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um So my session is on postoperative care. So, really, what that involves is, once you've done your operation as a surgeon or, you know, later on and in the future, you know, how are you going to help that patient recover and get back to a similar baseline to what they're at before? And that is a really important thing, and it's something that we often don't think about as medics. It's often something that can be left to the nursing staff or even the patients' families, and really deliver good quality care. It is something that medics need to be thinking about as well. So, uh, hopefully the presentation enlightens you a little bit on that, and this is just a funny picture. And this should be what your patient's all look like after their operations. Um, so I've got a couple of learning objectives we're going to go through, so we're going to understand the measures taken to enhance patient recovery, and we're going to discuss the importance of analyze easy a post operatively and discuss some of the different types. We're going to understand the significance of postoperative nausea and vomiting and how this can be treated within the operation and after the operation on the ward. And we're going to talk about the nutritional need. And I know we're in that some of that yesterday as well. Preoperatively, um I think we're in that most of this yesterday in the preoperative section, and then this will maybe be a more post operative slant and how you can adapt that to help the patient recover. And again, we have common post operative complications which may be relevant to some of the bombing surgeons amongst you. And we're going to talk a little bit about restarting drug regimes. So first of all, we're going to talk about in general how to enhance patient recovery. And I was in my geriatric placement recently, and I saw a poster up that that said and PJ Paralysis And I actually thought that was brilliant because a lot of older, older people, you know, you'll see in the ward and they maybe haven't been up and moving for days at a time, and this really does decrease their exercise tolerance and the thresholds they're able to achieve. Um, so I think that's something that's really great to bear in mind, particularly in the geriatric population, and you have to remember that a baseline is different for everyone. So if you're going to end the orthopedics, you know you might be working with an eight year old female with a fractured hip, and then the next day you could be working with a professional rugby player. So the professional rugby players going to need more intensive physio and more intensive follow up. And whereas any of the year old female, you know, maybe a quality of life for that person has been able to fulfill their activities of daily 11 going to the toilet, the kitchen, the shops. And if you're able to maintain that, that'll be a job Weld on for you and again, early mobilization is critical. If you've ever done a placement in orthopedics, you will see the early mobilization. They is on the forefront of their agendas, and mobility kills in the elderly. It causes PE DVT. Blood clots, um, decreases their function that can lead to depression, mental health illnesses and the elderly, which are often overlooked. Um, you know, if there if there's no call for reflex after the operation and they're too much pain to cough, you know, have aspiration pneumonia aspiration pneumonitis. So again, um, ability is something that can kill, and it's important that, especially orthopedics, they'll often be stressing that you'll want to mobilize the patient's the day after the surgery. At the very least, if not, the day of the surgery is in the morning, and they're fit to be up in their feet by the evening and again, something else that's very important as the multidisciplinary team. So speech and language therapy for a safe swallow, uh, physiotherapy for mobilizing the patient that they need a Zimmer freedom to move around and chest physio as well. Very, very important In the post operative period. Occupational therapists are very important to maximize what a patient is capable of in the home, and a social worker will be very important for organizing the disc, charging where someone's going to end up and that's going to stop the bed blocking. Um, if you're getting people discharged to appropriate places, so POSTOP recovery consisted to me in factors. First of all, you're gonna want to maintain normal physiology, so you're going to be monitored in your new score. Your nursing staff will do that. But you last not purely a nursing has us. And you need to be able to look at a news chart and be able to respond to that appropriately. And, uh, I've been told that the news chart really forms the foundation of much of your F one and F two. You're going to be looking at the patient's hydration status. So well, you need to prescribe fluids. You're gonna be looking, uh, are they maintaining an oral input and a G I output and you're going to look at the existing medications and you're going to resume s app, if possible. And analgesia is also very important and then again preventing complications, but will not get the end of that too much. Now we'll discuss that later on through the slides. So number one, the thing that I'm going to talk about is analgesia. Analgesia is so so important as a humanitarian duty of a doctor, and so really, it should be at the forefront of your mind. Um, whenever you are treating patient's who are in the post operative period and, uh, it's often analgesic as often prescribed in the hospital via the W H O ladder so starting from mild pain to moderate to severe and we'll go, we'll go into some of the drugs in each of those levels in the next slide. Another benefit of analogies is that permits cough and clearance of airway secretions. We mentioned that earlier that's going to prevent the likes of your aspiration pneumonia. It prevents early mobilization, which results in decreased pressure sores and reduces the DVT risk. Pain is also an important cause of delirium in the elderly again, something that you have to be really, really careful of. Um, because, as I've mentioned before, a baseline for an 80 year old female is going to be very different to the baseline for the 20 year old rugby player. But both of those things are equally important, despite the baselines been different, and you don't want to have an elderly woman going in and, uh, they becoming delirious in the hospital. You know, it's not very nice for them or their families that are possibly in visiting them, and it's going to lessen the stress response as well. From a physiological standpoint, um, so there's both the, you know, the softer humanitarian side, but then also, um there is, you know, the medical side of things, too. And again I went into some detail in the W H O P in ladder. So for mild pain, uh, you'll probably have come across this before parsing them all and said, Moderate peon, codeine, tramadol, severe pain, stronger opioid like morphine. I've got a little note at the bottom there, but using a judgment to decrease the toxic effects of opioids, Um, such as gabapentin. But again, you might want to be careful of that and elderly as it can cause sedation or dizziness. And don't forget simple paracetamol, an IV Paracetamol could be really, really useful. And someone that's just a minor procedure. So to the right of the screen, I have a picture of a car decks, and again you'll be following lots and lots of those out whenever your age in your doctor and the big red box at the top is obviously the allergies. And that's something you have to be paying really close attention to, like making sure they're all up to date, because again anaphylaxis can kill a patient. And that's something you really need to be on the ball with, and you're not making sure you have the identification label in the top. Right? So you've got the right patient and the right drug. So quite a common, uh, Kaskey question or exam question could be about opioid toxicity. And, like all things, are the difference between the side effects of opioids and opioid toxicity. So, um, a side effect, then being a physiological consequence of the action of the drug and toxicity being whenever the drug is into higher level. So an opioid side effect again is, uh, constipation itch, maybe a little bit of sedation. Um, whereas toxicity, you're getting to the point where that the patient is confused and they're decreasing their G c s. And ultimately that can lead to respiratory depression, which it really would be an emergency. And you don't want to be having a patient at the point where you need to call anesthetics down and they need tubed. Um, so that's something really important to be aware of, opioid prescribing again is something you might be involved in as a you and your doctor. And whenever you do that, you will always be consultant. That opioid conversion chart opioid conversions is not something you should be trying to memorize. Even senior doctors will look at their conversion charts to make sure that there they're getting the right dose for the right patient. And, uh, this will vary between morphine, oxycodone, fentanyl, different types of opioids. And the conversion will also differ between whether it's oral sub Kat IV, transdermal and, uh, again, that's not something You should be trying to memorize it. Something you should be consultant on the ward. Um, you should be consulting the chart in the ward to be safely prescribing. So another common surgical mode of analgesia is the PCA, the patient controlled analgesia, and, uh, quite a good story about this, actually. So recently I was volunteering as a simulated patient at a surgical course. And, um, this course was for, uh, doctors at registrar level, and they were going in, and they were had They had an ABC? Yes, at a B C D. Assessment to do. And I was one of the volunteers for this. So, uh, my, uh, almond I had I had a pc a, um and I was in dire peon from my laparotomy, and, uh, I was on my PCA and I was lying in the bed and I was yelling, screaming, I was in so much peeing and one of the registrars come in. And before they took a history from me and asked me about P. And they went straight to the examination and they actually were borderline feel for that station because right up until the very end they missed that I had insufficient. Anil is easier and they ended up going down completely their own path. And that's saying that I was having a pa and they were wanting to get the timers and do a CT p A. Um So again, it's not really basic that whenever you see a patient with a high news, you know, make sure they have adequate pain relief, make sure they're PCA is working. Um, because again, that's something you know, in quite a high level course, that or I just throw our missed, You know, they went past the analgesia, and at the end of the day, if that patient, uh, you know, if that was in real life, you know, that maybe would have been missed for that patient. So it's something that's something that you can be caught out on, um, in an office key setting and in real life. So, uh, what it is, it's an opioid connected to your giving set, and the patient will press the bottom for pain relief and the lookout time follows. So this is really good, because it is kind of self limiting. So if the patient gives themselves too much, you'll be able to become drowsy. They press the bottom less so it's a really good, uh, feedback system. And if the patient with the PCA isn't paying, check that it's not occluded. Check that it's within reach and even check that the patient knows how to use it correctly, because maybe the nursing staff or the doctor before has been in a rush and maybe hasn't explained how to use it. Maybe they're scared of becoming addicted. You know, it's all something that all things need to address with the patient to make sure they're recovering adequately. Post operatively and patient's receiving PCA should not be prescribed any other opioids other than whatever is in their PCA. Um, so yeah, and there's also, uh, further modes of analogies. I've got a little note at the bottom of epidural rectus. Cheap cut rate sheath catheters. You may also see I'll go into epidural and a little bit more detail because again, in the maternity ward, it's possibly something you'll see regularly. And what that is is a continuous infusion that's run through a catheter into the epidural space and that has sensory motor and sympathetic block sensory being the desired effect and motor and sympathetic being some of the undesired effects. So if you're blocking the motor system, that may be an inevitable consequence of an epidural. However, an epidural should not cause dance Motor block, I e. If you ask the patient, can you lift your leg off the bed? They should still really be able to do it. Um, if there is dense motor block again, that's something you're going to need to pass on to seniors and the on call anesthetist. So a big safety point to remember again sympathetic block can be an unwanted side effect. A really serious one, however you're going to want to look for is hypertension. If the patient is hypertensive on an epic girl, that suggests, uh, blockade of the sympathetic nervous system above T four, which is going to be suppressing uh, some of your respiratory drive, um, cardiac, you know, terrible side effects. They're you're wanting to do an A B, C D. Approach this an emergency and refer on to the on call anesthetist and bearing in mind again for the future. Surgeons. A well functioning epidural can mask underlying problems such as new Andrew abdominal pathology. So if you are suspicious of any new decline in the patient, a surgical review may be necessary to see if there's anything else going on there. Okay, and this is a table. It was in some of my notes from Queens and Belfast. I thought it was quite useful if the benefits and the risks could be something you're asked to talk about in a in a Noski. And I've just thrown it in there. If anyone wants to see if the slides to look through that early or do you okay, so postoperative nausea and vomiting moving on from pain. So the definition of postoperative nausea and vomiting is nausea or vomiting, which occurs within 48 hours. Post operatively some risk factors for this, including female gender, smoking status, history of motion sickness and previous postoperative nausea and vomiting. using Tool and Ra venous anesthetic reduces the risk, Um, as the Civil Fleurian gas, which is sometimes used an anesthetic that can promote nausea and again, um, note some of the side effects. So, uh, serotonin receptor antagonist, like a dance Atran and dopamine receptor antagonist, are associated with q t prolongation. Uh, so just be very careful of the anti emetics you're using to treat this and again. Dopamine antagonists shouldn't be used in patients with Parkinson's disease. I've got a list down below of some which are used. Intraoperatively, uh, the main ones I've seen intraoperatively would be and Dan's Atran and dexamethasone and again, post operatively on Dan's Atran would probably be the most common one that I've seen with prochlorperazine as an I am injection being one that's used for postoperative nausea and vomiting, which is quite hard to settle. But again, those drugs that you can go through in your own time and you know it's going to be something you'll need for your exams, and that's something you're going to have to take the time to learn. So nutritional, uh, support, um, have put in the most tool here, which is something that's quite important and or nursing colleagues would probably be a lot more familiar with this. Uh, then we would be, um, but what it is, it's a really, really simple tool to assess the risk of a patient who may have some sort of nutritional difficulty on the wards. And really, all you need is three things you need to know. The B m I. You need to know if they've had any unplanned weight lost, and you need to know if the patient is acutely ill, which I'm assuming if you're in the doctor, if you're the doctor in the ward, it would be a bad job if you didn't know that. So if you take these three things together that can you can add them, and that will give you a risk score between 0 to 2 zero being routine clinical care, encouraging foot and drink and to being referred to a dietician. Um, maybe starting to consider in G feeding. So this is something very simple. Um, it was something we covered in, or geriatrics module. And really, um, it is extremely handed of three things, and out of those three things you can categorize, um, the patient based on the risk and make sure you're providing the appropriate care post operatively. Okay, so I have some post operative complications now, Um, so the first one I'm going to talk about is postoperative nausea and vomiting. We've just covered that. And again, it's a humanitarian obligation to treat, and it can often be underestimated for the patient. Um, you know, it can cause significant anxiety, negative feelings, but your procedures, PTSD, um, I was recently attending an emergency medicine talk, and there was an ICU unit noticed. And, uh, he was saying that really quite a shocking number. I can't remember the exact statistic, but quite a shocking number of ICU patient's, um, had PTSD following, uh, they're admission to ICU. So really, you you have to bear in mind that the patient's mental state and I know this is maybe a little bit fluffy and and not as a lot of the It's not as discrete knowledge is, but we're in covered yesterday, but again, fire and things like this out and you're asking ever goes wrong because it's one of the key things you need to be doing as a doctor. You know, you need to be thinking about how the patient's going to recover and how that's going to affect them in the future. Um, and again increased pain. It's not just the fluffy social biopsychosocial, you know. Increased pain has increased cortisol and stress response, which is going to impair the healing and aspiration. Pneumonitis and aspiration. Pneumonia are real things that happened to patient and can cause serious morbidity and mortality. Post operatively. Um, so I'm going to talk now about bleeding. So a nursing colleague, My call your BLEEP on the ward about the early POSTOP patient with a high new score and with regards with a high new score after after an operation. Really, I think that the two main things that people think about is bleeding and sepsis. And this is something really, where you have to use your own initiative and that bleeding is probably going to occur quite soon. Post operatively, maybe the same day, 1 to 2 days after and said just maybe would start to is more of an insidious onset and then maybe began 5 to 7 days after the operation. So that's something to be like. You're going to have to use your common sense with to to distinguish between the two. Um, where is it? Reactive bleeding occurs 24 hours or less post operatively. And that's often due to a slip ligature amassed vessel. And they're often missed. Enter operatively due to enter operative hypo at hypertension and views of construction. And again, I have a picture of the news chart there, and I'm sure everyone will be very familiar with that. Um, by the time they're f on enough to so the main symptoms Tachycardia, uh, tachypnea, dizziness, agitation, hypertension. I'm sure everyone could rhyme those off as well as I can, but, uh, really, what that's alluding to you is that the patient is in hypovolemic shock and that needs to be managed with an A B C D. Approach. If the patient is very hemodynamically unstable, you're going to want to, uh, start the massive transfusion protocol. If a patient is losing a lot of blood, what you want to do is replace the red stuff with the red stuff. If you're given the patient a lot of fluids, what you're doing is diluting what's already there. And that gives a worse prognosis for the patient. So It's always replacing blood with blood. If it's a low, really low hemoglobin and the patient's hemodynamically unstable. The massive transfusion protocol requires a lot of communication between you as the doctor, the nurse who's running the lab and the blood bank. So bear in mind, this is a very complex procedure. And whenever you're in a situation like this again, this is going to be a B. C D critical patient. You're going to want to make sure you have seen your staff with you and even senior nurses. Um, one of the important things to do is close look communication. So say your senior nurse in the ward is called Alice. You'll say, Alice, can you commence the massive transfusion protocol? And 10 minutes later, Alice did you start the massive transfusion protocol and that ensures that no steps of the process or missed um, on some of our courses where we've practiced a. B. C. D. Um, a lot of the doctors would comment on how sometimes it's very tempting to talk under their best. You know, I'll start the massive transfusion protocol and you're talking to No. One and really in real life, sometimes it is it's tempting to do that. And the procedure, the investigation or the protocol which you want to start actually never does get started. So it's very important. And, you know, those anti personal skills are very important. Um, there is a little bit of controversy on the ratio of the massive transfusion protocol many experts advise. 12121 of packed red sails, too fresh frozen plasma, too platelets, although this may not be available locally, so the hospital I'm usually on placement and as Antrim Area Hospital and the blood bank there doesn't have platelets, the closest will be Belfast. Um, so in entering the the emphasis will be on piped red cells, which are to restore your red cells and the oxygenation of the tissues. And your fresh frozen plasma, which replaces coagulation factors as an actively bleeding patient is going to become very coagulopathic very quickly, and in a patient that's critically on well with a massive bleed, there are several fighters you're going to need to consider, so they may become hypothermic, so it's going to be very important to keep them warm. They may need a bear hug er, which is if you're on the ward if you've ever seen those sort of like inflatable blankets and they inflate with warm air, um, to keep the patient warm acidosis again, you'll be needing your A B G V B g. Whatever is the easiest to get your hands on first volumes. That is an idea of your tissue oxygenation, and you're going to want to be keeping your eyes out for any coagulopathic the, um as well, particularly in the obstetric population. When the I see could be a problem. You're gonna want to give these fluid our fluids that you want to want to give the blood through a large bore cannula. So 14 to 18 gauge with 14 been your orange, 16 being gray and 18 being green. If you cannot get a gray cannula in your gray cannula, is usually the go to and bear in mind with cannulas. A smaller number is a bigger size, as that can often catch people out. So in the massive transfusion protocol that's usually defined as 10 units of blood within 24 hours, and the lab will really fire you out maybe two or three units every every hour. So and they will continue to do that until you cancel the massive transfusion protocol, which again the something that was stressed to me in placement. Um, blood is a precious resource, and once the patient is stabilized or they've got they, they're in theater. It's important to cancel that protocol as well, so that it can be used for other patient's. And again, I have a side note at the bottom referred to seniors immediately. Surgery is the only solution for a surgical problem. You will not fix that at the bedside. So moving on the anti infection or other biggie after after surgery. So infection causes a distributive shock. And how that works is by a district dysregulated host response to infection causing systemic inflammatory causing a systemic inflammatory response. And this is what causes, uh, the septic shock and the distributive shock. It's not the infection itself. It's this dysregulated host response in the inflammation of the tissues, and this increases the risk of ICU. Stay more better in mortality, and it can cause make your organ dysfunction, which would warrant an ICU admission then Q Sofa score can be allow. It can allow us to evaluate this the full sofa score is complex and usually a Any doctors will be very, uh, has an anesthetic. Doctors will be very well versed in that queue. Sofa is a faster alternative, and it really what it does is it gives you grounds to pass on a patient to your seniors. So whenever you're doing your ass bar handover, you're gonna want to get, um, you're important details out as quickly as possible. Maybe your consultant is on call. It could be an as bad. Um, you're going to want to get the important details out. Is the systolic BP less than 100? Is the respiratory rate greater than 20? Is the Glasgow coma ski less than 14? Um, that is going to get the consultant out of their bed. I am sure if you were to tell them that, um, so it's all about effective communication and mentioning those big hitters that are going to make a consultant worry about a patient and again the sepsis. Six very important treatment door. The needle time for your IV antibiotics is one hour needs to be quick, and you need to be using your multidisciplinary team effectively. Um, sepsis. Sex is in the back of news charts. Um, so if you're ever if you ever forget any under pressure, it's always there. It's in the back of the news chart, and it's something you should be trying to start as quickly as possible. Next, I'm going to talk about delirium. Uh, and again, this is very important in the elderly. I know I go on about this a lot, but the elderly can be a subset of the surgical population that's often overlooked. And delirium is four cardinal signs so acute cognitive impairment, fluctuation and consciousness and attention and disordered thinking. The main one, and I've put that in bold is that it's a cute and this is how it differs from dementia. So a delirium is actually classified as a physical health problem because the delirium is an acute change in the mental state, secondary to physical health problem, and the solution for delirium is to treat the problem at hand. Whether that be infection, patient dehydration, electrolyte abnormalities. Uh, that is a solution. And again, this is a very negative experience for the patient. That's a negative experience for their family. Uh, no family member wants to be going into a and E and and seeing their their mother, their grandmother, um, you know, hallucinating A and, you know, sleeping more than G. C. S disturbed not knowing where they are, not knowing who they are. It's very unpleasant. And it's not as important the spot and make sure that this subset of patient's hasn't overlooked. Um, the main score incest in for delirium is called the 4 80 which is, uh, an abbreviation of a longer mini mental state examination. And you're going to assess at these four aspects. So number one alertness, it's more or less. You're off poo. Uh, are they fully alert? Are they sleepy? Uh, does it take a while to wake them? Are they clearly abnormal? Very noticeably. Uh, very noticeable. Reduction in the G. C. S. You're gonna want through the a m t four. So egg date of birth. Where are we? What? Building around And what's the year? Um, And then there's different points awarded for one mistake to mistakes or no mistakes and attention. So can you do them? Uh, can you say the month of the year backwards starting in december. Um, again, it says there one prompt is permitted, so don't be too harsh on them. And as they change acute and again, that's your biggie. That's four points, um, as well. So it needs to be an acute change. Cardio respiratory complications. A big one is atelectasis again at the critical care of the care of the critically ill surgical patient course where I was a simulated patient. This was a big one where their ages were shown an X ray of the long with atelectasis. Again, this has happened to most of the surgical population. Um, that have been through quite a significant operation. And it can be caused by various factors such as the the anesthesia, that the operation itself and really the key is pain control and physical therapy to get these people back in their feet and using their lungs again to their full capacity. And the most common clinical figures are raised respiratory and reduced oxygen saturations, which is probably which is to be expected, Um, two of your men, um, your main markers whenever you're going through an A B C D. Examination, um, treatment prevents permanent damage to lung function, and it prevents immune compromise leading to pneumonia. Pe okay. As a very, very big, big problem. If a patient has pe that's very bad and you need to be treating that quickly. There's some risk factors, so strong risk factors would be active cancer. So it has some statistics here. Active cancer is present and 22% of patient with a confirmed PE. So again, as as surgeons in the future, perhaps, um, you'll be if you're a breast surgeon, you're going to be operating the ladies with breast cancer and think of the cumulative risk factors you have their active cancer, um, ability. Uh, if they've been in hospital for a prolonged period of time prior to surgery. Um, the surgery itself is a massive risk factor in recent surgery, um is present in 29% of patient with a confirmed P. Um, previous DVT is also a strong risk factor. So, uh, with any part of your examination looking at those risk factors are very, very important. Some weak risk factors would be a piece of the varicose ve and smoking, uh, and family history. And then again, I have somebody heels. Common clinical figures include shortness of breath, paretic, KSPN, low oxygen SATs, look at the legs apart of all your examinations. Never forget the legs. Roll up the trousers. Um and you may see a big, red swollen calf, and that's going to massively increase your suspicion. A well score is going to guide treatment and the need for a d dimer. Any doctors will not be very happy if you do a d dimer in every patient because it can be quite nonspecific. But in the context of a high well score a d dimer is going to guide your diagnosis. CPPA is your definitive diagnosis, and the chest X ray is classically keep clear. Um, you will probably see this in past me at classically CG Change the S one Q three t three pattern. Uh, to me, I think that's more of an off ski nugget. Um, I was reading in some papers that that that can be present in anything from 12 to 50% of cases, so it's not very reliable. What, you well see as a Sinus tacky to compensate it from the hypoxemia. So a Sinus tacky I can guarantee you will see in a p uh, the S one Q three t three, while you may see in some cases, Um, I think that's possibly more of an or ski nugget or an exam. Look good. Um, VT risk should always be cyst, uh, recovered that yesterday. Very important. That needs to be done in every patient and usually two thirds of low molecular weight heparin, ted stockings or pneumatic compression devices. Inter operative Lee will be recommended for the surgical patient's of two out of three. So I'm going to talk a little bit about shock and the Periera rest patient Shaq is a state of hypo profusion. That was your definition for shock Again. I was asked that all the time. And my A and a placement to shock is a state of HIPAA profusion. And there are four different types. So you probably went into this in a lot more detail and your courses. But I've given a brief sentence summarize in each one because the new shot can be quite hard to get your head around. But it is also very important. Um, so systemic inflammatory response syndrome sepsis cause it causes a distributive shock, as does anaphylaxis. This causes peripheral views of dilation. Um, we're told as well this can be one of the only types of shock where the peripheries will be warm as opposed to cold due to the views of dilation. Uh, and this results in a loss of peripheral vascular resistance were just venous Return to the heart and deep increased perfusion. Do your vital organs. So back to that initial definition shock as a state of HIPAA profusion. If you're not perfusing these organs, they're going to feel hypovolemic Shock bleeding burns again. Decrease circulating blood volume, Not enough blood. Hypo profusion. And again, you're going to treat that you you might engage. If it's bleeding, you might want to engage your massive transfusion protocol burns. There's very specific fluid regimes for burns. Patient's um, that's, you know, you're treating the cause for each of these anaphylaxis. You you're going to want to get in quickly with your adrenaline. So bear in mind, you're wanting to treat because cardio Ganic pump failure, cardio cardiomyopathy, heart failure, am I a arrhythmia, decreased cardiac output, failure of the myocardium failure of tissue profusion and hypoxia obstructive again obstructive was one that I found quite difficult to understand at the start. But whenever you think about it, it really is just an external pressure on the cotton heart, which is causing cardiac output to fall. So a massive pe um, there's an obstruction in the lungs and tension, pneumothorax and tamponade or causing obstruction of the heart within the chest cavity. And that's causing the obstructive shock. And your cardiac output is going to fall as a result, Lead into hyperperfusion of your tissues. Um, so really, that was a long winded way of saying this is very important to know it. Welcome off on your exams, and it has some doctors will ask you about emplacement. And I mentioned there the Perry Areas patient. That's a link to the Resource Council training guidelines. Um, if you haven't looked at those as of yet as something really important to look at, um, I'm a strong believer. CPR be ls ls whatever level you're at, it's something that really as key as a doctor. Um, if you're a doctor and a a medical student, even and you're out in the community, you need to be knowing how to do these basic things. And it's something that's a very important part of our jobs. Um, it was recently attending a first aid course, and, uh, one of the guys taking it was saying he was at his local church and one of the members of the congregation took a heart attack. And the closest person, uh, help was actually an auxiliary nurse. So she was, you know, she was living on the street with my, uh this was in the street, and the closest person was an auxiliary nurse in the egg celery nurse's uniform or an HCA or whatever you want to call. And again, the public are looking to that person to help, even though me and you know, that person's a band three healthcare support to the public. They're wearing a medical uniform. You've got N h s and your lanyard that says, you know, health and social care Trust the public associate that as being you know, they associate that with being someone who's able to help in these situations, and it's really important that you are able to do that. So I would recommend, given those resources quite quan silver, um, similar to or in yesterday I would have a greater interest in anesthetics and surgery. So a lot of this has been something I've been learning myself, and it's been, uh, it's been very interesting to go through. Um, Anastomotic leak is, um, a leak of liminal contents from a surgical joint. And this is a very, very serious postoperative complication. If you have a patient on the surgical ward, this is the number one thing you're going to want to rule out if they are critically unwell. Um, I have some other complications on down. These are secondary to an anastomotic leak, so this can cause serious sepsis. Multi organ failure. We talked about that before the systemic inflammatory response caused by an infection, which is causing your peripheral capillaries. Two views. Oh, dilia body is under shock. Hypo profusion of the tissues patient becomes Piri arrest, and they may even arrest and and die. So it's very important that you notice that the risk is higher. If it's an emergency surgery that self explanatory, the doctors are under pressure. Um, and there may be trying to act quickly to see if a patient's life and the initial management. If you're the junior doctor in the ward. Nell by mouth and broad spectrum antibiotics. And again, don't be shy with the antibiotics I think, uh, the recommendation is, you know, maybe just 23, and with the IV taxes in there and just I just don't know accepts is that whenever you're doing the sepsis six, um, it's important to do your blood cultures before you give the antibiotics to make sure you're getting a good idea of what the offending pathogen is. It's also important whenever you're given your antibiotics to try and best specific as you can. So for chest sepsis, IV, amoxicillin and clarithromycin are two of the top antibiotics for that, Um, but if you're on share, it's a pyrexia of unknown origin. Um, I think most people I don't think you would be told off for going straight in with IV Taz to try and stabilize the patient. I know recently I did a couple of HCA shifts in the hematology award, and, uh, the patient's. There were often immunocompromised. They had active cancer, they were in chemotherapy, and the IV to season was it was by no means you sparingly. So it is if you, if your patient is very vulnerable. Um, don't be scared to be using the empirical broad spectrum antibiotics to treat that infection before it gets any worse. And again, we have some of the more minor GI complications Alias, which is more or less paralysis in the boil. So there's an arrest or a deceleration and intestinal mobility. The patient won't be moving there. Boils or passing flotus, and this can be managed conservatively. So now, by mouth Daily Blood's Reduce any opioids to encourage mortality. Adhesions are about consequence of part of me of gastrointestinal or boil surgery. So fibrous bands of scar tissue caused by previous surgery and one of the main causes, uh, of small boil obstruction. If you have a boil obstruction, which is uncomplicated, the tube decompression, they'll be mouth flu is an allergy. There is an appropriate response to that. If you have appropriated boil or broil ischemia, Um, that's gonna need escalated to surgeons and an incisional hernia protrusion of the contents. Macavity through a previously made a decision, and that is a common complication. Many people will, uh, live with this for many years, and it will not cause a problem. I suppose, in the grand scheme of things in the risk benefit ratio is possibly a small price to pay, um, given that they were maybe getting a tumor removed or some other form of, uh, of surgery. Uh, and it's a clinical diagnosis with CT to confirm if you're on share. Uh, the only caveat to that is aware of incarceration, which is whenever the boil becomes twisted and then becomes a scheme ick. That is again an emergency. And that's going to you're going to want to pass that on the seniors. Now I'm going to talk a little bit about commencing drugs. Postoperatively. I've deliberately put this this graphic and to show you how complex this can be. Um, these are the Northern Trust guidelines in my locality, and they are very, very complex. And like the opioid conversion, this isn't something you should be trying to memorize. This is something you should be consulting senior colleagues about, um and really, for for the purposes of medical students, I think I think it is enough to know some of the main points and the main safety point. I think for most of this lecture, I've tried to focus on on the safety points because often that's what you're asked about, because what medical schools want is for you to be a C F F one. You know, they're not wanting you to go out and do heart surgery. They're wanting you to be safe and show that you can show good patient care. Um, so if anyone was there for orange lecture, uh, had fantastic information on drugs and what I'm gonna do is just recap some of that, um, first of all, diabetes medications. Diabetic patient should be first on the list for surgery. And that does happen in most theory list I have been on and the local guidelines are often very comprehensive. So I would use this to guide you. The anesthetist will take control of variable re insulin infusion. It's not something you'll video and as a junior, and that's something the anesthetist will be taken control of. I do have some notes about some of the common diabetic drugs below SGLT two inhibitors or a meta in the day of surgery. There's a risk of euglycemia ketoacidosis. Um, so it's very, very important and diabetic patients' to check ketones as well as blood glucose measurements. Um, because your ketones are going to tell the full story. Uh, sulfonylurea is the big hypoglycemia risk. Admit it in the day of surgery until the patient is eating and drinking again until and again, uh, absolute minefield. I would be letting the seniors take control of this. Um, there are various guidelines between trusts. Um, and it's not something I'd be having managing as a junior. It's something I'd be wanting to. I'd be wanting to consult guidelines and consult anesthetic colleagues, um, and then metformin. If they're going to miss 1 May. Let's see if they continue. And if they miss more than one male, it there is a risk of lactic acidosis. So that's again something that will differ between patient's and something that you need to bear in mind. I have a new on steroids, and I have You will notice I have a point. And red and bold, uh, steroids need to be continued. And if anything, they may even need to be replaced at higher doses to meet the increased demands in the body during surgery. Um, surgery is a massive physiological stress and patient's, um, as akin to running a marathon. And as you'll be aware, not all patient's are A s a one and have a have a good level of physical fitness. So you do have to bear in mind the physiological tool that surgery can take and patient's. As I said, there is one of the greatest stressors on the border, and lack of increase in cortisol during stress can be fatal. Um, so I've got an image down at the bottom. I find these these images very helpful, actually, whenever it comes to remembering complications of different diseases, um, so patient with Addison's disease or are those who are steroid dependent Um, they're really going to be top of your priority. And it's going to be something you're going to want to consult seeing your staff about, uh, patient's that are steroid dependent will not produce, uh, their own steroids in the HPI a access they will not produce that, um themselves without, uh, the tablets that they're taking. Um, so, yeah, but and that would result in a lack of stress result a lack of stress response during the operation. So the patient could, uh, they could experience severe hypotension. Hypoglycemia. You know, the fighter flight isn't kicking in in the body. Um, other common drugs that you will want to take caution with. Well, B a R, B s s inhibitors and diuretics. There's a risk of hypertension, renal damage and AKI and you're gonna want to be cautious with anticoagulants again. Strict local guidelines. Um, there's a wide range of, uh, of medical school students here at this talk today. And, uh, it's something you would want to be consulting your local guidelines about, Uh, this is an image of the Yellow Book the warfarin patient's will have. This will be where they monitor their i N r will often carry this with them. So the doctor is an idea of what they're i n r. Control has been like, um, that's just a reminder. These patient's will often be experts in their own care and that, you know, they may know better than you at at times how best to be mad if they maybe have its previous surgeries, Uh, in the past, and sometimes they will be very capable. And then you know what they need. Uh, I'll just go back to the steroids again and do honest attention to the last point. They're the exact replacement. Regimes are dependent on the type of procedure. Um, and again, that's something where local guidelines needs to be consultant. I'm sorry that I can give you exact answers for a lot of this, but, uh, again, that is the way of medicine. It varies. Trust to trust. And every patient is different, and every procedure is different. Um, these are some of the websites I used to put this talk together. Um, they're very good. Revision resources. Teach me surgery is fantastic. I'm sure you I'm sure you're You're you're all aware you're probably avid. Users have teach me surgery and BMJ best practice. I find as a very useful website to resource council again, I can't stress how important that is If someone sees you in the street and you so much as have a medical school. Hurry on. Uh, they will assume, you know, consultant level CPR. Um, so it you know what it is. It is really something that you need to be on top of, and something I would recommend having a read over, um, which I'm sure I'm sure you do. Anyway, um, have some guidelines on on the coagulation. And again, the nice guidance at the bottom. So, um, that's just a little note. Um, from our partners at SEPTA, And that is our Web link where you can watch the recordings and see few to your sessions. Um, so if anyone has any questions, I don't actually see any in the chat, which is fantastic. Um, if anyone has any questions, feel free to fire away. But I hope that was useful. And everyone gained something out. A blessing to that. So thank you very much. Um, I think Hannah is away, so yeah, and if anyone wants to come down here for future sessions, I'm one of the regional routes Recip test. If anyone wants to come to any of the food, you're sessions. Uh, they should be advertised within medical school. Group chats. Uh, thank you. I seem incredibly well, Boris. I was probably one of the best compliments I received all year heading under clinical fields of medical school and a survival tips. Um, yeah, for me, he had an end of the clinical years of medical skill. I think one of the main things is to get involved on the wards. Um, me. Personally, I I really enjoy the practical side of medicines who have been involved in the ward. Um, getting to do tasks get involved for the time And really the best people to help you with, uh, with this are the nurses. Um, so if you're looking practice for bloods cannulas CCGs. The nurses are really the people to go to, so I'd really recommend getting as involved as possible. Um, and it does. It cuts down your your revision a lot later in the year. Like I find, if you're well engaged in placement, you'd be so surprised at what you pick up. So my tips would really be engage yourself well, and make use of the nurses that are there because they will be the ones to go to to get practical skills. Um, I'm trying to think what else? I think that's really my main tips for the clinical phases of medical school. It's just get involved, you'll get out of it. What you put into it. Um I haven't been a great believer of skipping placement to go to the library. I'm I'm about get involved, person. But different things work for everybody, but those would be my tips. Uh, thank you very much for the compliment. I'm glad it was useful. Um, thank you. Very much. So I'm going to sign off here and Yeah, thank you very much. I'm glad everyone came. And I hope to see you all again or fit your sessions, so bye. Thank you.