L L A C N O SURGICAL COVER

L L A C N O SURGICAL COVER R A R T IS G E R L A IC G R U S L A DÓNAL MURPHY. GENER ALS IT P S O H N R E H T R O N D N A AUSTIN

• Be your own boss • Less paperwork • Feel like a doctor! • You’re your own boss! • Busy/overwhelmed • Feel out of your depth

ROLE OF A COVER SHIFT • BE A LIASON BETWEEN THE PATIENT, NURSING STAFF AND SENIOR MEDICAL STAFF • PROMPT RECOGNITION OF POST OPERATIVE COMPLICATIONS • BEGIN INITIAL WORKUP AND MANAGEMENT OF UNWELL PATIENTS • CATCH ANY TIME CRITICAL TASKS HANDED OVER BY THE DAY TEAMS • NOT TO BE USED AS A DUMPING GROUND OF ROUTINE WORK NOT DONE DURING THE DAY

GENERAL ADVICE • ALWAYS ANSWER PAGES NO MATTER HOW BUSY – MAKE A LIST! • “JUST WANTED TO LET YOU KNOW DOCTOR…” - GO SEE THE PATIENT! • BE COURTEOUS - VERY SMALL WORLD IN MEDICINE • DOCUMENT EVERYTHING! • GET SENIORS INVOLVED EARLY • LOOK AFTER EACHOTHER • HAND OVER TO MORNING TEAMS • BE WARY OF DIRECT ED ADMITS NOT YET SEEN BY A REGISTRAR!!

WHERE TO START? • DIFFERENTIAL DIAGNOSIS • CO-MORBIDITIES • ATYPICAL PRESENTATION • STABLE VS THE SICK PATIENT • BEING WARY TO DETERIORATION • MIMICKING CAUSES OF PAIN • LENGTH OF TIME POST OP

IMMEDIATE COMPLICATIONS: DAY 0 -1 • PRIMARY HAEMORRHAGE (STARTING DURING SURGERY) OR REACTIONARY HAEMORRHAGE (FOLLOWING POSTOPERATIVE INCREASE IN BLOOD PRESSURE) REPLACE BLOOD LOSS AND MAY REQUIRE RETURN TO THEATRE TO RE-EXPLORE THE WOUND. • BASAL ATELECTASIS: MINOR LUNG COLLAPSE. • SHOCK: BLOOD LOSS, ACUTE MYOCARDIAL INFARCTION, PULMONARY EMBOLISM OR SEPTICAEMIA. • LOW URINE OUTPUT: INADEQUATE FLUID REPLACEMENT INTRA-OPERATIVELY AND POSTOPERATIVELY.

EARLY COMPLICATIONS: DAY 2 -3+ • PAIN. • ACUTE CONFUSION: EXCLUDE DEHYDRATION AND SEPSIS. MAY ALSO BE DUE TO OTHER VARIOUS CAUSES, INCLUDING PAIN, SLEEP DISTURBANCE, MEDICATION OR METABOLIC DISTURBANCES. • NAUSEA AND VOMITING: ANALGESIA OR ANAESTHETIC-RELATED; PARALYTIC ILEUS. • FEVER (SEE 'POSTOPERATIVE FEVER', BELOW). • SECONDARY HAEMORRHAGE: OFTEN AS A RESULT OF INFECTION. • WOUND OR ANASTOMOSIS DEHISCENCE. • DVT. • ACUTE URINARY RETENTION. • URINARY TRACT INFECTION (UTI). • POSTOPERATIVE WOUND INFECTION. • PRESSURE SORES. • BOWEL OBSTRUCTION DUE TO FIBRINOUS ADHESIONS. • PARALYTIC ILEUS. • PNEUMONIA.

HIPOI FRAMEWORK • HIPOI VIDEO

GENERAL INITIAL APPROACH • MOST IMPORTANT: GO SEE THE PATIENT! • BIG SICK OR LITTLE SICK? • STABLISIED? : ABC’S • FAMILIARISE YOURSELF WITH THE HISTORY • FULL BODY EXAM

INITIAL APPROACH • REVIEW THE HISTORY • VIRGIN ABDOMEN VS MULTIPLE PREVIOUS SURGERIES. ? • CO-MORBIDITIES? • WHAT INVESTIGATIONS HAVE BEEN DONE • WHAT YOU'RE GOING TO ORDER

HELP? !

USEFUL INVESTIGATIONS ON CALL • URINALYSIS • BHCG • ECG • VBG? • FBE UEC CMP LFTS CRP • CXR, AXR • CT + CONTRAST

GENERAL MANAGEMENT • IV CANNULA INSERTION • ANALGESIA • NG TUBE? • FOLEY CATETHER • ANTIBIOTICS? • REFER FOR DEFINITIVE TREATMENT VS CONSERVATIVE MANAGEMENT • REASSESS PATIENT REGULARLY!

CASES

CASE 1 • PAGED “ BED I 5 D PLS REVIEW FOR LOW URINE OUTPUT TNX #23434”

LOW URINE OUTPUT • WHAT IS LOW URINE OUTPUT? • DEFINED AS <0. 5 ML/KG/HOUR (OR ROUGHLY 30 ML/HR) • WHAT MORE INFO WOULD WE LIKE?

CASE 1 • 57 M POST D 1 POST RIGHT HEMICOLECTOMY FOR CRC • PMHX: T 2 DM • URINE OUTPUT LAST 4 HRS: 50 MLS, 40 MLS, 25 MLS, 10 MLS. • VITALS HR 95, SBP 100, 98% RA, 36. 5 • OTHER LOSSES?

ACTIONS • THINK OF THE CAUSES AND TRY TO REVERSE • POST- RENAL • IDC MANOEUVRES, BPH, POST SPINAL ANAESTHESIA • RENAL • INTRA-OPERATIVE HYPOPERFUSION ISCHAEMIA, NEPHROTOXINS • PRE-RENAL • HYPOTENSION/VOLEMIA • DRUGS DECREASING RENAL PERFUSION

CASE 2 • PAGED 11 PM “PLS REVIEW PATIENT BNO 5/7 UR 1234567 ASAP #23456” • ANNOYING PAGE? • IMPORTANT TO ASK YOURSELF WHY TELL ME NOW?

MORE INFO • 80 F DAY 5 POST OP ORIF NOF • PMHX: IHD, OBESITY, OA VITALS HR 70 BP 140/80 96% RA • EATING AND DRINKING NORMALLY

MORE INFO • EXAM: MILD DISTENSION SNT, COMFORTABLE • MEDS: TARGIN 10/5 AND OXYCODONE QID • LIKELY CAUSE? POST OP OPIATES AND IMMOBILITY • COMMON SENSE TREATMENT? ! • LAXATIVES IN MORNING • RATIONALISE OPIATES, MOBILISE AS APPROPRIATE

BUT WHAT IF (CASE 3) • 60 M POST OP DAY 4 LOW ANTERIOR RESECTION FOR RECTAL CANCER. • PERFUSE BILIOUS VOMITING , NG TAKEN OUT 2/7 AGO • HR 110 BP 110/80 96% RA • ALREADY HAD ONDANSETRON 8 MG AND METOCLOPERAMIDE 10 MG • O/E • DISTENDED ABDOMEN • REDUCED BOWEL SOUNDS • NO GUARDING

POST OP ILEUS • NIL BY MOUTH • DRIP AND SUCK • NGT • IVT TO CORRECT ONGOING LOSS AND MAINTENANCE • INFORM A SENIOR • BLOODS AND CORRECT ELECTROLYTES • IMAGING? ?

BUT WHAT IF AGAIN! (CASE 4) • SAME CASE: 60 M POST OP DAY 4 LOW ANTERIOR RESECTION FOR RECTAL CANCER. • INFORMED VOMITING, SHAKING AND ABDOMINAL PAIN. • VITALS 115 HR BP 90/60 95% RA T 38. 2, RR 27 • O/E • UNWELL LOOKING, RIGORING WITH COOL PERIPHERIES • TENDER RIGID ABDOMEN WITH PAIN ++ IN LIF • DIAGNOSIS? ?

CASE 4 – VBG? – PH 7. 4 PO 2 70 PCO 2 30 LACTATE 2. 0, HB 140 WHAT DO WE THINK IS GOING ON? MOBILE CXR MANAGEMENT STABILISE THE PATIENT – ABC

ANASTAMOTIC LEAK • CALL FOR HELP • AGSU AND ICU REG BUSY IN ED AT A TRAUMA CALL – WHAT NEEDS TO BE DONE? • IDENTIFIED THE PROBLEM – NEED TO STABILISE THE PATIENT • ABCD APPROACH

MANAGEMENT • LINES, BLOODS AND CULTURES • FLUID RESUSCITATION • BROAD SPECTRUM ANTIBIOTICS • NGT, IDC • CALL FOR HELP AGAIN – ALERT SENIORS (REG/FELLOW/CONSULTANT ON CALL) • FURTHER INVESTIGATIONS – CT SCANNING • NEED TO PREPARE FOR THEATRE

• IMPORTANCE OF ANSWERING PAGES TO GET MORE INFORMATION AND TO GO SEE THE PATIENT TO ASSESS THEIR CLINICAL STATE

CASE 5 • PAGED “MR SMITH POST OP DAY 1 HAS FEVER 38. 2 PLS REVIEW #23456”

POST OP PYREXIA • IMPORTANT TO GO EXAMINE PATIENT • APPROACH AS ANY SEPTIC PATIENT • POTENTIAL SOURCES FROM BEFORE OPERATION? • LIKELY POST OP CAUSES BASED ON DURATION SINCE OPERATION • INVESTIGATIONS TAILORED TO LIKELY SOURCES

POST OP PYREXIA DAYS 0 -2 • MILD FEVER (TEMPERATURE <38°C) (COMMON): • TISSUE DAMAGE AND NECROSIS AT THE OPERATION SITE. • HAEMATOMA. • PERSISTENT FEVER (TEMPERATURE >38°C): • ATELECTASIS: THE COLLAPSED LUNG MAY BECOME SECONDARILY INFECTED. • SPECIFIC INFECTIONS RELATED TO THE SURGERY - EG, BILIARY INFECTION FOLLOWING BILIARY SURGERY, UTI FOLLOWING UROLOGICAL SURGERY. • BLOOD TRANSFUSION OR DRUG REACTION.

POST OP PYREXIA DAYS 3 -5 • BRONCHOPNEUMONIA. • SEPSIS. • WOUND INFECTION. • DRIP SITE INFECTION OR PHLEBITIS. • ABSCESS FORMATION - EG, SUBPHRENIC OR PELVIC, DEPENDING ON THE SURGERY INVOLVED. • DVT.

POST OP PYREXIA >5 DAYS • SPECIFIC COMPLICATIONS RELATED TO SURGERY - EG, BOWEL ANASTOMOSIS BREAKDOWN, FISTULA FORMATION. • AFTER THE FIRST WEEK: • WOUND INFECTION. • DISTANT SITES OF INFECTION - EG, UTI, CHEST INFECTION. • DVT, PULMONARY EMBOLUS.

POST OP PYREXIA • ENSURE ANALGESIA IS OPTIMAL • ENCOURAGE DEEP BREATHING AND MOBILISATION AS APPROPRIATE • CHECK WOUNDS/LINES ETC FOR SOURCES • ASSESS THE NEED FOR CULTURING PATIENT • IS IMAGING WARRANTED URGENTLY? • ARE THERE ANTIBIOTICS CHARTED AND ARE THEY APPROPRIATE COVER • DISCUSS WITH SENIORS (ESPECIALLY IF ANTICOAGULATION MAY BE INDICATED)

CASE 6 • PAGED FOR RAPID REVIEW! • “POST OP LAP CHOLE XBED 11, HIGH OUTPUT BLOOD IN DRAIN RAPID REVIEW ASAP #23456” WHATS GOING ON? DO LAP CHOLES NORMALLY HAVE DRAINS?

MORE INFO • 57 F POST OP DAY 0 ELECTIVE LAPAROSCOPIC CHOLECYSTECTOMY FOR CHOLELITHIASIS AND BILIARY COLIC • 400 MLS OF FRANK BLOOD IN LAST 2 HOURS • VITALS HR 100 BP 120/70 (NORMAL? ) 97%RA RR 18 T 37. 3 • PMHX HYPERTENSION

MORE INFO • O/E PATIENT IS ALERT RUQ PAIN GUARDING AND TENDERNESS FRANK BLOOD CLOTTING IN DRAIN WITH CONTINUOUS OOZE. • WHAT NEXT? ? CLAMP THE DRAIN? ?

MANAGEMENT • ABCD APPROACH WITH SIMULTANEOUS MANAGEMENT • ENSURE ADEQUATE ACCESS • BLOODS – VBG, COAGS, GROUP AND CROSS MATCH BLOOD (RING THE LAB AS URGENT) • FLUID RESUSCITATION • READ THE OPERATION NOTES – INTRAOPERATIVE COMPLICATIONS • NEED EXTRA HANDS AND SENIOR HELP ASAP! ( MET CALL )

MANAGEMENT CONTINUED • HOW TO ESTABLISH THE CAUSE OF BLEEDING? • STABLE FOR A CT ANGIOGRAM AND IR? • NOTIFY THEATRE STAFF AND ANAESTHETICS OF POTENTIALLY UNWELL EMERGENCY CASE • OPEN LAPAROTOMY SETS NEED TO BE MADE AVAILABLE • CONSULTANTS MAY NEED TO BE CALLED IN FROM HOME – NEED TO KNOW EARLY

IN SUMMARY SURGICAL COVER • TRIAGE TASKS IN A TIMELY MANNER • KNOW AND BE ABLE TO RECOGNISE POTENTIAL POST OP COMPLICATIONS • BEGIN INITIAL MANAGEMENT • GET HELP EARLY • HAND OVER TO THE MORNING TEAM

THANK YOU – QUESTIONS? • REFERENCES • HTTPS: //LIFEINTHEFASTLANE. COM/INVESTIGATIONS/AXR-INTERPRETATION/ • RAY S, PATEL M, PARMAR H. MANAGEMENT OF ACUTE ABDOMEN: STUDY OF 110 CASES. . IAIM, 2016; 3(2): 18 -24 • AUSTRALIAN HOSPITAL STATISTICS AIHW HTTPS: //WWW. AIHW. GOV. AU/GETMEDIA/981140 EE-3957 -4 D 479032 -18 CA 89 B 519 B 0/AIHW-HSE-194. PDF. ASPX? INLINE=TRUE • HTTP: //TEACHMESURGERY. COM/GENERAL/PRESENTATIONS/ACUTE-ABDOMEN/ • HTTPS: //PATIENT. INFO/DOCTOR/COMMON-POSTOPERATIVE-COMPLICATIONS-PRO#NAV-9