Surgical Clerking and Making a Plan

Question 1

Which patients should you have a lower threshold for admission?

Answer 1

• Have a lower threshold for keeping elderly, more vulnerable patients in hospital and if you have any doubts, discuss the patient with your senior or admit them.
• You will likely face pressure regarding the scarcity of beds, but patient safety should always be your primary concern.

Question 2

WHO analgesic ladder

Answer 2

• Mild pain: non-opioid analgesics such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs)
• Moderate pain: weak opioids such as codeine
• Severe and persistent pain: strong opioids such as morphine and oxycodone
  Generally, every patient can be prescribed regular IV/oral paracetamol, as required (PRN) codeine and a PRN anti-emetic

Question 3

Antibiotics planning in appendicitis

Answer 3

Patients referred to the surgical team with right iliac fossa pain and clinical suspicion of appendicitis (i.e. not confirmed with imaging) generally fall into one of three categories:

1- Clear history and decision taken for surgery – give antibiotics
2- Unclear history, but decision taken for surgery – give antibiotics
3- Unclear history (inconclusive blood results and examination findings) and not for surgery – do not give antibiotics. These patients are clinically well and may be admitted for observation, to identify any deterioration on serial examinations and blood tests, and/or for imaging. Antibiotics will non-specifically treat any source of inflammation, so they will cloud decision-making

• Patients with imaging-proven appendicitis, either ultrasound or CT, should be prescribed antibiotics.

Question 4

What can be used to classify diverticulitis?

Answer 4

Hinchey classification

Question 5

Hinchey classification and management

Answer 5

• A system used to classify and stage acute complicated diverticulitis based on the severity of colonic perforation, and has four stages
• Can be applied to diverticulitis occurring anywhere in the bowel, not just the colon
• Broadly, it is uncomplicated (i.e. localised diverticular inflammation with no abscess or perforation) or complicated (i.e. associated with abscess, perforation or peritonitis).
• In general, abscesses in stage Ib and II may be drained by interventional radiology, and stage III and IV disease is managed with emergent surgery

Question 6

Antibiotic decision for diverticulitis

Answer 6

In cases of uncomplicated diverticulitis, antibiotics are generally not recommended unless the patient has systemic signs of inflammation or is high-risk (e.g. immunocompromised, elderly, multiple co-morbidities). However, department practice will vary, so follow your local guidelines.

Question 7

Antibiotic decision in pancreatitis

Answer 7

Although patients with pancreatitis will typically present with a systemic inflammatory response, acute pancreatitis is usually non-infected, so antibiotics are not recommended.

Question 8

Oral intake and/or nasogastric tube decision in surgical patients

Answer 8

• If in doubt, make the patient nil-by-mouth until the surgical registrar sees them. Ensure to inform the nurse looking after them so they are not given food or drink while waiting in ED. Most patients who are nil-by-mouth can still take oral medications with a sip of water.
• If you are concerned about persistent vomiting and the risk of aspiration, the patient requires a nasogastric tube (NGT), also known as a Ryle’s tube. Most nurses in ED or surgical wards will be able to place an NGT, but you should also be able to do so yourself if required.

Question 9

Imaging when clerking surgical patients

Answer 9

• CT of the abdomen & pelvis with IV contrast is the imaging of choice in unwell patients or those with concerning blood results or examination findings
• If a patient is clinically stable, alternative first-line imaging may be more appropriate
• Ultrasounds will not happen overnight, but you can still request them as part of your plan.
• There is a higher threshold for performing a CT scan in younger, particularly female, patients so it is often best to discuss these cases with your senior.

Question 10

Thromboprophylaxis in surgical patients

Answer 10

• Every patient admitted to hospital requires thromboprophylaxis of some sort, and most hospitals will have specific venous thromboembolism (VTE) documentation that needs to be completed on admission.
• If indicated, the choice of low molecular weight heparin varies according to hospital and is dosed according to weight.

Question 11

Things that need to be done in a patient that will have surgery

Answer 11

When pathology is confirmed and requires surgical treatment, inform your registrar and prep the patient for theatre:

• Make nil-by-mouth (NBM) and document when they last ate or drank
• Ensure 2 valid group & save samples are available
• Book onto the emergency operating/CEPOD list
• Inform the on-call anaesthetic team
• If appropriate, consent for the procedure
• Inform the ward and/or nurses looking after the patient
• Overnight, suitable cases will be postponed until daytime when more staff are available, and operating conditions are safer. However, this is a senior decision considering the entire clinical picture, so cases should always be discussed with your senior.
• If a case is for the next day and you have time, you can still prep the patient similarly and make them NBM from 2 am.