Post-op tachycradia Flashcards
What are some differentials for post-op tachycardia?
abdominal surgery
- intraabdominal collection
- leakage of bowel contents
- dehydration
- VTE
- sepsis/systemic infection
A and B
Airway: ensure airway patency
Breathing:
- Recheck oxygen saturation and respiratory rate.
- Administer high flow oxygen (15L through a non-rebreather mask).
- Examine chest – inspect, auscultate and percuss
C
- 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
D and E
Disability: conscious level, blood glucose, temperature, and pupils.
Exposure:
- Expose patient fully and take down dressing on the abdomen to assess for signs of wound infection.
- Examine the abdomen for signs of peritonitis
After A-E assessment
- Review the operation note: any complications or difficulties during the surgery?
- Review patient notes for recent entries and trend of recent observations – was this an acute deterioration? Other co-morbidities which may contribute.
- Review drug chart – has analgesia been given if the patient is in pain, have any medication such as antibiotics been missed
- Review recent results - bloods and cultures
- Escalate to senior if concerned by any of the findings.
What investigations would you order for post-op tachycardia?
Bedside: Urine dipstick and sample for MC&S, wound swab for MC&S, ECG
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 breakdown of appendix stump.
- CXR assessing for consolidation suggestive of lower respiratory tract infection or pulmonary oedema for fluid overload. NB pneumoperitoneum usually remain for 3-6 days post-op.
What information would you want to know if you were reviewing the operation note?
appendicectomy
- Type of appendicectomy e.g. open or laparoscopic
- Date and time of the procedure
- Operating surgeon
- Were antibiotics given on induction?
- Intraoperative findings e.g. free fluid in the peritoneal cavity, appendix ruptured/ or any contamination of contents.
- Ligation of the stump: number and type of ties or clips used.
What is an abscess?
An abscess is a pus-filled epithelialized cavity
How would you proceed and what management options would be available?
Dx: abscess
Reassess the patient using an ABCDE approach and ensure a ‘sepsis bundle’/ sepsis 6 (2021)
- Senior review
- Maintain oxygen saturation 94-98%
- Intravenous access, take blood – including lactate, blood cultures, glucose, FBC, U&Es, clotting
- Intravenous maximum dose broad-spectrum antibiotics according to Trust guidelines
- Intravenous fluid resuscitation
- Monitor: observations, urine output (catheter), repeat lactate (if raised)
To guide definitive management, I would discuss the case with a senior member of the surgical team.
Definitive management commonly consists of ultrasound or CT guided drainage or surgery.
What is NCEPOD?
NCEPOD stands for National Confidential Enquiry into Patient Outcome and Death and is a government supported scheme which aims to maintain and improve standards of healthcare through confidential studies and surveys. Initially National Confidential Enquiry into Perioperative Death, the organisation now covers all specialties and all patient outcomes, including patient mortality/ death.
The NCEPOD classification is a 4 code system used to determine the level of urgency of a procedure including ‘emergency’, ‘urgent’, ‘scheduled’ and ‘elective’.
How would you classify an appendicectomy in NCEPOD?
‘Urgent’ operation = code 2
see the table
