General Surgery MIS BMS CRS PBS Vascular Plastics Transplant Trauma
The management of the patient after surgery. This includes care given during the immediate post operative period, both in the operating room and the post anaesthesia care unit (PACU), as well as the days following surgery.
Relish in your position Enjoy the fruits of your labour in medical school Grow into the physician/surgeon role You will often stand alone with the family in the room You are the last line of defense Nobody will blame you, everyone will cheer you
Past Medical History Past Surgical History Social History Family History
Past Medical History CNS – prior TIA, CVAs, mobility post op. CVS – CHF, prior MIs ▪ Antiplatlet agents ▪ IVF administration Resp – COPD home O2, CPAP for OSA FEN/GI - Renal Failure – prescribe/dose all medications appropriately (no Enoxaparin for renal impairment patients), dialysis days? Endo – DM (no dextrose in IVF, ISS), Steroids – dose stress steroids appropriately
Past Surgical History Prior surgical intervention often makes further surgical intervention more complex Prior post operative issues are often relevant again
Social History Home support structure, if any EtOH ▪ Delerium Tremens (not unique to VA system)
Family History Most common bleeding diathesis vWF dysfuction Best way to determine if
If you did the case, you may be asked to… Write the brief operative note Talk to the family regarding the outcome of the surgery Write post operative orders Dictate the case Skin/Fascial closure, Final dressings, abdominal binder, transport the patient to PACU
Day case surgery Final review Appropriate Discharge Paperwork Discharge Prescriptions Follow up Appointment For Shands 352-265-0535 7:30am – 5pm, get an appointment for every pt. Family questions
PACU If called to the PACU attend immediately. Face to face discussion with MDs or RNs and address their concerns directly Perform a Post Operative Check Ordering appropriate investigations – ▪ Labs ▪ ABG, CBC, BMP, etc., ▪ 12-lead EKG ▪ Imaging ▪ CXR, CT brain Report concern to the Operating Team Know what room they are in or where they can be found Come with an Assessment and a PLAN
Post Operative Check – to be performed on EVERY patient, ABSOLUTELY NO EXCEPTIONS Consists of Chart review ▪ Surgical procedure (EBL, IVFs, intraoperative events) ▪ Pre-Operative medical/surgical conditions ▪ Pre-Admission Medications ▪ Current Post-Operative Medications
Finally go see the patient. Eyeball test – comes with experience Talk to the patient Examine the patient HS 1-2, Lungs, Abdomen, Incision sites ▪ Pulse check, Neurological exam Don’t for get Drains Volume, colour, consistency, smell Check Line sites, IVs, a-lines, CVLs, Urinary catheters, Chest tube sites.
Go back to the computer Final chart review Check Labs (perhaps order them) Check Imaging (perhaps order CXR/KUB) Monitoring (perhaps add a continuous pulse ox or telemetry) DOCUMENT your findings with a PLAN With experience this takes 10mins to perform
Keep eye on vitals Certain Chiefs will want to be called with information (i.e. post op checks, CT scan results), make sure you do this. No major moves overnight, keep watch till morning A change in condition of a patient, a transfusion, or change level of care mandates a prompt call to the primary team
Well its 4am they’ll be in a hour or two I’d rather the primary team handle it. I’ll call the Chief when things settle down after intubation and transfer to the ICU. I’ll call when I figure out exactly what’s going on. A plan doesn’t have to be exact. I have to work on my animal research grant rather than check on patients overnight.
Early post operative period Mobilization Incentive Spirometers Anaglesia Plan Diet/Nutrition Plan Wound Care Plan Antibiotics Plan Urinary Catheter Plan Drain Plan
Surgery Specific Management MIS - Swallow studies BMS - Drain care, Physical Therapy CRS - NG management, Ostomy volume consistency management PBS - Drains for amylase, nutrition plan (TPN) Vascular - Wound care, dialysis Transplant - Immunosuppressive therapy, dialysis Trauma - Disposition
Plans by System Neurological CVS Respiratory FEN/GI Endo ID Haematological Communication with ICU service
Write everything down on your list Have tick boxes or equivalents to help you manage your patient related tasks Do not move on to the next patient until your questions are answered Plans may change during rounds with the Attending Surgeon You may be asked to ‘run the list’ and list out your jobs with the patients
Daily notes to be written on all in-patients no exceptions Daily notes on consults Laboratory investigations AM labs ordered? AM CXR ordered? Electrolytes replaced? Daily contact with consulting Services
Identify with your team your ‘sickest’ patients and ensure their tasks are performed first Put in all orders on all patients at once Call consults early (UF Surgery is not like certain services that drop the 5:30pm bombshell) Half fill in boxes of tasks that have follow up CT scan order and reviewed
Gradual return to preoperative state Improved mobility and mood Reduction in IVF, toleration of PO intake Return to home medication regiment Return of Bowel Activity (flatus then BMs) Reduced Analgesia requirements and transition to oral pain medications. Wound healing Disposition and home environment
Look better/feels better No fever, normal VS, normal WCC, stable HCT/plt count, normal electrolytes Mobilisation of fluid Spontaneously negative I/O fluid balance Patient crosses legs in bed and starts to complain about hospital food
Fever Rising WCC Drop in HCT, Hb Electrolyte imbalance Drain output change Reduced Urine Output Pt has little to say for him/herself Surgery Specific Concerns POD 5 Colorectal pt with fever, elevated WCC Salmon coloured fluid escaping from a previously dry abdominal wound
Arrest Sudden change in mental status Sudden respiratory compromise Sudden cardiovascular embarrassment Audible Bleeding
Surgery specific complications… MIS – anastomotic leak BMS – haematoma Colorectal – anastomotic leak PBS – Bleeding, Sepsis Transplant – Organ rejection Vascular – bypass occlusion, pseudoaneurysms Trauma – DTs, withdrawal
Know your surgical procedures and their expected post operative courses Attention to detail Check vitals carefully looking for clues ▪ Tachycardia (gradually developing) ▪ Tachypnoea (gradually developing) Dare to think
Eyeball Distressed, obtunded, tachypnoeic, tachycardic Vital Signs IV access? Lines working Finger stick glucose Labs Imaging Monitoring (continuous pulse ox, telemetry) Level of care (floor, IMC, ICU)
Contact senior resident early with concerns and Plan Communication continues until resolution of the concern (may occur over days) Follow through on plan – CT scan etc…
PACU During Transfer CT scanner Interventional Radiology
Date/Time/Venue on all notes Time of incident to time of initiation of trial averages 18 months, how good is your memory?
Call your covering chief with information regarding – Current state of patient Your working diagnosis Your plan of action You will receive gentle guidance Calling is what you are expected to do As your experience level increases you will feel more confident and identify routine calls from serious pathology.
Tertiary Level University Teaching and Academic Center We take the cases that local hospitals refer to us for ‘Complexity of Care’ Level 1 Trauma care for local population
Standards are high Expectations are high You are all here for a reason Everyone here is capable of performing the tasks required