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Surgery > Post-op > Flashcards

Post-op Flashcards

1
Q

Wound infection aetiology

A

Most are caused by patients own flora
- MC = skin organisms e.g., staph aureus, staph epidermidis
- 2nd MC = contamination from opened viscera during clean-contaminated procedures –> GNs and anaerobes e.g., e. coli from GIT, pseudomonas from biliary tree

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2
Q

Clinical features of wound infections

A

Wound:
- pain
- tender
- erythema
- swelling
- warmth
- discharge
- possibly fluctuant due to contained pus

Systemic
- fever
- anorexia
- tachycardia
- malaise

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3
Q

Complications of wound infection

A

Bacteraemia = common but rarely significant

Septicaemia = rare unless organism is resistant/pt is immunosuppressed

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3
Q

Complications of wound infection

A

Bacteraemia = common but rarely significant

Septicaemia = rare unless organism is resistant/pt is immunosuppressed

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4
Q

Mx of minor surgical site infections

A

Surgical drainage and 0.9% NaCl irrigation is often adequate

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5
Q

When are ABx indicated in surgical site infections

A

Skin infection with associated cellulitis/infection of SC tissues

Infection of deep soft tissues e.g, fascia/muscles

Infection with systemic features

Sepsis/septic shock

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6
Q

Ix for surgical wound infection

A

Swab discharge –> MC&S

FBC, CRP

Blood culture

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7
Q

Empirical Tx for superficial surgical site infection

A

Procedure did not enter GIT/resp/genitourinary tract –> suspect GP bacteria
- PO di/flucloxacillin 500mg 6 hourly or cefalexin 500mg 6 hourly

Procedure did enter GIT/resp/genitourinary tract –> suspect GN bacteria
- PO amoxicillin and clavulanate 875+125mg 12 hourly

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8
Q

Empirical Tx for deep incisional surgical site infection

A

Source control: drainage, irrigation, debridement

Infection did not enter GIT/resp/GUT –> GP bacteria suspected
- 2g IV flucloxacillin 6 hourly or vancomycin if MRSA risk

Infection entered GIT/resp/GUT –> GP bacteria suspected
- IV amoxicillin and clavulanate 1+0.2g 8 hourly or piperacillin and tazobactam 4+.5g if pseudomonas suspected or vancomycin if MRSA risk

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9
Q

Empirical Tx for surgical site infection assoc. with sepsis/septic shock

A

Start ABx within 1 hour of pt presenting immediately after samples taken for culture

Piperacillin and tazobactam IV 4+.5g 6 hourly AND 25-30mg/kg vancomycin IV as loading dose

Source control: drainage, irrigation, debridement

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9
Q

Empirical Tx for surgical site infection assoc. with sepsis/septic shock

A

Start ABx within 1 hour of pt presenting immediately after samples taken for culture

Piperacillin and tazobactam IV 4+.5g 6 hourly AND 25-30mg/kg vancomycin IV as loading dose

Source control: drainage, irrigation, debridement

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9
Q

Empirical Tx for surgical site infection assoc. with sepsis/septic shock

A

Sepsis 6

Start ABx within 1 hour of pt presenting immediately after samples taken for culture

Piperacillin and tazobactam IV 4+.5g 6 hourly AND 25-30mg/kg vancomycin IV as loading dose

Source control: drainage, irrigation, debridement

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10
Q

Risk factors for wound infection

A

Increasing age
Malnutrition
Obesity
Immunosuppression (e.g., steroids/chemo)
Endocrine and metabolic disorders e.g., DM, jaundice, uraemia
Hypoxia
Anaemia

Type of procedure
Lengthy procedure
Foreign body including prosthesis/implants
Local malignancy
Haematoma/ischaemia
Necrotic tissue

Lack of ABx prophylaxis
Type and virulence of organism

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11
Q

Expected wound rate after surgical procedures based on type

A

Clean = no viscus opened e.g., hernia repair < 2%

Clean contaminated = viscus opened but minimal spillage e.g., cholecystectomy < 10%

Contaminated open viscus with spillage or inflammatory disease e.g., simple appendectomy 15-20%

Dirty (pus or perforation or incision through abscess) e.g., perforated appendicectomy > 40%

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12
Q

What factors contribute to increased risk of DVT after surgery

A

Virchow’s triad
- Altered blood flow: stasis/immobilised pt
- Hyper-coagulable state: post-operative increase in platelet count
- Endothelial injury

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13
Q

Risk factors for post-op DVT

A

Pelvic/hip surgery
Malignant disease
OCP/pregnant
Previous DVT/PE Hx
Older age

Obesity
DM
Polycythaemia
Varicose veins
Cardiac and resp disease
Thrombophilia e.g., factor V Leiden, protein C, protein S deficiency

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14
Q

Clinical features of DVT post-op

A

Systemic pyrexia at 7-8 days post-op

Calf swelling
Localised pain along DV system
Redness
Localised warmth
Asymmetric oedema
Prominent superficial veins

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15
Q

Dx of DVT

A

Wells criteria

D dimers are unlikely to be helpful as they are usually elevated after surgery

FBC, UEC, LFTs, coags

Venous Doppler and B-mode USS
CT/MRI venography if venous USS not conclusive

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16
Q

Wells criteria for DVT

A
  1. Active cancer
  2. Previous DVT
  3. Paresis, paralysis, or recent immobilisation of lower extremity
  4. Bedridden for 3+ days or surgery within last 12weeks
  5. Tenderness along DV system
  6. Swelling of entire leg
  7. Swelling >3cm compared to contralateral
  8. Unilateral pitting oedema
  9. Venous distension of symptomatic leg
  10. -2 for alternative diagnosis

2+ is a high score and warrants venous USS (or in non-surgical pts D-dimers)

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17
Q

Tx of DVT

A

Proximal DVT:
Apixaban 10mg PO BD for 7 days –> 5mg BD, or
Rivaroxaban 15mg 15mg BD for 21 days –> 20mg PO once daily

Distal DVT:
Mx as above or with 2-3 USS over 2 weeks following Dx for surveillance
- > 8cm thrombus extension, thrombus involving different vein, or extension into proximal vein –> Tx

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18
Q

What kind of drugs are apixaban and rivaroxaban and how do they work

A

Oral factor Xa inhibitors: selectively and reversibly bind to the active site of activated factor X which blocks the interaction with its substrate inhibiting thrombin generation

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19
Q

Before starting antigoagulation therapy what tests should be done

A

FBC
APTT
INR (PT)

UEC
Liver biochemistry

bHCG in women of childbearing age

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20
Q

Anticoagulation methods in special groups

A

Pregnancy:
- SC enoxaparin (parenteral LMWH) 1mg/kg BD

Severe renal impairment:
- PO warfarin
- IV unfractionated heparin 80 units/kg loading dose –>18 units/kg/hour vy IV infusion adjusted according to APTT

Cancer associated VTE:
- SC enoxaparin (parenteral LMWH) 1mg/kg BD

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21
Q

What should be done if starting warfarin for DVT Tx

A

Give a parenteral anticoagulant concurrently when starting therapy to overcome delay in achieving therapeutic anticoagulation and the initial increase in prothrombotic potential.

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22
Q

Why is unfractionated heparin useful in DVT Mx

A

Used for patients with severe kidney impairment or who have a high risk of active bleeding that may require rapid reversal of anticoagulation

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23
Q

How long should DVT anticoagulant therapy be given for?

A

Proximal DVT or PE 2˚ provoking factor no longer present: 3 months

Distal DVT 2˚ provoking factor no longer present: 6 weeks

Unprovoked DVT or PE: 3months or more depending on risk

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24
Q

What is a postoperative fever

A

Temperature > 38˚C on 2 consecutive post-operative days or > 39˚C on any 1 post-operative day

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25
Q

Causes of post-operative fever

A

First 48hours post-op
- self-limiting pyretic/inflammatory response to surgery

After 48 hours
- higher risk of infectious aetiology: UTI (day 5), wound infection (day 3-5+), pneumonia (day 5), superficial thrombophlebitis (day 5), catheter-associated intravascular infection, abdominal abscess, foreign body infection (graft, mesh, prosthesis), C diff colitis, sepsis
- wound haemaoma (> day 5 USS)
- drug fever (within 8 days of causative drug starting and associated with rash) e.g., PTU, heparin, allopurinol, phenytoin
- Anastamotic leak (> day 5)
- Intracavitary collection and abscess ( > day 5)
- MI, stroke
- Alcohol withdrawal
- Atelectasis (day 2-5)
- Fat embolism 2˚ major trauma or orthopedic surgery (48-72hrs post-op; associated with petechial rash and hypoxaemia)
- Transfusion reaction (during or up to 1 hour after transfusion)

2nd post-op week or later
- DVT
- PE

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26
Q

Ix of post-operative fever

A

Ix in first 48 hours usually unwarranted unless clinical features suggest an underlying cause

After 48 hours
- FBC
- UA + MC&S
- Blood cultures
- Wound cultures
- CXR
- Further radiology/laboratory testing based on suspected aetiology e.g., sputum cultures/abdo CT/stool cultures

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27
Q

Presentation and Dx of superficial thrombophlebitis

A

Pain at site of line or catheter insertion esp. central venous catheters
Catheter site erythema and tenderness
Purulent material may be expressed from the venous catheter exit site

Clinical Dx
+/- Culture of purulent discharge
+/- USS for abscess/thrombosis visualisation

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28
Q

What does a spiking fever after surgery suggest

A

Abscess e.g., abdominal abscess (Ix with FBC, blood cultures and CT abdo)

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29
Q

How is a fat embolism post-op Ix

A

CXR: diffuse interstitial pattern suggestive of ARDS

Chest CT: diffuse ground glass appearance

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30
Q

What is a fistula and list examples

A

Abnormal communication between 2 epithelial surfaces (lined by granulation tissue and colonised by bacteria)
e.g., pancreaticocutaenous, fistula-in-ano, colovesical, vaginovesical

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31
Q

Causes of fistulas

A

Abscess formation and spontaneous drainage e.g., diverticular abscess discharging into vagina with fistula formation
Penetrating wounds
Specific disease e.g., Crohn’s disease
Iatrogenic e.g., anastomotic leak discharging via wound
Neoplastic

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32
Q

Persistence of fistula is due to:

A

Distal obstruction of the viscus of origin
Presence of foreign material e.g., suture/bone in a sinus
Continuing active sepsis
Epithelialisation of the track
Malignancy in track
Chronic inflammation e.g., Crohn’s disease

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33
Q

Fistula management

A

Treat sepsis, fluid imbalances, and poor nutrition if associated
Ensure good drainage to ensure fistula extension
ID fistula anatomy (examine under anaesthesia or use imaging if required)
Biopsy if concern around underlying Dx

Definitive Tx:
- excision of organ of origin or closure of site of origin
- removal of chronic fistula track and surrounding inflamed tissue
- closure of recipient organ if internal or drainage of external site if to skin

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34
Q

What is an ileus

A

Ileus is a slowing/lack of GI motility (aperistalsis) resulting in interrupted normal passage through the bowel not associated with mechanical obstruction.

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35
Q

When does post-operative ileus usually present

A

2-3 days following surgery

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35
Q

What is prolonged postoperative ileus

A

Ileus lasting 4 days or more post-surgery

Defined as 2 or more of following occurring on or after day 4 post-ip without prior resolution of post-op ileus:

  • vomiting
  • abdo distension
  • inability to tolerate oral feeding
  • absence of flatus
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36
Q

Causes of ileus

A

Intra-abdominal or retroperitoneal surgery (e.g., spinal/pelvic) but can occur after any major surgery
Inflammation of intra-abdominal, pelvic, or retroperitoneal organs e.g., appendicitis, cholecystitis etc.
Abdominal, retroperitoneal or multi-organ trauma

Medications e.g., opioids, anticholinergics, TCAs
Endocrine: hypokalaemia, hypomagnesaemia, hyponatraemia

Neuropathy e.g., DM, Parkinsons disease, spinal injury
Vascular disease e.g., mesenteric ischaemia

Sepsis/other serious systemic illness

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37
Q

Pathophysiology of ileus

A
  1. Bowel irritation/inflammation/high catelcholamine levels
  2. SNS activation and local NO, CGRP, VIP, substance P release
  3. Decreased peristalsis and relaxation of intestinal smooth muscles
  4. Stasis of luminal contents –> bowel wall distension
38
Q

How does post-operative ileus usually resolve

A

Motility returns in SI (<24hrs) –> stomach (24-48h), LI (>48h)

Signalled by passage of stool/flatus and tolerance of oral diet

39
Q

Clinical features of post-operative ileus

A

Nausea, vomiting
Abdominal distension or tenderness
Obstipation
Discomfort and abdo pain

Decreased/hypoactive bowel sounds
Tympanic to percussion
No features of mechanical obstruction or peritoneal inflammation e.g., abdo hernia or peritoneal signs

Possible hypovolaemia (fluid sequestration/third spacing in bowel loops + osmotically active substances in lumen draw fluid in)

40
Q

What is the cause of distension in bowel obstruction or ileus

A

Swallowed air
Bacterial fermentation
Ingested GI contents
Fluid sequestration (osmotically active contents draws fluid into lumen)

41
Q

Dx of ileus

A

Clinical Dx

Consider:
FBC
UECs, CMP
ABG (alkalosis may present in dehydrated patients; acidosis may be present in intestinal ischaemia)

Imaging can be performed if concern RE mechanical obstruction
- Abdo USS, XR, CT with contrast

42
Q

Mx of postoperative ileus

A
  1. NPO and IV fluids (monitor fluid status and electrolytes)
  2. Reduce opioid analgesia and replace with non-opioid analgesia
  3. Encourage mobilisation
  4. Consider NG decompression if significant abdo distension, repeated vomiting, or high aspiration risk
  5. If prolonged give parenteral nutrition to patients who do not have any oral intake for more than 7 days
43
Q

What is oliguria?

A

Urine output < .5ml/kg/hr or < 400ml/day

Urine output that is inadequate to maintain physiological homoeostasis.

44
Q

What is anuria

A

No measurable urine output

45
Q

Causes of post-operative oliguria

A

AKI

Pre-renal
- hypovolaemia and resultant inadequate renal perfusion = MC (usually 2˚ to inadequate perioperative fluid Mx but can be due to sepsis)
- acute heart failure –> poor CO and failure to maintain adequate renal perfusion (may be 2˚ fluid overload, arrhythmia e.g., AF, myocardial ischaemia)
- drugs interfering with renal perfusion regulation e.g., ACEIs

Intrinsic
- nephrotoxic drugs
- prolonged hypovolaemia (and ATN)
- acute exacerbation of pre-existing renal disease

Postrenal
- UT outflow obstruction e.g., obstructed catheter/BPH

NB there is post-op antidiuresis (post-op ADH release increases)

46
Q

Work up of postoperative pt with anuria/oliguria

A

Hx
- pre-existing heart or renal disease?
- corticosteroids prior to surgery? stopped perioperatively? (can aggravate hypotension)

Ex
- well/unell
- drowsy/confused (could indicate severe shock)
- HR, BP, SpO2, RR
- postural and supine BP
- check fluid status (CR, temp, pulse strength, MMM, skin turgor, JVP, crackles on auscultation, sacral oedema, palpable bladder, ankle oedema)
- operative site and drains
- flush catheter

Drug chart: antihypertensives, NSAIDs
Op report and anaesthetic chart
- how much fluid intraoperatively
- epidural analgesia? (predisposes to hypotension)
Fluid chart
- complete anuria suggests blocked catheter –> flush it to check

NB. signs of shock may be masked by B-blockers or epidural anaesthesia

Ix: depending on clinical findings e.g.,
- FBC in haemorrhage (but note that Hb does not drop immediately due to Hb and plasma being lost in same amounts)
- HF: CXR, ECG
- UEC for renal impairment
- Septic screen if febrile

47
Q

Mx of post-op pt with oliguria/anuria

A

Aim = restore urine output and Tx underlying cause

Prerenal
- hypovolaemia: 250ml fluid boluses (smaller volume if elderly or heart disease Hx)
- urinary catheter inserted to monitor hourly output
- reassess (pt fluid status and urine output) –> 2nd bolus if UO still low and no fluid overload –> still low –> senior colleague help me
- fluid overload: diuretic (furosemide e.g., 20-40mg IV)

Intrinsic
- senior colleague help me

Postrenal
- insert or flush urinary catheter or Tx obstruction

48
Q

Causes of perioperative chest pain

A

Dull central ache
- myocardial ischaemia
- gastric distension

Central pain radiating to back
- thoracic aneurysm/dissection
- PUD, oesophagitis, rarely pancreatitis

Pain on mvmt
- msk pain
- chest drains

Pleuritic pain
- chest infection
- pneumothorax
- haemothorax, pleural effusion, empyema
- chest drain in situ
- PE

49
Q

Why might surgery precipitate myocardial ischaemia/infarction

A

Pts (esp. in vasc surg) may have pre-existing IHD exacerbated by:
- stress response to surgery (endogemous catelcholamine release triggered by anxiety, pain)
- fluid overload post-op
- profound hypotension
- failing to restart anti-anginal medication post-op

50
Q

What is post-operative atelectasis

A

Loss of lung volume caused by deflation of alveoli and subsequent collapse of part of the lung.

Commonpost-operativecomplicationsesp. after chest or abdominalsurgery

51
Q

Triggers for post-op atelectasis

A

Often precipitated by
- postoperative pain
- poor lung compliance
- retained airway secretions
- airway edema
- anesthetic effects
All interfere with effective coughing, deep breathing, and mobility

52
Q

Clinical features of atelectasis

A

Symptoms depend on the acuity and extent of atelectasis.
- Small number of affectedalveolior slowly manifesting atelectasis → asymptomatic or minimal symptoms
- Large number of affected alveolior rapid onset →acute dyspnoea, chest pain, tachypnea, tachycardia, cyanosis

Dull percussion note
Diminished breath sounds
Decreasedvocal fremitus over the affectedlung
Possible tracheal deviation towards side of lesion
- Possibly[tracheal deviation]

53
Q

Ix for post-op atelectasis

A

Consider ABG if pt in distress: hypoxaemia, possible respiratory alkalosis and low pCO2

CXR or CT: evidence of lobar collapse, displacement of fissures,homogeneous opacification of the collapsed lobe
+/- elevation ofipsilateraldiaphragm, displacement of the hilum and mediastinal towards the affected side, loss of volumein the affected sideof the chest, increased lucency and overinflation of unaffectedlung

Bronchoscopy can be done if aetiology uncertain
and mucus plugs can be removed

54
Q

Prevention of post-operative atelectasis

A

Prevention

  • Preoperative measures
    • Smoking cessation prior to electivesurgery (6–8 weeks)
    • Physical therapy e.g, breathing and aerobic exercises
    • Treatment of poorly controlledasthma, symptomaticCOPD and respiratory chest infections.
  • Intraoperative ventilation withPEEP: positive pressure ventilation reduces alveolar collapse bystentingopen theairways
  • Postoperative
    Incentive spirometry (most important)
    Pain control (opioids)
    Adequate mobilisation
55
Q

Treatment of post-operative atelectasis

A
  • Adequateanalgesia
  • Early mobilization
  • Lung expansion maneuvers thatincrease positiveend-expiratorypressure
    • Deepbreathing exercises
    • Directedcoughing
    • Intermittentincentive spirometry
    • Continuous positive airway pressurefor patients unable to performdeep breathing exercises.
  • Treatment of underlying condition (pneumothorax, tumour, foreign body aspiration etc.)
56
Q

Complications of atelectasis

A

Pneumonia
Lung abscess
Respiratory failure

57
Q

Presentation of post-operative confusion

A

Disoriented
Uncooperative
Hallucinating
Inactivity
Quietness
Slowed thinking
Labile mood

58
Q

Assessment of post-operative confusion

A

Assess if pt is oriented in time, person and place and perform a quick MSE if still unsure

59
Q

Common causes of post-op confusion

A

Medication (benzos, opiates, anticonvulsants)
Stroke
Hypoxia
Hypercapnea
Shock
Sepsis
Alcohol withdrawal
Metabolic disturbances (reduced glucose, Na+, and pH, increased Ca2+. creatinine, urea, and bilirubin)
Post-ictal
Pre-operative dementia
UTI/urinary retention
Dehydration

60
Q

Mx of post-op confusion

A

If pts behaviour poses a physical danger to themselves or others possible sedation as first-line e.g., haloperidol (beware if hypoxic/hypotensive → cardiorespiratory arrest)

Assess and Tx hypoxia and hypotension

Reassess drug chart and stop opiates and benzos

Correct abnormalities e.g., reduced glucose, reduced Na+

Alcohol withdrawal → diazepam

Neuro exam for FNDs and consider CT head to exclude stroke

Usually always reversible

61
Q

Describe the types of post-operative haemorrhage and broad causes

A

May be arterial or venous → both life threatening

Arterial:
- Significant arterial haemorrhage is rare and usually occurs from vascular anastamoses
- v. rarely arises from solid organ injury or loosening of arterial ties

Venous bleeding MC
- opening of unsecured venous channels or damage to liver/spleen at surgery

62
Q

Differentiate bw venous and arterial haemorrhages

A

Arterial:
- rapid, bright red in colour and often pulsatile

Venous:
- non-pulsatile, low pressure, dark in colour
- can be large volume

Both:
- mostly not overt and contained in body cavities
- drains are unreliable sign of bleeding

63
Q

Causes and features of post-operative haemorrhage

A

Primary haemorrhage: occurs immediately after surgery or as continuation of intra-operative bleeding
- usually due to unsecured BVs e.g., liver bleeding following trauma

Reactionary haemorrhage: occurs within first 24hrs
- usually venous bleeding and is commonly thought to be due to improved post-operative circulation and fluid volume exposing unsecured vessels that bleed (e.g., delayed splenic bleeding following minor trauma at laparotomy)

Secondary haemorrhage: occurs up to 10days post-op
- usually due to infection of operative wounds or raw surfaces causing clot disintegration and bleeding from exposed tissue

64
Q

Clinical features of post-operative haemorrhage

A

Symptoms
Confusion and agitation due to cerebral hypoxia secondary to hypotension

Signs
- soaked dressings
- acute wound swelling
- blood in drains
- pallor, diaphoretic, tachypnoeic, tachycardic, hypotensive (late sign in children and YAs)
- reduced UO

65
Q

Emergency Mx of post-op haemorrhage

A
  • Rescusitation
    • establish large caliber IV access
    • give crystalloid fluid up to 1000mL bolus if tachycardic or hypotensive
    • attempt to control superficial bleeding with direct compression (do not use torniquets)
    • take blood for emergency cross match if serum is not already available → order crossmatch for minimum 2 units of blood
      • only use O Rh- blood if pt is at point of dying
    • get senior help immediately if significant/consider alerting theatres or ICU
    • catheterise and place on fluid balance chart if hypotensive but stable
  • Establish Dx
    • cause may be obvious from bleeding or operation
    • read operation notes for any potential cause
    • if severe bleeding re-operation may be needed to establish Dx
    • if stable and re-operation is undersirable consider imaging → CT may reveal intra-abdominal or intrathoracic blood; angiography may reveal active bleeding sites and can be used for Tx (coil embolisation)
  • Definitive management
    • most post-op bleeding does not require re-operation
    • re-operation desirable → re-bleeding after solid organ trauma
      • definitive conservative Mx → radiologically guided embolisation, FFP infusion, controlled permissive hypotension?, monitoring
66
Q

What is a wound haematoma

A

Localised collection of blood beneath wound or at site of surgery usually characterised by swelling and discolouration

67
Q

Mx of wound haematoma

A
  • if occurs after vasc surgery, flap surgery, or procedures on limbs/neck → urgent surgical exploration and evacuation may be indicated to avoid ischaemia, compartment synromes, airway obstruction, flap failure or ongoing haemorrhage
  • apply firm pressure followed by pressure dressing
  • check clotting and FBC and Tx appropriately
  • withold heparin
  • surgical Mx is same as for haemorrhage
68
Q

Causes of post-operative DIC

A

May occur as a complication of sepsis, transfusion reAction, drug reaction, transplant rejection, and aortic aneurysm surgery

69
Q

What is DIC

A

Syndrome characterised by haemorrhage, thrombosis, and organ damage secondary to systemic activation of coagulation cascade  clotting factor exhausation and platelet consumption

70
Q

Causes of DIC

A

Sepsis/severe infection, including severe coronavirus disease 2019 (COVID-19) infection[3]
Major trauma or burns
Some malignancies (acute myelocytic leukemia or metastatic mucin-secreting adenocarcinoma)
Obstetric disorders (amniotic fluid embolism, eclampsia, abruptio placentae, retained dead fetus syndrome)
Severe organ destruction or failure (severe pancreatitis, acute hepatic failure)
Vascular disorders (Kasabach-Merritt syndrome or giant haemangiomas, large aortic aneurysms)
Severe toxic or immunological reactions (blood transfusion reaction or haemolytic reactions, organ transplant rejection, snake bite).

71
Q

Presentation of DIC

A

Circulatory collapse
- oliguria
- hypotension
- tachycardia

Micro/macrovascular thrombosis
- purpura fulminans
- gangrene
- acral cyanosis
- delirium
- coma

Generalised bleeding at at least 3 unrelated sites
- petechiae
- ecchymoses
- oozing
- haematuria

72
Q

Ix in DIC

A

FBC including platelet count
PT (INR)
APTT
Fibrinogen
D dimer

Other/imaging depending on underlying disorder and areas of thrombosis and haemorrhage

73
Q

DIC Mx

A

Tx of underlying disorder

+ platelets if < 20 or < 50 with active bleeding

+ FFP to replace coagulation factors and coagulation inhibitors if significant bleeding or very low fibrinogen
- cryoprecipitates and fibrinogen concentrates are second-line

74
Q

Delivering bad news

A
75
Q

Uses of surgical drains

A

To remove existing abnormal collections of fluid, blood, pus, air (e.g., drainage of subphrenic abscess, removal of pneumothorax)

To prevent build up of either normal bodily fluids (e.g., bile after surgery to bile duct) or potential abnormal fluids or air (e.g., bloody fluid in pelvis after rectal surgery)

Occasionally used to prevent or warn of potentially serious or life-threatening complications (e.g., neck drains after thyroid surgery)

76
Q

Potential complications of surgical drains

A

Damage to structures on insertion (even when CT/USS guided)
- e.g., spleen injury in subphrenic abscess drainage

Route of infection
- esp. external drain remaining in place > few days

Damage to nearby structures
- e.g., pressure injury to bowel if subjected to high pressure suction drainage

False sense of security/failure to drain the substance expected
e.g., failure to drain faecal fluid after anastomotic leakage

77
Q

Types of surgical drains

A

Open passive drain: conduit around which secretions may flow

Closed passive drain: drain fluid by gravity or capillary flow

Closed active drain: generative active low or high pressure suction

78
Q

Discuss discharge planning

A
  1. Knowing it is nearing time for discharge: infection markers trending down, bowels open, drains removed, passed TOV, drinking nourishing fluids or meals as appropriate, pain well managed, support at home
  2. Pt education: re what they can and can’t do (driving, work, diet, lifting) and red flags to look out for (infection/bleeding)
  3. Arrange wound care if required (Silverchain dressings, suture removal)
  4. Arrange follow up in clinic and referral to other specialties as required
  5. Liaise with social work, OT, physio and other services to assist with independent living at home, rehab, temporary help following surgery etc. as required
  6. Referral letter to GP outlining procedure and future care and follow up needs/how to be Mx in community
  7. Discharge with medications, letters etc
79
Q

Discuss complications arranged in timeframe

A
80
Q

DDx for PE

A

Acute MI
Aortic dissection
Septic shock
Chest infection
Haemothorax
Pneumothorax

81
Q

Clinical features of PE

A

Tachycardia
Dyspnoea, tachypnoea
Haemodynamic instability (hypotension)
Fever
Elevated JVP

Haemoptysis
Pleuritic chest pain
Dull chest pain
Pleural friction rub
Split 2nd heart sound (delayed pulmonary valve closure 2˚ HTN)

Signs of DVT

82
Q

What pattern is seen on ECG in PE

A

S1 Q3 T3 = pattern of RV strain

83
Q

Pathophysiology of PE

A

Embolus usually from DVT travels via IVC to RH and then into pulmonary vasculature where it lodges

  • V/Q mismatch due to impaired pulmonary blood flow –> impaired gas exchange and hypoxaemia and hypercarbia (CO2 not delivered to lungs for removal, and O2 not delivered from lungs into circulation)
    RESPIRATORY FAILURE
  • Pulmonary HTN –> RV overload –> RH failure –> CCF –> reduced CO and haemodynamic instability
    OBSTRUCTIVE SHOCK
  • Infarction of lung parenchyma –> inflammation, leaky capillaries (pleural effusion) and irritation of parietal pleura
84
Q

Investigations of Post-op PE

A

Wells criteria

D-dimers often elevated in post-op patients
FBC, UEC, coags, LFTs
ABG

ECG

CTPA (avoid in young patients due to radiation exposure, contrast allergy, renal failure)

V/Q Scan (renal failure pts, contrast allergy)
- limited use in patients with significant underlying lung disease, LV failure, or CCF

Echocardiogram

85
Q

CXR features of PE

A

Hampton’s hump (pleural wedge of opacity 2˚ infarction)

Westermark sign (translucency of under-perfused distal zone)

86
Q

Wells criteria for PE

A
  1. Symptoms of DVT = 3
  2. More likely than any other Dx = 3
  3. Past DVT/PE = 1.5
  4. Immobilisation for 3+ days or surgery within last month = 1.5
  5. Tachycardia = 1.5
  6. Active cancer = 1
  7. Haemoptysis = 1

Score of 4+ = PE likely

87
Q

What criteria should be used if there is low clinical suspicion for PE

A

PERC (PE rule out criteria)
No further investigation is indicated if a patient meets the PERC rule
If fail PERC rule request a D-dimer

88
Q

Outline PERC rule

A

Age <50 years
Heart rate <100 bpm
SaO2 on room air ≥95%
No unilateral leg swelling
No haemoptysis
No recent surgery or trauma (≤4 weeks ago requiring treatment with general anaesthesia)
No prior PE or DVT
No hormone use (oral contraceptives, hormone replacement, or oestrogenic hormones used in male or female patients).

89
Q

Mx of haemodynamically stable PE

A

Apixaban 10mg BD 7 days –> 5mg BD or
Rivaroxaban 15mg BD 21 days –> 20mg once daily

90
Q

Mx of haemodynamically unstable PE

A

Fibrinolysis
- e.g., alteplase 10mg IV bolus followed by 1.5mg/kg by IV infusion over 2 hour
- or tenecteplase

Following fibrinolytic therapy start a parenteral anticoagulant when APTT is < 2x ULN
- e.g., 1mg/kg SC enoxaparin BD
- UFH for renal impairment

Consider interventional Tx e.g., thrombus aspiration or surgical thrombectomy

91
Q

Routine post-operative nutrition management

A

Patients may be started on oral intake directly after most forms of surgery

Pts with PUD or dyspepsia should be started on IV PPI (+ avoid NSAIDs)

Downscale post-op analgesia from opioids to non-opioids ASAP to minimise nausea, vomiting, ileus, constipation, anorexia

Give regular IV antiemetics for persistent N & V

92
Q

Why is early enteral nutrition post-op important

A

Prevents breakdown gut-mucosal barrier
Reduced pulmonary, septic, and anastomotic complications

93
Q

Enteral nutrition methods

A

Feeding using GIT

Sip feeds
Fine bore NGT
Nasojejunal tube
Percutaneous endoscopic gastrostomy and jejunostomy
Open surgical gastrostomy or jejunostomy

94
Q

Indications for supplementary enteral feeding

A

Inadequate oral intake due to anorexia, practical difficulties with feeding, drug-induced nausea, poor oral health or dentition

Hypercatabolism exceeding normal intale (chronic sepsis, malignancy, trauma, burns)

Gut intact but absorption impaired excessive losses: chronic diarrhoea, high output stoma or fistula

95
Q

Complications of supplementary enteral feeding

A

Complications of feeding tube
- malposition (feed into lungs –> infection/respiratory arrest)
- blockage/tube kinking
- wound infection around jejunostomy tube
- pressure injury

Complications of administration
- pulmonary aspiration
- regurgitations
- diarrhoea (MC), bloating, nausea, cramps

Complications of contents
- vitamin and trace element deficiencies
- electrolyte imbalances
- contamination –> infection
- drug interactions

96
Q

What is Total Parenteral Nutrition

A

IV administered specially formulated feeds

97
Q

Indications for TPN

A

Failure of bowel to absorb food e.g., radiation damage, severe acute enteritis, malabsorption syndromes

Short bowel syndrome (inadequate length for adequate absorption)

GIT not accessible for enteral route e.g., acute severe pancreatitis, oesophogastric surgery etc.

Surgery (17 decks)

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