of cardiac um so responses. So your vaso constriction, your vasopressin that is all being sort of externally controlled by medications administered in the preoperative phase. Um So actually this can lead to sort of dependence on those medications and uh failure of the heart um constrict postoperatively leading to a heart attack, right? Um So in particular, one of the most common complications, postoperatively or one of the most common presentations, should I say POSTOP is pyrexia? So that's obviously having a high fever POSTOP, some of the common causes, as you can remember by the five Ws are wind, water wound, your wonder drugs and walking. So that image down below is a really good image cos it tells you sort of the timelines that these complications present or ha or if you presented with Pyrexia within these timelines, what the likely cause of them are. So, pyrexia within 1 to 2 days is caused by this wind. So what do you mean by that? That could be either pneumonia or atelectasis in 3 to 5 days postoperatively? That could be due to a uti um or your water infection 4 to 6 days is due to that walking. So that's a risk of DVT if you've had immotility or if you had a hypercoagulable state as you do get postoperatively. Um And then you have 5 to 7 days after that could be a wound infection or wound. Ahi. So we'll look at that in a bit more detail and then for finally post to seven days, if you're still getting that um pyrexia, then it might be due to the um side effects of the anesthesia. Now, this tends to only happen if the patient has malignant hyperpyrexia. So this could be either discussed preoperatively. Um, if they've ever had any surgeries before, they might have had that malignant hyperpyrexia before. So then you can manage it and manage, um, like you can be prepared for any outcomes. But the, if this is the patient's first anesthetics, all the patients by surgery and she wouldn't know if they had malignant hyperpyrexia unless they had sort of family history. But what it is important to know is that happens that's due to your drug, the drug administration. So being aware that that could be depending on the life, uh the time scale postoperatively, it is a very rare condition, but it can be very life threatening. Um So if the patient has sort of got pyrexia due to that malignant hyperpyrexia, then it's important that the patient is on the intensive care unit. Um because it can be fatal. One thing to note with this though, if the patient is Pyrexic POSTOP, the most common cause is um infective. And in fact, if you should take the approach that it's going to be infective until proven otherwise. So you'd like to do sepsis, sepsis. Six, look for the signs and sites of it. Um infection, whether that's wod whether that's, so that's your pneumonia, whether that's your uti s, whether that's your wound site, um wound site infections but tends to be infection being the commonest cause. And then how do you manage um pyrexia postoperatively providing adequate antibiotics? If there is a bacterial infection, anticoagulants, preventing the risk of any DVT modification and cessation of drugs and thus preventing your wonder about drugs, um elements and cause and then further surgical intervention, if you need to surgically deride any infections or take them back into surgery to prevent um to almost kind of counteract any um infection or problem with the lungs. You can do excited. So another complication that you can get in the POSTOP phase is POSTOP anemia. Um So FB FBC S should be taken for patients that are sort of not necessarily elective surgeries. More of your in case and inpatient um surgical operations. So FBC S should be mo um monitored to measure the hemoglobin and then treatment is dependent on the hemoglobin status for the anemia. So the hemoglobin is less than 100 g, then you can start them on an oral iron tablet. Um and that would be sort of adequate to bring that hemoglobin levels up and then if the hemoglobin is any less than 100. So you're looking at a 70 to 80 range, you're looking at starting an oral iron transfusion, um or a blood transfusion with oral iron as well. Things to count the symptoms of anemia. So that's fatigue and no energy. Having that increased heart rate, shortness of breath, headaches and dizziness. But also hemoglobin isn't very accurate at determining sort of times scales. You wouldn't just become anemic within that surgery. Psa it's important to do preoperative fbcs as well and either optimize the patient's hemoglobin levels prior to the surgery or just have that sort of oral iron or blood transfusion or even IV iron infusions on standby, ready to adequately support the patient. Um If the patient has symptomatic or underlying cardiovascular diseases, then a severe transfusion is needed regardless sort of of the hemoglobin status. I keep it. So we mentioned one of the causes of POSTOP pyrexia being atelectasis. So, what atelectasis is, is in fact, basal alveolar collapse. So this is a portion of the lungs that is collapsing. Um And again, we mentioned this at the start when we were looking at enhancing that patient recovery. Um and the sort of need for analgesia is to encourage the patient to take deep breaths and that's preventing this atelectasis. If the patient is in a lot of pain, they're going to be taking a lot of shallow breaths. And what ends up happening is the lung bases don't expand fully and you get collapse of the alveoli. Obviously, they've just come back from a surgery, especially if it's quite invasive. They've already got their, their lungs have been ventilated externally. A lot of the times um using oxygen masks, um and external, external anesthetic me uh machinery to sort of ventilate the lungs. So they've had it external ventilations, these base, the base of the lungs haven't been expanded as they normally would be. So, if you're doing shallow breathing in the first couple of days. Postoperatively, a lot of these lung bases can collapse and this is what this atelectasis is. So, if you've lost some of that basal lung, then you're gonna end up going into respiratory difficulty and can result in respiratory failure because you're not getting an adequate ot supply and you're retaining C OT because you're not expanding those lung bases. So, how do we detect atelectasis? First of all, you have those key signs. So you'd get dyspnea and hypoxemia, 72 hours, postoperatively, the patient will be struggling to breathe and you'd be able to hear fine crackles along those lung bases as well where you have that lung collapsed. Um How would we manage this? Well, you want to do a chest X ray. I need to look at the signs of lung collapse as well. Um You position the patient upright, encourage them to do deep breaths and you'd get the physiotherapist in as well to encourage them to take those longer deep breaths. And how do we prevent it as well as a whole? Like I said, it's um optimizing that pain management for the patient. Fundamentally, if the patient is in pain, they're not going to be breathing deeply enough to prevent the atelectasis. So, making sure they're on top of that pain medication, on top of that pain means that they're gonna expand their lungs and prevent this complication. Yeah. Yeah. Ok. So another course or another complication, POSTOP is bleeding. Um and it sounds quite trivial but obviously, bleeding can occur. If you're doing an invasive surgery, you're cutting through tissues, you're cutting through vessels. Bleeding is going to be inevitable. However, bleeding when it occurs 24 hours or less postoperatively and it's excessive and it's unexpected, that can be classified as a complication. So why it happens is ei either due to an error in the surgery, so it could be a slipped ligature or missed vessel. Um, that could have just been cut within the surgery. You can have wound dehiscence. You could just have increased bleeding if the patient's on any blood thinning medications and that's not been adequately stopped in time, you could just have that increased risk of bleeds. So why things get missed in surgery is due to interoperative hypotension and vasoconstriction. So, for the blood vessels are all nice and constricted. Actually, when you've made a mistake, it's not gonna necessarily start bleeding yet. Cos it's at a low pressure and they're constricted. Now, as the patient begins to recover in that postoperative phase, as is the anesthetics and the vasoconstrictors start to wear off that BP is going to increase the vessels going to dilate. And there you've got your problem of that sort of bleeding. So how can you identify it? It's a bit of a tricky one to identify bleeding, especially when it's internal. But one of the key giveaways is when the patient starts to become septic. So when they become feverish or they're getting that lethargy or confusion and then getting into that sort of septic state and you're looking for the signs and sites of infection. One thing to look for is if there's any evidence of any free fluid, either in the surgical area or throughout the whole body. So, if there's free fluid, you want to um, like ascertain where that fluid is coming from and it could be blood from any sort of problem within either the surgery or within the patient themselves. So, um again, how you're gonna identify, then the patient becoming septic cos you don't want them to become septic before you've identified it is by monitoring their news score. So as you can see on the right, you've got their news chart. So you're monitoring their BP, you're looking at the heart rate, you're looking at the fever and you're looking to see if you can calculate a new score and any new score that is suggestive of sepsis, then you want to, like I said, identify that source um of infection. Um And how do you manage um bleeding once you've identified it or once you've realized that the patient is bleeding is either taking them back into surgery or activating the major hemorrhage protocol, ensuring there's adequate blood um on standby to support the patient in recess revision, surgery can sort of stop and, and clamp those um ligatures of the vessels that you cut and that can prevent any excessive bleeding as well. So, more about hemorrhaging, er, certain how we can activate this major hemorrhage protocol. First of all, what a hemorrhage is, it's a loss of 50% of blood within three hours or the loss of one blood volume in 24 hours. So, imagine all the blood in that body getting lost within a day. So for this, the patient, if they were adult, that would be a 7% of the total adult body weight, if that amount of blood was lost. And for a child, if this was 8 to 9% of the total body weight. So on the right, you can see a sort of the cycle of activating the major hemorrhage protocol. So you're tr triggering that protocol, you're then um taking your blood samples either to do group and save and cross match. Um and you're looking for any clotting factors as well. If you need to um transfuse those if within three hours from injury, you give TriC acid 1 g, bolus over 10 minutes and then you follow that infusion um with another infusion of 1 g over eight h over eight hours. So that's both tram acid. Um then you're again going to have those bloods on standby and whatever blood products and blood components that you need. If the blood continues to um if the blood continues to bleed. So if you continue getting bleeding you don't think about considering giving platelets or cry precipitate or FF PS. Um So important things to note is that the blood is um refrigerated and that can lead to a lot of these transfusion complications. So, hyperthermia, the reason for that, like I said is the blood is refrigerated, but hyperthermic blood can impair homeostasis. So if it's cold, it might be that it induces more clotting or it doesn't. So it's just important that it's aware that it can have an effect on the clotting of that blood. You also have risks of hypocalcemia and hyperkalemia depending on what blood products you're providing and depending on the state of the patient. So if you um if you're getting hypocalcemia, it's because you're getting the shift of the curve to the left. Um And it's important to know that the F FP and platelets contain citrate. So that can further contribute to that hypocalcemia. And as the citrate can act as a chelation for the calcium. So if you're administering F FP and platelets, what that's gonna do is gonna reduce the amount of free calcium traveling in the blood. So it's gonna cause a hypocalcemia. Um important to know why you might get hyperkalemia. If you've got plasma of red cells. If that's been stored for around 4 to 5 weeks, this will tend to contain 5 to 10 millimoles of potassium. So the patient already has a fairly high level of potassium by administering these red cells that could lead to a higher level of potassium in the blood. Um You can also get delayed transfusion reactions and this can be due to incompatibly, incompatibly. I sorry, incompatibility issues between um the blood and it's cross match blood. Uh and that can happen if it was an urgent sort of transfusion needed or it wasn't cross matched prior to administration and you end up having this transfusion reaction. If you get transfusion related um lung injury, this is all to do with acute onset of non cardiogenic pulmonary edema. So you get fluid build up in the lungs due to this transfusion and you get this lung injury. So um this Charley is the leading cause of the transfusion related deaths. Um and it's the greatest risk of any complications is posed when you're transfusing plasma components. Um Yeah, that's lovely. OK. Yeah, next slide please. So another complication that we've mentioned. Another course is this Pyrex here in the postoperative period as well is due to a DVT. So just a brief little um flow chart on how you can calculate and risk stratify your DVT and that's using your T levels well score. So how you would monitor if the well score was above two and there was a likely DVT. Well, you do a proximal leg ultrasound but if not, you do ad dimer and await the results. So I just pop that little flow chart there. I leave that up there for a second for you guys to kind of understand. But again, it's just sort of aware, being aware that this is a postoperative complication, how we can prevent it, giving adequate anticoagulants if needed. If the patient is at high risk of developing a clot clot in the first place. Lovely. Ok. So if you do get a DVT, what is the risk of that? Well, it can develop into a PE. So your DVT is your deep vein thrombosis. Your pe is your pulmonary embolism. So your DVT could dislodge from the leg and find its way into the lungs and this could then cause the symptoms of your pulmonary embolism such as your pleuritic chest pain, your dyspnea and your hemoptysis. So some of the signs on um E CG that you might be able to see is your S one Q three T three sign. So I'll pop that first because a lot of people that is suggestive if you see that S one Q three T three, but there's pe going however, not all P ES will show up at this sign. In fact, you're more likely to see on an E CG sinus tachycardia. So actually, if you see sinus tachy, you want to rule out a pe. Um So I wouldn't look for that on T three T three sign sort of on an ECG in practice. Um because it's, it just doesn't tend to like occur very often. Um It's not a very common finding. Um and then you can also calculate your T levels. Um Well, score for pe um again, looking at whether the pe is likely to have occurred as well. So if you have got a um pe that is likely you'd want to do a C TPA. Um And in the interim, if you're having to wait a while, then you give anticoagulation. If the C TPA comes back positive, you manage the pe, if the C TPA comes back neg negative, you either do a um proximal leg vein ultrasound. If you've got a suspected DVT or you consider an alter alternative diagnosis, the P is unlikely. Again, you do that D dimer test and then if that is positive, you go on to doing a C TPA as that's very suggestive. So CT PA is a gold standard for diagnosing that pe um rather than doing any VQ mismatch um or VQ um scanning because that's just not used as much. So, the management of a pe if you've got a confirmed pe is to do an at e that um approach, making sure the patient is adequately like provided for if there's any need for recess or any um immediate medical interventions that that has been needed. And then from there, you can provide anticoagulation, oh clot removal. So, if the patient is hemodynamically unstable, you'd want to remove the clot either through thrombolysis with PLS or thrombectomies, that tends to be the gold standard is you provide anticoag coagulation with a Doac rather than anything like a warfarin or an Aspirin. But yeah, a very severe complication, postoperatively. Yeah. OK. So this is a very busy slide. I'm so sorry. I was going to put some animations on so we could go through them one by one. But it's fine. We will still try and look at them one by one. So one of the big complications POSTOP is shock and we have five different types of shock that the patient can kind of present with. The one that we're really worried about or the two that we're quite worried about are septic and hemorrhagic shocks. So, a septic shock is tends to be our infective cause and it is a high mortality rate. So it's a systematic infective res uh response um from the body and that's presenting as a fever with a high heart rate. So, tachycardic and high respirate and they can have a high or low white blood cell count depending on sort of the mechanism of this infection. Um Syn septic shock itself is having sepsis. So this infection, this fever with refractory hypotension. So you're gonna be tachycardic and hypotensive and that's because you've got excessive inflammation. You're gonna be in a high hyper coagulated state and you're gonna have fibrinolytic suppression. So it's important to be aware of that septic shock. How do we manage that? We do our sepsis? Six, which I think we're gonna go on to in a bit of detail and obviously provide adequate antibiotics. The second type of shock that's really important to be aware of is hemorrhagic. So as we've spoken about bleeding, this can lead to a hemorrhagic shock. So it can either be due to trauma. So not necessarily preoperatively, cos hopefully in the operative stage, I'm not causing the trauma. Um but it can be due to trauma, it could be due to a tension pneumothorax, any spinal cord injuries, myocardial contusions depending on the cardiac state of the patient, cardiac tamponage. So how do we manage a hemorrhagic shock? Let's talk about controlling that bleeding, preventing it from bleeding any further worsening the state of the patient. And then having um activated the he uh major hemorrhage protocol, normalizing the circulating volume tends to be that you try and just get the volume up to maintain the BP before you worry about the blood products. So you want to just maintain the BP because that's gonna protect the heart and that's gonna keep the cardiac output of the heart rather than worrying about any like hemoglobin or red blood cells or white blood cells. Um So you also have cardiogenic shock and these can be due to ischemic heart diseases, trauma, contusions, tampon hearts as well management. You're gonna identify using your transthoracic echo and just provide supportive management. If when necessary, you can also have neurogenic shock and this tends to happen following a spinal cord transection. And what it is itself is a decreased sympathetic tone with increased parasympathetic tone. So you'd get a vasodilation which results in decreased peripheral resistance and decreased cardiac output. So you're getting that sort of hypertensive state as well. It's a shock, you can kind of put it down to just hypertension really. Um And then finally, uh anaphylactic shock is a type one hypersensitivity reaction. Uh and this is where you have your compromise to your airways due to um an allergen. Um And how we can manage it is providing typically, obviously, this depends on the age as well. The dosage has changed. Uh It's adrenaline 500 mg, um intramuscular and where you administer it is the anterolateral part of the middle third of the thigh. So I definitely remember where you administer adrenaline excite, please. So, again, looking more um specific now at some of the surgical complications. So, wound dehiscence. So, wound dehiscence is the separation of a surgical wound, 12th, 1 week, post operative surgery, um post surgical, um or post surgery. And this tends to happen after abdominal surgery. So that's the most likely site um of the dehiscence and it happens in naught 0.5 to 3% of all surgeries. So it's not super common, but again, it's not that rare either. And what it is is like I said, it's just that separating of that surgical wound, depending on how many tissues deep it is could happen um within the surgery even if the top layer is sealed. So it's important to monitor and measure any signs of sepsis as well. Things that can increase the risk of wound dehiscence is anything that compromises sort of the healing process. So, diabetes, obesity being immunocompromised, that's all going to impair healing processes. So that can result in the wound dehiscence as well. Surgical techniques, for example, cutting in against sort of the tension lines of the skin that can result in dehiscence as the skin is now no longer aligned. If the sutures weren't adequately tightened or sutured in the first place that can increase the risk of wound acence in the postoperative care. The wound isn't healing and that's not being identified quick enough. If there's any infection kind of seeping in, it's making sure that you're monitoring the patient and you're keeping an eye on the wound site itself, preventing that dehiscence. Um How can you tell if there's any dehiscence or what signs would you see? You'd get a sharp pain at the wound site. Wound is quite literally opening, you'd get a serious discharge. It can be purulent if it's infected fever due to infections and also pain, you get an increased abdominal death. Obviously, you can have ex um external. Um what's the word? You can just have extrusions? Yeah, that's it of the abdominal organs. Um and that's because these internal organs are visible. So that's why you increase g in your abdomen, you also get swelling as well. And then some of the management of wound adhes is covering that wound with saline soaked, causes preventing any further infection, returning to theater to resuture, to wound vacuum, to remove any signs of infection as well and then optimizing that patient's health. So what do you mean by that any of those factors that are causing poor wound healing? Whether it's the diabetes, obesity, immunocompromised, making sure all those factors are well controlled so that you can sort of encourage that wound healing to take place. So that's when the wound opens up. So now we're going on to when that wound site gets infected. So you can have an infection without wound dehiscence, you can technically have wound dehiscence without infection. But actually, when you've got quite literally your internal abdominal organs sort of on display, it's very unlikely that it's like not going to get infected. Um But what's more common than wound adhes is just the infection of the wound site. But what can increase the risk of this again being immunocompromised, having anything that can cause a low white cell count, just having inadequate white cell count functioning. So, diabetes, smoking, immunosuppression, those can all increase the risk factors of getting infected in the first place as with everything else. But also if there's not good techniques occurring during the surgery, if there's contamination to some of the surgical um instruments, or if the procedure was particularly long again, you're just increasing the risk of having any infection itself. So, how can you tell us the site has been infected if you've got a mild infection and it's um, sort of an external infection rather than anything internal, you're gonna see erythema redness and swelling of the skin. It might be a bit tender, but there's no overall systemic response. You might not get any fever. Now, if you've got a severe infection on the site, you're gonna see more purulent discharge. So that's gonna have the external manifestation of the infective organism. You're gonna have the fever, more septic signs, more of those systemic signs of infection and it can result in an abscess formation as well. So how do you manage if you've got your infection? Well, you're going to swab the wound site and the, and the um surgical site and initiate the sepsis, sepsis six. So for those that need, I think we're gonna go on to, yeah, we'll go to 66 in a second. Um adequate analgesia because the pain is going to be um fairly there. If you've got an infected organism there, regular wound care, making sure the wound dresses get changed regularly, provide any oral IV antibiotics. Um depending on what you've cultured in your swab um drainage and debridement. So, if you've got an abscess formed, you'd like to incision and drain it debridement. If you've got a severe infection or any like sort of necrotizing fasciitis, you'd want to return to surgery to remove it um and allow the wound to heal by secondary intention. So that's just allowing the wound to kind of heal itself um and providing that adequate support for it too. Um Going on a little bit more about infection just making sure we're happy with the sepsis. Sepsis six protocol. So why sepsis happens itself is decreased blood flow to the vital organs because you've got systemic vasodilation. So you're becoming entirely hypertensive. So, sepsis, it is dere dysregulated host response to infection as well. Uh You can use the Q sofa score in order to look at the criteria for, for sepsis. And it's a way of just allowing you to establish whether there's any organ failure going alongside the septic response. So how do you manage your sepsis? You do your sepsis six. So you're gonna give three and take three. So you're going to give oxygen to keep the SATS above 94% you're gonna give IV antibiotics and you're gonna give fluids. But before you give any i the antibiotics, you want to take a blood culture. And that's because you're gonna then be able to give either more targeted antibiotics once you've cultured it. But also that the antibiotics aren't gonna affect what um the culture cultures at the end of it, you're gonna ma measure the lactate and you're also gonna measure the urine output to look at the overall state of the patient, please. Um, so again, more specific um, complications now looking more. So at sort of abdominal surgeries, we've got anastomotic leak and we're gonna look at ileus in a second as well. So what an anastomotic leak is, is a leak of Luminal contents from a surgical joint. And this can happen 3 to 5 days POSTOP. Like I said, this is more common in um, bowel surgery in abdominal surgeries. So it's, um, a serious complication of this bowel resection surgery and it can lead to sepsis because you're having a lot of infection and you're getting free fluid within the abdominal cavity that can get infected and that can lead to death as well. So, if you've got a patient on recovery POSTOP, if they're deteriorating or they're not progressing as they should. So you're not noticing any signs and they've had this bowel resection surgery. I assume that there's an anastomotic leak. So how can you detect if there is where you're going to do a CT scan? With contrast, you're going to look themselves with that CT scan. Is there a bit where I can see the contrast not in the bowel cavity? Is it going into the abdominal cavity? Is there any free fluid or sort of available moving around? Because that can get, um, well, it can get infected. You can lead that can lead to use like sort of spontaneous bacterial protein as well. So, the symptoms of your ANAs leak, uh regular symptoms of inflammation and infection. So that's your pain, tachycardia, fever, tachypnea, and IUS. So we'll talk about eli in a second. But like I said, it's that sepsis. So you want to, we do either do sepsis sixth and monitor that. Um, patients status. How do you manage an anastomotic leak itself? Are you going to keep the patient i by mouth? Obviously, the bowels not really working, it's not going to be, um, so it would be good for the patient if they continue to eat and digest, you're gonna provide them with antibiotics to control and cover any infections IV fluids if they're gonna be septic, um, catheterize as well. Um, and that means you can monitor the urine output. Um, you can take them back into surgery and form um, an intervention where you form a stoma and that's gonna prevent any anastomotic leak because it's allowing the bowel to heal. Now, that can be a permanent stoma. It could be temporary just while the bowel heals and you can also do endoluminal vacuum therapy. So, removing any of that free fluid or any of that leak, the Luminal com er contents from the abdominal cavity preventing that infection. So, again, more specifically, abdominal surgery, ileus, one of the complications of an anastomotic leak is a pic small bowel. So ileus can happen a lot of times it's fairly common in regards to abdominal surgery. And that's just because, uh, it's the stopping of peristalsis due to tends to be like the handling of bowel during surgery. So even simply just moving the bowels excessively within an abdominal surgery, which you tend to have to do, especially because the abdominal contents quite mixed around in there. So if you're doing any general surgery, you'd have to, that can cause this ileus. It's just decreased um, gastric motility. So, um, injuring the bowel as well, that can cause your ileus. If you've got any inflammation or infection nearby the bowel, that can also cause this um, peristalsis to stop and any electrolyte imbalances. How would you detect if someone has got ili, well, if they've got absolute constipation and lack of flatulence, that's a really key sign postoperatively. So, you know, they're not going, passing, um, any, uh feces and they're not, um, able to sort of pass any flatulence or a wind as well. That's a sign that their pa A small B is paralyzed because they're not able to sort of excrete um, other signs of sort of a bowel obstruction. So your green bullous, vomiting, distention, diffuse abdominal pain and absent bowel sounds. So it's general bowel obstruction signs. How do we manage? Same, how we manage any other sort of bowel obstruction, um, keep them nail by mouth and pace an NG tube for nutritional support. Also, the drip and sack method. So you can place in your tube and provide IV fluids and hopefully after time that small bottle will start working again and that will allow for mobil er early mobilization and make sure the patient's kind of getting up eating a little bit at a time. Postoperative is gonna prevent any further ideas developing in the postoperative stage. Um Right delirium. Ok. So yeah, one of the last complications that we're gonna be looking at is delirium. So, delirium is this acute cognitive impairment and the fluctuation in conscious thinking, inattention and disorder thinking in a patient. So it's mainly common in elderly patients, they have a higher risk of developing delirium and any hospital admission. Regardless of whether it's surgical or not, can have this effect of delirium. Some of the causes there. As you can see, drugs, electrolyte, imbalances, liver failure, infections, retention. So that's either urinary retention or constipation. Any intracranial problems, either increased pressure or space occupying lesions, uremia, any problems with the kidney and developing a high level of um urea in the body. So from an AK I or any metabolic problems as well. So any electrolyte disturbances, um another acronym that you can use. So you can use delirium to remember the causes of delirium. But I prefer the pinch mox. So that's making it pain just having any pain. So that's why making sure that they are on top of that pain management is important to prevent delirium infection. So again, controlling your sepsis, six nutrition encouraging that oral, adequate um nutritional support constipation, providing them with any laxatives, if they're taking any opioids, hydration medication and environment. And I think that last one is really important, making sure the patient at the end of the day is comfortable. If they've got a long stay and it's not an elective surgery, then, um, and the elderly and they're in pain and you want to ensure that the environment is comfortable around them as possible as that can really affect sort of their state and their um cognitive awareness. If the patient has gone into delirium, it's important to um understand what the cause is. So if it is, whether they've just not got adequate pain relief, if they've got signs of infection, important to treat the underlying cause, modifying the environment, maybe putting them in a side room, putting them with 1 to 1 nursing, having sort of good lighting, um quiet environment, regular visitors and family members, things like that can really help a patient, not only in this delirium stage, but in general, um patient recovery as well, but if the patient is unsettled and you're not able to kind of put them at ease and they're getting quite agitated, then you can provide them with haloperidol, either either Haloperidol or OLANZapine. Um But obviously, these are drugs that are contraindicated. In Parkinson's, they can worsen the Parkinson's symptoms um and it can cause this drug induced parkinsonism. So, in Parkinson's, you want to give them QUEtiapine or cloZAPine. So you're more atypical um medications So just a couple of other things regarding other medications then, um, in the postoperative phase. So we're gonna look at just, um, briefly diabetic medications and steroids. So, just looking at how we monitor and manage diabetes, pre and post operative and the main thing to take with this is you want to avoid the risk of hyperglycemia. That's what you're trying to prevent. So you don't want to give them too much of their diabetes medication. Don't forget surgery already. They're going to be nil by mouth. So they're not gonna have any glucose store, they're gonna be going through an intense and stress surgery. So their body stress response is to um release glucose. So if that's their stress response, they're going to have less glucose stores in the long run. So you don't want to just keep on um giving them their diabetes medications. It's going to impair their healing response as well and it's just going to increase their risk of hyperglycemic effects. So, if the patient is on SGL T two inhibitors, so your dapagliflozin, um you emit them on the day of surgery and restart them when the patient's eating and drinking again. So when the patient's eating and drinking again, that means that the glucose is obviously going back through the cycle periods with their diabetes. So that's when you can re add them in there. Um, with sulfonylureas, um IE or Gliclazide, there is a high risk of hypoglycemia already with them. So they should be admitted on the day of surgery again until the patient is eating and drinking insulin that can be dependent on the type of surgery that they are. So, they might be on insulin during the surgery if they are short surgeries or long surgeries. But it's just depending on local guidelines. Um, and looking at the VNF and what sort of insulin dosage that the patient themselves are on? Metformin is a bit easier to control. So you, if you miss one of the meals on the day of your surgery, then it's fine to continue. If you miss more than one you raise, run the risk of lactic acidosis. And AK I, so you want to stop the Metformin once the m the vast begins to reduce the risk of hypoglycemia as well. And then finally, we're just gonna look at how we monitor, um, steroid medications. So, patients with adrenal atrophy, which, um, is due to being on long term steroid medications can have a fall in BP if you just stop the medications. So the thing with steroids is as soon as you stop them, they can go into this adrenal insufficiency, they can go into this adrenal crisis, which is not good because patients are gonna have a high risk of, um, so it, it can be quite faithful. So, um, you should provide a steroid cover during the anesthesia and in the postoperative period whether or not it's a long surgery and therefore we need to increase the steroids um to provide the um a adequate stress response that the body goes through. But that's again dependent on procedures and guidelines. I then put a little um poster up there just about some of these other drugs that you can stop prior to surgery. But I'm sure these have been covered in the preoperative discussion. So just looking at the contraceptive pills, looking at lithium making that gets, making sure that gets stopped the day before any potassium sparing diuretics and ace inhibitors and then looking at anticoagulants as well, making sure the anticoagulation medication is stopped in adequate time prior to the surgery. Right. So, um, I believe that's it in terms of everything. I think we've covered all the learning objectives. Um But yeah, I've popped on the last side. Any, just like useful websites that I found. But thank you for listening and I hope that was helpful. Thank you so much. That was an incredible talk. Um, and we've all learned a lot and a lot of practical applications as well. Um, what I've done is I put the feedback form in the chat. If everyone who's attended wants to fill out to gain a certificate. Um, and any other additional questions add on to the chat. Um, thank you so much. Everyone I just wanna pop on and say a massive thank you. Er, I'm Florence. I'm one of the chairs, an amazing talk. Thank you so much. Um Make sure you follow us on med all and you'll get an email notification with any of our future talks and also give us a follow on Instagram where we'll have M CQ so you can test your knowledge. Um Also a little bit of extra incentive to fill in that feedback form. There is discount codes on there on the certificate that you will get for some of our sponsors resources. So make sure you follow that. And then finally, next week we have um two teaching sessions on lower gi both clinical conditions and also anatomy and they will be on the 13th and the 15th of February starting at 6 p.m. So first, thank you so much to everyone who came this evening and a massive thank you to Isha cos that must have taken such a long time to put together so much amazing content. So, thank you and have a nice evening. Thank you so much, everybody. Make sure you fill in that feedback form and you'll also get slides and also access to recording afterwards as well. Thank you.