Comprehensive Approach to Pre/Post-Operative Emergency Management

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Case 1
Bleeped by nurse
Mr Anderson, 56,
3 days post op right hemicolectomy
c/o abdo pain
Case 1: Initial assessment
A: patent, talking
B: Sats 98% on 2L, RR 20, chest clear, no CXR
C: HR, 72, BP 120/82, U/O 60ml/hour
D: GCS 15, coherent speech
Bloods:
HB 10.6, U+Es normal, LFTs normal, WCC 10, CRP 250
O/E
right sided abdo tenderness, no masses
Abdo drains have gradually reduced
passing wind, started oral fluids today, no vomiting
Case 1: plan
Analgesia
Regular paractemaol
PRN oromorph
Wean oxygen
Sit out/chest physio
Most surgical FY1s are
bleeped about…
PAIN RELIEF!
So do we just prescribe better pain killers?
When post operative pain
becomes serious…
Abdo surgery
Anastamotic/bile leak – peritonitis
Obstruction
Vascular surgery
Acute ischaemia (re-occlusion/embolus)
Ortho surgery
Compartment syndrome
Urology
Urinary retention
Targeted post-op assessment
Abdo surgery
Clinical:  abdo tenderness/distension, drains
Radiology: USS, contrast study, CT
Vascular surgery
Clinical: foot pulses/temperature, doppler, ABPI
 
COMPARE WITH PREVIOUS DOCUMENTATION
Radiology: duplex (routine), angiogram
Orthopaedic surgery
Clinical: neurovascular status, compartment pressures
Radiology: Post op X-ray (routine)
Don’t forget other post op
complications…
A: not so much (more an issue in ENT surgery)
B: atelectasis, pneumonia, PE
C: dehydration, hypovolaemia, cardiac event
D: post-operative confusion
E: electrolytes and glucose
Infection (line sepsis, collections, ANYWHERE)
Wound dehiscence
Haemorrhage
Initial assessment
A: look listen feel
B: RR, sats, chest exam, ?x-ray
C: HR, BP, UO, drains, ?ECG
D: GCS
Drains/stomas
Output rate
Content
Check drug chart
Things to omit? Things to add?
DVT prophylaxis
Bloods (previous and new set)
Routine: FBC, U+E, LFTs, electrolytes (Mg, PO4)
Targeted: ?VBG/ABG, lactate
Other radiology
to look up
to order
Treat as you
go along!
Wound
Wet/dry?
?dehisced
Case 2
Bleeped by nurse
Mr Anderson, 56,
3 days post op anterior resection
Hypoxic and pyrexial
Case 2: Initial assessment
A:
B: sats 93%, RR25, right basal creps, Temp 38.2
C: HR 100, BP95/60, U/O: 10ml/hour
D: GCS 14, confused
Examine
Generalised abdo tenderness, guarding
Hyperactive bowel sounds
Drains
Abdo drain increased in rate over late 2 hours
Content darker
Bloods
Hb 10.6, WCC 14, Cr 180 (70  pre-op) , CRP 400,
ABG: pH 7.30, pO2 9.5, pCO2 4.3, lactate 0.5
Case 3: management
Problem:
Unwell patient (pulmonary & circulatory compromise)
High possibility anastamotic leak
Acute renal failure
?pneumonia
Supportive therapy
Oxygen, Fluids, pain relief
Escalate
Need senior surgical opinion URGENTLY (SpR, consultant)
?straight to theatre ?imaging first (CT)
Call microbiology for Abx advice
Prepare for theatre
NBM, pre-op bloods (incl. G&S), call anaesthetist, call theatre coordinator
Needs urgent exploration and repair of anastamosis
Anaesthetic workup
(?ABG)
Blood results, Blood products
Cannula, CEPOD priority, (?CXR)
Drugs (anti-platelets, warfarin)
ECG (?Echo)
Food (time last ate)
Grade (ASA)
History (Cardio-pulmonary)
Angina, CCF, COPD, asthma,
Exercise tolerance
NB: this is all needed for less
urgent cases pre-operatively
URGENT cases may not have
time to have all these
investigations!
CEPOD
Grade 1 - Immediate
Ruptured AAA, compartment syndrome
Grade 2 - Urgent
Bowel perf with peritonitis, critical limb ischaemia, fracture
fixation
Grade 3 - Expedited
Tendon/nerve injuries, obstructing tumour
Grade 4 - Elective
Elective lap chole/AAA repair, joint replacement etc
Case 4
Bleeped by nurse
Mr Anderson, 56,
1 day post op right fem-pop bypass
severe leg pain, cold foot
Case 4: Initial assessment
A:
B: sats 98% ON 2l, RR24, chest clear, Temp 36.5
C: HR 90, BP120/705 U/O: 50ml/hour
D: GCS 15
Examine
Cold right foot cf. left, absent pedal pulses, no doppler signals
ABPI immeasurable
12 hours post op: pedal pulses and biphasic doppler documented
Drains
Abdo drain increased in rate over late 2 hours
Content darker
Bloods
Hb 9.6, WCC 14, CRP 250
Case 4: management
Problem:
Acutely ischaemic right foot
?graft failure
Supportive therapy
Oxygen, Fluids, pain relief, may need heparin infusion
Escalate
Need senior surgical opinion URGENTLY
Vascular SpR, consultant
Prepare for theatre
NBM, pre-op bloods (incl. G&S), call anaesthetist, call ODP
Needs urgent revascularisation
Case 5
Bleeped by nurse
Mr Anderson, 56,
2 days post op ORIF tibial fracture
severe  leg pain and swelling despite opiate
analgesia
Pain out of proportion to expected
Case 5: Initial assessment
A:
B: sats 98% ON 2l, RR24, chest clear, Temp 36.5
C: HR 90, BP120/705 U/O: 50ml/hour
D: GCS 15
Examine
Very tense anterior aspect of leg
?impalpable pulse ?paraesthesia
Pain on extending large toe
Bloods
Hb 9.6, WCC 14, CRP 250
CK 2000
Case 5: management
Problem:
Compartment syndrome (pressure over 30mmHg)
Supportive therapy
IV Fluids, pain relief
Escalate
Need senior surgical opinion URGENTLY
Ortho SpR, consultant
Prepare for theatre
NBM, pre-op bloods (incl. G&S), call anaesthetist, call ODP
Remember…
Any case of post op:
Severe pain
Obs deterioration
Needs to:
Be taken seriously
Have a full assessment
Have suspicion of post op complication
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Many thanks,. Any questions?
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The provided content covers a case of a patient post right hemicolectomy with abdominal pain. Initial assessment and management plan are discussed, emphasizing the importance of targeted post-operative assessment and recognizing serious post-operative pain causes. Other potential complications and evaluation strategies are highlighted, guiding healthcare professionals in managing post-operative emergencies effectively.


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  1. Pre/post operative emergency

  2. Case 1 Bleeped by nurse Mr Anderson, 56, 3 days post op right hemicolectomy c/o abdo pain

  3. Case 1: Initial assessment A: patent, talking B: Sats 98% on 2L, RR 20, chest clear, no CXR C: HR, 72, BP 120/82, U/O 60ml/hour D: GCS 15, coherent speech Bloods: HB 10.6, U+Es normal, LFTs normal, WCC 10, CRP 250 O/E right sided abdotenderness, no masses Abdodrains have gradually reduced passing wind, started oral fluids today, no vomiting

  4. Case 1: plan Analgesia Regular paractemaol PRN oromorph Wean oxygen Sit out/chest physio

  5. Most surgical FY1s are bleeped about PAIN RELIEF! So do we just prescribe better pain killers?

  6. When post operative pain becomes serious Abdo surgery Anastamotic/bile leak peritonitis Obstruction Vascular surgery Acute ischaemia(re-occlusion/embolus) Ortho surgery Compartment syndrome Urology Urinary retention

  7. Targeted post-op assessment Abdosurgery Clinical: abdotenderness/distension, drains Radiology: USS, contrast study, CT Vascular surgery Clinical: foot pulses/temperature, doppler, ABPI COMPARE WITH PREVIOUS DOCUMENTATION Radiology: duplex (routine), angiogram Orthopaedic surgery Clinical: neurovascular status, compartment pressures Radiology: Post op X-ray (routine)

  8. Dont forget other post op complications A: not so much (more an issue in ENT surgery) B: atelectasis, pneumonia, PE C: dehydration, hypovolaemia, cardiac event D: post-operative confusion E: electrolytes and glucose Infection (line sepsis, collections, ANYWHERE) Wound dehiscence Haemorrhage

  9. Initial assessment A: look listen feel B: RR, sats, chest exam, ?x-ray C: HR, BP, UO, drains, ?ECG D: GCS Treat as you go along! Wound Drains/stomas Output rate Content Wet/dry? ?dehisced Check drug chart Things to omit? Things to add? DVT prophylaxis Bloods (previous and new set) Routine: FBC, U+E, LFTs, electrolytes (Mg, PO4) Targeted: ?VBG/ABG, lactate Other radiology to look up to order

  10. Case 2 Bleeped by nurse Mr Anderson, 56, 3 days post op anterior resection Hypoxic and pyrexial

  11. Case 2: Initial assessment A: B: sats 93%, RR25, right basal creps, Temp 38.2 C: HR 100, BP95/60, U/O: 10ml/hour D: GCS 14, confused Examine Generalised abdo tenderness, guarding Hyperactive bowel sounds Drains Abdo drain increased in rate over late 2 hours Content darker Bloods Hb 10.6, WCC 14, Cr 180 (70 pre-op) , CRP 400, ABG: pH 7.30, pO2 9.5, pCO2 4.3, lactate 0.5

  12. Case 3: management Problem: Unwell patient (pulmonary & circulatory compromise) High possibility anastamotic leak Acute renal failure ?pneumonia Supportive therapy Oxygen, Fluids, pain relief Escalate Need senior surgical opinion URGENTLY (SpR, consultant) ?straight to theatre ?imaging first (CT) Call microbiology for Abx advice Prepare for theatre NBM, pre-op bloods (incl. G&S), call anaesthetist, call theatre coordinator Needs urgent exploration and repair of anastamosis

  13. Anaesthetic workup (?ABG) Blood results, Blood products Cannula, CEPOD priority, (?CXR) Drugs (anti-platelets, warfarin) ECG (?Echo) Food (time last ate) Grade (ASA) History (Cardio-pulmonary) Angina, CCF, COPD, asthma, Exercise tolerance NB: this is all needed for less urgent cases pre-operatively URGENT cases may not have time to have all these investigations!

  14. CEPOD Grade 1 - Immediate Ruptured AAA, compartment syndrome Grade 2 - Urgent Bowel perf with peritonitis, critical limb ischaemia, fracture fixation Grade 3 - Expedited Tendon/nerve injuries, obstructing tumour Grade 4 - Elective Elective lap chole/AAA repair, joint replacement etc

  15. Case 4 Bleeped by nurse Mr Anderson, 56, 1 day post op right fem-pop bypass severe leg pain, cold foot

  16. Case 4: Initial assessment A: B: sats 98% ON 2l, RR24, chest clear, Temp 36.5 C: HR 90, BP120/705 U/O: 50ml/hour D: GCS 15 Examine Cold right foot cf. left, absent pedal pulses, no doppler signals ABPI immeasurable 12 hours post op: pedal pulses and biphasic doppler documented Drains Abdo drain increased in rate over late 2 hours Content darker Bloods Hb 9.6, WCC 14, CRP 250

  17. Case 4: management Problem: Acutely ischaemic right foot ?graft failure Supportive therapy Oxygen, Fluids, pain relief, may need heparin infusion Escalate Need senior surgical opinion URGENTLY Vascular SpR, consultant Prepare for theatre NBM, pre-op bloods (incl. G&S), call anaesthetist, call ODP Needs urgent revascularisation

  18. Case 5 Bleeped by nurse Mr Anderson, 56, 2 days post op ORIF tibial fracture severe leg pain and swelling despite opiate analgesia Pain out of proportion to expected

  19. Case 5: Initial assessment A: B: sats 98% ON 2l, RR24, chest clear, Temp 36.5 C: HR 90, BP120/705 U/O: 50ml/hour D: GCS 15 Examine Very tense anterior aspect of leg ?impalpable pulse ?paraesthesia Pain on extending large toe Bloods Hb 9.6, WCC 14, CRP 250 CK 2000

  20. Case 5: management Problem: Compartment syndrome (pressure over 30mmHg) Supportive therapy IV Fluids, pain relief Escalate Need senior surgical opinion URGENTLY Ortho SpR, consultant Prepare for theatre NBM, pre-op bloods (incl. G&S), call anaesthetist, call ODP

  21. Remember Any case of post op: Severe pain Obs deterioration Needs to: Be taken seriously Have a full assessment Have suspicion of post op complication

  22. Many thanks,. Any questions? THE END

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