post op f1

7/23/2019 post op f1

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Dr Tom Hampton

(CT1)

Dr Simon Bellringer

(CT1)

Post Operative Care and

Surgical Ward Based

Emergencies

7/23/2019 post op f1


Aims

Cover common post-op surgical problems and

develop a logical approach to them.

- 1. Hypotension

- 2. Oliguria

- 3. Hypoxia

- 5. Sepsis and temperatures

- 6. Nausea and vomiting

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Assessment of any patient

Airway - Patent, speaking?

Breathing - Sats, RR, Resp Exam

- CXR, ABG

Circulation - BP, HR, examine i.e JVP, odema,HS, mucous membranes

- ECG

Disability - GCS, pupils, movement of limbs

Expose - abdominal examination

Assess other information available; including - DrugCharts, Fluid Balance Charts, Observation Charts(for patterns ), Bloods Folder/WinPath.

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Management of any patient…

l Manage according to what you find on your

assessment of ABCDE.

l Escalate to SHO/SpR if appropriate.

l Make a plan to review whether youmanagement plan has worked!!!

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Managing your time…

l This is particularly important when on call

where you need to be as efficient as possible

l

Make use of your team – From SpR to HCA!l What could be done for the patient before

you get there?

and

l What will make you assessment easier?

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1. Hypotension

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Assessment of hypotensive

patient

l A and B…

l C – LOW BP!

Tachycardia

Low/unseen JVP Cap refill >2 seconds

Dry mucous membranes

Pallor

l D – GCS reduced, AVPU (this is what is on mostObs charts)

l E – Negative fluid balance or poor urine output

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Causes of Hypotension

• Hypovolaemia or Haemorrhage

• Epidural

• Sepsis

• Cardiac

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Hypovolaemia

There are lots of reasons surgical patients become

hypovolaemic:

-Blood loss

-Sepsis/SIRS

-GI losses i.e. diarrhoea, vomiting, high stoma output,

ileus

-Low albumin reducing osmotic pressure and increasingfluid leak out of vessels

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Epidural

l Epidurals block sympathetic nerve fibres

l Decreases systemic peripheral resistance

l Increased pooling of blood in peripheries

mimicking hypovolaemia.

l Treatment:

l Elevate legs only

l Small boluses fluid

l Slow infusion and d/w anaesthetist if stopping

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Treating hypotension

l Try to identify cause!

l ABCDE approach

l Fluid boluses 250-500mls

l Give blood if indicated

l Reassess response to ‘fluid challenge’

l (Even if it means asking to be called back!!)

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2. Oliguria

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Oliguria

Minimum acceptable urine output (adults):

0.5mls per kg per hour

i.e. 70 kg man 35mls per hour.

N.B. Be aware of haemodialysis patients on

Surgical Wards!!

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Oliguria

• Pre-renal

- Hypotension/hypovolaemia

• Renal• Nephrotoxic drugs

• Intrinsic renal pathology e.g. ATN, CKD,

Nephritis

• Post renal

• Blocked catheter

• Ureteric blockage (extrinsic or intrinsic)

• Urinary retention (drugs/prostate)

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Managing Oliguria

l Identify cause if possible

l ABCDE approach

l Check renal function

l Fluid challenge

l Stop nephrotoxic drugs – NSAIDs, ACE inh,

Gent (levels).

l Flush catheter/check position

l Discuss with seniors

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3. Hypoxia

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Causes of hypoxia

l Surgical Causes;

l Atelectasis

l PE

l Non Surgical Causes

l Pneumonia (inc Aspiration)

l Pleural effusion

l CCF

l COPD

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Atelectasis

Exacerbated by pain and

immobility

Signs:

-Decreased air entry in bases-Crackles at bases

- éRR and low sats

Management:

- Sit up- Analgesia

-Chest Physio – in mean time

encourage deep breathing and

coughing.

-O2 if required

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Pulmonary emboli

Risk factors:

- Surgery

- Cancer patients

- AF

- Prev VTE

Signs/Symptoms:

- Sudden SOB

- Pleuritic chest pain

- Low sats (not always!)- Mild pyrexia

- Check calves for signs of DVT (often absent)

- ECG – Tachy, R Heart

Strain, S1Q3T3.

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P.E.

Investigations:

- ECG

- ABG

- CXR to ensure no other causes!

l Treatment dose heparin (LMWH normally) started only after discussion with the medical team and seniors as these patientsmay have had recent major surgery.

l CTPA is of value to confirm the diagnosis but should notchange your immediate management.

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ECG Changes –P.E.

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Pulmonary effusions

l Patients may complain of shortness of breath and pleuritic chestpain.

l On examination, they will have:l reduced breath sounds at the bases

l stony dull percussion

l decreased vocal fremitus

l Management:l Improve nutritional status

l Monitor clinically

l If very symptomatic discuss with seniors re. therapeutic tap.

l NB – BTS guideline state Respiratory Team should be doing this.

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Pleural effusions

lIn relation to surgery, pleural

effusions are usually notpathological butreactive/physiological.

lPost gastro-intestinal surgery,

patients tend to have aconsiderable drop in their albumin levels.

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Pneumonia

High risk are those with

underlying resp

disease.

Findings:

- Low sats

- Tachypnoea

- Focal signs

- Fever - Productive cough

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Pneumonia Management

-Bloods (bloods cultures if T >38.0)

-CXR

- ABG-Sputum MC&S

-Empirical ABX as per policy (HAP vs CAP)

-Mobilise and chest physio

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Post Operative Hypoxia -

Summary

l Ask nurses to give O2 to get Sats above 96%.

l Give O2 even to COPD patients.

l Regular review however to ensure not becoming narcosed

from hypercarbia.

l Investigations: - CXR

- ABG

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4. Sepsis andtemperatures

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Temperatures

l Post operative temperatures are a common occurrence and do

not necessarily mean that there is infection on board.

l A temperature of < 38.0ºC within the first 48 hours after surgery

can simply be a physiological response to injury.

l A temperature of ≥38ºC should be considered pathological

and investigated accordingly.

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SIRS and SEPSIS

l SIRS

l Temperature >38 or < 36

l HR > 90

l RR >20 or PaCO2 <4.3kPa

l WCC >12 or <4

l Sepsisl SIRS plus identifiable organism (+ve culture)

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SIRS cont.l Severe Sepsis

l SEPSIS + organ hypofunction-skin mottleprolonged cap refillDecrease urine outputLactate >2

confusionplts <100 ARDSECHO

l Septic Shockl Severe Sepsis + MABP <60mmHg after challenge

l DOPAMINE…

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Approach

l Systematic approach

l ABCDE

- Culture everything (urine, sputum, wounds as

baseline)

l Common sources

l Pneumonia

l Urinaryl Wound infections

l Collections (intra-abdominal)

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Post Operative Temperatures – Post

Operative Collections

l Patients often complain of increasedabdominal distension and pain.

l On examination there abdomen may be non-

specifically tender or locally peritonitic.l Further imaging is usually required in the

form of an Ultrasound Scan or CT.

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Post Operative Temperatures –

Anastomotic Leak

Anastamoses have the

potential to leak,

especially in high risk

patients, e.g. smokers,

high BMI, diabetics,

Jaundice etc.

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5. Nausea andvomiting

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Nausea and Vomiting

l Causes:

l Drugs (opiates and anaesthetic drugs)

l Obstruction or ileus

l Ileus:

l Ensure electrolytes normal. Aim K+ 4.5

l Consider imaging if prolongedl Question nutritional supplementation i.e. TPN on day

3 of NBM

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Management

l Assess patient and take history

l ABCDE

l Look at charts (especially drug chart)

l Management:l Trial anti-emetic – try to choose an

appropriate one.

l If concerned about obstruction:

l Sips or NBM

l AXR and erect CXR

l NGT if vomiting or grossly obstructed

l Inform senior

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Scenarios

For these we will require

some audience

participation

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Example Telephone Call – Mr P

l S

l B

l

Al R

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Example Telephone Call – Mr P

l S – I have a patient on L8Tower with a low

blood pressure.

l B – 80yr old man with a background of T2DM

and PVD who had a below knee amputation

yesterday evening.

l A – Very Sleepy, BP 85/60, HR 110bpm,

Sats 96%OA.

l R – Can you come and review the patient??

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Mr P

What can you ask for before you get

there??

Notes and Charts?

Bedside tests?

Any intervention?

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Mr P

A - Patent

B - Increased RR, R=L with no addedsounds.

C – Cool Peripherally, CRT 3 seconds,

Pale, BP and HR as previously mentioned,

JVP not seen, thready pulse.

D – Drowsy (Responsive to Voice)

E – Dressings stained around BKA site.

How will you assess the patient?

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Mr P

What is you management?

A

B

C

D

E

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Mr P


Post Operative Hypotension secondary to

blood loss.

Give Fluids/Blood.

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Example Telephone Call – Mr R

l S

l B

l

Al R

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Example Telephone Call – Mr R

l S – Patient on L9AW with a temperature of

38.6C

l B – 75yr old man with a background of an MI

8 years ago. Admitted with diverticulitis 3

days ago and is on IV ABX (Co-Amoxiclav)

l A – Temperature 38.6, RR 22, HR 105, BP

120/60mmHg, Sats 93% OA.l R – Can you come and see the patient???

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Mr R


there??

Notes and Charts?

Bedside tests?

Any intervention?

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Mr R

A - Patent

B - Increased RR, R=L with no addedsounds, decreased chest expansion

(shallow breaths)

C – Warm to touch, CRT 4 seconds, BP and

HR as previously mentioned.

D – Drowsy (Responsive to Voice)

E – Globally Peritonitic Abdominal

Examination.


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Mr R


A

B

C

D

E

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Mr R – Erect Chest Radiograph

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Mr R


Perforated Diverticulum – Needs an

operation; so prepare the patient for theatres!

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Example Telephone Call – Mr D

l S

l B

l

Al R

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Example Telephone Call – Mr D

l S – I have a patient on L8Tower who hasn’t

passed any urine for 6 hours

l B – 65yr old man who was admitted with

frank haematuria yesterday.

l A – All his obs are fine but his NEWS score is

now 5 because he is on Oxygen and he

hasn’t passed an urine for 6 hours.l R – Can you come and review the patient?

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Mr D


there??

Notes and Charts?

Bedside tests?

Any intervention?

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Mr D

A - Patent

B - Normal, R=L with no added sounds.

Sats 100% on 2L.

C – Haemodynamically stable. No urine

output despite being catheterised

D – Alert and in no pain.

E – Some ‘rose’ coloured urine in the

catheter bag beneath the urometer.

Abdomen SNT.


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Mr D


Blocked Catheter secondary to blood clots.

Likely to require bladder irrigation if catheter has been blocked once already.

Example Telephone Call

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– Mrs W

l S

l B

l A

l R


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– Mrs W

l S – Patient on L9AE who is vomiting

l B – 66 year old lady who had a Hartmanns

Procedure 4 days ago but had been fine

since then.

l A – BP 100/60, HR 110, Sats 92% OA,

Temperature 36.5C.

l R – Can you come and see the patient??

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Mrs W


there??

Notes and Charts?

Bedside tests?

Any intervention?

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Mrs W

A - Patent

B – Decreased air entry at both bases.

C – CRT 2 seconds, BP/HR as previous,

UO 15ml/hr for last 4 hours.

D – Alert, vomiting.

E – Distended abdomen, Soft and mildly

tender.

Assess other information available to you


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Mrs W


A

B

C

D

E

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Mrs W


Ileus/Obstruction

NGT

NBM/Sips

Inform senior

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Any Questions??

post op f1

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