Clinical Post-Operative
CCriSP
Scenario 1
You are the on call General Surgery SHO and are called to see an unwell patient on the ward. They are day 3 post laparoscopic cholecystectomy. They appear clammy and complaining of abdominal discomfort. How do you proceed?
Answer: It is important to recognize early on that this is could potentially be a critically unwell surgical patient. For this reason alone, you should assess and examine them in a systematic and thorough fashion. Following the CCriSP formula that you have developed to initially assess and manage this patient
On your initial assessment, you are told the heart is elevated, the blood pressure is low, tachypnoeic and febrile. How do you proceed after your initial assessment and management?
Answer: On your initial assessment, you should have routinely addressed the initial management of this acutely unwell patient. This includes intravenous fluids through 2 large bore cannulae, intravenous antibiotics, catheter etc. But your ABCDE is not where it ends. I would like to arrange some INITIAL investigations including BEDSIDE tests. Blood tests (FBC, UEs, CRP, LFTs, INR) and a urine dipstick test. I would also like to arrange RADIOLOGICAL investigations for this patient, a chest x ray in the first instance exclude a pulmonary pathology and to see if there is any evidence of intra-abdominal free air
Now is the opportunity to gather more information. If the patient is communicable, take a history and examination from the patient. Review the patient’s documentation, importantly the operative notes, and see if there is anything that can help aid your diagnosis. It would also be a good opportunity to see if there are any recent blood results that could be useful, ideally, this would have been requested on your ABCDE.
The patient's operation was uncomplicated and was making a satisfactory post operative recovery. The patient’s inflammatory markers remained elevated with temperatures and abdominal pain. The liver function test, notably the bilirubin, is elevated. What is your differential diagnosis and how would you proceed from this?
Answer: That is a lot of information and it is likely this will be given to you in chunks. You should be able to answer these questions systematically using correct vocabulary. My DIFFERENTIAL diagnoses consist of specific post operative complications including a bile leak, perforation or intra-abdominal sepsis. I would also like to exclude more general differential diagnoses including a urinary tract infection or a chest infection. Depending on the STABILITY of my patient’s condition, they may need to go straight to theatre or DEFINITIVELY diagnose the pathology with further imaging, in this case, a CT of the abdomen and pelvis.
This patient is diagnosed with a bile leak post laparoscopic cholecystectomy. What do you do next?
Answer: If not done so already, this is the opportunity to escalate to your senior. It is tricky to time this right as you don’t want to call for senior help to early before doing your basic initial assessment but you also may not want to leave it so late that it seems unsafe. As soon as a critical differential diagnosis is considered, you should notify your senior. This patient is likely to return to theatre for a laparotomy, performed by a senior member of the team. As the General Surgical SHO, your responsibilities are not performing the operation but ensuring the operation can be performed safely. These include:
- Ensuring the patient is Nil By Mouth
- Ensuring the patient is safe to go to theatre (clotting, INR)
- Discussion with the multidisciplinary team (anesthetists, theatre staff etc)
- Discussion with HDU/ ITU for post operative care
For further information on this specific pathology, please visit the below link:
https://www.uptodate.com/contents/complications-of-laparoscopic-cholecystectomy
Scenario 2
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?
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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.
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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
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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.
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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
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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)
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Other less common causes include ARDS, pneumothorax and iatrogenic causes following intubation.
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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
You the Orthopaedic SHO on call. You have been asked to see a patient who was admitted earlier in the day with a left isolated, closed mid shaft tibial fracture. They have been complaining of severe pain. Would you review this patient?
Answer: A leading question like this, your response should always be you would review this patient. This is an isolated problem and you should already be thinking of compartment syndrome as your top differential. If there is an indication to repeat you ABCDE assessment then do so but if not, proceed to a taking a history and examination
On inspection, the left leg is in an above knee backslab. Is there any examination you would want to perform and are there any measures you would take in your initial management of this patient?
Answer: This is testing your knowledge of assessment of compartment syndrome
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History – Ask the patient if the pain has worsened since admission? Are they experiencing any parasthesia? Any numbness? C
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Examination – Examine the neurovascular status of the remaining exposed limb. Passive stretch of the compartment in question – if the pain is disproptionate to the injury then this is highly suggestive of compartment syndrome
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Chart review – What are there observations (particularly blood pressure)? What is the lactate of the patient? Have they been given appropriate analgesia as per the WHO pain ladder
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Initial management – Is the limb elevated above the heart level? Is the backslab on too tight, would it be safe to split any circumferential dressings?
After attempting initial management strategies, the patients pain has gotten worse and you are suspecting compartment syndrome. What are your options?
Answer: Importantly, you must alert your senior. With a high suspicion of this Orthopaedic emergency, prompt operative treatment may be required. If there is diagnostic doubt, you should mention there is the option to measure the compartment pressure. However, it is a clinical diagnosis and this patient should be taken to theatre.
You alert your senior who has agreed this patient requires an urgent fasciotomy. They are off site and are making their way into the hospital. What can you do in the interim?
Answer: As the Orthopaedic SHO, you will not be expected to perform the fasciotomy but you will be expected to prepare the patient for theatre
- Mark and consent the patient. If you are not comfortable with the theory of a fasciotomy (you should know the basics) then say you would get the documentation ready for the registrar
- Ensure the patient is nil by mouth
- Discuss the diagnosis and management plan with the patient
- Inform the multidisciplinary team (anaesthetist/ theatre staff/ ward nurses)
Scenario 4
You are the on call General Surgery SHO and are called to see an unwell patient on the ward. They are day 3 post laparoscopic cholecystectomy. They appear clammy and complaining of abdominal discomfort. How do you proceed?
Answer: It is important to recognize early on that this is could potentially be a critically unwell surgical patient. For this reason alone, you should assess and examine them in a systematic and thorough fashion. Following the CCriSP formula that you have developed to initially assess and manage this patient
On your initial assessment, you are told the heart is elevated, the blood pressure is low, tachypnoeic and febrile. How do you proceed after your initial assessment and management?
Answer: On your initial assessment, you should have routinely addressed the initial management of this acutely unwell patient. This includes intravenous fluids through 2 large bore cannulae, intravenous antibiotics, catheter etc. But your ABCDE is not where it ends. I would like to arrange some INITIAL investigations including BEDSIDE tests. Blood tests (FBC, UEs, CRP, LFTs, INR) and a urine dipstick test. I would also like to arrange RADIOLOGICAL investigations for this patient, a chest x ray in the first instance exclude a pulmonary pathology and to see if there is any evidence of intra-abdominal free air
Now is the opportunity to gather more information. If the patient is communicable, take a history and examination from the patient. Review the patient’s documentation, importantly the operative notes, and see if there is anything that can help aid your diagnosis. It would also be a good opportunity to see if there are any recent blood results that could be useful, ideally, this would have been requested on your ABCDE.
The patient's operation was uncomplicated and was making a satisfactory post operative recovery. The patient’s inflammatory markers remained elevated with temperatures and abdominal pain. The liver function test, notably the bilirubin, is elevated. What is your differential diagnosis and how would you proceed from this?
Answer: That is a lot of information and it is likely this will be given to you in chunks. You should be able to answer these questions systematically using correct vocabulary. My DIFFERENTIAL diagnoses consist of specific post operative complications including a bile leak, perforation or intra-abdominal sepsis. I would also like to exclude more general differential diagnoses including a urinary tract infection or a chest infection. Depending on the STABILITY of my patient’s condition, they may need to go straight to theatre or DEFINITIVELY diagnose the pathology with further imaging, in this case, a CT of the abdomen and pelvis.
This patient is diagnosed with a bile leak post laparoscopic cholecystectomy. What do you do next?
Answer: If not done so already, this is the opportunity to escalate to your senior. It is tricky to time this right as you don’t want to call for senior help to early before doing your basic initial assessment but you also may not want to leave it so late that it seems unsafe. As soon as a critical differential diagnosis is considered, you should notify your senior. This patient is likely to return to theatre for a laparotomy, performed by a senior member of the team. As the General Surgical SHO, your responsibilities are not performing the operation but ensuring the operation can be performed safely. These include:
- Ensuring the patient is Nil By Mouth
- Ensuring the patient is safe to go to theatre (clotting, INR)
- Discussion with the multidisciplinary team (anesthetists, theatre staff etc)
- Discussion with HDU/ ITU for post operative care
For further information on this specific pathology, please visit the below link:
https://www.uptodate.com/contents/complications-of-laparoscopic-cholecystectomy