Post-op pyrexia Flashcards
What can you do if a nurse calls about a patient?
Tell the nurse you’ll see the patient then you can ask them to:
- give oxygen
- IV access and start fluids
- collect bloods/culturs/VBG
- ECG
- get patient notes and ward entries
What is the guideline for surgical patients who get sick?
Care of the Critically Ill Surgical Patient
What is the basics of CCrISP?
- ABCDE
- Full assessment: chart review, history and systematic examination, available results
- Decide and plan - INFORM senior
What is the extra thing to do in C for CCrISP?
Commence a fluid challenge of
- 10mls/kg warmed crystalloids as normotensive
- 5ml/kg in a cardiac patient
- 20mls/kg in hypotensive patient
What are extra things to do in E?
- check dressing, assess for wound infection
- examine abdomen for peritonitis
- review drain outputs and fluid balance
Who to contact about this patient?
- registrar on call
- operating team
- consider critical care outreach
What are differential diagnosis for pyrexia on pt with hemicolectomy and anastomosis?
- anastomotic leak
- intraabdominal collection
- wound infection
- systemic infection e.g. UTI, chest infection
- non-infective: drug induced, VTE, pain, atelectasis, physiological stress-response to surgery
What investigations to order for post-op pyrexia?
Bedside:
- ECG
- urine dip and culture
- wound swab for MC+S
Haem:
- FBC, U+E, LFT
- clotting, G+S
- blood culture
- blood gas
Radio:
- abdo USS for free fluid or collections
- CT AP - free fluid, abscess, anastomotic leak
- CXR - LRTI, pulm oedema
What would you review in the patients notes?
Charts:
- obs - other temp spikes/tachy, gradual/acute
- fluid balance chart, drainage outputs and content
- missed medication e.g. Abx, LMWH, analgesia
Clinial and op notes:
- preop presentation: indication and premorbid state
- prev abdo surgery?
- comorbidities e.g. DM, cardio, resp, obesity
- op notes: open/lap? complications? stapled/sutured?
- post-op reviews: acute/gradual deterioration? prev concerns?
Results:
- recent bloods
- periop imaging
- MC+S
What are risk factors for anastomotic leaks?
- Patient factors: age, smoking, steroid use, DM
- Pathology: collagen disorders, IBD, autoimmune conditions, vascular disease
- Technical: op technique/skill, quality of ends, blood supply, tension of anastomosis, site (end-to-end is better than colon-rectal)
- Modifiable: smoking, alcohol, obesity, nutrition, medication e.g. steroids
- Non-mod: age >60, male, Hx radiotherapy, DM, high ASA, renal disease, vascular disease, pulm disease
What is sepsis?
Defined as ‘life-threatening organ dysfunction caused by a dysregulated host immune system’
What is septic shock?
A subset of sepsis with circulatory and cellular/metabolic dysfunction associated with higher risk of mortality than sepsis alone.
Define shock
A life-threatening condition characterised by tissue perfusion, which is inadequate to meet metabolic demands.
How would you manage abdominal free fluid and anastomosis dehiscence?
Pt needs emergency surgery and assessment
Inform:
- gen surg reg/cons
- Emergency anaesthetists
- HDU/ITU
- theatre coordinator
Preop prep:
- reassess pt and manage pt to prime condition for surgery
- book case in emergency theatre
- discuss with patient
- NBM
- preparing consent form
- marking surgical site
- check bloods, ensure crossmatched
- analgesia
What are the differential diagnoses of pyrexia, productive cough, tachypnoea, tachycardia?
- postoperative pulmonary atelectasis due to mucus accumulation in bronchial tree
- pneumonia
- PE/DVT
- wound infection (unlikely very soon after surgery)
- other sources of infection e.g. UTI, celluliitis, pressure sores
What factors can be responsible for postop atelectasis?
Patient
- pack yr Hx
- COPD
Periop:
- gases, intubation
- muscle relaxant
- mechanical ventilation
- lying prone
- laparoscopy - CO2 insufflation
Post-op:
- reduced mobility
- pain from coughing and deep breathing
- inc risk of aspiration pneumonia
