Comprehensive Approach to Pre/Post-Operative Emergency Management
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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Pre/post operative emergency
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 abdotenderness, no masses Abdodrains 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 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)
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
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
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
Many thanks,. Any questions? THE END
