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Hello, everyone. I hope you're all doing well. My name is Rashida. I'm one of the chairpersons here. Welcome to the second session of our annual teaching series. This week we are focusing on perioperative care and I'm very happy to have all of you here with us today. Today, I am joined by Joe who will guide you through postoperative care. Joe is a better student from the University of Southampton to make the session as engaging as possible. We'll be releasing both throughout the session. These are completely anonymous. So we encourage you to participate actively. If you have any questions during the session, please pop them in the chart and we'll address them at the end of the session. We'll also share a feedback form at the end. If you have any uh if you complete this, you will receive a certificate of attendance and exclusive discount codes for the MRC S and teaching surgery. This session is being recorded and the recording and slides will be shared on a me page as well as a website a couple of hours after the session. So be sure to keep an eye after that as some of you you know, we have launched our very own learning portal which is hosted on our website through this learning portal. You get access to practice questions, session recordings, as well as revision material as a bonus. All members will get a discount code to get 10% off the mes anatomy flashcards, surgery, flashcards, and knowledge bundle membership is completely free. So be sure to head on to our website after the session to exclude this. We also have an exciting opportunity for all our attendees. Two lucky people will win free access to the GKI Medics surgical flash and the GKI medics stations to enter simply complete the Google form at the end of the session and enter the unique code. We will provide the more sessions you attend live, the higher your chances of winning. So be sure to stay until the end of today's session and attend as many of our other sessions as well. Finally, before we begin, we'd like to thank our, which is the Royal College of Surgeons England Medics, the MDU more than skin deep metal sur uh teaching surgery and past the MRC S without further ado, I'll now hand it over to Joe. Yeah. Um Hi, good evening. Yw. My name is Joe. I'm a third year medical student from the city of uh it's great to have you all here. I believe it's a long day regardless when you are coming back from placement or wherever you are in the world, um, hope that you are doing well. So, er, today, ah, ah, I'm here to share with you about preoperative and postoperative care as this is a continuation from what mark our previous speaker delivered in the first session, which was about preoperative care. So, these two sessions are mainly covering, er, the scope of like, uh, what anesthetist surrounds surgery. So, obviously, the role of anesthesist cannot be undermined. Uh, this is a team effort is N DT, you know, you know, without anesthetist, you know, um, you know, some might see that their role might not see their role as evident as the surgeons, but everyone's role in d is equally as important because there is work to be done in before, before, during and after surgery. So, er, these are some of our partners for S PA, including, uh, I CE MDU and among many. So, um, what we will be going through today, ah, includes a few learning outcomes which I will share with you all if in any moment that if you, there's any questions or you like to share anything, just feel free to pop the questions in the chat and we have a few people to discuss and we can discuss it at the end as well. So, um, there, there are a few things that we will be going through today. First of all, we will be, uh, just slightly going through prior drug management, which mark covered yesterday, which includes uh, medications such as steroids and diabetes and also some drugs which, what are some drugs that you need to stop change or stop? And then we also talk about, ah, good and safe and as well as cross matching, which are essential components to be checked and screened before carrying out surgery. Then we also slightly go through some preoperative procedures and protocols, emergency cases. Er, m, some measures to enhance patient recovery, as you understand, um, as someone goes through surgery, ah, the body ultimately takes a toll and the stress on it. Hence, er, what are the necessary steps needed to, uh, lead to, ah, optimum recovery after surgery. And we go through the sequence of events during surgical anesthesia. Like what happens, er, m was the, what, what's the, when you see anesthesis, you know, injecting all in strange checking the monitor, what, what they, what they are actually doing. And we go into a bit of pharmacology in terms of exploring the types of anesthesia and their mechanism of actions. And, yeah. So coming. So those were like before and during surgery and you can talk about what happens after surgery such as, er, postoperative nausea and vomiting, ah, usage of catheters, nutritional support, which is an important component as well. And many, many more. And lastly, we come down to the post surgical review and, uh, what you do during what rounds? Yeah. Ok. So we can start now. So, yeah. So what does the pre-optive medical management mean. So the pre optive period actually extends from pre optive day through operation and two postoperative recovery that means before during and after. So this whole process right here before during and after, it is important as this is to try to help prevent or at least minimize the complications that the patient can face to reduce postoperative pain, and most importantly to accelerate recovery to get them home. So there are a few components of prior optive medical management. So, um, this was uh covered in the first session as well. For example, uh first of all, understanding, um, what, ah, the, the, ah, before surgery happens, ah, having the patient understanding what surgery you are undergoing is indication for it, you know, and what are some things to take caution about? So that needs to be accurate documentation of preoperative medication. And if we were to stop some medications, what are the rationale behind it? Um, are there some drugs that we should give beforehand? For example, analgesia, analgesia or VT prophylaxis and many, many more. So, when we come to the topic of diabetes, it can be a tricky one, you know, as you understand that, um, first of all, uh, that patients with diabetes are actually at a higher risk for peroperative complications. Actually, in a study carried out in the US. Um, among uh 1042 patients underwent total hip replacement. Um, the, the rate of postoperative infection in people who had diabetes were higher than people without diabetes. And this could be um uh due to several reasons. For example, people with diabetes are more prone to uh longer wound healing times, you know, uh and they have more risk, uh more further complications, both micro and microvascular complications as well as well as a neuropathy uh complications if not achieving glycemic control. Hence, adequate glycemic control is very essential prior to elective surgery. So, the goal of prior optic control is to avoid ketosis and to maintain glucose levels within the optimum range. So generally, um we will try to aim for ah the glucose levels to be around 6 to 10 millimoles per liter. Uh But 4 to 12 is an acceptable range uh for wider scope. So there are various units use such as MG per as well. But um we will be looking at it from most per in this case. So um that is for GG levels in terms of HBA1C, which is a more accurate marker where uh H one C is measures uh component in your blood every three months. So HBA1C monitoring this according to the nice guidelines. So um if a person's HBC is more than 69 million moles per mole, um you have to refer to MDT team uh who manage the diabetes optimization and surgery may or may not proceed and if it does proceed it, there has to be some caution with it. But uh, if there hb one C is more than 85 million per more, that could mean the person's GIC control is probably not that well and say you still have to refer to diabetes team to discuss and surgery could still be proceeded if there is a necessary need. And of course, all this is pending on discussion of the ND. So there are many, many factors, er, of how we titrate and depend blood glucose concentrations include, for example, ah, required duration of fasting, uh timing of surgery, whether someone is having it in the morning or afternoon. Uh, what are the usual treatments? Someone is on, is it insulin, uh, especially if they are type one or diabetic or antiae drugs or what's the usual diet, other comorbidities and many, many more. Um, according to nice guidelines, all patients should have emergency treatment for hypoglycemia written on the chart upon admission. So here is a table um, summarizing some of the common uh diabetic drugs, uh, and what we should do during, before, during and after. So, for example, if you are having an oral hypoglycemics, for example, ides for Metformin or sulfonal, um, like, uh, because I, so the day before surgery, we would discontinue and on the day of surgery, we omit the dose and during surgery, we would give insulin either subcutaneous or IV formulation. And after procedure, insulin is given until patient is no longer, uh, near by mouth. Uh, whereas for insulin is the user dose before surgery. But on the day of surgery, it is omitted, similar to oral harpo. Ok. So that is for diabetics. Now we come to steroids. So we did mention about as someone undergo surgery, the normal physiology of the body is ah to release cortisol because body is under symp, ah, is under a lot of stress. So, sympathetic nerve system is activated and a lot of cortisol and all is released to equip my body to deal with all these er external stimulus injuries to the body and many more and more. So when it comes to uh someone who is on patients who are on long term steroid therapy, er m whether to provide preoperative supplementation doses is quite a tricky topic. Um and several studies shown that a stress dose is only needed when uh the hypothalamic pituitary internal axis is suppressed. So the image on the right here shows um the the three centers of the stress response system can imagine it as like the hypothalamus being the factory uh of being a factory manager instructing the workers, which is the pituitary grant to uh to us the retail stores, which is the adrenal glands to produce the final product. So it's like a three step pathways. Yeah. So when using pair uh steroid supplementation doses to parallel the physiologic response of normal adrenal gland to surgical stress. Ok. So with uh covered diabetic and steroids. So here are just a rough image of several drugs that should be stopped before surgery, which include ace inhibitors, A BS, um, uh combined CO CPS as well as ah antidepressants. Ok. So now we come to something that we should start uh, prior to surgery, which is uh VT prophylaxis. So, when, whenever a patient comes into hospital first, the first thing you will be doing is uh risk assessment for te, so it's actually a preop evaluation to determine a patient's risk of developing a blood clot. Um So blood clot has potential to lead to uh pulmonary embolism and many, many more further complications. So this is done upon admission to the hospital and after 24 hours, it is done again. And whenever uh the clinical situation changes, it's deemed to be uh if it's deemed suitable and it will be carried out. So there's actually three parts to this. The first part, as you can see on the image of the right, this is a form by the Department of Health. The first one asset uh evaluates the person's mobility, whether persons will be lying on a bed for a long time or is it, is it like a day procedure? He goes in and come out then probably is not necessary. And second part is thrombosis risk and the third part is bleeding risk. So, based on this assessment, um then you will determine whether VT prophylaxis is necessary. So VT for to reduce the risk of VT in surgical patients, uh regional anesthesia should be used over general anesthesia if possible. And there are two types of uh VT prophylaxis, mechanical and pharmacological. So, um mechanical prophylaxis, there are two types. One is antiembolism, stockings and intermittent pneumatic compression. So you usually see that some patients, uh they would have these stockings uh ready and like the nurses will prep them as we go into surgery. Uh So this should be offered to patients with major trauma or those undergoing like abdominal thoracic or elective spinal surgery. So this should be continued until the patient is sufficiently mobile or discharged from the hospital. So that is for mechanical prophylaxis. What if in terms of pharmacological? So this should be considered in patients undergoing general or orthopedic surgeries when risk of vte outweighs the risk of bleeding because it's always trying to balance the benefit and the risk of when you are trying to give BT prophylaxis. So there are a few types which uh mark did mention as well yesterday such as uh low weight heparin, uh fro sodium and many, many more. Of course, this uh prescription of T prophylaxis. So depends on several factors such as persons, uh renal function and many, many more. Ok. Now we come to uh group and safe and cross matching guidelines. So good and safe is like the pink bloods which you guys have time to take. So the main difference between group and safe and cross matching is that good and safe. We are trying to determine some patients blood type, whether it is a bo and their research uh factor. However, for cross matching is actually part of the final step of pre transfusion uh compatibility testing. So in group and safe, we actually are screening for atypical antibodies. We are not mixing any blood, but in cross matching, we are actually mixing the patient blood with the donor. But as this is the final step before we give the blood to the person who needs it. So, um we are trying to see if there is an immune reaction in cross matching. So, er, here comes to our first question which you kindly ah release the question. So we have our first question here if everyone can see it, we like to ask, er, which of the following is the primary purpose of performing a cross match before a blood transfusion. What do you guys think is the most? Uh what's, what's the reason we performed cross match? 90% of the people have said DD? Oh, sorry, is it B or D B? So the last option? Oh OK. So uh it's actually b is to ensure compatibility between the donors and recipients blood because earlier I mentioned crossmatching, we are mixing the donors and the patient's blood because we're trying to see if there's any immune reaction. Uh As this is the final step of our before trans transfusing the blood to the uh patient who needs it. Yeah. Um, it is not really to identify any existing infections in the donor's blood and a, to determine the donor's blood type that is uh for good and safe where we usually take two pink bottles. Ok. Um ok. So now we come to uh moving on into pre op procedures and protocols. So you can actually see in this picture here, this picture actually illustrates the sort of the pathway that someone's always say how someone goes through the, what their body, er, goes through when they are having elective and emergency surgery. So normally when we have surgery, I, we tend to drop a bit but we will tend to recover as the body as the body is always, is trying to, ah, get back into having negative or positive feedback to reach back into homeostasis, which is a balance level. But it actually you see in emergency surgery, um, what a person's body actually goes through is much more of a harder road or curve. As you can see as from the baseline, they get an acute illness and there, there is some reequilibration before they go back to surgery. Hence, er, it's even more crucial for someone who is undergoing emergency surgery to have adequate care and support. So, er, now we come to talk about uh A RS protocol which is known as enhanced recovery after surgery. So A R which is a program in by Professor Henry Kelly in the 19 nineties is actually er m important focus of pre-optive management after many types of surgeries such as colorectal vascular and many, many more. So, these programs were set in place in terms to try to modify the physiological and psychological response, major surgery. And it's actually uh good outcomes such as reduction in complications, reduced hospital stay, improved pulmonary function, earlier return above function. And uh people can get back to their normal life. Many, many uh much. So there are a few key principles of this protocol which includes preoperative counseling, uh which includes um uh giving patients information about surgery, what you go through and how, how, what's the necessary steps they should take after surgery. There's also preoperative nutrition. So before I patients undergo surgery, there is a screening tool which you can use is called malnutrition. Universal screening tool must. So it actually assesses the patients uh status as someone with malnutrition, er, is even more susceptible to postoperative complications. Er m however, if true, ah clinical examination, if someone who is really, you know, looking routine that very severe muscle wasting, that could be a sign of malnutrition as well. However, that's why uh dieticians play a key role in this. And of course, also um uh avoidance of pre-optive fasting and carbohydrate load up to two hours preoperatively. Uh and also the uh standardized anesthetic and energetic regimens and early mobilization to try to get patients to uh moving and, and try to get back to their normal self as soon as possible. Ok. So that's why we have covered um all the drugs to stop, to change, to start, you know, so some of the protocols now we have come to anesthesia. So what exactly happens during anesthesia? So when a person is put under general anesthesia or what to say they have gone to sleep, there's three components to this. The person is deemed to be unconscious, person is put on analgesia to um relief uh to reduce pain and also muscle relaxation. So, there are few stages of stages of anesthesia, which is induction maintenance and emergence, which is to wake the person up. OK. So uh some common techniques seen in anesthesia includes uh the laryngeal mask airway with spontaneous ventilation. So this is generally used for elective or emergency surgeries in patients who have been fasted and there is no risk of aspiration of gastric contents. So come some common risk factors for aspiration if it does happen, include like a person has reflux or intraabdominal pathology which raises intra abdominal pressure. So this can be used in patients in supine or lateral positions. So because the position of insertion um of the I gel is uh starting from, you know, the pigo this um until the point uh behind the um laryngopharynx. And here we can see images uh two images which first one is the endo trigger tube, which is the to provide a definitive airway uh and to have anesthesis can also control a patient's ventilation. So this allows them to have a good control over the situation. And also there's other, another one called rapids uh induction, which is to protect the airway if there is any risk of uh aspiration of gastric contents. So, the anatomy shows the location of applying pressure over the quick coin cartilage. Ok. So, um going through the uh sequence of events, now we come to stages of anesthesia. So how does someone go from, you know, from alert to go to sleep? So the first stage, this is based on Goodell's classification is based uh stage one is analgesia or disorientation. So this is the induction state. So patients are sedated, they slowly get relaxed, their breathing gets a bit slower and more regular. Stage two is deemed to be the excitement or the delirium stage. So it's a bit more uncontrolled movements. Patients could have a bit delirium, um hypertension, tachycardia, but every reflexes remain intact during this phase and they are often hypersensitive to stimulation. So, if you want to do any uh maneuvers or intubation, this is still not the stage yet where stage three surgical anesthesia. So this is when eye movements are seized and there's respiratory depression. So every manipulation is safe at this level. So stage three is where usually we want to reach. Uh stage four is the stage where you want to try to avoid as this occurs when too much anesthetic agents is given relatively to amount of surgical stimulation. So this is stable, summarizing a clinical assessment of stages of anesthesia. So stage one, stage two and in stage three, you can see there's multiple planes as well. Ok. So um why do anesthesis give general anesthesia? So because surgery is painful. Yeah, you are making incision. Yeah. Yeah, you are trying to save patient. So you try. So the goal of general anesthesia is to try to make a patient as comfortable as possible to render them unconscious and such that they are unable to feel the painful stimuli while controlling autonomic reflexes. So there are a few classes of anesthetic agents. IV inhalation. You have a neuromuscular blocking drugs and many many more. So this is quite a complicated slide. Uh illustrating the mechanism of action of general anesthesia. Practically. Uh what is uh is important is that it has something to do with the Gaba receptors in our neurons in our brain and also, and how the codium uh like chloride channels are involved in this. So if you can look here, Gaba, a receptors are involved in this and Gaba is actually ah inhibitory neurotransmitter. So, Gaba is released inhibitory synthesis and bind to postsynaptic Gaba A receptors. So uh OK receptors. Yeah. And these allow chloride to enter the postsynaptic neuron. So it actually cause hypo polarization of the postsynaptic neuron. Uh and this inhibits the pain. OK. So there are few types of uh IV anesthesia among them includes propofol. Um So it's usually used for induction and maintenance of anesthesia. Um and it, the advantage of propofol is that it can await someone with minimal residual sedation even with prolonged infusion and it has some antiemetic properties as well. So is actually propofol. It binds to Gaba Gaba receptor A and this causes influx of chloride ion leading to hyperpolarization and inhibition of uh action potential propagation in the postsynaptic membrane. Yeah. And now we come to inhalation anesthesia. So some in inhalation anesthesia include like nitrate oxide for gasses. So the key measure for inhalation, anesthesia is minimal alveolar concentration. So this is a concentration that that will prevent movement in 50% of patients in response to painful stimuli such as surgical incision. So here is a table uh illustrating the differences between IV and inhalation. So the main difference IV is usually used uh most of the time and it provides a quick smooth induction of anesthesia which bypasses the few stages of anesthesia I mentioned earlier like stage one, stage two, which is assignment and delirium and finally stage three surgical anesthesia. Whereas for inhalation, anesthesia um can be utilized in patients with difficult IV access. For example, if they have a lot of bruises, a fistula, many many wounds. So it's difficult to access that and or sometimes it could be a person who really afraid of needles of, for example, pediatric patients. So those who can tolerate. So those who need the mask, you know, and can tolerate them better than inhalation, anesthesia an option. Um But there is also talk like the effects of like nitrous oxide on the environment and you know, and of course, some research are now ongoing on how we can tackle this issue. So IV uh anesthesia besides propofol, there are a few other types such as opal desflurane and sevoflurane. OK. So, um now we've come to the second question, which is uh what is the most, which of the following is the most common side effect associated with the use of inhalational anesthesia, anesthesia? Is it hypertension? Is it nausea, vomiting, radicaria or hyperthermia? What do you guys think? Ok. Um Joe, what people are answering? Do, do you mind pressing hard on the little top of the, the bottom of your screen? Ok. Sorry. Thank you. That's all right. We have 54% seeing breath, bother and 45% seeing nausea and vomiting. Ok. So it's still quite close. Ok. Um ok, so the answer is actually nausea and vomiting. So, er, re is also is quite a common side effect but um we usually observe that nausea, vomiting, uh happens after administration of volatile agents such as ISOFL Sero Deane. So this is something called postoperative nausea and vomiting, which we will come about later as well. So there are many reasons behind this, such as the type of anesthesia use what the procedure is about. And of course, it differs from patient to patient. Um Yeah, whereas uh malignant hyperemia uh is like um is quite a um it is quite a rare side effect of anesthesia drugs, but it is quite a serious one and, but there is a reversal agent for it. Ok. So um now that we talk about anesthesia, we come to analgesia, which is um what you call it to painkillers in simple terms. So according to wh O they have released the analgesia ladder. So for someone who is experiencing pain, so pain is a really subjective thing and you and me, everyone, we experience pain in our life and some of us can tolerate it well, some less likely. So, er and pain has exert a huge burden on the healthcare system as well. So the type of ener energy that we give has to be uh quite systematic as well. Hence, wh O has released this sort of like ladder in terms of the steps in terms of linking to person's severity of uh of condition in, in terms of like matching the right analgesia. So if someone is having like very mild pain, they probably a non opioid plus or minus with eye driven therapy for, for example, like paracetamol. However, if someone is having like very severe, you know, very severe pain, then interventional treatments, you know, uh should be given, you know, like opioid in IV formulation, probably uh uh like oxyCODONE or many, many more. So just now you mentioned about some ones like side effect of anesthesia, which is postoperative nausea and vomiting. So this affects approximately like 20 to 30% of patients within the 1st 24 to 48 hours post surgery. So it can be quite distressing for patients. Um, you know, as they can't control it, but they just feel like, you know, it's so just don't feel well, you know, and you poop everything out, you know, that's not a good feeling. So this actually increase recovery time, hospital stay can also lead to metabolic alkalosis and also aspiration pneumonia and many, many more. Ok. So here are some risk factors for postoperative nausea and vomiting. Split it into patient surgical and anesthetic factor. So those are reason, female females are more prone to postoperative nausea and vomiting as well as the elderly. Er, likewise for people who have previous episodes of uh nausea and vomiting and motion sickness. And for someone who undergoes like intradomal laparoscopic surgery or if that prolonged operative times, this can also contribute to postoperative nausea and vomiting. Some anesthetics factors include like for example, opioid analgesia inhalation agents and many, many more. Ok. So this is such a tricky thing. How do we tackle this issue? Definitely, it is not a feeling good feeling right now that because of like feeling nauseous and you want to vomit. So there are some ah, ah, drugs that we can give, but first we have to understand the physiology behind ah nausea and vomiting. Hence, er, you know, we have enteric nervous system as well as the chemo receptor trigger zone in uh you know, our brain region, you know, brain stem cerebellum. So, er m whenever you know there's increased like intraabdominal pressure or there is electrolyte imbalances, you know, or anything like the triggers like the risk factors mentioned earlier. This can actually um trigger the chemo chemo receptor trigger zone which leads to ah sending impulses to the vomiting center from at the medulla which initiates the vomiting reflex. So there are a few pathways here which um some drugs can target, for example, find his history antagonist, you know, using, you know, on the, you know, or metacide, you know. So the key takeaway from this slide is that um there is no one to use all drugs. So there's like uh multiple drugs should be used to tackle this issue as there are multiple pathways which can lead to initiation of vomiting reflex. Ok. So now we talk about urinary catheter. So urinary catheters are also known as foley catheters. So you can, these are, you can see this frequently in patients who are undergoing surgical procedures. And if you can see in this image here, um the anatomy of the female and the male uh uh uh system. So the catheter is in through the urethra into the bladder. So what's the reason behind this, why do we have to put catheters? So it actually serves to prevent bladder distension or incontinence when the patients anesthetized as well as to facilitate measurement of urine output during and after surgery. Because we can expect someone to be less mobile, be compared to when they, before they were in the surgery. So, er, m we would really want to avoid the scenario of them, you know, having a full bladder and then having a full outburst, something like that. Yeah. So this is slides, uh showing the possible infectious and noninfectious urary catheter complications, um such as uh bacteria, urea, you know, increased incidence of uti can lead to hematuria if someone tries to pull it out, you know, and clots many, many more if it is not keep clean. So, hygiene is quite important. So this is the patient education is quite important as well. So, but ultimately, this is um not something to be kept in place forever unless the person is having, you know, issues with his or her bladder. Hence, we will first we will try to always after a period of time to go with trial with a catheter or we call it to. So, er, to is when the catheter which has been previously inserted is removed for a trial period to see whether patients are able to pass their urine as normally as they were before. So they will be asked to drink plenty of fluids and then if the urine pass is sufficient, then everything is all right. Ok. So, you know, we've covered quite a lot right now. So, um but now it's moving to the after stages of surgery. So now we can talk about postoperative nutrition. So we know that surgical procedures can induce a hypermetabolic response in the body, uh where body increasing protein and energy requirements. Hence, nutrition is an important component here where the dietician's role cannot be overstated because postoperative nutrition can actually impair immune function, increased mortality, increased length of stay, compromise, wound healing and increased complication rates. So, there are few types of er postoperative nutrition, er depending on patient's condition. For example, when a patient is able to um to have something uh to uh able to take medication, she hit her mouth and eat and able to eat normally or if. But if someone is like after a major uh like uh gastric bypass, you know, any abdominal surgery you might have or any, you know, like after a week, both, you know, and you might have a, an anastomosis, they have to might have to be on NG tube or NG tube for feeding. Yeah. So here's a like showing table showing the hierarchy of feeding. So for example, if the esophagus is blocked or dysfunction, then someone could be uh the patient could be indicated for p percutaneous and, and gastroscopy. And also if the stomach is inaccessible outflow, there's outflow obstruction, then the judges Junot is done uh to allow ju feeding. OK. So then um now we come to calculation of individuals nutrition needs. Ultimately, there are many, many calculation methods out there. Er m but there is one here which is the guide which actually divides the food and drinks that we consume usually into five main groups. So on average woman, women should have around like 2000 calories a day or men should have around 2005 calories a day. And, but this does not apply to Children because they have different nutrition needs. But obviously, this is very vague and, er, much of it depends on the patient's condition and also, um, a discussion between the MDT team and also the role of dieticians here as we need to, uh, like if anything understand that to refer to them so that they can come up with a suitable diet plan to improve the nutritional status of the patients. Of course, considering both the clinical picture and as well as the individual preferences. Ok. So now we come to quite important common postoperative complications. So, um, complications do happens at times and they are talked about uh, prior to surgery. So a more them, the list of it is, um, ah, nonexhaustive, you know, there are many post operative complications such as anemia, you know, wound DEHA, where it's a suture, it's not tight enough and falls out of place, you know, and then sepsis AK I delirium and many, many more. So we go through a quite a few key ones here. So, postoperative complications can be general or they can be specific to a particular operation and they can be classified according to the time of onset, whether it is immediate early or late. Ok. So the first one you come to atelectasis. So what is atelectasis? So it's actually like a collapse of the areas of the lung. And this can actually result in pulmonary complications such as hypoxia. So if you see this image here, this image shows the lung with the carina, the right lung with three lobes, left lungs, uh with two lobes suppressing by the oblique fissure. And here is the ide. So you can see in the picture downwards, um the left lung is actually like reduced in size because of collapse. Ah Yeah. So this is actually a atelectasis. So, hey, sorry. So if a chest X ray is done, um you could actually s uh s see here like there's some consolidation and so you may uh clinical examination may show reduced basal and entry with reduced lung volume on chest X ray. So what's the management for atelectasis? So we can provide humidified oxygen. So, ah symptomatic treatment, especially anesthesia, if someone is having pain, uh trying coughing, trying to promote them to cough. And so the roles of chest physio uh to try to get them to improve their lung function. And also to provide a CPAP which is continuous positive airway pressure. Ok. After that, we come to postoperative hemorrhage, which is quite an, er, important one as well. Uh, when I was in my H PB placement, I did come across a case where women who just, I think a few days after she had her, we both, yeah. Er, suddenly from like, her drains, you know, there was blood, you know, and then everyone was quite shocked, you know, and then they had to be like emergency laparotomy. Ah, yeah. So postoperative hemorrhage can be quite distressing for both patients and also er, healthcare professionals. So, hemorrhage can be split into three which is primary reactionary and secondary. So, primary means bleeding occurs within intraoperative period during the surgery. Reactionary means uh hemorrhage occurs within 24 hours of operation. So this could be due to a ligature that sleeps or miss vessel and this can often be missed intraoperatively due to intraoperative hypotension and vasoconstriction. Whereas a secondary hemorrhage occurs 7 to 10 days postoperatively. So there's quite a period of time after surgery and this is often due to erosion of a vessel from a spreading infection such as when the heavily contaminated wound is close, primary, uh primarily. So, er, here is a table showing patient of hemorrhagic shock with four classes by the American College of surgeons, advanced trauma life support. So here it shows that, you know, the uh percentage of blood loss and so the heart rate BP. So the key vital signs into classification of hemorrhagic shock. Ok. So some, what are some risk factors or what, what makes someone more prone to bleed after surgery? So for example, if someone is who is on some uh particular drugs such as Heparin Warfarin nsaid antiplatelet, so you notice that it's more like the anticoagulant antiplatelet drug groups or if someone has congenital bleeding disorder such as 11 will uh disease hemophilia A or B. And there's also if someone has acquired bleeding disorder such as disseminated intravascular coagulation sepsis. Yeah. Ok. Now we come to delirium. Um So what is delirium? Ok. So delirium is actually ah an acute confusional state which can occur postoperatively in any patient. And it can be more especially prominent seen in the elderly care or like wards. And there are many, many reasons for delirium. There are some acronyms used for delirium like pinch me pain infection, you know, m uh malnutrition, nutritioner medications. So these are a lot of factors can lead to delirium when someone is just confused at that moment of time and place. So there can be hypoactive delirium, hyperactive delirium or mixed in between. For someone who is hyperactive delirium, someone can be very agitated, f friends and families to say that they are more, they are like unusual. Their, their behavior is more unusual. They were getting very agitated. Whereas hypoactive, the you may just see the patient sitting quietly in his, his or her chair or he, he he or her may just be lying on a bed for the whole day or mix could be in between both. So there are quite a few risk factors for delirium as shown here, like pain sleep distortion, even for patients who have like extended stay in the hospital can also lead to uh delirium as well as like uh delirium secondary to infections, um medications, age and many, many more. And now we come to reduce bowel function, which is, um, a key thing that happens after surgery, particularly for like gi surgeries. So we call it where it reduced like persis. So this reduced bowel function can actually lead to abdominal distension. Er, someone may be more prone to nausea and vomiting if increase intraabdominal pressure and reduce absorption of oral drugs. So, cons constipation is a key thing that, uh, we try to take note of, especially in, ah, patients after surgery because as there are many, many painkillers, you know, opioids can tend to cause constipation as well. Um, so we monitor their, their, their stool chart. The Bristol chart and management can include ensuring that they are adequately hydrated if they do not, especially if they can, if they are not like under heart failure. So then they should drink more. Also the appropriate nutrition and laxatives, you know, um, and postoperative I can be caused by intraoperative bowel manipulation, pain, immobility, hypokalemia. And yeah, all parts So, usually I will resolve around 24 to 26 hours and management includes insertion of a ship to analgesia, ah, and all reduce, ah, oral intake. However, if you know, it's longer than that, then you probably could suspect, you know, a small bowel or large bowel of fraction, which could be something more sinister. So, now we come to, um, the third question, which is, what do you guys think is the most common cause of postoperative fever in the 1st 48 hour surgery. So, 46% have said surgical site infection. Ok. Ok. So it's actually a surprisingly, it's actually atelectasis, ah which is actually a partial collapse of the lung er, in the 1st 48 hours after surgery. So actually the key, the key word here is the like the duration of time after surgery. So, uh at uh it it occurs due to shallow breathing and reduced lung expansion after surgery, especially for those who undergo abdominal or thoracic surgery. So person can present with fever, which is usually low grade and this comes about with some respiratory symptoms such as cough or diph ea. Uh yeah, whereas uh surgical site infection is also a common cause of fever. However, it is usually beyond the initial 48 hours. And the other options here include DVT, which could also lead to fever but less likely to be the cause in the 1st 48 hours. And UTI S can also typically lead to fever. However, er, they are more common in patients who have like uh catheter in situ for a long time. Ok. Yeah. Now we come to next question, which is as well. Um which is a key risk factor for the development of postoperative delirium. So we talk about like delirium. Um uh Someone is, you know, acute confusional state, 93% have said advanced age. Ok. Yeah, really, you guys are right. So advanced age is actually one of the strongest factor for the development of postoperative delirium. So, um the elderly are actually more susceptible to um like uh connective decline, uh especially if they are not really active usually. Uh and usually they have would have multiple comorbidities such as metabolic syndromes, like high BP, diabetes, uh hypercholesterolemia and due to those few conditions, they are usually on many medications like with the polypharmacy and with mild connective impairment that could also lead to changes in brain function. So deli is actually a really common postoperative complication particularly after major surgery or when there's other stressors such as infections or metabolic disturbances. So high BM I, you know, usage of vaginal anesthesia, long de duration of surgery could also influence postoperative recovery, but they are not as strongly linked to as advanced age. Yeah. Ok. So now we've come to almost the final part of our presentation, which is the post surgical patient review. So the patient has gone through a tough long day of surgery, you know, and like after caring before the preparation, before surgery during surgery and now it's after surgery. So surgery is done. So, what do we do? So, first again, on the post, take what round, you know, come in the morning, see patient again. Ah, you making your notes, patient demographics, their full name, age listing down what operation they did and POSTOP, uh, like what, uh, what day they are? POSTOP is it day one, day, one, POSTOP, day two, post, all these are key information. We should be listed down during what round the type of operation they underwent is a lab. We post procedure and what was the reason behind it? And like what's the plan management for it? Uh Yeah, so we go through some of that as well. So in terms of ah, investigations that we do is um uh like uh BC where we check their inflammatory markers, like CCR P is quite important. So, uh this may rise for the first two days postoperatively, but it should fall after that. Yeah, because the halflife of C RP is about like, er, 19 hours. Ah, and then also like things like hemoglobin electrolytes, especially trying to electrolytes. If you know they are a bit haywire, then it could cause arrhythmias and more other complications. And of course, other new investigation results. If anything that pops out. Ok. So here, um it covers like a wide scope of what we would do. For example, when we are talking a patient, we ask them, uh, are they feeling any symptoms, any issues? You know, are they eat, uh, are they eating and drinking? Well, if they, if they, if they could, uh, have they been able to sleep well, is the pain controlled, you know, as pain is definitely a key thing after surgery. And, you know, we, we always try to keep patient as comfortable as possible. Are they immobilizing? Well, we don't want them to stay in bed for too long, you know, and if they are, is PT for in place and the nursing charts, the observations, er, full balance, you know, uh, for example, especially if after abdominal surgery, are there any aspirates from the NG tube? Anything like that stool charts? You know, if someone, you know, is like last bowel movement about seven days ago, that could be a cause for concerns, you know, and you want to explore more about that. The food charts, are they eating? Well, what type of food are they eating? You know, should they be on a low fat diet? You know, depending on surgery that they have underwent and of course, uh, examination as well. For example, tubes in C two, do they have a chest drain in place? Do they have, uh, wound catheters, you know, ah, and drain quantity and output. For example, someone who has underwent a wh you know, having drains, you know, trying to check the drain ambulance, you know, what's the color of the drain? Um, is it cow, you know, or anything like that, any wounds, you know, infection of the surgical site, you know, whether there is any infection rashes, you know, and of course, if deemed necessary focus systems examination. So these are actually all part of the patient assessment uh done after surgery. So after surgery it doesn't stop there. You know, there's still much to be done to ensure that, you know, patient is, you know, recovering well and making the necessary steps to get back to the normal state which they were in. And of course, based on after all this assessment, you make the necessary plan based on the impression and also to uh for medications review. So yeah, so you guys, I think, oh, just in time. Yeah. So here are my references. So most of them are from nice guidelines and yeah, so yeah, I reached the end of this presentation. Um Do you, does anyone has any questions or you like to discuss or share about any topics which we covering today would be more than happy to do? So. Thank you. That was really, really good. And I hope all of you enjoyed it as much as I did. Uh Before I carry on, I wanna invite, who's one of the pharmacy directors of s to talk to you about uh learn. Hey Joe, wonderful session. Thank you. So. Much mate. Um Just before we get onto the Q and a bit, I just want to show you guys the learning portal that we've set up for up to this year. Um I'll share my screen. So for those of you that are here, were here yesterday, you'll be familiar with this. But on our website s.uk, we've built this new learning portal to go along with our teaching sessions this year. Um So as you log into the website, you'll see um this join now for the learning portal, you'll click this and you'll be prompted to create an account on the website. Um You'll have to create two accounts to access it, which is a bit an annoying quirk of the system. But there you go. And when you log into the learning portal, you'll be presented with this landing page, you can click the learning portal link and it has recaps of all the sessions that we, which we're delivering this year including the one which Joe's just delivered to you. Um So you can click the session. Um We'll have a recording of the session at the top and then some bullet point summaries, summarizing the content to go along with it. Um At the bottom of each page, we've got a whole load of multiple choice questions that you guys can um answer to, to recap your knowledge and, and consolidate it for the, the sessions. Um Along with that, we've got a uh dedicated multiple choice question bank um with questions that we'll be adding to after every session. So at the moment, there's only a small number but um before long, it will be a very large question bank and a good sort of vision for you guys. Um I'll uh I'll leave it there. Thank you so much, Jo Thank you. Thank you, go and I hope it convinces all of you to go get this doctor uh just a couple of finals. Now, the feedback form is available in the chart. So don't forget to fill it out to receive the certificate and discount codes to teach him surgery and plus the MRC. Um Also be sure to complete the global form for a chance to get a free access to the surgical flash be and the stations. The link for this is available on the chart and the uni code is also available. Um Our next session will be on the 10th which is next Monday at 630 this is going to cover cardiothoracic surgery. So I'd love to, I'd love to have you guys again with us. Uh Make sure to follow us on the social media platforms. The links for all of this is available in our chat. You will be able to receive updates on our upcoming sessions via all these platforms. We've also posted additional SPS on 11 platform that just showed you. So definitely check that out. We hope you found today's session, helpful and engaging and we'll see you guys next week. Thank you everyone. Yeah. Yeah, so. Ok.