The surgical junior doctor is the first person called. Rasheed Zakaria and Ashok Handa explain how to manage eight common presentations
ne of your first responsibilities as a junior doctor is the care of surgical patients in the wards. Surgical and clinical commitments may mean that your seniors are not immediately available, and in an emergency you will invariably be the first person to be called. This article covers situations encountered commonly in patients who have had operations—shortness of breath, venous thromboembolism, pain, wound problems, confusion, transfusion reactions, nausea, and pyrexia. We hope to highlight the diagnoses you should have at the forefront of your mind, why they occur in surgical patients, how to avoid them, and how to initiate management before advice is available. As always, if in doubt, call for help.
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Shortness of breath Respiratory complications are common after surgery, especially in older patients (box 1). Be particularly vigilant for patients with pre-existing
cardiac or respiratory disease, smokers, immobile patients, patients who have had a general anaesthetic, and patients who have had thoracic or upper abdominal incisions. Minimise the risk by ensuring that patients have good analgesia. Enlist the help of a physiotherapist to give appropriate therapy and to teach the patient breathing exercises. Encourage regular changes in posture and early mobilisation. Reassure the patient and sit them up. Give high flow oxygen. Some patients with obstructive airways disease will not tolerate 100% oxygen, but do not let this deter you from giving sick patients oxygen.w1 Quickly familiarise yourself with the history and examine your patient’s heart and lungs. Check pulse oximetry and consider sampling arterial blood gas. Obtain an urgent portal chest x ray film.
Tension pneumothorax Act immediately if you suspect tension pneumothorax—trauma, central lines, and unintentional opening of the pleura during nephrectomy or cervical operations are particular risks. Insert a 14 gauge cannula in the second intercostal space in the mid-clavicular line and call for immediate help. If you are right then your patient needs a chest drain. This is rare but immediately life threatening. The signs to recognise are decreasing air entry, Box 1: Causes of shortness of breath in postoperative patients • Atelectasis • Aspiration • Pain • Pulmonary embolism • Infection (pneumonia) • Pulmonary oedema • Pneumothorax • Pleural effusion • Adult respiratory distress syndrome
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hyper-resonant percussion, pain, and deviation of the trachea away from the affected side.
Atelectasis is the commonest respiratory problem after surgery.w2 Bronchial secretions plug small airways, and distal alveoli collapse causing a ventilation perfusion mismatch, with a consequent fall in the partial pressure of arterial oxygen. In addition to shortness of breath, your patient may be tachycardic and pyrexial. Large collapses may be evident on the chest film. Contact your physiotherapist urgently and ensure adequate analgesia. Nebulised bronchodilators help clear secretions. Most cases can be safely managed on the ward, but severe cases may require respiratory support. Box 2: Risk factors for venous thromboembolism Most surgical procedures increase risk, but particularly: • Pelvic or lower limb surgery • Surgery for malignant disease • Long operations • Surgery in elderly or obese patients, and in pregnant women • Previous venous thromboembolism • Patients taking the contraceptive pill or hormone replacements
Aspiration General anaesthesia suppresses protective airway reflexes. Postoperative inhalation of vomit or gastric contents can precipitate a sterile chemical pneumonitis, although infection may develop subsequently. Emergency operations on patients who have not been starved pose a particular risk. Shortness of breath can ensue rapidly, and patients can become sick, with cyanosis, tachycardia, poor air entry, and diffuse crepitations on auscultation. Bronchial lavage and ventilation may be required. Most patients will be given broad spectrum antibiotics and bronchodilators, some doctors also advocate steroids. Although infection can complicate aspiration pneumonitis, it can also develop gradually. Poor swallowing in elderly patients who have had operations can result in chronic aspiration of food or secretions. Your patient will usually have the clinical signs of infection, but remember that elderly patients may not always develop pyrexia. Take sputum and blood cultures and start broad spectrum antibiotics until sensitivities are available.
Venous thromboembolism Surgery is one of the key risk factors for venous thromboembolism but you should be aware of the
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an operation—be vigilant for any signs of occult blood loss.
Pain
others (box 2).w3 The most feared complication is pulmonary embolism. The “classic” presentation of a pulmonary embolism is the sudden onset of shortness of breath associated with pleuritic chest pain, cyanosis, hypotension, haemoptysis, and raised jugular venous pressure. An electrocardiogram may show the classic SI, QIII, TIII pattern (S wave in lead I, and Q wave and inverted T wave in lead III). However, many pulmonary emboli present with few of these signs. The more common clinical picture is one of tachycardia, dyspnoea, and low grade pyrexia. Because these signs are relatively non-discriminatory and characterise many postoperative complications, it is important that pulmonary embolism is considered in any breathless postoperative patient. If the signs of a small pulmonary embolism are ignored then a larger or fatal pulmonary embolism may follow.
Management The most reliable diagnostic tests for pulmonary embolism are ventilation-perfusion scanning, pulmonary angiography, or a computed tomography pulmonary angiogram. Because these tests take a while to organise, you should initiate management when your clinical suspicion is high. Arterial blood gas analysis may be helpful—the partial pressures of oxygen and carbon dioxide tend to be low. So first arrange oxygen, chest x ray, electrocardiography, arterial blood gas analysis, and blood tests. The mainstay of treatment is anticoagulation. This can be achieved in many ways, but low molecular weight heparin is the preferred option. There is no loading dose: you can give a subcutaneous injection once a day, with the dose determined by the patient’s weight, and there is no need to monitor anticoagulation. Once the diagnosis is confirmed, oral warfarin should be started. Remember that anticoagulation may precipitate haemorrhage soon after Box 3: Reasons for poor wound healingw5 •Smoking •Obesity •Steroids •Jaundice •Poor nutrition •Previous radiation therapy •Contaminated or infected wounds •Poor surgical technique •Diabetes •Immunosuppression
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When called to see a patient in pain after an operation, check first to see what sort of operation they have had, where the wound is, and what level of analgesia has been tried and found to be inadequate. Confine yourself to a limited range of analgesics of different strengths and routes of administration so that you become comfortable in their use and know their side effects. Take the same history that you would for any patient presenting acutely with pain: where is it, sudden or gradual onset, what makes it better or worse— for example, deep breathing—and don’t just assume that all pain after an operation is because of the wound.
Wound pain Wound pain is usually worse with movement. It should gradually settle after the first two days. Exacerbations in wound pain after this time should be taken seriously. Look for signs of wound infection, breakdown, or dehiscence. Pain in the legs—Always ask about this and examine for signs of deep vein thrombosis and superficial phlebitis. Abdominal pain—Examine the abdomen carefully and consider in particular urinary retention; constipation; leakage from a bowel anastomosis; intra-abdominal sepsis or abscess; new bowel pathology—obstruction, ischaemia, perforation. Chest pain— Always rule out respiratory and cardiac causes; an electrocardiogram is mandatory.
Wound problems A call to see a patient whose wound has “fallen apart” can be worrying. Most of the reasons why a wound fails to heal as expected will be out of your control: risk factors are mainly related to the patient and the surgical technique (box 3).w4 When you examine a wound do so carefully and palpate it gently with sterile gloves. Ask yourself whether it is generally inflamed, or are the signs of infection localised. Is there an obvious abscess or haematoma? Do the deeper layers of the closure seem intact? Beware the serous wound discharge in a patient who is generally unwell, possibly with a low grade fever. These are early warning signs of dehiscence. Wound dehiscence should be taken seriously as it has a high mortality.
Management Broken sutures can be gently removed— you may find that this releases pus. Take swabs from the wound, particularly any obviously infected areas. If there is clear evidence of infection then start antibiotics that will cover most staphylococcal and streptococcal infections—for example, flucloxacillin and benzylpenicillin. Change to a specific antibiotic when you know the sensitivities. If you cannot see any evidence of dehiscence then ask the nursing staff to cover the wound with a loose sterile dressing and ask seniors to review the wound as promptly as practical. If you suspect dehiscence, call your reg-
istrar. Resuscitate your patient if necessary, place them “nil by mouth,” and prepare them for theatre. In the meantime they need analgesia, intravenous fluids, intravenous antibiotics, and sterile dressings.
Confusion Postoperative confusion is common and ranges from mild disorientation to extremely disruptive behaviour. It is always distressing for the patient and their relatives. Try to remain calm, do not raise your voice, and seek to reassure. Establish the pattern of behaviour. What was the patient’s preoperative mental state? How rapidly has this current episode evolved? Consider these causes: » Hypoxia (caused by cardiac or respiratory complications or anaemia) » Drugs (analgesics)—are there any recent changes on the drug chart? » Alcohol (usually withdrawal but occasionally intoxication) » Sepsis » Pain » Retention of urine » Electrolyte-fluid disturbance » Hypoglycaemia. Try to examine your patient with these diagnoses in mind, and perform routine investigations, including full blood count, urea and electrolytes, blood gases, and glucose blood monitoring. Also arrange electrocardiography, chest x ray scans, and urinalysis. Check the drug chart and stop or substitute non-essential drugs that might be contributory. If you have to sedate the patient for his or her own safety or for that of others in the ward then consider
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pressure, bowel obstruction, or diabetic ketoacidosis.w7 A thorough history of how much, how often and content is complemented by thorough abdominal exam for distension and tenderness. Look at fluid balance and stool charts if available in the nursing notes, and find out whether the patient is opening their bowels. Request urea and electrolytes tests if vomiting is recurrent or severe then give an appropriate antiemetic by an appropriate route. Cyclizine is a cheap and effective antihistamine which can be given orally, intramuscularly, or intravenously. If obstruction and perforation have been excluded a pro kinetic such as metoclopramide may be given orally, intramuscularly, or intravenously. 5-HT3 antagonists, such as ondansetron are expensive but highly effective, particularly for patients also receiving chemotherapy.
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3-5 mg intramuscular haloperidol, or 5-10 mg intravenous or oral diazepam. Remember that sedating a patient doesn’t take the cause of their confusion away, and you should continue to search for it. Make sure that a sedated patient is carefully monitored.
Transfusion reactions Always respond quickly to a call about an unwell patient who is being transfused. Before prescribing blood or blood products bear in mind the volume of fluid that you are prescribing (a unit of packed cells is about 280 ml). Consider stopping other intravenous fluids while the blood is being given and if fluid overload is a concern—for example, for patients in cardiac failure— you may coprescribe oral furosemide with alternate units. Whenever you suspect a transfusion reaction, ensure that any units of blood given to the patient are returned to the laboratory for analysis with a further blood and urine sample. Check the patient’s details then check again.
Haemolytic transfusion reaction A haemolytic transfusion reaction usually occurs within minutes of starting the transfusion. When severe this is characterised by anxiety, chest pain, nausea, and headache, which give way to shock, dyspnoea, rigors, and vomiting. Haemoglobin may appear in the urine. The cause is nearly always ABO mismatch and this is nearly always because of clerical error.w6 » Call for help » Stop the transfusion » Give 100 mg hydrocortisone and 10 mg chlorpheniramine intravenously
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Your patient may need aggressive resuscitation and intensive support.
Temperature is usually checked every 4-6 hours after an operation, and you should be alerted if it rises above 37.5°C. The time elapsed since surgery will give you some idea of likely causes (box 4).w8 Develop a routine for assessing a patient with a postoperative fever, but pay particular attention to respiratory and urinary symptoms and calf pain. Examine the chest and consider electrocardiography or chest radiography. Examine the wound (take swabs), the calves, and the sites of intravenous cannulas. Send blood, sputum and urine cultures. If your patient is sick and is not already taking antibiotics then start broad spectrum antibiotics— for example, a cephalosporin—while you wait for results. Prescribe paracetamol too.
Non-haemolytic febrile transfusion reaction This usually occurs within hours of the start of a transfusion. It arises in patients who have had multiple previous transfusions and who have developed antibodies to human leucocyte antigen or granulocyte antigens. It is characterised by pyrexia, sweating, tachycardia and rigors.
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Stop the transfusion Give paracetamol If severe, give 100 mg hydrocortisone intravenously.
Nausea Vomiting may be a relatively benign effect of pain, opioid analgesics, or mild gastroenteritis but occasionally indicates a severe underlying complication of surgery—for example, raised intracranial
Finally Take seriously requests from nursing staff to review patients after operations. Develop a routine for dealing with common calls. Don’t hesitate to ask for advice from your registrar when you are unsure—the chances are that they have encountered the situation before. It is better to call for help and be reassured than not to for a sick patient who then deteriorates. Rasheed Zakaria foundation year 1 doctor, Chelsea and Westminster Hospital, London
[email protected] Ashok Handa tutor in surgery, Nuffield Department of Surgery, John Radcliffe Hospital, Oxford
Competing interests: None declared.
References w1-w8 are on student.bmj.com.
Box 4: Causes of temperature in postoperative patients 0-24 hours • Most likely to be inflammation and necrosis as a result of the metabolic response to surgery • Consider also respiratory complications and fever associated with postoperative transfusion First few days • Respiratory complications • Sepsis in the wound or development of an abscess 5-7 days • Failure of anastomoses with leakage or fistula development • Venous thromboembolism • Urinary tract infection >1 week • Deep abscess; sepsis distant from the operation site • Thromboembolism
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