Post-op abdo pain Flashcards
What would be your concern with post-op abdo pain?
- intra-abdominal collection
- bile leak - intraop injury to bile duct
- retained calculus (cholecystectomy) +/- ascending chalangitis or pancreatitis
- perforated bowel
- wound infection
- systemic sources of sepsis
A + B
Airway: ensure airway patency
Breathing:
- Recheck oxygen saturation and respiratory rate.
- Administer high flow oxygen (15L through non-rebreather mask).
- Examine chest – inspect, auscultate and percuss
C + D
Circulation:
- Recheck blood pressure and pulse rate
- Capillary refill, JVP and ask for 12 lead ECG
- IV access with 2 wide bore cannula
- Commence a fluid challenge of 10mls/kg warmed crystalloids as normotensive or 5ml/kg in a cardiac patient (Or 20mls/kg in hypotensive patient) As per CCrISP
- Bloods: FBC, U&E, LFT, Clotting, G&S, Blood culture
- Blood gas including serum lactate
Disability:
- Check: conscious level, blood glucose, temperature and pupils.
E + everything else
Exposure:
- expose patient
- take down dressing and assess for wound infection
- review drain contents
+
- examine abdo for signs of peritonitis
- full patient assessment
- review chart
- check available results
- dicuss with senior
- analgesia
What would you look for in the patient notes/ electronic patient records to assist with your diagnosis?
-
Charts:
- Observation charts – other temperature spikes or tachycardia? Gradual or acute.
- Fluid balance chart (properly documented? Any fluid deficits? Drainage outputs: high output? Contents – bilious? Blood? Pus?
- Any missed medication e.g. antibiotics, LMWH, regular analgesia given for pain -
Clinical and operation notes:
- Preoperative/ presentation: indication, elective procedure or ‘hot’/ acute cholecystectomy
- Previous abdominal surgery? co-morbidities e.g. diabetes, cardiac, respiratory, obesity?
- Operation note: open, laparoscopic or conversion to open? Intraoperative difficulties or complications e.g. bile leak, injury to structures, haemorrhage, adhesions with challenging anatomy? Number of ligature clips used on cystic duct?
- Post-operative reviews – acute deterioration or gradual? Any concerns identified previously? -
Available results
- Recent blood tests or blood gases for trends
- Perioperative imaging – ultrasound, CT scan, MRCP, ERCP – reports and review of films.
- Microbiology culture results and sensitivities
What investigations would you order?
Bedside:12 lead ECG, urine dipstick and sample for MC&S, wound swab for MC&S.
Haematological: FBC, U&E, LFT, Clotting, G&S, Blood culture, Blood gas
Radiological:
- Abdominal ultrasound for free fluid or collections
- CT abdomen and pelvis – free fluid, abscess and anastomotic leak.
- CXR assessing for consolidation suggestive of lower respiratory tract infection or pulmonary oedema secondary to fluid overload.
- ERCP +/- therapeutic drain insertion
- MRCP for possible retained stone (if the patient is stable)
How would sepsis management be delivered in this case?
Sepsis 6 within 1 hr
1. Ensure senior help attends (ST3+) (added 2019)
2. Give oxygen if required aiming for saturations of 94-98% (or 88-92% if risk of hypercapnia)
3. Obtain IV access, take bloods. Including cultures, glucose, lactate, FBC, U&Es, clotting.
4. Give intravenous antibiotics (maximum dose broad-spectrum according to Trust Policy)
5. Start intravenous fluid resuscitation
6. Monitor: use NEWS2, measure urine output (may require catheter), repeat lactate at least hourly if elevated or clinical condition changes.
involve critical care if pt is persistently hypotensive or persistently raised lactate >4 - to consider vasopressors
The CT abdomen scan reveals a perihepatic fluid collection, the patient remains tachycardiac and is now hypotensive. How would you proceed with further management?
Pt is unstable with septic shock, so needs definitive management, likely with surgery
- inform senior surgeons
- reassess pt with ABCDE and sepsis bundle
- NBM
- prepare consent
- d/w on-call registrar
- d/w anaesthetist
- d/w theatre coordinator
