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uh, with that, you know? Never know. It says people. Three. How many people did you say? Um, 19. We are. Live. Well. Hello. Evening. Everyone will just let a couple more people join. So we'll give it just a couple of minutes, and then we'll Then we'll get started. That with people. Okay. Yeah, just another minute or tea, and then we'll get day. Can everyone hear me? All right, before we, um before we crack on. So I wouldn't mind just putting a message in the shot, maybe. Yeah. Okay, great. Thank you, Gabriel. All right, one more minute, and then we'll get a game. Yeah, that's right. Okay. All right. Let's get started. Um, so evening, everyone. My name is Lawrence. Um, I'm an F two. Currently at guys in Saint Thomas is doing urology. And I'm just coming off a general surgery job today. I've got the the honor of delivering the final lecture of our mini series, the theater experience. So if you joined us before, um, in the pre op or intra up, um, lectures. Welcome back. And if this is your first time joining us, then welcome. Um, So today's election is going to be on post complications and without further ado, let's get going. So as a background to the talk, having done six months of this, um, in the last six, yeah, and just gone. So I've noticed if ones are often the first people called to review unwell patients, Um, and it's a really, really common scenario. So to get a grasp of this, um, or just even a field which will then build into, um, your jobs if you're just starting or, um, just thinking about if you're a medical student at the moment going into the future, Um and it's really common you'll encounter it definitely in surgical jobs, but also in medical jobs when you're in an on call team and you get called to see surgical patients on the ward as well. Um, so and just obviously, because it's so common knowing how to assess the patient and start some initial management, um, is really important. And then being able to escalate that to the correct person at the right time because no one has an F one. No one's expecting you to sort of solve all the problems, but it's just to get things started. to try and make them try to make things as safe as possible and to get the right people involved. So in terms of the scope of today's talk, I'm going to try and keep this as a practical and clinical uh, as you would have it in your job when you're on call, for example, on would cover, um, rather than a lot of theory. Obviously, there's a lot of theory behind all of medicine, but we'll, um, leave, leave much of that for now and just try and be a bit more practical. It's, of course, a huge topic. The range of operations that are done, uh, today in medicine is absolutely huge, so we won't be able to cover everything, Uh, and even even in, say, single specialty that would. That would be probably to enough post complications to cover sort of 10 of these lectures. So we try and to sort of scope it down a bit, Um, I've decided to focus largely on general surgery. Firstly, because it's probably the most common are definitely the most common F one surgical job that people will have, and also it's a good foundation for other surgical specialties and a lot of the complications. You find a general surgery. Patients will be applicable to patients who've had other types of operations. Okay, so today's objectives just to run through very quickly. So we'll start with just a brief recap of a structured approach to assessing any patient. I'm sure you guys have all done that before. Um, we're going to learn about build some awareness of common and and or serious post complications, how to identify them and how to start some initial management. As I said, that's a really important skill, um, understanding when to escalate to a senior and or other specialties and which specialties those might be. Um, And we're going to do this through a sort of case based approach, um, to what would be a common common bleeps or pages If you're not from the If you're not, If you're listening from elsewhere, are you not? The UK might call them pages. Um, that you would get on, say, a busy ward cover shift about your patients who had just had operations. Yeah. Okay. So, um, as I said, we'll start with a structured approach. Now, most of you, I'm sure. Well, no This is an A to assessment, so we won't labor the point too much. Um and so we have airway breathing, circulation, disability and exposure. Now, of course, the reason we do things in that order, um, is because these are the order of things that kill that would kill the patient, the fastest, and you need to address them in the correct order. Um, and it's a sort of comprehensive way to make sure you don't miss anything now. We're not really going to talk much about airway, but it's, um, and there won't be any airways scenarios and what we're going to talk about today. But it's supposed to say if the patient's talking in full sentences, it's fairly certain that the patient's airway is patent. And we say it's their own airway, as opposed to a sort of tracheostomy or endotracheal tube, for example. Now, if there's any sign, if you assess the patient's any signs of airway distress like stride or gurgling things like that that you're worried about, then you have to initial things that you can do. And this is all from sort of life support training. So you have the airway maneuver so head tilt chin, lift your thrust and you have some airway adjuncts like your Goodell airway nasopharyngeal airway. And to be honest, I'd say, as an F one or someone just starting, um, it's I would definitely be calling. If there's any airway problem, you need to get the right people involved. And that's the anesthetist or the I. T. U team, Um, to help you with the airway. And I would you would call a parry arrest using the number 2222 in most if not all, UK hospitals. I believe so. We'll move on from that, and we'll leave me alone for pretty much the rest of the talk because there's not that much for us to do about it and that you just need to call for help. So the next one is breathing. Now when when you go through and you're assessing these things, you need to have a sort of structural approach. So I'd like to check the observations. Obviously, there are important. So here you have respiratory saturations will be the important one, and also whether they're on oxygen, whether they're requiring oxygen, I should have added that to the slide. Um you can look at signs to give you clues about when you're assessing breathing. So whether they're cyanotic, for example, if there's any signs of respiratory distress, so that could be sort of accessory muscle use in the neck or if they're sort of leaning over and tripoding so to speak, Um, as you might have been like an asthmatic patient. For example, when you examine, there's lots of things to examine much more than what I put on the slide, but in particular, so your trachea position is quite important. If it's deviated to one side, then you might, um, something like a tension pneumothorax would be sort of on your mind more and auscultation. Obviously you're listening for any crackles, any decreased sounds. Any decreased breathing sounds, Um, and it's giving you clues about things like infections, infusions or collapse. For example, your investigations are really important to think about as you go through a to assessment. So when you get to breathing, particularly an arterial blood gases, always really useful to see what the oxygen and CO2 in the arterial sample is. Amongst other things, Um, and a chest X ray is always quite good just to just to actually visualize the lung fields. Um, and you sort of compare that against your examination. Now, in most scenarios, if the patient is, um if it's sort of acute an acute scenario and the patient isn't Well, then the best thing to do is to you don't want your unwell patient being pushed from the ward, um, to the x ray department, which is probably an item 10, 15 minutes away just by a porter and no medical staff. So the best thing to do is to get a portable chest X ray. Now, often the you have to call up the radiographers for this, Um, and they will sometimes be a bit begrudging to come. Now, the key phrase for this, um, as you'll find out when you work, is to say that the patient is to clinically unstable to come to the department and then that usually solves all the problems, and they radiographers will come around and do your X ray for you moving onto circulation. So again are observations. Here mainly would be pulse and BP. You can look for signs of things like pallor. Um, and obviously, if there's any sort of obvious bleeding that would be important towards your circulation. If it's if it's a large for you. When you examine some of the most important things would be your capillary refill time. So you just press on the finger, hold for five seconds and then you see how long it takes to refill. Normal would be less than two seconds, and prolonged would be anything more than that and give you an idea of how sort of well perfused they are now. You also need to you can palpate a pulse important to know whether it's regular or irregular. Um, now, all surgical patients can have sort of medical things as well, like heart rhythm abnormalities. But we won't go into that too much today. Um, and heart sounds nice just to complete your examination. Really? Um, investigations. Now, blood tests, of course, are going to be important for any unwell patient. Um, and if there's any sort of infection or sepsis and blood cultures would be really important and again to do with sepsis. Um, your you would like to do a blood gas, which you might have done an arterial one already and be, um, if not. You want to do a venous one just to see what the lactate was? That's a marker of your tissue ischemia. Obviously, when tissues are, um, respire ing and aerobically, then you start to get a build up of lactate. So it's a marker of not just infection, but also things like any any other cause for ischemia as well. Um, and the C G is important just to, uh, surgical patients can have all sorts of things like, um, I guess, or rhythm disturbances and other things and see that I would normally look for urine output is really important because it's a marker of how well perfused the kidneys are. And if the patient sort of in shock, for example, the for whatever reason, whether that's sort of septic or hypokalemic, then your urine output is going to decrease quite significantly. So it's a really good measure of how well perfused as a whole the patient is now. It's not strictly an investigation at all, but ensuring the patient has IV access, particularly unwell. Patient is really, really important. And so the best thing to do is you're going to be taking blood anyway, so I'd make it as part of your practice just to pop in a cannula and take bloods through the cannula when you're taking blood in this scenario, because you don't want to take your blood and then realize you need a cannula anyway and you're doing it twice, basically. Okay, of course. Any questions? Just pop them in the chart. Apologies. If I'm getting quick at all, but just yeah, and then the will go through very quickly. So you would assess them on, well, normally go for an avenue. So, um, for those, you know what that means, It means you don't know what that means. So you measure them on whether they're alert, responding to voice, responding to pain or unresponsive. Um, and that's just a really quick way of just describing that, um, you can use a GCS as well, but it's a bit longer. And whether it gives you much more information is sort of up for grabs, particularly when it's not a neurology scenario. Um, it's good to just check the pupils quickly. Um, and just check whether they're responsive to light and temperature here as well is really important. And then e is, um, e is actually very important when it comes to surgical patients. Um, and it stands for exposure. So you need to sort of expose the patient fully try and maintain the dignity there. Dignity as best as possible. Um, but you do need to actually examine the patient sort of talk to too, Um, including rolling the patient having a look, um, sort of on the on the back and particularly looking for any P r bleeding, which sometimes can be quite hidden when there's sort of blankets. And the patient's, uh, quite big and you can't see sort of what's on the bed itself, and you want to check for rashes as well. Um, normally, my full abdominal examination here, particularly just feeling the abdomen for any sort of tenderness guarding, Um, take this time as well to check drains or a catheter. What's the output of these? Are they bleeding? Is it blood, or is it something else? Um, and e. Just because it begins with an E is I sort of think of as everything else and escalate, So if you think you need help, then then you need to escalate to a senior colleague and whether that's your S H O or your registrar. Now, my sort of rule of thumb with escalating is that I think initially a lot of people are worried about sort of bothering people. But I say if you're in any doubt about anything, then it's always best just to check and just sort of just pops on a quick message, saying, Can I run this by you? Um and in my experience, I've never had Really. I've never had any sort of bad or any issues with just running things by people. If you're unsure, that's what that's what everyone is in the hospital. They're four. And the people you're escalating to get paid a lot more than you do, and that's what they're there for. Um, so don't worry about that at all. Um so everything else I'd like to have a quick run through the drug chart, check what medications they're on if there's anything important and also think about involving other specialties Now, in a really sick patient, Um, sort of an acutely unwell patient. You don't think you can manage on the ward, then I see you is the next step up. So you think about talking to them. And also in surgical patients. Often it's really useful to have imaging imaging often require particularly CT scan often requires talking to a radiologist just to get that scan before it will, uh, it will go through those Sorry for those who don't know what betting means. So you have to call up the radiologist and talk through saying this is the scan. This is the scenario. This is what we're worried about. Um, I would like to do this scan to check for this problem. I would you do the scan? And so all normally all CT scans need to be run past the radiologist because that would be the ones reporting it in the And once you have the go ahead from the radiologist, then you can get the patient down to the scanner. Right? So we'll run through that a two mg. Um, if anyone has any questions, just put them in the chart very quickly. If not, we will move on. Damn, and we'll get into our cases. Okay. So fantastic. Stunned to silence. Um, okay, case one. So, Doctor, Doctor, your patient is in pain now. This is This is so, so common happens uh, happen to you every day. So this case, we have a 68 year old male who's day one after a laproscopic right hemicolectomy for bowel cancer. Um, and the patients reporting severe abdominal pain, he hasn't mobilized. He's been in bed for the last 24 hours since the operation, and he hasn't opened his bowels yet. So you do your 80 as a very good, um, F one and the airway, um, as I believe it to you earlier is fine. Um, breathing. So you have saturation of 95% of the respiratory rate of 18, and the chest is clear when you examine it. The BP is 95/63 so a bit low, and the heart rate is 105 which is slightly high. Your capillary refill time is four. Um, if you guys remember. So I said normal was less than two. Um, and the heart sounds normal. Um, the patient's alert and he's talking to you, uh, GCSF 15. Um, the temperature is 38.2 degrees. So it's running a slight temperature, um, in your exposure. So you don't see any bleeding or rashes when you do your abdominal exam. So the abdomen is 10 is very tender with generalized guarding. So throughout the abdomen. And you look at the wound. You look at the wounds. Got multiple cameras, like wounds. Um, and they all look dry with no sort of erythema around or discharge or signs of infection. Okay, say, I'll let you all just read that very quickly, and then we're going to move on to our first pole. I'll just go into this, and then we'll go back to that scenario when I put up the whole just so people can read it. So what's the diagnosis? And while you have that up, I'll just put this in this scenario in the background, so I'll give you a minute. Okay. Keep keep putting your answers in. I think we've still got a few people. Um, who haven't submitted answer yet, so we'll just keep the pool open until we've got a few more responses. Yeah, uh, if you're not sure. Just guess space. Um okay. Any more for anymore? All right, that's fine. We'll carry on, Say, now we've got 17% of people have gone for expected POSTOP pain. 5% of people have gone for constipation or the numbers of changes I go through. That's very confusing. 38% of people have said Anastomotic leak, 22% have said wound infection, and 11% have said intra abdominal bleed. So the diagnosis here most likely is an anastomotic league. Now we'll go through each each answer very quickly. So expected postoperative pain now that every patient after an operation is, of course, going to have pain because you've made an incision and whatnot. Um, the things that I would say is the patient's observations were fairly abnormal. Now, for your back thinking back to the case, the BP was quite low. Um, the patient was tachycardic, Um um, with with a long prolonged capillary refill time. So that's suggesting that the patients not perfusing Well, um, the patient's also running a temperature now. You wouldn't really. You might expect a bit of tachycardia with with pain, and that's normal. Um, but I wouldn't really expect the rest of the observations to to show that the other big important the important thing is that the patient is guarding now. What that means is you get guarding when you have an irritation of the parietal peritoneum, Um, and essentially what you feel our examinations. You just sort of press ever so slightly. And the patient is sort of like jumping up at you and is really, really tender. It's just even with minimal pressure now. You wouldn't expect that from postoperative pain. Constipation. Now, I said the patient hadn't opened his bowels for 24 hours. Now, after any sort of abdominal surgery, that's not unexpected, to be honest, um, so I wouldn't call it constipation at this stage may be much later down the line if a patient hadn't opened their bowels, but again, I wouldn't expect the observations to be off the next answer. So wound infection. So now these do happen, and the patient did have a temperature, which sometimes can be infection. But, um, the if you remember the examination in the all of the dressings were dry and there was no erythema, no discharge, and so no signs of infection around the wound and as well come out to talk to you later about wound infection. They typically happen a bit later in the course of the postoperative recovery, intra abdominal bleeding so that this one is quite important. And it can cause quite a lot of pain it can cause guarding. And, um also the the you would expect sort of a low BP and, uh, tachycardia to sort of the, um I just wanna, uh what's the word, anyway? That's what you would expect from intraabdominally. To compensate to compensate for a bleed. Um, however, I wouldn't necessarily expect a temperature. Um, but it's that's that's that's definitely a another serious one that you'd be worried about. So now let's talk about the correct answer, and mathematically, So just to run through this operation very quickly So, um, just to help you understand a little bit more so right hemicolectomy is if you look at this diagram and you're taking out the right hand side of the colon for some sort of tumor, that's anywhere in that in that area, so and then what you do is you. You join up the that part that's labeled small intestine, which is the terminal ileum to the transverse colon, and they just sew it together and they're just saying it together, using their eyes and using their hands and the sutures. Um there's no sort of fancy techniques, and it is really down to the surgeons technique as to whether as to how strong that that joint is now. Not to say that all anastomoses it leaks are surgeons, faults, Um, and these things do happen with sort of poor wound healing and whatnot, But it is a sort of serious, and it is a complication that we should be aware of, especially when there's any operation where you're joining bowel back to bowel. Um so and say that that for that reason, that's the correct answer. And you expect because you you've essentially gonna have fecal matter within the abdomen because it's leaking out of the bowel. And that's irritating the peritoneum you're getting guarding because of that. And also because you've got all of this foreign material in your abdomen, it's You're getting a significant inflammatory response, and essentially, it's a sort of like septic shock type reaction. So how did you manage this? So a A and B. So anyway, the breathing, that's fine. Um, and I think we can leave those as they are for now. Um, the observations were okay, so you see, so the capillary we know that patients, um, under filled, um or sort of in shock, because the capillary full time and the pulse and the heart rate are are what they are. So it's best to start off with some, uh, bolus of fluids to try and fill the patient a bit up a bit more. Um, and the patient also definitely needs IV antibiotics. Now, you check your local guidelines for peritonitis or sort of fecal peritonitis, for example. It would probably be under, and that would probably be fairly broad spectrum something like, um amoxiclav and metronidazole, um, also, and see em getting IV access or even a second IV access and taking your bloods. So you want a full blood count? Um, and you'd be looking at your hemoglobin and inflammatory markers. Renal profile, um, to see how well perfused the kidneys are. CRP is another inflammatory marker. You also want to do a coagulation screen and a group and safe, and I'll bring you back to if you watch the preoperative assess preop optimization lecture. This is just in terms of getting your patient ready for theater, because it's quite likely that this patient might need to go back to theater. So you want to have those things ready? Um, and just think in advance because you don't need to come back and take blood from this patient later on. Um, a VBG looking for the lactate again is quite important, because this is sort of like a septic shock. And it will inform a decision as to whether the patient needs to go back to the theater. Or it can be, um, if the patient doesn't have a catheter already, then catheter is also part of the steps, uh, monitoring the urine output. At least it's part of the sepsis. Six. Um so definitely consider putting one of those. And if the patient will have it now, this is a really serious surgical complication, and as I said, it often requires a trip back to the theater. Now, as the one, you will not be doing that by yourself, of course. So you need to escalate to your S h o. If you have one or you register our most likely, you'll be the one to talk to the consultant or the one who will actually get the patient back to the theater. Um, because they're going back to the theater, you might consider talking two anesthetics. I'd probably wait until your your surgical reg has seen the patient. And they're sort of agreeing with what you say before you start making your own plans to send the patient back to theater again. When you think about other specialties, say imaging is really, really important. And this patient is likely to need some sort of see some sort of scan. And this scenario would be a CT, abdomen and pelvis. Just to see exactly. Is that leaking? Where is it exactly? Where is it leaking from? And you you have a good idea, but you'll see. You'll confirm your diagnosis on a scan, and often surgeons will want to do that before they take the patient back to theater. Um, okay, so I think we're on to the next case. Oh, no, sorry. So we just go through very quickly. So management of expected POSTOP pain, I said every patient will have pain after an operation, and analogies is really important. This is the wh pain bladder, which I'm sure many of you are familiar with. So you start at the bottom with non opioid non opioids for mild pain. So that would be your parasites model and ibuprofen and parasites. More pretty much all patients will get ibuprofen. You need a little careful in terms of the renal function. Or if they're sort of quite elderly patients, it can cause, um, sort of gi I upset and g I bleeding is something you're worried about. So be a bit more careful with NSAIDs in the elderly population or in renally impaired patients. Now, um, if that's not enough, then you need to go to the next level, which is weak opioid. So things like codeine, hydrocodeine, tramadol, um, and then the stronger NSA is like naproxen diclofenac. Um, and then when you get severe pain, sort of, for example, after her, if the patient had a big surgery like a laparotomy, then definitely need to be on a stronger pain killer say things like morphine, oxycodone, and then some places even talk about 1/4 ladder. 1/4 step on the ladder, which is things that basically any cysts or prescribe. So things like fentanyl, PCATS, nerve blocks and that sort of thing. But you don't need to worry about that, Really. You just might see them on the ward and patients who come back from theater. Okay, so the other thing I wanted to run through very quickly as well was just bleeding. So I said, this is, um the I mean, our scenario was not it was an anastomotic leak, but bleeding was not something you probably definitely need to think about at the same time. Now, I said it wasn't going to be heavy on theory, and I brought in this this big table of the four different classes of hemorrhagic shock. So I apologize for that. And I just want to draw your attention to just one thing in this, um to be aware of. So you have four classes of hemorrhagic shock and the top row tells you, um, it's separated. Classified by what is the volume of blood loss. So class one is 7 50 miles, for example. Now jewelry, attention to the line that says sbp say systolic BP. Now, a lot of people think that BP will drop when you start bleeding. But actually, just the only my only point that you take home from this this slide is it actually takes quite a lot of blood loss before you start dropping your systolic BP so you can see even in class, to when you've lost a liter and a half of blood, your systolic BP will not change. Um, and it was actually your heart rate that changes first. So just to be aware of that, and it's only when you start losing over a liter and a half that your BP is going to start dropping. Um, so just be aware of that bleeding a phrase Where where does bleeding happen? So floor the floor and for more is the sort of classic surgical phrase. So the floor is there might be blood on the floor. And then there's four more places that you can bleed. Um, so that's into the chest, we think, with a hemothorax, abdomen, pelvis and long bones. So, um, that's one to remember that people with things like, um, femur fractures or humorous fractures can actually believe, quite significantly into from that because they're quite vascular. Um, if you're worried about bleeding, um, and you think that the patients say, for example, the patient's having, uh, he is having a BP drop after what you think is a bleed, um, and say, for example, you walk in, there's blood all over the floor and the patient's dropping the BP. Then you know they've lost at least at least 2.5 of blood. And you probably need to activate what's called the major hemorrhage protocol. And you do that again by calling to to To To If you're in the UK hospital, Um, and that will sort of start a chain of events which long story short, we end up with your patient having sort of blood and other blood products. Um, in the meantime, while you sort out, um, that the cause of the bleeding just to stabilize the patient again, you're obviously going to escalate to a senior. This is above the pay grade of an F one to manage by themselves. But it doesn't mean you can't do things initially. Um, you're likely to need a CT scan again. Surgeons like CT scans um, be a recurring theme throughout this talk, often with contrast, so you can see exactly where is it bleeding from? Um, and you need some sort of intervention, whether that's going back to theater or sometimes An interventional radiologist can sort of nip in with a wire and try and stop the bleeding. But that would be sort of getting in touch with other colleagues. But you need a few imaging few images before that that leads us on to our next case. So, um, just to give you 30 seconds, just in case anyone had questions about that one. Nope. Okay, let's go. So, Doctor, Doctor, your patient has a fever again. Really common. So you have a 63 year old male who's day seven after a Hartmann's procedure for severe sigmoid diverticulitis. Just for those of you don't know what heart procedure is, you could open another tablet. Just have a quick look at the diagram, so I haven't got one. But essentially what it is is you chop out the left hand side so the sigmoid, um sigmoid, um, colon. And you bring the bit before that you've dropped out and you bring it out into the stoma onto the outside of the abdomen. And then you just so over the bottom, the bottom and which will be what's called a rectal stump. Um, and it's an emergency operation just to get rid of it. Either sort of a perforation or a tumor obstructing tumor in the sigmoid or upper rectum. Normally, so you have a temperature of 38.4 degrees. Um, and the patient has a past medical history of type two diabetes. So diligent F one that you are. You do your 80. So your airway is patent and there it. The respiratory rate is 16 and the stats in 96 the chest is clear, all looking good. So far, BP is 130 over 78 the heart rate is slightly high, 102. The capillary refill is two seconds, and the heart sounds are normal. The patient's alert pupils are normal, and the temperature is 38.4. We really said when you examine them, there's no bleeding anywhere that you can see on the floor or in any drains. Um, and the abdomen's tender around the midline laparotomy wind. But it's soft. It's not guarding. It's not paradigmatic as it was in the last scenario. You see some purulence discharge from the lower end of the wind, so po two, you should always be able to see that pole. And I'm just going to flip back to the scenario so you can sort of sit in the background and I'll give you Let's do one minute until for everyone to, um, sending an answer. I Yeah, James's right. Thank you, James. Um, Okay. 30 seconds. Yeah. Okay. Nice and easy. Um, I see the vast majority of people have got this right. One person has gone for the silly answer. Um, so yeah. So you're all right. So this is a wound infection. Pretty clear cut case, I'd say, Um and so obviously that you have a temperature and you got discharged from the wind. It's sort of kind of is what it says on the tin. Um, we'll go through a few more of the other things that, um so Well, let's go through the management first of what you would do if you saw a patient with this sort of weird infection. So again, a, A and B are okay, um, in terms of see, um, where if you go back to the, um uh, thinking back to the case. So the BP was all right. Patient was slightly tachycardic. Now that could be to do an underlying, uh to do with the infection. And there might be slightly because of the inflammatory markers that could be sort of slightly fluid. Deplete or well, sort of volume deplete, um, and and giving some fluids will will definitely sort of make them feel a bit better and as well as giving some antibiotics. And normally we give IV antibiotics, at least at least in the first instance. Um, so you want to do your blood in terms of investigations and see, so you do your blood so full blood count renal profile CRP so as your inflammatory markers, essentially your kidney function and you probably you want to do your blood cultures at this point as well. Um, and those will take a couple of days to come back, but they're really useful. Um, and it might might help you sort of direct your antibiotic choice. Other things that you would do, particularly in particular for a wound infection is really important is to take. You can see pus coming out of the wound, so you want to take a swab of that and send that to the lab to check for your cultures. and sensitivities, And that will really help your microbiologist guide the guide, the antibiotic choice later on. Now we'll come on to this, but there are that it might look very clear cut. But there are other other things that you might not have seen so far. And I say often there's no there's no harm to send a urine culture, which you'll look for you look at in a couple of days when it comes back. And if there's any diagnostic uncertainty, or if there's anything wrong with this sort of respiratory rate or the stats were you find anything on examination, then alongside the discharging wind, and I wouldn't I wouldn't be sort of it wouldn't be the wrong thing by any means to just do a chest X ray if you find anything on examination, to be honest, um, and just just as a sort of part of your septic screen, okay, so a bit later on, when your blood's back, you notice the inflammatory markers are really high, so your CRP is 300. Normal would be sort of less than five and white cells at 18, so normal white cells to be less than 10 or 11. Um, And you start wondering whether there is this a superficial infection, or is there anything underneath? Is there any sort of infected collection now of of sort of infected pus or fluid? So it brings us on to our next pope. So what sort of imaging would you want to talk to your radiologist about to try and, um, try and sort of under answer that question. Is there a collection of infected fluid again, Any for answers. So we'll give you a minute. Okay. 30 seconds. Yeah. Okay. We will call that there. Um, but keep answering if you want. So a couple of people saying X ray majority saying, uh, slim majority saying ultrasound over CT. And now I'm saying MRI. Okay, so the answer for this one, um today is CT, so we'll go through the beach. So an x ray Now, X rays are obviously to de, uh, yeah, X ray is obviously to d, so it's a bit difficult to see A A collection, which is obviously a three d structure, Um, and with an x ray. So, unfortunately, that that wouldn't be the correct answer. MRI, Um, to be honest, I think is just logistically extremely difficult to organize. Um, and at least for that reason, we would never do that for this. For this scenario, Um, at least not that I've seen on ultrasound and CT is a very good good question. And the ultrasound isn't necessarily a wrong answer. Um, it would probably help you a bit. So if you think back to the case So the patient has diverticulitis, um, severe diverticulitis that they're required an operation for to remove that part of bowel. So there is definitely a deep source of infection of what was infected material inside the abdomen. For that reason, you're thinking you want to rule out the worst thing, um, in terms of collection, and that's a really deep collection inside the abdomen. Now, ultrasound obviously is just coming from the sort of exterior, um, and that you can only get so far with your ultrasound sort of imaging. Um, And so for that reason, I say that CT is probably the investigation of choice. Ultrasound is really, really good for seeing collections within the abdominal war. And this may well be something like that. Um, and it sort of sounds like it it passes sort of actively coming out of the wind. But also you definitely can have collections that sort of go deeper and then sort of make a track that come out through the wind. Um, so I think in this scenario it is a bit of a judgment decision. But I think most people would go for a CT here, say, hopefully that sort of, um, that explains things now going on to sort of talking more generally about fevers or pyrexia after surgery. Um, sort of as a rule of thumb. Now, there are no hard and fast rules and medicine, too, but, um, Day one. So when you have temperatures after surgery, and this is a rough time line of when how to sort of pinpoint infections so they wanted to. The most common cause of of pyrexia from an infectious scores is likely to be the chest, Um, and so you'll need a chest X ray. Obviously, after your examination. Now, just remember, you can. It can be a normal inflammatory response that gives you a temperature after a procedure, so it's not always pathological. Um, but you should still get and assess your patient day 3 to 4 is more likely to be a urine infection. So you send a urine sample. Um, day 5 to 7 is when you start getting your wound. Surgical surgical site infections plus or minus collections. And it would really be, um, if you have any sort of discharge from the wound or if you have really high inflammatory markers, sort of CRP is over sort of 200 sort of when you're thinking more about collections. And of course, as we talked about, you do wind up other things that can cause pyrexia that are not infectious sort of infections in nature to DVTs. Um, I haven't seen this myself, but I've been told that and sort of seen in articles that DVTs can cause, um pyrexia in the absence of any other signs of DVT. Um, which is worrying. But do you examine your patients fully? Um, and even medications and sort of paradoxically, antibiotics after people have been on them for more than seven days can cause pyrexia. Um, so just something to have in the back of your mind. But I'd say these are quite rare things. Okay, so let's go on to the next case. Um, So, doctor, Doctor, your patient is de saturating, and I mean that in terms of oxygen saturations. So your case, you have a 48 year old female whose day to paste a laparoscopic cholecystectomy. So that's removal of the gallbladder. She has a 28 pack year smoking history and a high BMI, and she's on chemotherapy for breast cancer. So airways, her own saturations are 88% on 15 liters of oxygen. And her respirations 20 for her chest is clear when you examine her. BP is low. 85/64 she has a Sinus tachycardia. With a heart rate of 100. She is alert pupils and normal temperature is normal. The abdomen is normal. No bleeding. But when you examine her fully, you notice she has a tender right car for the erythema. So what's the diagnosis? Let me start the pole. There you go. And I will just put this slide back on, and we have one minute. Yeah. All right. Keep the answers rolling in. Okay. All right. Very clear. Cut. Everyone has got this right as expected. So Okay. Um, so diagnosis here is pulmonary embolus. Now, Um, I was going to ask people to put in the chat some risk factors that you can think of from the case. But I think we're sort of running a bit tight on time, so we'll just go through them very quickly. So we come back to the if we come back to the case. So, um, risk factors with primary ambulance very quickly as we go through. So the patient has had surgery. Now, that is a risk factor in itself. Um, surgery is a bit of a double whammy and that your sort of inflammatory markers and what not make you hyper coagulable. Also, patients who are in pain don't tend to leave their bed and are quite immobile. Um, patient also has a high b m I, which I think is A and that might contribute to sort of decreased mobility. And the patient has a background of cancer. So lots of reasons why this patient might have a, uh, sort of be hypercoagulable. Um, so, yeah, so going through the answers very quickly say hospital acquired pneumonia. Now your things that point away from this so the patient doesn't have haven't had any temperatures and the chest is clear. Um, Atelectasis is something that's quite common after operations, and that's just sort of collapse of the sort of like a sort of a collapse of the sort of sections of normal at the bottom of the lungs. And it can happen after laparoscopic surgery because essentially filled up the abdomen with, and you sort of crossed the bottom of the lungs. At least that's the way I think about it. Um, but that wouldn't wouldn't typically cause the sort of respiratory decompensation that we've seen in this patient. Shouldn't and patients shouldn't with that. Alexis shouldn't need that much oxygen and shouldn't affect the BP. Even, um, exacerbation of COPD. Again, the patient is just a bit too unwell to have this. The patient does have a strong smoking history, but there's no temperatures, and actually the the chest, we said, was clear. But you might expect to hear a wheeze, Um, and some crackles with that a pill could Overdose is an important thing to think about and POSTOP patients expect, but the respiratory right here was 24 that's sort of high. Whereas a good overdose, you would think would, uh, you would normally have a lower respiratory rate. Sort of at least less than 12. Okay, so your management now, this is a really unwell patient. Um, so a is fine. Um, we move on to be. So the patient's already on 15 liters and ornery breath, so you just need to continue that because they're only saturated at 88%. So you need to continue that, Um and that's basically the most you can do on the ward. Um, doing an arterial blood gas is really, really important in this scenario. Um, and that will give you an idea of the partial pressure of oxygen and carbon dioxide in the in the arterial sample, which is information that you're definitely going to need, Um, and will come down to one. Um, you know, also like to do a portable chest X ray. This patient is definitely too unstable to go down with reporter to the X ray department, so they need to come to you. Just use those magic words clinically unstable. Um, basically, what you're doing here is you already think this is a P, but you just want to make sure that there is nothing obvious on the lungs before you do any other scans to confirm a P, which are quite high radiation doses. Um, so just check that there's no consolidation or collapse or infusions, but you're already very much thinking along the lines of pee say, just going back to the case. So remember the observation. So there was 88% on 15 liters. That is the most oxygen you can give on the ward. 88% is not. It's not terrible, but it's not high, but it's not. It's definitely low still. And so I say that that oxygen saturation on that amount of oxygen is quite catastrophic, actually, Um, also the patient's hemodynamically unstable. And from what we know about peace, that's quite important. Obviously, your, um, you're blocking the cardiac output. Um, and if it's a particularly big PPI, these patients can go into cardiac arrest. Um, so for that reason, I'd say that this would be a patient that I would very, very quickly be calling for peri arrest call. And that would be 2222, and you'll be getting the most important people to manage this patient and getting the best results for the patient. So you need the medical registrar will be there, Um, and the I t u team as well, because this patient could well, need I t u might need thrombolysis. But this isn't a medical talk, so we'll move on from that. But essentially, you need to get the right people involved in this patient's care. Um, and that will be you'll get all of them in a terrorist call. Say, let's move on. So this is the last scenario. We got nine minutes left, so that's good. Um, doctor, Doctor, your patient is vomiting. So again really common. And you have a 44 year old man is day three after a low anterior resection of erectile tumor. Now obviously a bit more complicated than than what I'm about to say. But essentially, you're you just cut out the rectal tumor and you join the the answer back together, um, within an estimate basis of the bell. So the patients reporting is quite a big operation. Um, patients reporting severe vomiting and abdominal distention. Um, and he hasn't passed or phlebitis yet. So always normal. Breathing wise, he's slightly technique, but the saturation is okay. And the chest is clear in terms of blood in terms of see, everything looks fine there to me. Um, this disability says alert pupils are normal. Temperature is normal. When you examine the abdomen, the abdomen is quite tense and descended, and it's slightly tender, but it's not. It's not paradigmatic by any means, not guarding on the side. You see, there's a large bowl of on it by the bedside. Okay, say this is I believe I lost it all. Same. What's the diagnosis? We'll have one minute again and we'll make sure that we finished on time. Yeah. Okay. 10 more seconds. Okay. Right. So the correct answer in this scenario is see, paralytic I list now, we'll just go through the answers very quickly. So and as automatically we've talked about reasonably extensively. And, um, we know what that looks like already, and it doesn't look like this. Um, I'll then skip over the two most popular answers. Um, and go to constipation. Now, the patient hasn't opened their bowels. Um, obviously, that that could be a constipation thing, but it's the patient has had quite major surgery. Um, and constipation wouldn't You wouldn't expect constipation to cause such vomiting, Um, and abdominal distention, unless it was really, really severe. And three days of constipation is sort of not really long enough to sort of back your whole colon up and start. Start causing vomiting, though, um, in severe constipation, you'll probably see it that that can It can happen. Just not, in this case, gastroenteritis. Bit of a throwaway answer. But yeah, it's just not that, um so going back to so it is a bit of a toss up between mechanical bowel obstruction and paralytic ideas. Now, the patient is day three after a surgery where the bowels have definitely been sort of manipulated by the surgeons. And any sort of touching or manipulating of the bowel is, um will cause the bowel to get into a degree of Alias. Now, this is quite a big operations. You expect that that degree of ideas to be more than in a sort of minor or laproscopic operation now, um, in terms of differentiating between the two, um, at least from my experience. So you sort of expect alias after any operations, any big operation where they're manipulating the bowel. And so for that reason, I say it's the most likely answer. Um, now, not to say that it's definitely not mechanical bowel obstruction, but at least what I've seen in practice is that normally treat the treatment for these conditions is, um, is fairly similar initially, Um, and so you treat the patient as if they're in Alias often. And then if things are not resolving, then you need to do a scan to to sort of exclude any obstruction. Now the other thing to say about obstruction is that it's because you've, um they've had an operation which sort of removes what you assume was potentially obstructing mass. Um, that it's sort of a bit less likely to have obstruction directly after surgery, because you sort of, um, the surgeons would have seen sort of any any things that would cause obstruction at that time. And it's a bit too soon postop to have. It's quite a lot too soon for anything like adhesions to form um, or hernias, for example. This tend to happen like quite a lot later, after people have had some sort of surgery. Um, but you, as I said, it's it's a bit of a toss up, but I think Normally, this most likely thing here is a serious. Before we go on to the management of areas, um, and then questions. I'm just going to send out a feedback form. So I'd be very grateful to you. Or if you'd be happy just to fill this out quickly. 2030 seconds or so. Um, And then we will come back to the management of Alias and and then draw the session to a place. Okay, keep filling out the feedback, please. And then we will get back to the lecture. Just another minute or two. Okay, Right. So in an attempt to finish on time, let's carry on. So management of islets. So, um, airway was fine again. So breathing. So, um, those you remember the case with a respiratory rate was 22 which is slightly technique now, not something you manage sort of in a normal, conventional breathing way with oxygen or things like that. So the most likely reason that they're having a higher respiratory rate is because the abdomen is completely is so full. That is doing what's called splinting the diaphragm, and it's essentially sort of pushing the whole diaphragm up. And they're not getting the full volume of their their lungs. And so they have to breathe a bit faster to maintain their saturations. Now, you fix that a bit later. So Well, come on to that now, see or come back to again because it makes more sense in the context of of what you're going to do. So the first thing is that you don't want the The problem with this is that the patients vomit well, firstly, patients can perforate and secondly, they can vomit and aspirate and give themselves sort of really, really quite serious aspiration pneumonitis which can which can sort of lead to a really bad outcome. Um, so you want to make the patient know by mouth you don't want to keep forcing things down into this bowel, which is essentially on strike. Um, and so you need to make the patient know by mouth, and you also need to put in the Royals. Tube was essentially a big n g tube, um, and you attach it onto a bag and put it on three drainage, essentially just to get as much content out of the bowel, and you want to decompress the abdomen as much as possible and let the bowel sort of rest and it will start to work. It usually resolves over time. Sort of it can take sort of five days. Seven days. Um, as I've seen, um, and what? You just need to keep an eye on the energy output. Um, and hopefully you see it when the energy output is high. That means you're not absorbing things. But hopefully what you see after a bit of time is that the energy output starts to decrease. Um, and that means essentially that your secretions and everything, the fluids are going through the abdomen, and that's a really positive sign. You also need to just keep the patient on a stool chart, ask the patient, Are they passing wind? Because there's all If they're passing wind, then then stool is soon to follow. Um, and that's good. And the balance obviously working. And that's when you can start having sort of more fluids and sort of soft diet data, and you build things up slowly. Um, it's really important to consider here. Well, um, and, um, as with any pre any patient who's know by mouth, you need to think about their medications. Um, and we won't go into this too much. But just make sure your things like your Parkinson's medications. You're, um you thought about your insulin. You've thought about your anti epileptics, and there's all these really, really crucial medications. Um, so just going back to B and C. So essentially, when you decompress the abdomen, then you're going to solve your splinting of the diaphragm without anything like oxygen or anything like that. So you should see an improvement there, um, and then see So the patient is not by mouth, so they'll need to be on some maintenance IV fluids. Otherwise, they're going to get really dehydrated. Okay, so that's that's the main management ideas. And it does get better if it's not getting better. Um, then, well, you're you're you're registrar is probably going to examine this patient over the course of sort of 345 days, and the consultant at some point will. If it's not getting better, we'll probably go for a CT and just visualize what's happening in the, um and does it look like a serious or is there something else more sinister? Okay, say that brings me on two. We're finished at two minutes past eight. Um, so does anyone have any questions? Please put them in the chat. Um, just give people some time to type if they have anything. Um, but yeah, if you need to head off. Obviously. Um, please head off. If you don't have a question, then. Thank you. You're very welcome. Uh, in terms of sort of logistics and things, I think the talk will be available on metal afterwards. A recording, So Yeah. Okay. You're very welcome. Um, just as a short plug to our the rest of our talks. So we have another series coming up in a week or two. Um, and that will be running through a lot of the common on core things that you'll see, Um, in quite a few different surgical specialties. So, please, um, look out for that on the S ts, um, social media and whatnot. Okay, John is ask the questions. So, uh, thanks for an interesting teaching. You're very welcome. I was wondering, what drugs should we stop for paralytic areas? Um, just thinking what, exactly what you mean by that? Um Say who? I think well, the cause of islets is very much a mechanical thing. So it's the sort of manipulation of the bowel. Um, I can't think of any drugs inherently. That would make things much worse. But what would make it worse? Um, the I think there's always a question of laxatives in Alias and whether you need to sort of give bowels stimulants. Um, from my experience, it's a bit sort of a case by case, and some surgeons will want to give sort of stimulant things. And some people will just say, Just leave it alone and wait, Um, now things like metoclopramide are stimulant laxatives. And I mean theory would say that if your bowels sort of on strike and stimulant laxatives might help the scenario. But again, we talked about the fact that this could also be bowel obstruction, and you don't want to be stimulating the bowel against, um, an obstruction and and causing a perforation. So I think for that that that for that reason, we don't tend to sort of at least the majority of surgeons that I've worked with and normally say Just hold off. Just leave this alone. It will get better. Um, I don't think there's any specific drugs that you you need to stop, so to speak. Um, that that people would like regularly on was there. Was there anything, you know, specific. You were thinking of John? Or if I've missed the the sort of the the point of that question Yeah. What about on Dansetron? Yeah, okay. Really good point. Yeah. So, um, ondansetron is an anti emetic really is probably the most popular anti emetic in surgery. Yeah, and it can be constipating. Okay. Opioids as well. Okay, this is a good point. So opioids are also constipating now it is, um it's a bit tricky because you're okay. So in terms of the anti, you start the antibiotic. So the patient's vomiting because they're about their abdomen is sort of completely full. Now, there's no amount of antibiotic on this earth that will stop what is a essentially very mechanical cause of, um, emphasis. So the thing that will solve their nemesis is an n g tube, and it should resolve after that, ondansetron can be constipating. So I think if the patient has an energy tube in and then hopefully stop vomiting, then you shouldn't need ondansetron opioids. Now, the patients just had the patient had, like, quite a major surgery. And if you don't give, the opioids are going to be sort of absolute agony. Um, so at least from what I've seen, the opioids continue because it's just horribly unpleasant. Um, to not, uh, Steven electric electrolyte imbalances like hypoglycemia. Is this in the context of Alias? Um, assuming it is. So, yeah, you need to check your bloods and, um, sort of treat accordingly. Um, yeah. Yeah, that's a really good point. Thank you, Stephen. Yeah. Okay. If there are no more questions, then I think we'll call this here, but thank you all very much for attending and two. Um Well, just to the few remainders. Um, but I'll call. I'll call this close and thank you very much. And please do come to our next lecture series.