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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_958_Библиотеки_им_академика_М_И_Перельмана
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Postoperative care
https://t.me/med1917
Summary of postoperative problems
Chapter 10: General surgical principles 145
Immediate Delayed
• Primary haemorrhage
• Shock
• Low urine output
• Pain
• N&V
• Confusion/delirium
• Infection (pneumonia, UTI, wound)
• Pressure sores
• Paralytic ileus
• Secondary haemorrhage (7–10d post)
• Acute MI (in first 72h)
Immobilisation:
• DVT, PE, stroke – give LMWH/aspirin
• Urinary retention & AKI
• Chest infections – in elderly/ventilated
• Atelectasis
• Pressure sores & muscle wasting
Anastomotic leak
AETIOLOGY: leak of luminal contents from a surgical join → important
complication of GI surgery
RISK FACTORS:
Patient risk factors Surgical risk factors
• Medication (steroids/
immunosuppressants)
• Smoking/alcohol
• DM, obesity, malnutrition
• Emergency surgery
• Longer intra-operative time
• Oesophageal–gastric or rectal anastomosis
• Peritoneal contamination (by free pus or faeces)
Common sources of post-op pyrexia
& infection
Chest (infection)
Catheter (UTI)
Cut (infection)
Cannula (infection)
Calves (DVT)
Central line (infection)
Collections (abdo/pelvis)
1–3d: respiratory
3–5d: urinary
5–7d: wound/abscess/leak
Ix: blood cultures, CXR, urine dip / MCS, cannula
site, surgical wound swab, CT/USS of surgical site
Start SEPSIS 6 if
potential sepsis
(qSOFA score ≥2 /
clinical judgement)
CLINICAL PRESENTATION: 5–7d post-op (often due to ischaemia)
• Abdo pain ± peritonism
• Fever, tachycardia, new atrial fibrillation
→ consider in any patient failing to progress post GI resection
INVESTIGATIONS:
• FBC, CRP, U&Es, LFT, clotting, VBG
• Group & save
• CT with contrast = diagnostic
MANAGEMENT:
• SEPSIS 6 (IV ABX)
• Larger leaks may need drainage or laparoscopic exploration / surgical
intervention
Intra-abdominal abscess
RISK FACTORS:
• Intra-abdominal infection (e.g. appendicitis, diverticulitis)
• Recent intra-abdominal surgery
CLINICAL PRESENTATION:
• Fever
• Anorexia/N&V
• Abdominal pain
• Altered bowel habit / prolonged ileus
CT abdo with contrast
= diagnostic
MANAGEMENT:
• IV ABX + drainage (+ send fluid for culture)
• May need to return to theatre
Surgery
146 Chapter 10: General surgical principles
https://t.me/med1917
AETIOLOGY: reduced intestinal motility → very common following abdo/
pelvic surgery
RISK FACTORS:
Paralytic ileus
Patient risk factors Surgical risk factors
• Increased age
• Electrolyte derangement (e.g. Na+, K+
and Ca2+)
• Neurological disorders (e.g. dementia/
Parkinson’s)
• Use of anti-cholinergic/opioid medication
• Pelvic/abdominal surgery
• Extensive intra-operative intestinal
handling
• Peritoneal contamination (by free pus or
faeces)
More detail on haemorrhagic shock in
Critical illness
Chapter16:
CLINICAL PRESENTATION:
• Failure to pass faeces/flatus
• Abdo distension & absent bowel sounds
• N&V
MANAGEMENT:
• IV fluids & daily bloods (electrolytes)
• Encourage mobilisation
• Review analgesia (opiates) in
conjunction with pain team
• Consider if need to be NBM ± NG
tube (remove stomach contents
toreduce vomiting)
INVESTIGATIONS:
• FBC, CRP, U&Es
• Electrolytes (Ca2+, PO
• Consider imaging: AXR ± CT
(to rule out other pathology
e.g.obstruction)
Ix are done to rule out
more serious pathologies
–
, Mg2+)
4
Post-op haemorrhage
Primary bleed – within intra-operative period → resolved during operation &
close monitoring post-op
Reactive bleed – within 24h of operation → usually a missed vessel / slipped
ligature
Secondary bleed – 7–10d post-op → usually erosion of a vessel 2° to infection
SIGNS/SYMPTOMS: tachycardia, tachypnoea, dizziness, reduced urine output
(NB: hypotension = late sign)
Risk factors for urinary retention:
• >50y
• Spinal/epidural
• Neuro comorbidity
• Paralytic ileus
• Pelvic/uro surgery
Surgery
• Opiates,
antimuscarinics
• Infection/sepsis
• Constipation
INVESTIGATIONS: thorough examination for signs of bleeding/swelling/
discolouration/tenderness/peritonism
MANAGEMENT:
1. ABCDE → IV fluid resuscitation + direct pressure on bleeding site if visible
2. Urgent senior review → may need to return to theatre
3. Urgent blood transfusion – if moderate/severe bleeding (activate major
haemorrhage protocol if necessary)
Urinary retention
PRESENTATION:
• Reduced output
• Suprapubic mass/pain
INVESTIGATIONS:
• USS bladder (residual volume)
• Kidney function: eGFR, U&Es
MANAGEMENT:
• Withdraw causative agents
• Catheter
Work-up for AKI:
• Fluid status
• FBC, CRP, U&Es, LFT
• Urine dip
• USS KUB
Chapter 10: General surgical principles 147
https://t.me/med1917
Postoperative assessment
Use mnemonic: ‘IMPORTANCE’
I Introduction Background of patient
(demographics, type of surgery & anaesthetic, any complications, days post-op)
M Mental state AVPU/AMT10 (compare to their baseline)
P Pain 1. Identify: SOCRATES
2. Manage: regular or PRN analgesia (check if any SEs & if it can it be or )
O Observations 1. Calculate EWS & assess obs from last 24h
2. CVS/respiratory/abdominal exam if needed
R Renal 1. Assess fluid chart (urine output & fluid intake)
2. Check any catheters / surgical drains → assess output volume & colour
T Thromboprophylaxis 1. Check appropriate prophylaxis in place (LMWH, stockings, foot pumps)
2. Check calves for DVT, ask about SOB
3. Mobilise ASAP (encouragement, physio/OT)
A Abdominal 1. Are they eating/drinking?
2. Any N&V? Abdo pain?
3. Have they opened their bowels yet?
N Neurovascular status
C Cut Check post-op wounds, dressings & any drains
E Exercise Have they mobilised yet? (how far? any aids? does physio need contacting?)
Check pulses & sensation → document clearly
Assessment of pain with 'SOCRATES'
S: Site
O: Onset
C: Characteristic
R: Radiation
A: Associations
T: Timing
E: Exacerbating factors
S: Severity
Other things to consider
• Any post-op bloods/imaging that need doing
• Discharge planning & follow-up arrangements
• Anyone else you need to contact (e.g. seniors, nurses, physio/OT, family)
Surgery
148 Chapter 10: General surgical principles
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Fluid therapy
Distribution of fluids
Within extracellular fluid:
75% goes to interstitial,
25% to intravascular
If a patient loses 1000ml of blood, 4000ml of
0.9% NaCl is needed (as 25% of this will replace
the intravascular blood loss)
Interstitial fluid (¾)
10.5L
*carbohydrate-rich layer lining the
vascular endothelium
Things to consider before prescribing fluids:
1. Type of fluid loss
2. Concomitant electrolyte abnormalities
3. Renal & cardiac function
→ fluid distribution is determined by extracellular Na+ concentration
• Water: distributed throughout total body water
• Isotonic crystalloid: stays in extracellular fluid →0.9% NaCl
• Hypertonic crystalloid: draw fluid out of cells → 3% NaCl
• Colloid: intravascular (& some extracellular fluid)
• Blood: intravascular
• Glucose 5%: will distribute throughout all compartments (same as H2O)
Total body water
42L
Extracellular volume (⁄)
14L
Intravascular (¼)
28L
Endothelial glycocalyx* Plasma Fig. 10.1
Transcellular
0.5L
Intracellular volume (⁄)
28L
Total body water = 0.6 × weight
e.g. 70kg man has 42L TBW
Assessing fluid status
• History: limits to intake, thirst, quantity & composition of losses
• Examination: pulse, BP (± orthostatic), CRT, JVP, oedema
• Obs: NEWS2, fluid balance charts / urine output, weight
• Bloods: U&Es, Cr, FBC
• Medication review: diuretics, antihypertensives
→ If still unsure of fluid status, can do passive leg raise manoeuvre (mimics
increased fluid to heart) – if >10% in SV suggests patient will respond to fluid
administration (need invasive monitoring of HR, BP & SV)
Colloids: blood, dextrans, gelatines, human
albumin solution
→ costly & risk of anaphylactoid reactions so
rarely used
Surgery
Types of uids
Na+ (mmol/L) Cl– (mmol/L) K+ (mmol/L) Additives
Plasma (EC fluid) 135–145 100–110 3.5–5.3 Lactate, calcium, glucose
0.9% NaCl 154 154* –
Hartmann’s 131 111 5 Lactate, calcium
5% dextrose – – 50g/ml glucose
0.18% NaCl + 4% dextrose 31 31 40g/ml glucose
* Risk of hyperchloraemic acidosis
Possible side-eects of uid therapy
• Sodium overload (oedema)
• Hyperchloraemic acidosis
• Coagulopathy
• Fluid overload (pulmonary oedema, dilutional hyponatraemia)
→ Stop IV fluids
→ Furosemide
→ SL/IV nitrate
→ CPAP
Principles of uid therapy
https://t.me/med1917
Chapter 10: General surgical principles 149
1. Do not prescribe fluids pre-emptively → regularly review & reassess to
adjust fluids
2. Regular monitoring: UO, BP, pulse, clinical signs of hypo-/hypervolaemia, U&Es
3. Clear prescription & fully completed fluid charts
4. Daily weights if have CCF
5. Switch from IV to enteral fluids ASAP
Resuscitation uids
Appropriate fluid: 0.9% NaCl or Hartmann’s
1. 250–500ml bolus over 15min
2. Reassess (BP, UO, CRT, HR, RR)
3. Further bolus if needed (if >2L get help)
→ Replace blood loss with: RBC, FFP, platelet infusion
See
Chapter 16: Critical illness
on hypovolaemic shock classification
Beware: do not blindly administer fluids if no idea of vital
observations / type of shock
(IV fluids may exacerbate cardiogenic/obstructive shock)
for full table
Classification of hypovolaemic shock:
Volume lost Grade Clinical signs
15% (750ml) 1 Mild tachycardia, CRT 2–3sec
15–30%
(750–1500ml)
30–40%
(1500–2000ml)
40–50%
(>2000ml)
Routine maintenance
Appropriate fluid: NaCl (0.18% or 0.9%) + dextrose (add K
• Calculate daily requirements based on weight
e.g. 70kg patient needs 2100ml/d water (30ml × 70)
e.g. 70kg patient needs 70mmol/d Na+, Cl–, K+ (approx. ½ bag 0.9% saline – as this
contains 154mmol Na+ & Cl–)
Daily requirements account for:
→ 1.5L urine output/day → aim for minimum 0.5ml/kg/h
→ 500–800ml insensible losses/day → increases if febrile
Additional sources of fluid loss to consider & account for:
→ GI losses: if severe diarrhoea/vomiting or high stoma output
→ Drains: biliary, pleural, peritoneal
→ Bleeding/burns
Additional sources of electrolyte loss to consider & account for:
→ Sweating: Na
→ Diarrhoea / high stoma output: Na+, K+ & HCO
→ Vomiting: K+, Cl–, H+ (hypochloraemic metabolic alkalosis)
+
–
(+ Cl– if stoma)
3
+
if needed)
Fluid need
increases 10%
for every degree
of pyrexia
Fluid checks
1. Drug: appropriate fluid chosen?
2. Dose: appropriate volume & rate calculated?
3. Duration: start & review/stop date
documented?
2 Tachycardia, cool peripheries, CRT 3–5sec
3 Marked tachycardia & tachypnoea, reduced BP,
oliguria, confusion
4 Marked tachycardia, low GCS, low BP
Cannot add K+ to Hartmann’s so NaCl may
be better choice of maintenance/replacement if
need K+ replacement
For potassium replacement either:
+40mmol or +20mmol to saline
Max peripheral infusion rate = 10mmol/h
Daily requirements in health:
• Water: 25–30ml/kg (1.5ml/kg/h)
• Sodium: 1mmol/kg
• Potassium: 1mmol/kg
• Chloride: 1mmol/kg
• Glucose: 50–100g
Replacement
Appropriate fluid: NaCl (0.18% or 0.9%) + dextrose (aim for oral replacement if
possible)
Replacement = deficits + maintenance requirements
1. Assess fluid status: examination, fluid balance chart, U&Es
2. Calculate maintenance requirements
3. Add in any deficits (previous & ongoing) e.g. D&V, sweating, stoma output
4. Consider ‘complex’ patients: old, obese, renal/liver/heart failure
5. Monitor: daily bloods & hydration status
Appropriate rate of replacement: 1L over 4–6h
NB: in closed head injury maintain euvolaemia
with 2/3 of maintenance with isotonic solution
to minimise cerebral oedema
Surgery
https://t.me/med1917
151
https://t.me/med1917
THE ACUTE ABDOMEN
General overview.................................................................152
Acute pancreatitis ...............................................................154
Meckel’s diverticulum ...................................................... 156
Acute appendicitis .............................................................. 157
ABBREVIATIONS
AAA – Abdominal aortic aneurysm
ACEi – Angiotensin-converting enzyme
inhibitor
ARDS – Acute respiratory distress
syndrome
CF – Cystic fibrosis
CMV – Cytomegalovirus
CTAP – Computed tomography abdomen
& pelvis
DIC – Disseminated intravascular
coagulation
DKA – Diabetic ketoacidosis
DNACPR – Do not attempt CPR
DRE – Digital rectal examination
EBV – Epstein–Barr virus
ERCP – Endoscopic retrograde
cholangiopancreatography
FB – Foreign body
GORD – Gastro-oesophageal reflux disease
IAP – Intra-abdominal pressure
IBD – Inflammatory bowel disease
IDA – Iron-deficiency anaemia
LHS – Left-hand side
LIF – Left iliac fossa
LN – Lymph node
MI – Myocardial infarction
Diverticular disease ........................................................... 158
Gastrointestinal perforation ....................................... 159
Intestinal obstruction ...................................................... 160
Hernias ........................................................................................ 162
11
MRCP – Magnetic resonance
cholangiopancreatography
OGD – Oesophagogastroduodenoscopy
PID – Pelvic inflammatory disease
PR – Per rectum
PSHx – Past surgical history
RIF – Right iliac fossa
SLE – Systemic lupus erythematosus
SMA – Superior mesenteric artery
UC – Ulcerative colitis
UTI – Urinary tract infection
152 Chapter 11: The acute abdomen
https://t.me/med1917
General overview
• Gallstone disease
▶ Biliary colic
▶ Cholecystitis
▶ Cholangitis
• Hepatitis
• Liver abscess
• Early appendicitis
• Bowel obstruction
• Strangulated hernia
(paraumbilical/umbilical)
Right
hypochondriac
region
• Pancreatitis
• Peptic ulcer
• Inferior MI
• Oesophagitis/
GORD
Epigastric
region
Left
hypochondriac
region
ANY REGION
• AAA rupture
• Mesenteric ischaemia*
• Obstruction
*Mesenteric ischaemia:
consider in patients with
out of proportion pain ±
metabolic acidosis
• Splenic abscess
• Splenic rupture
Right
• Renal calculi
• Pyelonephritis
• UTI
• Appendicitis
(late)
• Ureteric colic
• Crohn’s
• Testicular torsion
• Ectopic pregnancy
Fig. 11.1 This diagram should be used as a guide to the differentials of acute abdominal pain. It is important to note that any of the mentioned
pathologies can present with pain in any area of the abdomen, and thus it is important to correlate location of pain with other clinical signs and
• Meckel’s
diverticulitis
• PID
• Ovarian cyst
• Salpingitis
• Hernia
investigations, and not to rule out differentials based on the location of pain alone.
lumbar region
Right iliac
region
Umbilical
region
Hypogastric
region
• Testicular torsion
• Urinary retention
• Cystitis
• PID
Left lumbar
region
Left iliac
region
• Diverticulitis
• Ulcerative
• Testicular
• Ectopic
• Renal calculi
• Pyelonephritis
• UTI
colitis
torsion
pregnancy
• Sigmoid
volvulus
• Constipation
• PID
• Ovarian cyst
• Salpingitis
• Hernia
Medical causes of acute abdominal pain
Inflammatory Obstructive Perforation Visceral
Peritonitic pain
→ fever, tachycardia
→ WCC, ESR, CR
Surgery
P
• DKA
• UTI
• Basal lobe pneumonia
• Poisoning/overdose
• Addison’s disease
• Hypercalcaemia
• Spontaneous bacterial peritonitis
• Mesenteric adenitis
• Constipation
Patterns of pain
Type of pathology
Colicky pain (waves of pain)
→ vomiting, constipation
→ distension, tinkling sounds
Peritonitic pain = worse on inspiration & movement → lie still, shallow breaths, rigidity & guarding
Sudden localised then peritonitic pain
→ shock ( HR, RR, BP)
→ N&V
Poorly localised pain (referred)
→ specific Sx e.g. jaundice
Investigations & management
https://t.me/med1917
Chapter 11: The acute abdomen 153
INVESTIGATIONS:
• Obs: BP, HR, RR, sats, temp, ECG
• Pregnancy test: in all females of child-bearing age
• Bloods: FBC, U&Es, LFT, CRP, amylase, glucose, clotting, ABG (lactate)
• Urinalysis: protein, nitrates, leukocytes, blood, glucose, pH
• Imaging: USS, erect CXR, abdo CXR, CT
• Specialist tests: MRCP/ERCP, MRI, barium swallow, OGD, colonoscopy
→ not always indicated
INITIAL MANAGEMENT: early senior input if concerned
• ABCDE + targeted Mx of suspected cause
Things to consider:
• Nutritional and feeding status – keep NBM if surgery likely soon or vomiting
• Hydration and fluid balance – IV or oral fluid maintenance, consider catheter
• Are antibiotics indicated? – signs consistent with infection
• Investigations to guide/aid management – blood cultures, ABG, G&S, CXR, ECG
• Is blood transfusion / major haemorrhage protocol required?
• Is theatre / surgical intervention needed? – NBM, consent, book theatre slot
IMAGING INDICATIONS:
X-ray Abdo USS CT
• Obstruction
• Toxic megacolon
• Foreign body
• Biliary pathologies
• Kidneys, ureter, bladder
• Gynae pathologies
• Appendix (in a female patient, no role
in male)
• AAA/vascular
• Malignancy/mass
• Complications of obstructions
• Appendix if >50y
NB: Not all acute abdominal pathologies
present with pain – often absent in the
elderly, children, diabetics & pregnant women
Amylase can be raised in some pathologies
other than pancreatitis e.g. perforated
duodenum
Erect CXR: may show air under diaphragm;
however, a negative erect CXR does not
exclude pneumoperitoneum
CONSIDERATIONS FOR SURGERY:
Patient health:
• Anaesthetic review
• Comorbidities/frailty
• Ceiling of care: ReSPECT form / DNACPR
• Morbidity/mortality calculation e.g. P-POSSUM score
Patient wishes:
• Current wishes
• Advance directives / ReSPECT forms
• Discussion with family
NB: the decision to operate is a complicated one and many factors should be
considered.
See Chapter 16: Critical illness (and Chapter 10: Anaesthetics in the companion
Clinical Specialties book) for further details.
ReSPECT = Recommended Summary
Plan for Emergency Care and Treatment,
apatient-held form
Surgery
154 Chapter 11: The acute abdomen
https://t.me/med1917
Acute pancreatitis
An acute inflammatory reaction due to enzymes released from damaged acini
↳ Direct damage: drugs/alcohol/infection → panlobular damage
↳ Duct obstruction: gallstones/tumour → periductal damage
Symptoms:
• Severe epigastric / upper abdo pain
→ radiates to back
→ better sitting forward
• Nausea & vomiting
Signs:
• Fever, tachycardia
• Jaundice (in 30%)
• Oedema ± hypovolaemia
• Cullen & Grey Turner signs
Very late signs
Causes: ‘I GET SMASHED’
Idiopathic (20%)
Gallstones (40%)
Ethanol (35%)
Trauma (15%)
Steroids
Mumps (CMV, EBV)
Autoimmune (SLE, polyarteritis nodosa)
Scorpion venom
Hyperlipidaemia, hypercalcaemia, hypothermia
ERCP
Drugs (thiazides, sulphonamides, ACEis, NSAIDs)
AXR only done if looking for additional
pathology, but would show:
• loss of psoas shadow
(due to retroperitoneal haemorrhage)
• sentinel loop of jejunum
(air-filled dilation due to ileus)
Investigations
• History & examination – drugs, alcohol, infection
• Routine bloods: FBC, CRP/ESR, U&Es, LFTs, clotting, calcium, lipids
+ pregnancy test
• Serum amylase or serum lipase – depending on what is available at your
local Trust
• ABG: monitor acid–base status
• Erect CXR: exclude perforation
• Normal CXR: check for ARDS
(a possible complication)
• Other imaging:
▶ USS – if suspect gallstones / no obvious cause
▶ MRCP/CT – detailed view of severity / extent of damage
▶ Endoscopic USS – if other imaging negative
lipase = more sensitive &
specific → amylase also in
GI perfs & mesenteric infarct
amylase = very sensitive in first
24h then levels start to drop
Determining severity of acute pancreatitis
1. Modified Glasgow Score (MGS) / ‘PANCREAS’ score
P PaO2 <8kPa
A Age >55y
N Neutrophils: WCC >15×10
C Calcium <2mmol/L
R Renal: urea >16mmol/L
E Enzymes: LDH>600 or AST>200
A Albumin <32g/L
S Sugar: glucose >10mmol/L
9
Score ≥3 = severe
Discuss with ICU/
HDU
Ranson’s criteria:
Scores similar
parameters
2. APACHE II score
Assesses disease
severity in patients
admitted to ICU
Considers: clinical
parameters, age &
comorbidities
Surgery
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