Clinical Post-Operative

CCriSP

 

Scenario 1

x-ray.jpg

You are the General Surgical SHO on call. You are asked to review a patient who has increasing abdominal pain.


Answer: Ironically, the most useful approach for managing this patient is dealt with in a course that only Core Surgical Trainees can attend; yet it regularly appears in your interview process. That does not mean you should not be prepared for it.

  • Immediate management of ABCDE. The examiners will prompt you in how much details to go and provide you with the paramaters needed to guide your management




This patient has a heart rate of 120, a blood pressure of 90/60, a respiratory rate of 32, oxygen saturations of 94% and a temperature of 39.2. How would you manage this patient?


Answer: If given the observations in a list format like this then state the overall principles you would apply to your immediate management by front loading your answer –

I would manage this patient as per the CCriSP protocol and implement management for acute sepsis. Using my ABCDE approach, I will ensure their airway is patent (pause). I would provide this patient with oxygen through a non-rebreathe mask and auscultate the chest. I would insert 2 large bore cannulae (pause) to provide this patient with a fluid challenge of 1 litre of Normal Saline given over 15 minutes before which I would take a full blood count, check the patients renal function and electrolytes, the CRP and the clotting for this patients (pause). I would also send off a group and save for this patient in case they need to return to theatre and I would also take blood cultures. I will also run an urgent gas to check the lactate of my patient and I would also consider inserting a catheter so the fluid balance of this patient can be monitored (pause). I will then auscultate the heart and check the gross peripheral vascular system of this patient through a capillary refill check and palpating a peripheral pulse (pause). I would also like to get an ECG. I will go on to check if there is any dysfuntion of the central nervous system by using an AVPU measure of the patient cognitive state and a more formal GCS if there are any concerns (pause.) Throughout my immediate management I will reassess the patient after applying my interventions to see if there is a response to the initial resuscitation.

This is an example of how to thoroughly answer a question like this. I have inserted pauses as some examiners may want to give further prompts or want you to proceed to another question. Always take hints given by the examiners, they are trying to help you!




The patient has transiently responded to your measures and this has given you time to arrange any further investigations and to establish more details of what may be going on.


Answer: The blood results are likely to be given as you ask for them. If not, they are holding them back for when you may need to use them to help guide your decision making process. With a question like this they want you to go beyond ABCDE and approach this in a more realistic manner.

  • Review the patients observations over the past 24 hours
  • Take a history and a systematic examination (notably the recently operated on abdomen)
  • Check available results (trends in blood results)
  • The operation note and post operative documentation
  • Discuss with the nursing staff on how the patient has been throughout the day

In your head, you will already have a list of differentials, so try and guide your investigations based on this

  • Initial bedside investigations
    • Urine dip (as a possible cause for the sepsis)
    • Repeat observations
    • Fluid balance for this patient
  • Radiological investigations
    • An urgent bedside chest x ray (to look for air under the diaphragm)




Is there anything else you would do now the patient is relatively stable?


Answer: Alert your senior. As a core surgical trainee, you should be able to perform immediate management and reassess the patient. You will alert your senior, this is inevitable. This is also the time you would consider a CT abdomen and pelvis with contrast if the patient is stable enough and there is diagnostic uncertainty and for surgical planning.




This patient had a primary anastomosis following a Hartmann’s operation. What is your top differential diagnosis?


Answer: You should have a list of differentials for your septic/ unwell postoperative patient. Here they only want your top differential, which is likely to be an anastomotic leak.

Anastomotic leaks are a common and complex surgical complication. Initial assessment and management and recognition make a Core Surgical Trainee however below is a detailed insight into the pathology:

https://www.acpgbi.org.uk/content/uploads/2016/03/management-of-colorectal-anastomtic-leakage.pdf





 

Scenario 2

lungs.jpg

You are the Urology SHO on call overnight. The ward nurse bleeps you about a patient they are concerned about.


Answer: This station starts with a simulated phone conversation with the nurse. Continue as though this is the case. This isn’t a trick question but the most counscious and composed candidates will respond appropriately to the immediate question. Now is the time to gather information from the nurse over the phone (initial observations and end-of-bed assessment) and to start any initial management too.




The nurse informs you the patient is hypoxic but stable otherwise. You have requested oxygen to be administered and have agreed to review the patient as a matter of urgency. On arrival to the ward, you perform your initial ABCDE assessment and also establish hypoxia. On reading the notes, you understand this patient had an uncomplicated Hartmann’s procedure and stoma formation four days ago. What is your differential diagnosis and how would you investigate this?


  • Answer: Not all scenarios are looking for you to rattle of ABCDE. They are also not expecting you to diagnose the patient’s hypoxia from the limited information provided. They want to explore your knowledge of postoperative hypoxia and how to investigate each cause in a systematic fashion.

  • Intra abdominal pathology – Although isolated hypoxia may not traditionally preclude a perforation or post operative abdominal complication, it is something you should consider. This can be investigated with INITIAL investigations (FBC/ UEs/CRP etc) and a chest X ray and DEFINITIVELY with a CT AP. If the patient becomes systemically septic and not responding to initial resuscitation then they may need to go straight to theatre

  • Pneumonia – This could be aspiration or hospital acquired. It would again require INITIAL investigations of a chest xray, sputum cultures and inflammatory markers. This should be managed with intravenous antibiotics with close monitoring. This could worsen and may require intensive care support for ventilator support.

  • Atelectasis – This would normally accompany a cough or even chest pain and can be investigated with a chest xray. It is a diagnosis of exclusion; the blood results should not show raised inflammatory markers, which could suggest pneumonia. The management includes chest physiotherapy and early mobilization to improve lung function

  • Pulmonary embolism – Common associated symptoms include dyspnoea, pleuritic chest pain, cough and palpations are common symptoms, with hypoxia being the main sign. Examination of this patient may reveal pain on palpation of the calf, which could indicate a DVT. Auscultating the chest would also form part of the examination. Clinical findings, laboratory tests (markedly elevated Ddimers, despite being non-specific) and imaging (CT PA) are used to make the diagnosis. ECGs may also show characteristic signs of pulmonary embolisms. The treatment is complex in postoperative patients and should be a multi disciplinary team decision, weighing up the risks of bleeding and further clotting on the commencement of LMWH. This should be discussed with the hematologist. (NB: Had this been an orthopaedic patient, it would be important to mention a fat embolism and potentially list this higher in your differentials)

  • Other less common causes include ARDS, pneumothorax and iatrogenic causes following intubation.

  • For more detailed information on postoperative hypoxaemia, at our course we will have the CCriSP textbook, which can be reviewed. This covers the diagnosis, investigations and management.





 

Scenario 3

feet.jpg

You are the Urology SHO on call overnight. The ward nurse bleeps you about a patient they are concerned about.


Answer: This station starts with a simulated phone conversation with the nurse. Continue as though this is the case. This isn’t a trick question but the most counscious and composed candidates will respond appropriately to the immediate question. Now is the time to gather information from the nurse over the phone (initial observations and end-of-bed assessment) and to start any initial management too.




The nurse informs you the patient is hypoxic but stable otherwise. You have requested oxygen to be administered and have agreed to review the patient as a matter of urgency. On arrival to the ward, you perform your initial ABCDE assessment and also establish hypoxia. On reading the notes, you understand this patient had an uncomplicated Hartmann’s procedure and stoma formation four days ago. What is your differential diagnosis and how would you investigate this?


  • Answer: Not all scenarios are looking for you to rattle of ABCDE. They are also not expecting you to diagnose the patient’s hypoxia from the limited information provided. They want to explore your knowledge of postoperative hypoxia and how to investigate each cause in a systematic fashion.

  • Intra abdominal pathology – Although isolated hypoxia may not traditionally preclude a perforation or post operative abdominal complication, it is something you should consider. This can be investigated with INITIAL investigations (FBC/ UEs/CRP etc) and a chest X ray and DEFINITIVELY with a CT AP. If the patient becomes systemically septic and not responding to initial resuscitation then they may need to go straight to theatre

  • Pneumonia – This could be aspiration or hospital acquired. It would again require INITIAL investigations of a chest xray, sputum cultures and inflammatory markers. This should be managed with intravenous antibiotics with close monitoring. This could worsen and may require intensive care support for ventilator support.

  • Atelectasis – This would normally accompany a cough or even chest pain and can be investigated with a chest xray. It is a diagnosis of exclusion; the blood results should not show raised inflammatory markers, which could suggest pneumonia. The management includes chest physiotherapy and early mobilization to improve lung function

  • Pulmonary embolism – Common associated symptoms include dyspnoea, pleuritic chest pain, cough and palpations are common symptoms, with hypoxia being the main sign. Examination of this patient may reveal pain on palpation of the calf, which could indicate a DVT. Auscultating the chest would also form part of the examination. Clinical findings, laboratory tests (markedly elevated Ddimers, despite being non-specific) and imaging (CT PA) are used to make the diagnosis. ECGs may also show characteristic signs of pulmonary embolisms. The treatment is complex in postoperative patients and should be a multi disciplinary team decision, weighing up the risks of bleeding and further clotting on the commencement of LMWH. This should be discussed with the hematologist. (NB: Had this been an orthopaedic patient, it would be important to mention a fat embolism and potentially list this higher in your differentials)

  • Other less common causes include ARDS, pneumothorax and iatrogenic causes following intubation.

  • For more detailed information on postoperative hypoxaemia, at our course we will have the CCriSP textbook, which can be reviewed. This covers the diagnosis, investigations and management.





 

Scenario 4

intestine.jpg

You are the General Surgical SHO on call. You are asked to review a patient who has increasing abdominal pain.


Answer: Ironically, the most useful approach for managing this patient is dealt with in a course that only Core Surgical Trainees can attend; yet it regularly appears in your interview process. That does not mean you should not be prepared for it.

  • Immediate management of ABCDE. The examiners will prompt you in how much details to go and provide you with the paramaters needed to guide your management




This patient has a heart rate of 120, a blood pressure of 90/60, a respiratory rate of 32, oxygen saturations of 94% and a temperature of 39.2. How would you manage this patient?


Answer: If given the observations in a list format like this then state the overall principles you would apply to your immediate management by front loading your answer –

I would manage this patient as per the CCriSP protocol and implement management for acute sepsis. Using my ABCDE approach, I will ensure their airway is patent (pause). I would provide this patient with oxygen through a non-rebreathe mask and auscultate the chest. I would insert 2 large bore cannulae (pause) to provide this patient with a fluid challenge of 1 litre of Normal Saline given over 15 minutes before which I would take a full blood count, check the patients renal function and electrolytes, the CRP and the clotting for this patients (pause). I would also send off a group and save for this patient in case they need to return to theatre and I would also take blood cultures. I will also run an urgent gas to check the lactate of my patient and I would also consider inserting a catheter so the fluid balance of this patient can be monitored (pause). I will then auscultate the heart and check the gross peripheral vascular system of this patient through a capillary refill check and palpating a peripheral pulse (pause). I would also like to get an ECG. I will go on to check if there is any dysfuntion of the central nervous system by using an AVPU measure of the patient cognitive state and a more formal GCS if there are any concerns (pause.) Throughout my immediate management I will reassess the patient after applying my interventions to see if there is a response to the initial resuscitation.

This is an example of how to thoroughly answer a question like this. I have inserted pauses as some examiners may want to give further prompts or want you to proceed to another question. Always take hints given by the examiners, they are trying to help you!




The patient has transiently responded to your measures and this has given you time to arrange any further investigations and to establish more details of what may be going on.


Answer: The blood results are likely to be given as you ask for them. If not, they are holding them back for when you may need to use them to help guide your decision making process. With a question like this they want you to go beyond ABCDE and approach this in a more realistic manner.

  • Review the patients observations over the past 24 hours
  • Take a history and a systematic examination (notably the recently operated on abdomen)
  • Check available results (trends in blood results)
  • The operation note and post operative documentation
  • Discuss with the nursing staff on how the patient has been throughout the day

In your head, you will already have a list of differentials, so try and guide your investigations based on this

  • Initial bedside investigations
    • Urine dip (as a possible cause for the sepsis)
    • Repeat observations
    • Fluid balance for this patient
  • Radiological investigations
    • An urgent bedside chest x ray (to look for air under the diaphragm)




Is there anything else you would do now the patient is relatively stable?


Answer: Alert your senior. As a core surgical trainee, you should be able to perform immediate management and reassess the patient. You will alert your senior, this is inevitable. This is also the time you would consider a CT abdomen and pelvis with contrast if the patient is stable enough and there is diagnostic uncertainty and for surgical planning.




This patient had a primary anastomosis following a Hartmann’s operation. What is your top differential diagnosis?


Answer: You should have a list of differentials for your septic/ unwell postoperative patient. Here they only want your top differential, which is likely to be an anastomotic leak.

Anastomotic leaks are a common and complex surgical complication. Initial assessment and management and recognition make a Core Surgical Trainee however below is a detailed insight into the pathology:

https://www.acpgbi.org.uk/content/uploads/2016/03/management-of-colorectal-anastomtic-leakage.pdf