Post-Surgical Complications 2024 RCSI PDF

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Title Post-Surgical Complications Class Year 3 Course Surgery Year 2024 Lecturer Lecturer Name POLL ID surgery2024 LEARNING OUTCOMES For each case we will: Describe the initial assessment...

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Title Post-Surgical Complications Class Year 3 Course Surgery Year 2024 Lecturer Lecturer Name POLL ID surgery2024 LEARNING OUTCOMES For each case we will: Describe the initial assessment of a patient with postoperative complications. Formulate a differential diagnosis list. Choose appropriate investigations. Explain the principles of treatment. Utilise strategies for effective multidisciplinary team management. Department of Surgery, RCSI. IMPORTANCE OF EARLY RECOGNITION Early detection is critical for improving outcomes. Delayed diagnosis can lead to severe morbidity and mortality. Vigilance during postoperative care. Department of Surgery, RCSI. INITIAL ASSESSMENT History: Recent surgery details, presenting symptoms, comorbidities. Physical Examination: Inspection, palpation, percussion, auscultation Vital Signs: Blood pressure, heart rate, respiratory rate, temperature, oxygen saturation. Department of Surgery, RCSI. CASE 1 A 48-year-old female, 5 days post-breast surgery, presents with increasing pain, redness, and warmth around the surgical site. Symptoms: Fever of 38.5°C, erythema, tenderness. Objective: Determine the initial assessment and appropriate management steps of this pateint. Department of Surgery, RCSI. POLL: WHAT IS YOUR TOP DIFFERENTIAL CELLULITIS – DIFFERENTIALS Cellulitis Surgical site infection (SSI) Deep vein thrombosis (DVT) Necrotising fasciitis Haematoma Department of Surgery, RCSI. CELLULITIS – INITIAL ASSESSMENT History: Pain, redness, warmth at the surgical site. Physical Exam: Erythema, induration, tenderness. Vital Signs: Fever, tachycardia. Department of Surgery, RCSI. CELLULITIS – INITIAL INVESTIGATIONS Bedside Wound swab culture Bloods Full blood count (FBC): Leucocytosis. U&E LFTs Blood cultures. CRP Imaging Ultrasound (to rule out abscess). Department of Surgery, RCSI. CELLULITIS – INITIAL MANAGEMENT Antibiotics: Broad-spectrum initially, tailored based on culture results. Supportive Care: Pain management, hydration. Monitoring: Regular reassessment of the affected site. Department of Surgery, RCSI. CASE 2 A 55-year-old male, 7 days post-colectomy, presents with a fever and purulent discharge from his surgical incision. Symptoms: Redness, swelling, pain at the incision site, temperature 38.7°C. Objective: Identify the potential complication and decide on the next steps. Department of Surgery, RCSI. INITIAL ASSESSMENT History: Postoperative pain, purulent discharge, fever. Physical Exam: Redness, swelling, pus at the incision site. Vital Signs: Fever, possibly hypotension in severe cases. POLL: WHAT IS YOUR TOP DIFFERENTIAL? SSI - DIFFERENTIALS Surgical Site Infection (SSI) Cellulitis Abscess formation Wound dehiscence Necrotising fasciitis SSI - INITIAL INVESTIGATIONS Bedside Wound swab culture. Bloods Blood cultures, FBC, CRP Imaging Imaging (ultrasound, CT) if deep infection is suspected. Department of Surgery, RCSI. SSI - INITIAL MANAGEMENT Antibiotics: Empirical coverage initially Wound exploration and Debridement Wound Care: Regular dressing changes Department of Surgery, RCSI. CASE 3 A 62-year-old male, 10 days post-laparotomy, presents to A&E with confusion, a high fever, and a rapidly deteriorating condition. Symptoms: Fever of 39.2°C, hypotension, tachycardia. Objective: Discuss the initial assessment, differential diagnosis, and urgent management required. Department of Surgery, RCSI. INITIAL ASSESSMENT History: General malaise, fever, chills, confusion. Physical Exam: Abdominal tenderness, Wound is clean, Signs of systemic infection, hypotension, tachycardia. Vital Signs: Fever, tachycardia, hypotension. Department of Surgery, RCSI. POLL: WHAT IS YOUR TOP DIFFERENTIAL? SEPSIS - DIFFERENTIAL DIAGNOSIS Sepsis o Intra abdominal source o Hospital acquired pneumonia o UTI o Line infection o Surgical site infection Bleeding Dehydration Anaphylaxis Department of Surgery, RCSI. SEPSIS - INITIAL INVESTIGATIONS Bedside Urine Dip Bloods Blood cultures (before antibiotics). FBC (Hb, leucocytosis), CRP U&E and LFTs VBG/ABG; Serum lactate (indicator of hypoperfusion and ischaemia). Imaging studies (CT, ultrasound) to identify the infection source. CXR Department of Surgery, RCSI.  URGENT MANAGEMENT – SEPSIS 6 Department of Surgery, RCSI. CASE 4 A 65-year-old female, 2 days post-abdominal surgery, presents with shortness of breath and chest discomfort. Symptoms: Mild fever, decreased breath sounds on the right side. Objective: Assess the condition and suggest appropriate differentials, interventions and management. Department of Surgery, RCSI. INITIAL ASSESSMENT History: Dyspnoea, cough, chest discomfort. Physical Exam: Diminished breath sounds, crackles. Vital Signs: Tachypnoea, low-grade fever. Department of Surgery, RCSI. POLL: WHAT IS YOUR TOP DIFFERENTIAL? ATELECTASIS - DIFFERENTIAL DIAGNOSIS Atelectasis Pneumonia Pulmonary embolism MI Bronchospasm Department of Surgery, RCSI. ATELECTASIS - INITIAL INVESTIGATIONS Bedside ECG Bloods Arterial blood gases (ABGs): Hypoxia. FBC: Rule out infection. CRP Imaging Chest X-ray: Show areas of collapse. Department of Surgery, RCSI. ATELECTASIS - INITIAL MANAGEMENT Incentive Spirometry: Encourage deep breathing exercises. Chest Physiotherapy: Percussion and postural drainage. Mobilisation: Early ambulation. Medication: Consider bronchodilators Department of Surgery, RCSI. CASE 5 A 60-year-old female, 7 days post-hysterectomy, experiences sudden onset of shortness of breath and sharp chest pain. Symptoms: Hypoxia, tachycardia, pleuritic chest pain. Objective: Discuss the likely differentials, investigations and management plan. Department of Surgery, RCSI. INITIAL ASSESSMENT History: Sudden onset dyspnoea, pleuritic chest pain, haemoptysis Physical Exam: Tachycardia, tachypnoea, hypoxia. Vital Signs: Sudden drop in oxygen saturation, hypotension in severe cases. Department of Surgery, RCSI. POLL: WHAT IS YOUR TOP DIFFERENTIAL? PE - DIFFERENTIAL DIAGNOSIS Pulmonary Embolism Myocardial infarction Pneumothorax Pneumonia Aortic dissection Department of Surgery, RCSI. PE - INITIAL INVESTIGATIONS Bedside: ECG: Sinus tachycardia, S1Q3T3 pattern. Bloods: D-dimer (useful for ruling out in low-risk patients). ABGs: Hypoxia, respiratory alkalosis. Imaging: Chest Xray CT Pulmonary Angiography (CTPA). Department of Surgery, RCSI. PE - INITIAL MANAGEMENT Anticoagulation: Therapeutic low molecular weight heparin or direct oral anticoagulants. Thrombolysis: In massive PE with haemodynamic instability. Supportive Care: Oxygen, analgesia. Department of Surgery, RCSI. PE - INITIAL MANAGEMENT Department of Surgery, RCSI. CASE 6 A 50-year-old male, 10 days post-knee replacement, presents with leg swelling and pain. Symptoms: Unilateral leg swelling, erythema, calf tenderness. Objective: Evaluate the condition, create a differential diagnosis, and outline an investigation and management plan. Department of Surgery, RCSI. INITIAL INVESTIGATIONS History: Recent immobility, leg pain, swelling. Physical Exam: Unilateral swelling, warmth, and tenderness in the calf. Vital Signs: Typically normal, but may have a mild fever. Department of Surgery, RCSI. POLL: WHAT IS YOUR TOP DIFFERENTIAL? DVT - DIFFERENTIAL DIAGNOSIS DVT Acute limb ischaemia Cellulitis Lymphoedema Superficial thrombophlebitis Muscle strain  DVT - INITIAL INVESTIGATIONS Specific Bloods D-dimer: To exclude DVT in low-risk patients. Imaging Doppler Ultrasound: First-line imaging. Venography: Rarely used but definitive. Department of Surgery, RCSI. DVT - INITIAL MANAGEMENT Anticoagulation: Therapeutic low molecular weight heparin followed by oral anticoagulants. Compression Stockings: To prevent post-thrombotic syndrome. Mobilisation: Encourage early movement. Department of Surgery, RCSI. CASE 7 A 67-year-old male, 3 days post-colorectal surgery, presents with abdominal distension, nausea, and the absence of bowel movements. Symptoms: Abdominal bloating, discomfort, and vomiting Objective: Determine the differentials, investigations and management plan for this complication. Department of Surgery, RCSI. INITIAL ASSESSMENT History: Recent abdominal surgery, nausea, vomiting, absence of flatus or bowel movements. Physical Exam: Abdominal distension, tympanic sounds on percussion, decreased bowel sounds. Vital Signs: Typically normal, but may show signs of dehydration (tachycardia, hypotension). Department of Surgery, RCSI. POLL: WHAT IS YOUR TOP DIFFERENTIAL? ILEUS - DIFFERENTIAL DIAGNOSIS Post-Operative ileus Mechanical bowel obstruction (e.g., adhesions, hernia). Pseudo-obstruction (Oglivie syndrome) Toxic mega colon Department of Surgery, RCSI. ILEUS - INITIAL INVESTIGATIONS Bedside Bedside: Presence of peristalsis Bloods U&E: To check for electrolyte imbalances (e.g., hypokalaemia). Imaging Abdominal X-ray: Dilated loops of bowel without air-fluid levels (consistent with ileus). CT Scan: To exclude mechanical obstruction. Department of Surgery, RCSI. INITIAL MANAGEMENT NPO (Nil by Mouth): Rest the bowel. Nasogastric Tube: For decompression if vomiting or severe distension. Fluid and Electrolyte Replacement: Correct imbalances. Mobilisation: Encourage early ambulation to stimulate bowel activity. Department of Surgery, RCSI. CASE 8 A 73-year-old female, 2 days post-major abdominal surgery, presents with oliguria and rising creatinine levels. Symptoms: Reduced urine output, fatigue, generalised oedema. Objective: Assess the differentials, choose appropriate investigations, and outline the management strategy of this pateint. Department of Surgery, RCSI. INITIAL ASSESSMENT History: Recent surgery, reduced urine output, history of nephrotoxic medications, hypotension. Physical Exam: Peripheral oedema, signs of fluid overload (e.g., raised JVP). Vital Signs: Blood pressure may be low (hypotension) or high (fluid overload). Department of Surgery, RCSI. POLL: WHAT IS YOUR TOP DIFFERENTIAL? AKI - DIFFERENTIAL DIAGNOSIS Pre-renal AKI (e.g., hypovolaemia, sepsis). Intrinsic renal injury (e.g., acute tubular necrosis). Post-renal AKI (e.g., obstructive uropathy). Acute exacerbation of chronic kidney disease. Department of Surgery, RCSI. AKI - INITIAL INVESTIGATIONS Bedside: Urinalysis: Look for haematuria, proteinuria, casts. Bloods: Serum Creatinine and Urea: To assess renal function. Electrolytes: Check for hyperkalaemia, acidosis. Imaging: Renal Ultrasound: To rule out obstruction. Department of Surgery, RCSI. AKI - INITIAL MANAGEMENT Optimise Haemodynamics: Fluid resuscitation or diuresis depending on the volume status. Avoid Nephrotoxins: Hold NSAIDs, ACE inhibitors, etc. Monitor Electrolytes: Treat hyperkalaemia, acidosis. Renal Replacement Therapy: If indicated for severe cases - Consult Nephrology. Department of Surgery, RCSI. CASE 9 A 75-year-old male, 3 days post-cardiac surgery, suddenly develops right-sided weakness and slurred speech. Symptoms: Hemiparesis, facial droop, dysarthria. Objective: Recognise this emergency, outline the differential diagnosis, and discuss the immediate investigations and management. Department of Surgery, RCSI. INITIAL ASSESSMENT History: Sudden onset of neurological symptoms, history of atrial fibrillation, hypertension. Physical Exam: Neurological examination revealing focal deficits (e.g., weakness, aphasia). Vital Signs: Blood pressure may be elevated; irregular rhythm Department of Surgery, RCSI. POLL: WHAT IS YOUR TOP DIFFERENTIAL?  ISCHEMIC STROKE - DIFFERENTIAL DIAGNOSIS Ischaemic stroke. Haemorrhagic stroke. Transient ischaemic attack (TIA). Postoperative delirium with focal findings. Department of Surgery, RCSI. URGENT INVESTIGATIONS Bedside: ECG: To check for arrhythmias (e.g., atrial fibrillation). Telemetry: Paroxysmal Afib Bloods: FBC, coagulation profile, electrolytes, blood glucose. Imaging: Urgent Non-contrast CT Head: To differentiate between ischaemic and haemorrhagic stroke. CT Angiogram/Carotid Doppler: Outrule large vessel occlusion CT Perfusion: help identify areas of the brain at risk of ischaemia MRI Brain: More sensitive for detecting early ischaemic changes. Department of Surgery, RCSI. IMMEDIATE MANAGEMENT NIHSS: Standardised assessment done as part of clinical examination calculating stroke severity 0-42. Thrombolysis: If ischaemic stroke and within the window for thrombolysis (typically within 4.5 hours) – IV r-tPA. Thrombectomy: >4.5 and