Surgical complications

Louise Chesshire FY1 Respiratory Alicia Tomkinson FY1 Upper GI surgery

AIMS AND OBJECTIVES

3 real life case studies of common post op complications YOU will experience as an F1 SLIDESHOW!! (Hopefully full you with super confidence for your examand life as an F1)

Case 1
You are the F1 on-call for general surgery. You get a bleep for Mr Big, 56 yr old. You have been asked to see the patient because they are complaining of abdo pain and feeling a bit sick. What do you ask the nurse over the phone.

What you ask the nurse.

Patient demographics What was the procedure? Obs are they stable. How many days/hours are they post op? Have they vomited?

You make your way to the ward and go to see the patient what do you ask him?

Questions for the patient?

SOCRATES of pain. Have they actually vomited? When did they last open their bowels? Are they passing flatus? Have they passed urine?

You examine the patient and.abdo distension, PR empty rectum, clinically dry, lungs clear, tinkling bowel sounds.

Differentials.
UTI Constipation Obstruction Wound dehiscence Intra-abdominal Infection Perforation Ileus MI What investigations do you want to do?

Investigations
Bloods and phosphate and Mg Abdo/Chest xray ECG Urine dip If high RR consider ABG

Case 1
Bloods: NAD ECG sinus tachy ABG: resp alkalosis Causes: 1) Post op 2) Electrolyte imbalance 3) Uraemia 4) DM 5) Anti-cholinergic drugs

Management of Ileus
Obviously ABC NBM IV fluids Wide bore NG tube alleviate gas DO NOT GIVE LAXITIVES Analgesia IV Usually resolves within a few days

Case 2
You are the F2 on the orthopaedic ward, you get called by the nurse at 04.00 because a patient has spiked a temperature and is a bit tachycardic. Mr Fit is 39 years old. You go to take a history from the patient

What questions are you going to ask the patient?

What op they have had and how long ago? Any chest/urinary symptoms? Any paraesthesia/pain in arms/legs Bowels opening?

You perform an examination: HR 105, BP 134/83, RR 18, Sats 95% RA. No abdo tenderness, chest clear, HS normal, calves SNT

Differentials
Any source of infection Pain PE Cardiac event

What investigations do you want to do?

Investigations
Routine bloods ECG ABG Urine dip +/- MSU CXR D-Dimer?!?!? TNI Blood cultures

Results
WCC 15.56 CRP 152 Urine dip +ve for leucocytes, protein and blood. No nitrites (from catheter bag) ECG sinus tachycardia ABG C02 3.4, 02 8.9. Ph 7.37 DIAGNOSIS: PE Management: Treatment dose LMWH and supportive 02.

Case 3
You are the F1 on call, covering Bexley Wing. You are called to see a patient by the nurse.
RR 22 Sats of 92% Pyrexia of 38.5 HR 120 BP 85/55

Go see your patientquick!

Patient history
What procedure? What symptoms are they having?
SOB Pain (everywhere) Coughing (but too painful to cough properly) Feels hot/cold Feels rough Hasnt passed urine since lunch

Examine your patient

Examination
Chest coarse crackles on right base, resp rate 22, dull percussion on right base Abdo SNT HS normal, regular, tachy Wound site clean and dry

What differentials are you thinking of and why?

Differentials
PE Chest infection Cardiac event What investigations are you going to do now?

Investigations
Routine bloods ABG ECG CXR Blood cultures Urine dip

Results
Hb 13 WCC 16.5 CRP 150 Us&Es/LFTs NAD ABG PaO2 -10.8 PCO2 5.5 lactate 2.4 ECG sinus tachy Urine dip NAD

SIRS:
HR 120, WCC 16.5, RR 22

SEPSIS!!
SIRS plus point of infection Actually severe sepsiswhy?

What is this?
Hospital acquired pneumonia Why? What organisms are the most common cause?

What are YOU going to do now?

ABC O2 Fluids Catheter Antibiotics which ones? Inform senior

BUFALO!! In an hour

SLIDE SHOW
Pens and paper ready. 40 seconds per slide 11 slides.

What do these photos show? What sign of?

Which rhythms are these? Which are shockable?

a) b)

c)

This patient is SOB. This is their CXR. Give 3 points of management.

Give 3 criteria for having this procedure

What does this show and what would be your management?

Pt presents with distended abdo, vomiting and complete constipation. What does this XRAY show and what is the MOST likely cause?

ABG time
21 year old female in A&E with SOB and wheeze, known asthmatic. Barely speaking in full sentences, use of accessory muscles. Tachycardic. PEFR 190 (predicted 400) pH 7.38 pCO2 5.8 (range 4.7 6) pAO2 9.9 (>10.6 normal) HCO3 24 (22-28) Describe her gas exchange, which value gives cause for concern? Classify the severity of this asthma attack

What does this classic ECG show?

What is this rash? Give 3 causes for it?

What classic sign is this? What disease is it associated with?

Name the pathology in this ECG. If this continued name some more abnormalities that could occur.

ANSWERS.

What do these photos show? What sign of?

Which rhythms are these? Which are shockable?

a) b)

c)

This patient is SOB. This is their CXR. Give 3 points of management.

Give 3 criteria for having this procedure

What does this show and what would be your management?

Pt presents with distended abdo, vomiting and complete constipation. What does this XRAY show and what is the MOST likely cause?

ABG time
21 year old female in A&E with SOB and wheeze, known asthmatic. Barely speaking in full sentences, use of accessory muscles. Tachycardic. PEFR 190 (predicted 400) pH 7.38 pCO2 5.8 (range 4.7 6) pAO2 9.9 (>10.6 normal) HCO3 24 (22-28) Describe her gas exchange, which value gives cause for concern? Classify the severity of this asthma attack

What does this classic ECG show?

What is this rash? Give 3 causes for it?

What classic sign is this? What disease is it associated with?

Name the pathology in this ECG. If this continued name some more abnormalities that could occur.

 Tall tented T waves of hyperkalaemia Tented T waves are the first sign As potassium increases progressive atrial paralysis occurswidening and flattening P waves and increasing the PR interval due to AV node dysfunction As it increases further the QRS lengthens and starts to look mega bizarre due to lack of active conducting tissue, any type of heart block can occur which results in significant bradychardia A pre terminal sign is sine waves