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Well, we kind of noticed. Was that surgeries? Daughter drawing bounder graduate curriculum. Really? And you know, you don't get a lot of sore teaching on surgery as a whole on what we try to do is get a lot of different aspects that you'll get in G I. A bit of neuropathy, cardiothoracic so and put it together in the series that's designed to pitch at the level of an undergraduate in the UK Um, and we really just trying to sort of cover that material won't be able to cover everything, but we're going to try to cover sort of common things. Um, mainly focused on general surgery, But as I said, a bit of neuropathy of cardiothoracic six s. So keep an eye out for future events. They're all following the same format way. Also have a lot of other events running this year's I'm going use. This is a potential to tell you a little bit. Um, we have our careers based events are sort of like a portfolio Siris, and the first one of these is on Thursday. So that's really good series of breaking down surgical implications we have. Events are about interest to surgery So ever inaugural Tolkien Wednesday on That's delivered by Professor Steven Recorder is Regis professional in and, um, Breath and we have our schools clubs. Well, so if you're based on that American, come along to that, um, and we teach people how to structure all levels. Very welcome, Andre. Have sort of other flax of events like our careers richer and our conference. So if you follow ups, um, feast. But if you follow a P, John Majal will be able to keep up with everything. So I want that light bother on for much longer. It'll just introduce her sneakers through. Today we have Allesandro is cool leading this entire series, actually, not just this session else Sanders and F Way three and Colorectal and Adam. But he's also the lead for the research cooperative. He's going to be giving today's talk. So 100 hotels under thank you much for you mean share me supply. It's just no, there we go and to do, we're going to have a chance. So postoperative carrying complications. This is definitely going to be a certified taste. So what can happen after a new patient? Unfortunately, we cannot call the everything and is going to be something big general, just to give you an overview off different problems that happen after the operation and what could be the first line investigations with that problem and what could be the first line management's. So just to go through the learning outcomes. So as a said, the session is going to be split into two parts. The first part is going to be presentation and which is that going to be followed by some clinical scenarios? But a little thing I use, you know, going to be dividing to smaller groups so that we can have our be about interaction, keeping yourself and and your and your tutor. So, as I said, the main objectives off the session are to describe the most common possibility. Problems identify what could be first line investigation for that problem. That outlying the treatments and the management options and as we said, apply all devolved to the clinical scenarios and actually, I said, feel free to post any questions. I'll answer the precedence at the end of the hall before starting clinical studies. So just to give you an overview, these what we're going to talk about today. So afternoon creation. Many things can happen, and people usually are sore. People make. It'll be a temperature sometimes difficult to have a chest being or deer. Heart rate is a is a bit to fuss. People can be sick on can and be vomiting quite a lot. Sometimes people can be confused on people can be short of breath of a higher, spiritually eight. And what family? Sometimes people can have a good urine output. So this is a day agenda for the different topics that we're going to touch upon. Today is definitely a compliance. It a list of possibilities problems each operation as their own specific possibility problems. But these are problems that more or less happened. What could happen after any operations? So just ever be of a chance? Do you think these are problems for complications? Well, the answer is yes and no. Most patients will experience, to a certain degree all the previous mentioned problems. But when do they come? Complication is a is a complication from the baby in, but it is just a problem. But it's simple. Let's speak nausea know just common after the operation. But if the nausea is long it stays. It stays there for a few days and it doesn't go away. Maybe that's a complication, then all the same for pain, and everyone will be sore after. Know patient. If if the pain is very excessive and it's not controlled by what you think is an adequate level off analgesia, that's that's when it's a signal for a complication. So there is a very fine line between what could be a post hepatic problem or a complication. I would say they're all complications. Start US problems, and if you can identify them early on and correct them, then they remain problems and go away. But if you see on them, that's when they become complications. So we're going to start by talking about fever, so we could just give you a definition. It's a temperature that's higher than 30 degree salt. Is fever is very, very common in the postoperative periods. Uh, a really on after the operation is a sports likely due to be a natural, inflammatory response to the tissue injury. If you think, for example, just giving example a big black part to me, well, you've got someone on the perative table for hours and hours, and a lot of surgeons that are in inside the abdomen, cutting all the tissues and using cautery to stop the bleeding. That's quite high level off tissue injury, and the body's going to react to it. Then one way possible reaction is just by increase the body temperature, and that's that's fairly common so that take a message from this line these no every temperature he's on. Infection causes off temperature can be infections, for sure, but no old temperature are caused by infections as a patient moves along after the operation, There are several things that could go the temperature, and usually the equation will be that the longer patient is after the operation, the more likely because of the temperature is an infection, so to give you out. But I'm Monica in terms off at 25 different cause you off off the temperature. It is that quite common, my money called the five Ws, which, which means wind, wind, water wounds, walking and wonder drugs and is defined according to postoperative D off off the temperature. So usually in the early postoperative feel, we're talking about one or two off the reservation, a temperature is usually caused by respiratory problems such as a pneumonia or on aspiration for a pulmonary embolism between a three and five, you've got to start thinking about the waterworks. Does the patient have a Catholic? Do the counter have become infected? Or if the patient is not a Catholic baby days now are, you know, trying affection? Uh, what I said on the 5 to 7, something's extends Big 10. That's when the wound, the surgical operation itself, can become problematic and can be the source of the temperature. So that's when you should start thinking about Perhaps they wouldn't. Sicher has become infected, or perhaps day and abdomen if if there was an abdominal pain. Maybe something like maps is or something that it's really, um, important to remember is you've got some citrucel so inside abdomen's thanks when you join two pieces of bubble together, for example, and these two pieces of bowel sometimes can have a lake, and this leakage can lead to some infant on the infection. You to the GI I contact becoming lose inside the abdomen so you're on the 5 to 7 that's that's appeared when the infection or the fever s a P when the fever perhaps is related to the abdominal or patient itself after the five. If you start thinking about clots, which could start in the legs, you got deep into road from poses and if they move up towards the lungs and that's when they cause a pulmonary embolism, and then there are some causes that can happen any time after the operation and these usually our drug reactions or transfusion reactions. So how do we investigate temperature? But the first thing is always to go and have a look at the patients and always remember to look at the surgical wound itself. And the first thing to do is always to do on 80 assessment. But there are some investigations first line investigations that you can request very simple ones are some blood tests, uh, blood count using these COPD latitude just to okay, you some more information. It help being point to the cause of the temperature. Um, cultures always quite good idea. Um, blood, urine, sputum. If if they're coughing ones work. If there is some discharge from the scar has two cultures. If the body area sometimes it could get CD from from the antibiotics, and I should pull something to mention is at the moment. It might be worth by also doing a copious ball, but you never know. Uh, imaging. You can always start from a chest X ray. It's quite expensive. And if you think because off off the fever, ease spirit trees, what while doing And then this can be full. But some second line investigations such a CT scan or ultrasound if you're looking for something more specific. But usually these are ordered by some seniors, and so you won't need to run it past them first. So how do you manage temperature? Well, and I would say it depends on what's what's the underlying cause. And if there are other associative signs and symptoms. So if you follow your atria assessment and you see that they're High Popsicle, then it's a good thing to put option on. If you see that they're technically dry, um, hypothalamic. Then put some fluids on. Also, remember that fever is going to increase insensible free loss, so on the fluid balance charge, they may seem to be positive or equal. But if you also taking the counter fact that they're losing quite a lot off fluids because of the temperature, Then they may be on the negative side on the negative side, actually, and it's always a good thing to give some analgesia. And Patrick's The only possible fever can also be caused by pain. In terms of antibiotics. I would I would stay away from antibiotics unless you definitely know it's an infection. Schools. You definitely don't want to commit to antibiotics unless unless there's an infection and in also attention and calculation if you think it's a clot. But this is a very senior decision you have to think of. These patients have just had an operation and there may be a quite high risk of bleeding. So there's definitely not something that you can decide on your own moving onto another problem that can happen after the operation is being. Everyone is going to be sore after the operation, and it's it's really important to stay on top of the pain for and quite she's in's if you think that someone is sore, but not the not really wanting to mobilize at all. No, we do not going to get out of bed in the same time, If if, for example, taking a deep breath, it's by sore, they're going to try and breathe as little as possible. And this is going to lead to just more problems. If if, you know, mobilize things don't get up under feet, they don't get their strength back. If they don't breathe properly, then they're going to know Expand the lunch probably. And that's just quite problematic because they're going to become a sitting duck for lung infections. So that end of the day. If you don't control paper properly, you're going to just have more possibility complications, which will increase pain again. So what you need to do, you need to break the special cycle, and you need to stay on top of the pain. And three here, a visual analog scale and there are different scales is just one of them. But I can give you a nice DEA that just by looking at the picture from the end of the bed, you can you can have an idea off house or the patient is, and so we go a few strategies that we can use to optimize the analgesia off patients and prevent and complications that we talked about allergies that can be preemptive, meaning that can be given before the operation before the operation starts. Oh, are even before waking the patient, so this could be some local infiltration. So if you think of a beach abdominal incision before finishing the searcher weaken injects and local anesthetic, and that will when? When the patient wakes up, it means that will be more comfortable in some operation signals performer. Regional nerve block that means for a temple. When you've got someone with a hip fracture or you're going to operate on on a link we can do, you tend anesthetist on the nerve that's going to get a lot of central information from that part of the body and so that the patient is definitely going to be pain free. And then there is another technique for traffic and abdominal analgesia. Let's call it deodorant on GE. So if you look at the picture on the left, you can see there is a weed green calf there and that is being inserted at the bank, uh, through the skin, through the ligaments off the spine. And then it will just sit in the year old's piece, which is just upside the dura matter, and that's going to provide uh, some sensory blocks to the nerve roots. Essentially, the patient will be able to move the loops but will not be able to feel anything, uh, the level of the skin and in science as well. And then after the operation, there are other things that we can use the catheter that was inserted for the bureau and algesia. It can be left in place, and that means that you can just have a machine. Next patient bedside. They will deliver a small amount of an aesthetic every hour. Threat. Intinusa infusion. Maintaining there for the zip your analgesia and it's usually kept for up to three days. Another form off analgesia. It's quite useful is called patient control and easier. You can see the picture on the right. Essentially is through on ideally drink, and the patient has got battle and the picture to compress the bottom to have a small release off analgesia. It is quite useful for many reasons. The first is controlled by the patients. With the patient is store is going to press the button and get some relief. About the same time, If if the patient is too drowsy because of the analgesia, patient won't be able, would not be able to press the button. And so you can also stay away from and the side effects off. The strong medications changes, UH, two, Um, but quite strong sedation and respiratory depression. Analgesia medications are quite good, but you also need to be aware that they come with some side effects. The two most common ones used are nonsteroidal anti inflammatory drugs, and your case, Or actually it's more in general. So no sores on the inflammatory drugs. Examples would be had proofing or people finish. And they come with a bleeding risk because they act on the platelets and they prevent the aggravation. And they've also be sure to have effects on kidney function. And so that's the reason. Perhaps they're not very popular after major patient, where patients could be a risk of kidney impairments, and they also come in with a risk of tell stricken station. But this is sometimes quite easily avoidable with the use of some protein pump inhibitors. Change the med result on the soap lansoprazole. Okay, it's on the other hands. They're they're quite strong medications, and they consider he's and confused, efficient, quite heavily to the point where that can cause the spiritually depression and coma. If you do not recognize these point uh, really, it can also cause, you know, retention and nausea, vomiting as well as an al use, which is when the bowel it's completely frozen and doesn't work, so they're quite good. But you need to be aware that they do come with some side effects. So when when? When this pain become a complication, right, it's always a problem. But is it a complication sometimes? Well, yes, when pain is not control. What, my boy, you think, is an addict, quite analgesia. That's when you have to think about something wrong going on just to give you a classic example. There will be compartment syndrome after the surgery, and the patients will be extremely sore. You're going to through the patient's shouting for help from the corridor, and the pain is way, way bigger than the injury, the heads, and it doesn't matter what type of final Jesus going to give them. It's not going to help. So this is just one extreme case. But just to give you an idea or how paying itself could be a complication, right? Lisa? Sign off a complication moving onto, you know, gym vomiting Fairly common after a patient. Common causes are a prolong. Surgery, especially due to their on aesthetic gas, is usually used to be your patient or the handling off the bowels and spell. Okay, it's a sweet said before, and pain is, well, compressant sweet nausea and vomiting it is generally self limited tends. It tends to go away, especially when the anesthetic gases where we're off. But sometimes you can you can see for question disease. And that's when you think about possible complications to If it if it's belongs, I would say Always suspect on values. What a mechanical bull obstruction, especially if after abdominal police. And you also have to remember that patients they feel sick or or vomiting but no are not really good to have a big appetite, and they're not going to eat or drink properly and open a shins. I got up abdominal patients, but any pieces in general, they are going to affect the metabolic state off the organism quite heavily, and they're going to push there organism into a Catholic state where it's going to burn. A lot of energy is of these patients they need to eat. They need to make their clock ticking, teach all the way, just going to go through all the muscle mass to try and compensate for the lack of nutrition. So this is something that is important to recognize. And I told by early on. So we said, What happens if the nausea and vomiting do not go away? Well, I said, Think about paralytic callous or mechanical obstruction. You have got to abdominal X ray pictures just to give an idea off how to look like on imaging. You've got the bowel obstruction on the left. You can see that there are some dilated looks. You've got a small bowel looked dilated up to 46 millimeter. Overall, you don't you don't have that many like on the right. When when you go on, I lose. Everything is donated small bowel and large bowel, because if you if you look at the cartoon on the right, essentially you've got first and guts and there is lot of peristalsis it. Ease what that means. He's there is no mechanical obstruction, but the bowel itself has gone on strike, so it's no, it's no function properly, and it's not going to push anything towards day words directive and a Xultophy been to have a status or just a natural. A shin a builder for flutes inside the bowel, Uh, which is going to make the patient feeling quite six if no, uh, bombing thing is. So what? What could be some management options for nausea and vomiting? Well, we've got some bill you done kinetics and that that should be your first line, uh, normal medications used our cyclizine ondansetron or mental open my eyes. I'll do it. Wouldn't use it for my after and abdominal surgery because it's a prokinetic. We said these patients are not going to have a good borderling teach, so you definitely to stay behind them and help them with something. Trevino's fleas. And when it comes to nausea and vomiting, they're going to lose a lot of electrolytes to think about chloride. Think about passing and sodium, so we need to correct those and balances as well. If someone gets an electrolyte imbalance, one of the manifestations of that could be nausea, so you you need to break that cycle. You need to replace electrolytes as well. If if they start feeling really well, every uncomfortable and they develop what he's standing up to me, uh, then you need to answer to me is a gastric tube for human reasons. One. You're going to decompress the abdomen, and that's going to want to make them breathe okay much for easily on. So to avoid also spiritual implications. But the same time is going to take away any pressure from forehead, temple, abdominal incision and the same time it would prevent episodes of vomiting, which really to aspiration if if they're still not able to eat after all these interventions. But you need to think about different ways off meeting their chlorine contagious and a possibility. He's called Portal Parental Nutrition. But essentially you've got some big lines going into, uh, arms or the neck, delivering what we call some feet. Um, he's quite, uh, invasive procedure, and he's usually reserved for patients that are not eating for a police seven days for the simple reason that it's no the common type of nutrition our body take. So our body needs some time to adapt these nutrition and the minimum time, um, has been shown to be required the seven days. So total friends. Nutrition is only started if you expect your patient to be healed by mouth but please seventies going on to cough, shortness of breath in tachypnea. Ah, your spirit components are going to be the main underlying problems behind these symptoms, but it could be also other causes of chest pain. We said before, If if the patient has got a big scar on under tummy, they're not going to be willing to breathing unless they've got some very good pain relief. And in some patients, wheat that preexisting cardiac problems, shortness of breath could be my first Asian flu. It overloads. So, going back to the spectrum problems, we can see that there are many, many causes. I just put here a few examples. In most common ones, you've got pneumonia aspiration got lumber collapse or all your clamps. The second one of your collapses, also called atelectasis, is I'll show you a few pictures. Extremely strong and pneumothorax can happen is well, if you think that a patient is artificially inflated, Ah, the's can increase the pressure in the lungs that could be small lakes leading to pneumothorax, and patients that have got preexisting closes off. The lungs, or COPD are more prone to a new authorities. And then we said that could be some pulmonary embolism as well in all these circumstances, in all, in all these cases always start with a chest X ray. We're going to get most of your answers from a chest, and here's here are some pictures off the most common causes mentioned. Four. You've gone on the left. You consider that is quite some white opacifications in the left lung. Next, where that's that's a pneumonia. If if you look at the picture in the middle, you can see that the lung is collapsed. I'm going to move the breads cursor here. You can see that's the lunch, all these black space here. He's just here, meaning that the line is completely collapsed and then looking at the picture on the rights. You've got the Lang. It's just produced to a small portion, and you've got a loss white space here that's pushing the line up. So in this case, you've got collapse off the bill I and a reduction in in in the Lung surface and you've got elected. He's so how do you differentiate between? And pneumonia? Atelectasis is well, if you if you think the longer it's a black balloon and normally you for why inflated black balloons If you've gotten the morning, uh, the size off the balloon doesn't change, but the color does. He becomes white, the neck stickies on the left. You can see the longest fully expanded, but the color inside has changed from black to wait. If you understand about collect Izzie's, you've got that the size is reduced, so no Elise White, but the size is also smaller. That's because this will collapse. So what would be a first line intervention for someone presented with cough, shortness of breath and tachypnea? Well, if if you're if you're 80 to the assessment, make sure you're correct and the abnormalities you find every step. So if somebody is short of breath. If some of these hypoxic, certainly some oxygen enable eyes is they may need some chest physical therapy to try and help recruit all the daylight are not working properly. And then if if If you suspect it's formally demon, you can start with some direct. It's but I would definitely run it past somewhere more senior patients after the operation, they tend to be on the dry side, so pulmonary edema is not very common. And we said that pain could be a very common cause off someone breathing really fast. So there some analgesia is perhaps definitely going to help if you think they're gone. You, Monje, the antibiotics conduct me help. And if you think that got clots in the lungs on some on tradition is the right treatments. But again, because they're POSTOP, there might be high risk completing. So this is definitely seen your decision and the last what the last thing to mention is when you got the motor. Actually, if the pneumothorax is quite significantly big in size, then you'll do need a chest train inserted. Gesturing is not always there. First line treatment for pneumothorax Most of the time. If the pneumothorax is small, it can just less. It could just be left there on his own, and it's going to be absorbed. But it's quite big in size and exposing a lof pox. Yeah, and respiratory problems, and you need surgery. And the other problem that could happen after the operation. Egypt. Your patient becoming tachycardia called developing some chest Be that card. It's quite common, and it's usually erected to either the patient being dry for the patient being sore. If the patient is trying because it's after the operation, you always have to ever the back of the mind. Easiest patient bleeding Or is he just the hydration? Other cause you off tachycardia be the patient developing many RV Aetna We said that the operation is going to affect the organism that many levels is going to push the organism Intracath bolic state. And that's going to release off Saturday things and off four ones. And these can affect the heart as well. Pretty the heart into some arrhythmias, and we're going to have a look of feces later on, and tachycardia is also sign of infection. So if you think about someone being Satake, their heart can be affected as well by all the circulating cytokines. Uh huh, chest pain under the science. Always make sure the rule out any mark are going faction. But if you think about the chest, that is not just the heart that could be the Lantus well, so chest pains also caused by land problems such as a new monitor pulmonary embolism. So, as I said, always have bleeding at the back of your mind when you are investigating a patient with tachycardia. Yes, it is always a very good starting point is going to give you a lot of information. If you suspect it could be some lung problems, Uh, or your chest eat tree. If you think about pulmonary embolism, the second line then will be a CT pulmonary injury. Um, if the EKG showed that there to be some estimate changes compatible weeds, amount, card of infraction, then on the troponin and the last point you always remember that these could be just symptoms and signs, often underlying infection to just have a look. If you say geez, the most common one you're going to find a patient that has got high heart rate is Sinus tachycardia, so you can see that afternoons regular curious complex are narrow. You can find a way before every single dress complex, so these quite straight forwards and maybe he's fishies dry. So these keys are finding out whether it's due to bleeding. Always do to just and the hydration. But sometimes you can get some arrangements that these were being a big a big creature here. Our summary, um, it's written. It's generating at the level off the atrial, and the most common one you're going to see, perhaps, is atrial fibrilation, and that's the street. But the top. You can see that it's irregularly irregular rate, and there are really no P waves or if there are there no associated with your eyes complexes. The characteristic often atrial arrhythmia is curious. Complexes are always going to be narrow, but just keep that in mind if you've got someone with a white US complex. Tract is not coming from the atrial, but it's coming from the ventricles. Something seems like to a F, but it's something it's all often mistaken for F is atrial flutter. You can see that you've got more regular pattern here, and you've got Meineke weeks. But no, all the waves porosity. You're curious complex, and it's what it's called a C so appearance. In this case, you've got 3 to 1 block. You've got three P waves before you get one azure. It's complex, and then the third quite common atrial arrhythmia would like to mention these called super ventricular tachycardia. That's the street by the bottom. So you can. You've got your regular dress complex. You go your regular patterns of the distance between curious peaks. It stays the see. Yeah, you don't really see the weeks. So that's something that, and still originating the atrial you could call narrow, direct us complex. But it's something below the senior center little notes and before the intraventricular note. And then there are some easy Geez, that are quite, uh, have to say you need to act on them very, very quickly and and definitely call for help. So the one of the top is, uh, ventricular fibrillation. We have got on absolutely Celtic pattern. There are no ways that you can identify, and this is someone that could, uh, very easily go into cardiac arrest, if not already being cardiac arrest on that last thing that you need to always remember is to look for the skin. Changes in this case is quite, uh, very easy example you've called. They be elevation off the ST segment. In the interior leads you ever look be to be three and before and is there some something that requires an urgent geology bits and possibly are. And it was very much variation of the coronary arteries. So what do we do when we got some we tachycardia chest pain. So after our 80 assessment, if if we find the patient is drying and we're going to start some place and arrhythmias can be caused by electrolyte imbalances such as I potassium or low sodium um, low calcium. So make sure to replace those as well. We said the patient that are sore, be tachycardia as well. So analgesia is always a good option, and all the other inputs, all the other interventions don't become quite senior. You're definitely going to ask for help if you want to start some freedom or reckon for medications in occasions, little flatter or F or super big, cheaper cardia. If the patient is dry because it's bleeding has been to me the box infusion. If the patient has septic and that's a reason for the patent card, then you're going to need antibodies. If it could be because of pulmonary embolism again, think about regulation. If you've got someone that's sore in the chest of the pneumothorax, perhaps you would need a chest re and the last one ease. If you've got someone is having a ST Elevation myocardial infraction. Then you need, uh, to send them to the catheterization lab really urgently. For a revascularization off the coronary arteries. Put your output is very, very common. After a patient and produce starting at one in August, we're going to get many phone calls about people know passing. You know, I feel so definition of urine up. It's interesting you don't 0.5 ml off the ground. Uh, pick your armpit hour. It is quite, um, not intuitive. So I would suggest asking for their weight and then dividing the weight by two. And that's port. The urine output paid. Our should be. So if someone waits and 70 kg, you are going to expect a listen 35 ml per hour off urine output. If someone is doing 100 kg, you're going to expect something around 50 ml per hour. If someone is very tiny, such as a lady around 45 Children's or 50 kg, so you're going to expect something around 25 urine up. It can be essentially caused by two main reasons. One could be patient is not able to get rid of urine. And second reason he's the kidneys are not producing unit all. The first one is quite easy to act on it. We said patients, uh, many things can happen after know patient and sometimes patients are sore, sometimes patient, too much opiates and sometimes patient had, uh, background off a big prostate. And that's just going to present with acute urinary retention when the patient is not able to empty your bladder or another. Very common cause is what you've got blocked half there. There are many, many cases when the patient comes back to the world or intensive care, and the nurses of worried that no passing urine. Then you can see that they climb the catheter in theatre during transfer from back to bed, and no one remember too young. Clump it then. If if the patient is not producing unit, all, the most common cause is usually hypovolemia again secondary, the other bleeding on the or the integration essentially is a criminal cause off hyperbole, off off, reduce urine production and what to do in the sixties, we said, always have bleeding as a possibility in the back of your mind, you can start from someplace investigations such as using these or bladder scan Using. These are going to let you know about the kidney function, whether it's a naked eye causing the reduce urine production on the bladder scan is going to have a look at the volume off urine in the bladder, and it's usually if it's a ball 500 ml, better immunity or even 250 millions. In some cases, it's an indication poor. Insert a catheter and relieve the retention. If you think the patient has a blocked catheter, then you can always flashes and trying to get any clots or sediments that formed away from the women. The intervention are quite straight. Forwards. If somebody's if someone's got reduce your own apple because they're not producing urine trying, then you can start some points. Or you can transfuse if the cause is bleeding on. We said the studies. If they're in retention, then what we need to do is in certain very Catholic to release. And the retention catheter is always good, even if there is no retention for the simple reason that it's going to allow you to monitor the union up. It's very closely, and that's something you want to do if they got a very severe ache, and I, or if they're worried they're not producing urine at all so Catholic could be inserted it. And if there is no stretch and the last from, um, I would like to talk about is the little, and this is quite common, and he's also quiets on the recognized or few reasons we're going to see later on. So the lady, um, is defined as a fluctuating acute confusion else state, which some reduced cognitive function and there human forms. It could be hyperactive. So you see patients becoming very agitated, screaming, shouting, Want to get out of bed trying to pull the catheter out today, cannulas out. They're trying to punch the nurses in some extreme cases or yourself a well, or it can be very hot, very lethargic. So that's when he is describing hyperactive, where they're not moving a toll. They're know engaging. They're not eating, not drinking. And I said, the Librium is quite under recognized because the most common form is high point. If and when someone is high part, we usually don't really pay that much attention and not because we don't want to go for a simple reason that we tend to be busy. And if someone is no causing us problem, we don't think of off. That person is requiring our attention, but that's definitely something that we need to work on. Yeah, the living can, because by many, many, many causes, the list here is definitely not. Complaints of one is just give you an idea. It could be due to hae pops infection drags. Maybe there were some medications before coming in, and you stopped the medication. Maybe they are drinkers and they're not. They're not getting the booze. And so you need to think about how cold withdrawal as well. Maybe they're sore. Maybe that constipated. Maybe you're in retention. Or maybe is due to some electrolyte imbalances. There are many, many, many, many causes. If there's a take home message from these line, is that pharmacological intervention so medications or drives are no effective between the liver? The treatment off the Librium is very, very frustrating. It takes time, it takes energy, and it's a very long, um course. The most effective ones are known pharmacological intervention is we're trying to reduce the let the background noise or, uh, suggests, or trying to get a family do visit as much as possible. You know you're trying to have a good sleep wake cycle if the patient is agitated. That's when sedatives are attributes to make sure that the patient does not hurt anyone or there's no hurt himself herself. That's the only case where medication should be used for the little. In all these cases, all these problems could be the tip of the iceberg off except, he said. So we always have to think sepsis as a sort of cause off off the patient, being well after a know patient and the bottom line you use. If you think the patient said that, you need to like, very fast you've got the Sector six pathway I'm sure you're familiar with on the right. The three in three out, um, critical what I like to use to scream someone very quick very quickly. If that got except the sexes or not, is called you So phone, which is a week sepsis related organ failure assessment you for the three criteria. The bottom left essentially, whether they've got an ultra mental status. It's probably a juicy s less than 14. They've got fast respiratory rate. So there, breathing up more than 20 to respiratory acts for a minute. What is a drop in your BP? Less. It started last 100. You just need to after three of them to label someone anesthetic. But if that's the case, you need to act very, very, very quickly. I'm sure pops. You effort off day golden hour. Essentially, I got one hour to start all the appropriate interventions. After that, mortality is going to increase it. So that's the last light before moving onto the scenario is just to summarize. Well, why would you do when you find someone with a possibility? Problem first, always, ever looked. The patients. You've got your 80 assessment that's going to be your best friends. And if you're not sure what's going on, let's, um, first line investigations. You need to have more information to understand what's driving Problem with talked about EKGs. We'll talk about Testim trees, some baseline bloods and some cultures you could figure is infection and finally always escalate probably and always get some extra help and some more scenery involved, if you're more in about a patient. So that was the presentation of hope. It was useful. And then we're going to work on and or just explaining that in this scenario is I'm not sure if they have questions. Perhaps a Sharia can point in the right direction or just perhaps a capital before moving this to this. Now use. What do you think? Sure. Uh, thank you so much for that. That was really, really good. Uh, I can't see any new questions in the child. That was one question that Leo has kindly answered. Um, okay, so, yes, if anybody has any other questions, please put those in the chat. In the meantime, just before we move on to our breakouts things I'm gonna just launch it pulled and everybody could vote on, indicate there your of from study, eh? So whether you're in failure of medical school above or penultimate here, and we can divide up the recovery room. So based on that Onda, while you do that and post any questions you have, I just want to quickly announce that, uh, sss were fundraising for a child. People, kids, a lot of this year on. It's an organization that focus on 20 access to, say, surgery for Children all around the world. Um, and this month and next month, we're taking part in there so far to some of calendars. Is in fundraising, challenged mentally. So all of our talks in the series, actually. But we really grateful if you could make a donation towards the cause, Um, using the link that will just post in charge in a minute, you're still waiting on a few people, too beautiful. And that's like in the chapel for the Chantix. Okay, so that's 20 people are 20 who voted their seat people in final year and then 12, 4 penultimate, sure and below. So do we want to do to break up groups or should we do three? I was under old Any views and we've got to be your feet just so I make one breakout room for final urine about and then I'll make two for canal to make urine Onda. If people could just divide themselves up. So just once This now