MO Handbook Surgery

SURGERY
Contents
1. Preoperative Management 5
2. Routine Medications and Surgery 10
3. Prevention of Venous Thromboembolism 14
4. Post-operative Management 16
• Ward rounds 16
• General system principles 16
• Fluid and electrolyte management 17
• Communication 19
• Hand Hygiene 19
5. Common Postoperative Problems 21
• Hypotension and Shock 21
• Oliguria 22
• Confusion (Please also see the “Geriatric Medicine” section for details) 24
• Fever 24
• Atelectasis 25
• Pneumonia 25
• Fat Embolus 26
• Clostridium Difficile 26
• Post-thyroidectomy bleed 27
6. Surgical Wounds and Drains 28
• Wound problems 28
• Surgical drain tubes 29
7. General Surgical Conditions 33
8. Other Surgical Problems 41
9. Nutrition 48
• Preoperative Management
Consent
• This must be appropriately and legibly filled in:
• NO abbreviations eg, Left must be written as left, not L; laparoscopic
cholecystectomy + intraoperative cholangiogram must not be written as
lap chole + IOC.
• Operative site clearly identified
• Expected procedure appropriately described (“Laparotomy + proceed”
should be rarely used).
• If the patient does not understand English, an official interpreter must be
used. Family or friends should not be used as interpreters as (1) there may
be a conflict of interest (specific details may be withheld from the patient); or
(2) they may not have the medical terminology knowledge to be able to
interpret adequately.
• The Interpreter must also sign the consent form.
• If the patient is incompetent, then consent must be sought from the patient’s
legal guardian.
• Consent is the responsibility of the consultant or registrar. It is important that
the registrar/consultant from the team performing the procedure discuss
consent with the patient rather than relying on other teams – this especially
applies to consults.
• If you cannot fully discuss the nature and complications of a procedure
do not consent the patient.
• Interns are not allowed to consent patients for procedures.
Operation Lists
• To be in Department of Anaesthetics before 10 AM the day prior to surgery
(otherwise special arrangements required).
• Lists need to specify:
• Patient name
• Medical record number
• Age
• Ward
• Operation
• Site
• Special equipment required and
• Team contact details.
• The list should be checked by the registrar of the unit.
ICU or HDU Beds
• Should be booked and confirmed preoperatively if the patient is expected to
require close monitoring postoperatively. This is the surgical team’s
responsibility, not the anaesthetics team.
Preoperative Investigations
• In general, preoperative tests should not be ordered “routinely”
• Considerations for whether preoperative tests should be performed will
depend on:
• Type of surgery
• Age
• ASA grade
• Comorbidities
• Specific tests and considerations:
• ECG
• Known cardiorespiratory disease
• Known cardiovascular risk factors
• Major surgery
• CXR
• Smoker
• Recent upper respiratory tract infection
• COPD
• Cardiac disease
• FBC (especially Haemoglobin)
• Major surgery
• Liver disease
• Extremes of age
• History of anaemia, bleeding or haematologic disorders
• Coagulation studies
• Certain major surgery (eg, liver surgery)
• Renal or liver dysfunction
• Known bleeding disorders
• EUC/LFT/BSL
• Known or risk of renal or liver dysfunction
• Endocrine disorders
• Certain perioperative therapies
• Urinalysis
• Prosthesis implantation
• Urologic procedures
• Urinary tract symptoms
• Group and hold
• Major surgery where there is major risk of bleeding
• Renal or liver dysfunction
• Bleeding disorders
• Reference: Guidelines from the American Society of Anaesthesiologists
Task Force on Preanesthesia Evaluation (NGC-9000)
• The following procedures can be considered “Major surgery”:
• Colorectal Surgery
• Colorectal resectional surgery: Abdominoperioneal resection,
anterior resection, hemicolectomy
• Major perineal surgery
• Surgery for large bowel obstruction
• Small bowel resection
• Pelvic Exenteration
• Hepatobiliary, pancreatic and oesophagogastric surgery:
• Oesophagogastric resection (oesophagectomy, gastrectomy)
• Hiatus hernia repair
• Bile duct exploration,
• Splenectomy
• Pancreatectomy (pancreatoduodenectomy, distal
pancreatectomy, total pancreatectomy)
• Hepatectomy
• Head & Neck, ENT, Plastics
• Major excisional and reconstructive head and neck surgery
• Laryngectomy
• Neck dissection
• Breast and Endocrine Surgery
• Mastectomy
• Major oncoplastic procedures
• Free flap reconstructions
• Axillary clearance
• Adrenalectomy
• Thyroid surgery
• Vascular Surgery
• Vascular bypass and non-aortic aneurysm surgery
• Endarterectomies
• Major Amputations
• TEVAR/EVAR (endovascular aneurysm repair)
• Transplant
• Renal transplant
• Renal/pancreas transplant
• Orthopaedics
• Long bone fractures,
• Joint replacement
• Austin Moore hip surgery.
• Urology
• Nephrectomy
• Prostatectomy (transurethral, open, laparoscopic and robotic)
• This is of course not a comprehensive list. Many cardiothoracic,
neurosurgery and maxillofacial surgery can be considered as major
operations.
Bowel preparation
• Amount and type vary
• Comprised of 2 components:
• Dietary restriction
• Oral lavage solution. This can be further divided into:
• High volume
• Low volume
• The dietary restriction is generally clear fluid or low residue diet
• The oral lavage solution is generally given the day before procedure
• High volume preparations are relatively safe for patients where fluid
loads/shifts are dangerous (eg, renal, liver and cardiac failure patients
and patients at extremes of age), however, they require drinking large
volumes of lavage solution which can be quite unpalatable and
therefore not tolerated.
• Polyethylene glycol (PEG) is an example of a large volume
preparation
• Low volume solutions are better tolerated, but induces fluid shifts and
dehydration
• Example is “picoprep”, a solution of sodium picosulfate, citric
acid and magnesium oxide.
• Ask the registrar or consultant regarding preference (varies widely).
• Watch fluid status – elderly patients with renal impairment may require
supplementary intravenous fluid replacement.
• The following is a possible regimen:
• PEG: 1 litre at 1pm, 1 litre at 3 pm, 1 litre at 5pm
• Clear fluids the day prior to surgery or colonoscopy
• “Rescue prep” – fleet enema the morning of procedure if output is not
yet clear
• Remember that the later the bowel prep is given, the more likely the patient
will be running to the toilet in the middle of the night (therefore, start the prep
early)
Prophylactic antibiotics
• Used to prevent surgical site infections
• Generally, prophylactic antibiotics are required for:
• Clean-contaminated or contaminated wounds where treatment
antibiotics are not being administered:
• That is, where a lumen of a viscus is opened during surgery
without or with (respectively) gross contamination of the
operative site
• Insertion of prosthetic material (eg, mesh, joint replacement)
• Clean wounds where the following exists:
• Impaired host defences
• Consequences of postoperative infection is severe (eg,
neurosurgery)
• Choice of antibiotics depends on:
• Likely organisms causing postoperative infections, generally:
• From commensals resident in the viscus
• From the skin
• Patient allergies (especially beta-lactam allergies)
• Spectrum – narrowest which covers expected pathogens
• Local antibiograms of bacterial flora (eg, some areas have high
incidence of MRSA)
• Cost – least expensive drug
• Timing (only intravenous route considered below):
• At time of induction if a bolus is given
• If the drug requires an infusion, (eg, vancomycin, metronidazole), it
should be commenced earlier such that the infusion finishes just before
induction.
• Doses:
• Generally a single dose is adequate
• If the procedure is prolonged (>4h), then further doses can be given at
4 hourly intervals
• Continuing prophylactic antibiotics postoperatively is generally not
recommended
• Examples of Specific Regimens
• Gastrointestinal surgery (enteric Gram negative and anaerobic
bacteria)
• Intravenous metronidazole (or clindamycin) + cephazolin (or
gentamicin)
• Metronidazole maybe omitted in cholecystectomy unless
previous biliary instrumentation
• Cardiac, neurosurgery orthopaedic and vascular surgery
(Staphylococci)
• These are largely clean operations where the source of
pathogens is from skin (note that operation of infected wounds is
considered treatment and not prophylactic antibiotics)
• Intravenous cephazolin
• If MRSA positive, then intravenous vancomycin (with or
without gentamicin)
• Lower urinary tract surgery (Gram negative bacteria)
• Intravenous gentamicin
• Upper respiratory tract surgery (aerobic, microaerophilic, streptococci,
anaerobes)
• Intravenous cephazolin and metronidazole
• Vancomycin can be considered above based on local bacterial flora.
However, this is not routinely recommended as overuse will lead to the
emergence of vancomycin resistant organisms (eg, VRE).
• Detailed guidelines can be found from the Department of Anaesthetics and
online on eTG (therapeutic guidelines).
• Reference: Australian prescriber 2005; 28:38-40.
Infective Endocarditis
• Another indication for antibiotic prophylaxis (to prevent infective endocarditis
rather than surgical site infections). This is considered separately as
indications for antibiotic use differ.
• Patients at risk
• Rheumatic heart disease
• Prosthetic valves
• Congenital disease
• Pacemakers
• Procedures requiring prophylactic antibiotics
• Dental procedures
• Tonsillectomy
• Complicated childbirth
• Urinary catheterisation
• GIT or respiratory tract surgery
• Infections eg. Abscess
•
Routine Medications and Surgery
• General rule is to continue all regular medications perioperatively.
• Acute cessation may worsen disease status or cause withdrawal syndrome.
Nil by mouth (NBM) and medications
• “Nil by mouth” orders for surgical patients can be due to a variety of reasons.
This has implications for the administration of oral medications depending on
the specific reason for this order.
• If the patient is NBM awaiting surgery, patient can generally have their
usual medications with a sip of water.
• The reason for NBM is to minimise aspiration – giving
medications with sips of water does not increase aspiration risk.
• If the patient is NBM for postoperative ileus or bowel obstruction, non-
essential medications should be withheld and essential medications
(eg, antiepileptics) should be converted to parenteral alternatives
• The reason for NBM is the non-functional gut. Medications
given by the enteral route will not be reliably absorbed.
• If the patient is NBM for aspiration risk or for upper gastrointestinal
perforation/fistula, medications may be given through the enteric
feeding tube (nasogastric, nasojejunal, feeding jejunostomy)
• In this case, the gut is generally functional, therefore
medications can be given via an enteral route.
• Note that some medications are not suitable for tube
administration due to enteric coating or high propensity for tube
blockage (eg, extended release formulations, proton pump
inhibitors).
• These medications may need to be changed (to regular
formulations or to alternative drugs which have syrup
formulations).
Anticoagulant and antiplatelet medications
Anticoagulants
• Warfarin (See Haematology chapter)
• Usual indications:
• Metallic prosthetic heart valves
• Prophylaxis for patients with atrial fibrillation
• VTE treatment
• General principles of management (prescribing physician/anaesthetist
should generally be consulted on a case-by-case basis):
• Check INR on preadmission clinic visit
• Cease warfarin 5 days before surgery
• Check INR on day prior to procedure (needs to be < 1.5)
• Bridging anticoagulant therapy may be required depending on
the thrombotic risk:
• High risk – Bridging therapy with therapeutic dose
LMWH/UFH.
• Intermediate risk– Bridging therapy with prophylactic
dose LMWH (subcutaneous low molecular weight
heparin) or therapeutic dose LMWH/UFH (intravenous
unfractionated heparin)
• Low risk – No bridging therapy required
• Risk stratification:
• High risk –
• Hypercoagulable state:
• Known thrombophilia
• Recurrent or recent (<3 months) arterial or
venous thromboembolic events
• AF
• Rheumatic cause
• Intracardiac thrombus
• AF + mechanical valve
• AF + history of embolism
• Mechanical valve
• Old style mechanical (mitral)
• Recent mechanical valve placement
• Intermediate risk –
• Multiple strokes
• Newer style mechanical valve (mitral)
• Older style mechanical valve (aortic)
• AF (multiple risk factors but no history of embolic
disease)
• VTE (not recent, >3 months)
• Low risk
• VTE (>6 months ago)
• AF without multiple risks or history of embolic
disease
• Newer model mechanical valve (aortic)
• Emergency reversal
• Intravenous vitamin K 10mg (by itself, the full effect takes 24 hours)
• Prothrombinex 25-50 IU/kg (provides Factors II, IX and X, ie, no VII)
• FFP 150-300 ml (provides Factor VII)
• Non-emergent reversal
• Withhold warfarin with or without low dose (2mg po or 1mg iv) vitamin
K
• Restarting anticoagulation:
• If no bridging therapy is required postoperatively, the patient should be
commenced on VTE chemoprophylaxis.
• If bridging therapy is used, it may need to be restarted postoperatively
• When it should be restarted varies amongst surgeons and also
depends on the assessed risk of postoperative bleeding.
Therefore, team registrar or consultant should be consulted prior
to restarting therapeutic anticoagulation.
• When oral intake can be resumed, warfarin can be restarted
• Often takes 3-5 days, although preoperative vitamin K may
render patient relatively warfarin resistant.
• New oral anticoagulants
• Dabigatran (thrombin inhibitor), rivaroxaban (Xa inhibitor), apixaban
(Xa inhibitor)
• Indications:
• Non-valvular AF
• VTE prophylaxis after hip and knee replacement surgery
• Rivaroxaban – secondary VTE prevention
• Do not require monitoring
• Currently, there is no specific reversal agent
• If planning for elective surgery, discontinue drug for 2 days and consult
haematology
Antiplatelets
• Aspirin
• Affects platelet function by irreversible inhibition of COX
• Often does not need to be stopped for most types of surgery
• If in doubt, please consult the subspecialty registrar/consultant
• Benefits of continuing aspirin is often considered to outweigh
bleeding risk
• If need to be stopped, it should be stopped 10 days before elective
surgery
• Clopidogrel
• Pro-drug of non-competitive irreversible platelet adenosine
diphosphate receptor inhibitor
• Generally the prescribing physician should be consulted prior to
stopping
• If prescribed with aspirin (dual-antiplatelet therapy), aspirin could
often be continued perioperatively
• If clopidogrel is used as a single agent and need to be stopped,
one should consider prescribing aspirin perioperatively
• Dual antiplatelet therapy should be continued for patients who
undergo surgery within 6 months and 12 months of insertion of
bare metal and drug eluting stents respectively (ACCP
guidelines).
• If clopidogrel needs to be withheld, it should be stopped for 7 days
preoperatively.
Other medications
• NSAIDs
• Stop 24 hours before surgery
• Can exacerbate renal dysfunction
• Antihypertensive
• Usually continue taking right up to morning of surgery
• Monitor BP perioperatively
• Omit if hypotensive (systolic BP < 90)
• Resume postoperatively with sip water
• Be aware that ACE inhibitors may exacerbate postoperative
acute kidney injury (usually precipitated by hypovolaemia from
fluid shifts). This is especially the case when it is used in
conjunction with diuretics and NSAIDs. If the drugs are used in
this combination and/or there is anticipated hypovolaemia or
other causes of acute kidney injury, one should consider
stopping ACE inhibitors preoperatively (alternative
antihypertensives may be required in some cases).
• Anticonvulsants
• Continue until surgery
• Resume postoperatively
• Consider IV alternatives if gastrointestinal function is unreliable
postoperatively (eg, ileus)
• Oral contraceptives
• May Increase VTE risk
• Stop 4-6 weeks before elective surgery
• Advise alternative contraception
• Diabetic medications and steroids (Please see endocrinology section)
• Prevention of Venous Thromboembolism

• Prophylaxis can be divided into:
• Chemoprophylaxis –
• Low molecular weight heparin (eg, clexane)
• Unfractionated heparin
• Physical prophylaxis –
• Sequential compression devices (“calf compressors”)
• TED stockings
• Early mobilisation
• Patients should be categorised into high and low risk groups depending on
risk factors for VTE.
• Both medical and surgical risk factors need to be considered.
• Incidence of Thromboembolism in the surgical patient:
• General Surgery 25%
• Total Hip replacement 51%
• Total knee replacement 47%
• Hip fracture 45%
• Neurosurgery 22%
• Gynaecological Surgery 14-22%
• Contraindications to anticoagulation:
• Active bleeding
• Haemophilia
• Thrombocytopenia (Platelet <50)
• Severe hepatic disease (INR >1.5)
• Anaphylaxis
• Contraindications for mechanical prophylaxis:
• Severe peripheral artery disease
• Severe peripheral neuropathy
• Risk factors:
• Surgical
• Hip or knee surgery
• Major trauma
• Cancer Surgery
• Surgery >45 minutes in duration
• Abdominal surgery
• Medical
• Previous VTE
• Known thrombophilia
• Cancer
• Ischaemic stroke
• Decompensated cardiac failure
• Acute on chronic lung disease
• Acute on chronic inflammatory disease
• Age >60yrs
• The following tables outlines the Australia/New Zealand VTE prophylaxis
practice guidelines:
Surgical patients
PROPHYLAXI
RISK FEATURES DURATION DOSAGE
S
Enoxaparin
-Hip or knee 40mg/day +
arthroplasty TEDs^ and/or
-Major Trauma calf
compressors
Enoxaparin
-Hip fracture 40mg/day or
5-10 days
surgery Heparin
except 28-35
-Other surgery 5000U TDS +
LMWH or days for hip
HIGH with prior VTE TEDs^ and/or
UFH# arthroplasty/
and/or active calf
fracture
cancer compressors
surgery. **
Enoxaparin
20mg/day or
Heparin
-Major 5000U BD or
Surgery*, age TDS + TEDs^
>40rs and/or calf
compressors
Enoxaparin
20mg/day or
Other surgery LMWH or Duration of
LOW Heparin
<45 minutes UFH# admission
5000U BD or
TDS + TEDs^
*Major Surgery: intra-abdominal surgery or any surgery >45 minute duration
** Extended VTE prophylaxis may also be considered after major abdominal cancer
surgery (eg, colorectal or upper gastrointestinal cancer surgery)
#Dose adjust for renal impairment
^TEDs 16-20 mmHg at ankle
Non-surgical patients
PROPHYLAXI
RISK FEATURES DURATION DOSAGE
S
Ischaemic
stroke
History of VTE
Active cancer
Decompensat
ed cardiac
failure Duration of Enoxaparin
Acute on admission or 40mg/day or
LMWH or
High chronic lung until resolution Heparin
UFH#
disease of acute 5000Units BD
Acute on medical issue or TDS
chronic
inflammatory
disease
Age >60yrs
-
Thrombophilia
Low Nil Nil
• Reference: Prevention of Thromboembolism: Best Practice Guidelines for

Australia & New Zealand (4th Ed). The Australian & New Zealand working
Party on the Management and Prevention of Venous Thromboembolism
•
Post-operative Management
Ward rounds
• All patients should be seen on the ward round at least once daily. Patients
who are in critical care wards (ICU/HDU) or have been identified during the
day as unstable should be seen again in the evening.
• Remember to check operation notes when patients return to the ward. Things
to look for:
• What operation was actually performed? This may differ significantly
from the planned operation due to intraoperative findings (eg,
conversion of a curative operation to a palliative one).
• Intraoperative problems or issues
• Drains and where they were placed
• Postoperative orders
• Important aspects of post-operative care that should be considered every day
on the ward round include:
• Adequate analgesia
• Activity (ie, SOOB/mobilise, weight bearing status)
• Chest physiotherapy
• Drain and catheter management
• Drugs (antibiotics, anticoagulants, antiplatelets etc)
• DVT prophylaxis
• Diet (Clear fluids, free fluids, light diet etc)
• Fluid therapy and balance
General system principles
• Cardiac
• ECG monitoring if arrhythmias present or operative infarction
suspected.
• Generally, invasive blood pressure and CVP monitoring is required for
the haemodynamically unstable patient who requires vasopressor of
inotropic support. However, use of these should be guided by the
anaesthetics or ICU teams:
• The classic use of CVP measurement for monitoring patient
volume/cardiac output is no longer considered reliable. The use
of central venous access for giving medications not suitable for
peripheral administration and for difficult access situations
remains valid.
• Strict fluid balance is generally required.
• Hourly urine output is usually required after major surgery,
although fast-track protocols may dictate the removal of the
urinary catheter, in which case urine output can be measured
each time the patient passes urine.
• Respiratory
• Adequate analgesia is important to allow full respiratory effort.
• Especially for major abdominal and thoracic surgery
• Early liaison with the pain registrar (page 9288) especially for
high risk respiratory patients (including known or suspected
obstructive sleep apnoea)
• Early ambulation is important:
• Sit the patient out of bed (or at least keep chest erect) as soon
as possible
• Patient should mobilise as soon as possible
• Chest physiotherapy and deep breathing exercise should be performed
for all patients undergoing abdominal surgery.
• CXR if evidence of collapse, consolidation, pneumothorax, effusion or
after insertion of central venous catheters.
• Renal
• Pre and intra-operative hydration is important.
• Low urine output is most likely due to hypovolaemia and therefore
should not be treated with frusemide
• However, do not over treat post-operative fluid retention and sodium
conservation with excessive intravenous fluids.
• Avoid nephrotoxic drugs, and check drug levels (eg. gentamicin).
• Urine output should be greater than 0.3mL/kg/hr. Any less than this
requires careful evaluation. In postoperative patients, hypovolaemia is
the commonest cause of oliguria.
• If renal impairment is present, then monitoring of urine output and fluid
balance is crucial.
Fluid and electrolyte management
• For details, please consult the fluid management section of the handbook
• However, some general principles for the specific management of surgical
patients are outlined below.
• Fluid management is especially important in surgical patients as fluid shifts
are more complex in such patients. Fluid shifts, loss of fluids through
gastrointestinal tract or drains, as well as third space losses are common.
• All fluid orders should be charted in mL/hour rather than the old-style
“every x hours” as infusions are now controlled by infusion pumps
where the rate is measured in mL/hour.
• Minimising variation (and therefore human interpretation) in
prescription will help minimise human error
• This includes “TKVO” order. This should be charted as 20mL/hr or
40mL/hr.
• Generally, intravenous fluids are given in the following situations:
• The patient is NBM awaiting surgery where there are no abnormal fluid
losses
• The patient has an acute surgical problem where there are continued
fluid losses
• The patient has an acute surgical problem where the patient is already
hypovolaemic and requires fluid resuscitation
Maintenance requirements (See also, the section on “Oliguria”)
• The basic maintenance requirements are:
• Sodium: 2mmol/kg/day
• Potassium: 1mmol/kg/day
• Water: A general guide is the “4/2/1 rule”. 4mL/kg/hour for first 10kg;
2mL/kg/hour for second 10kg, 1mL/kg/hour for the rest of the patient’s
ideal body weight
• Note that this only serves as a guide to the fluid requirements for
the patient and in actual fact, often over-estimates the patients
actual requirements
• As a consequence of the above, note the following points:
• In general, few patients require 3L per day as a maintenance fluid
requirement.
• Giving multiple bags of normal saline for maintenance generally leads
to over administration of sodium and chloride. As a result, metabolic
acidosis may occur.
• A balanced salt solution such as Hartmanns solution is a better
choice.
• The potassium requirements dictate that almost each bag of fluid
should contain potassium unless the patient has significant renal
impairment. Eg, 60 kg patient requires 1x60=60mmol potassium per
day whilst water requirements is 40+20+40=100mL/hour=2.4L/day. If
we gave 2 bags of 1L fluids for the patient, both bags would need to
contain potassium (30mmol per bag) to provide the patient’s
maintenance requirements
• The above formula for water requirements provides an estimate. The
patient’s urine output is in the majority of cases a much better indicator
of ongoing fluid requirements.
Fluid losses
• On each ward round, the input/output charts must be examined
• All fluid inputs and outputs should be documented and a total fluid balance
calculated
• Losses should generally be replaced:
• Classically, it is taught that losses proximal to the duodenum should be
replaced by normal saline and those distal should be replaced by
Hartmanns solution.
• In general, however, it is safe to replace all gastrointestinal
losses with Hartmanns solution.
• Often, fluid is lost into the “third space” and this will need to be estimated.
Fluid Resuscitation (See also, section on “Hypotension and Shock”)
• For patients with hypovolaemia who require resuscitation one should use
either Normal Saline, Hartmanns solution or other balanced salt solution (eg,
Plasmalyte).
• Dextrose containing fluid should not be used in resuscitation
situations
• In general, in an acutely unwell patient, resuscitation should be pursued
aggressively and the patient’s response continuously monitored.
• Patient’s response to resuscitation is a good guide for ongoing
resuscitation requirements.
• Blood pressure, heart rate, respiratory rate, peripheral perfusion, urine
output and serum lactate levels are all useful indicators to guide
resuscitation.
Electrolyte replacement
• As a general rule, postoperative patients should have:
• Serum K >4mmol/L
• Serum Mg >1mmol/L
• Serum PO4 around 1mmol/L
• Significant deviations from these values should be replaced, generally
intravenously by adding the following to the patient’s iv fluids (if the patient
has intravenous access):
• Potassium – KCl, or KH2PO4 (if phosphate replacement is required
also)
• Magnesium – MgSO4
• Phosphate – KH2PO4, or NaH2PO4
• Note that care should be taken when replacing electrolytes in a patient with
renal impairment
Communication
Ward rounds
• At the end of the ward round, the JMO is required to handover any changes of
patient plan to the Nurse Unit Manager or the appropriate nursing team
leader.
• All changes should be documented in the notes in a timely manner
After-hours
• Surgical patients may deteriorate quickly. Therefore effective and timely
communication is essential. Some tips for effective communication include:
• Do not hesitate to call the surgical registrar, and if necessary, the fellow
or the consultant
• No one would fault you for discussing the case with the surgical
team if in doubt
• This is particularly the case for post-surgical patients
• When communicating with the surgical team, keep the story succinct
and focussed with the problem at hand. The ISBAR approach is
generally an effective way of clinical communication.
• Make sure that you have all the information at hand, eg, vital
signs, input/output charts, blood tests, etc.
• The surgical team (the surgical registrar on call is the first port of call) should
be notified in these situations:
• If a surgical patient develops a new problem or if there is a
deterioration of a pre-existing problem
• If you have made any significant changes to the patient’s management.
This includes commencing a new medication regularly or changing
other orders such as diet.
• If there is an ALS, PACE call
• If there is any significant changes to the patient’s vital signs
• If there is a patient review necessitating escalation of care
• Level of review, eg, requiring consultation from the medical or
ICU registrar
• Level of care, eg, patient entering HDU/ICU
• Unless there is an obviously simple or chronic problem, one should not write
“for team review in the morning”.
Hand Hygiene
• Hand hygiene is important to prevent health care associated infections.
• The World Health Organisation’s 5 moments of hand hygiene should be
followed:
• Before touching the patient
• Before aseptic procedures
• After body fluid exposure
• After touching the patient
• After touching patient surroundings
• Hand hygiene can be performed by using the alcohol handrub or by washing
hands
• The exception to this is when managing patients who have clostridium
difficile infection where hand washing is necessary.
• Common Postoperative Problems

Hypotension and Shock
• Shock is defined by inadequate tissue perfusion and is, whilst not
synonymous to, usually accompanied by hypotension
• Causes:
• HYPOVOLAEMIA is the most likely cause in postoperative patients
• Bleeding
• Fluid input/output imbalance
• Inadequate intake
• Excessive losses (both measurable and third-space)
• Distributive shock is due to vasodilatation leading to an effective
hypovolaemia
• Sepsis is the most common cause in postoperative patients
• Drugs (eg, epidural anaesthesia)
• Spinal shock
• Cardiogenic shock – CO = SV x HR. So a failure can be related to
either abnormalities in heart rate or abnormalities in stroke volume
• Dysrhythmias
• Heart failure
• Myocardial infarction
• Obstructive shock – either due to an obstruction in the inflow (eg,
cardiac tamponade), or outflow (eg, saddle pulmonary embolus)
• Pulmonary embolus is one of the most important considerations
in the postoperative patient
• Cardiac tamponade and tension pneumothorax should be
considered in patients who have undergone thoracic surgery/
trauma or is having positive pressure ventilation.
• Assessment
• Clinical assessment
• “ABCDE”
• Check BP yourself, postural BP (compare with pre-op BP)
• Patient likely Pallor, cool, tachycardia, narrow pulse pressure
• Check operative site, drains, IV lines.
• Myocardial status, eg. chest pain, arrhythmia.
• Chart review:
• Pulse rate, urine output, mental state.
• Check fluid input/output for evidence of hypovolaemia, eg.
under-replaced water or blood loss, continuing blood loss,
evaluate possible `third space' loss.
• Medications, eg. narcotics, spinal anaesthesia,
antihypertensives.
• Past medical history, eg, cardiac history
• Tests as indicated, for example
• Haemoglobin to look for evidence of blood loss
• Inflammatory markers for signs of inflammatory/septic process
• Septic screen, eg urinary m/c/s, CXR, blood cultures, line
cultures, drain cultures
• ECG/CXR/cardiac enzymes/echo to evaluate cardiogenic
causes
• Appropriate cross sectional imaging to look for surgical causes
(eg, CT abdomen to look for signs of an anastomotic leak).
• Management divided into immediate and definitive:
• Immediate:
• Volume replacement is desirable for most causes of
hypotension/shock. Even in cardiogenic causes, giving volume
will allow the heart to operate further along the Starling curve
leading to improved cardiac output in most cases.
• 20mL/kg bolus of either 0.9% NaCl or Hartmanns solution is a
good rule of thumb. If patient has poor cardiac history or is fluid
restricted for other reasons (eg, anuric on dialysis), 10mL/kg or
less may be desirable.
• Other immediate management is cause specific, eg needle
thoracostomy for tension pneumothorax and ceasing the
epidural infusion in the case of overdose.
• Definitive management will depend on the cause.
• Note that it is of vital importance that the team is notified of any such
unstable patients. Postoperative patients usually have a primary
surgical cause for their instability – despite a medical cause being
apparent. The classic example is an anastomotic leak causing atrial
fibrillation with rapid ventricular response causing hypotension. A
surgical registrar (or higher grade) assessment is vital in all cases of
unstable surgical patients.
Oliguria
• Oliguria is a common problem postoperatively
• Note however, most patients are relatively oliguric for 24-48 hours post-
operatively. This is partly due to the body’s “stress response” to the surgery.
• A “normal” urine output is between 0.5mL/kg/hr to 1mL/kg/hr. However, if
reacting “hour-to-hour” using a threshold urine output of 0.5mL/kg/hr by giving
fluid boluses below this level, one may run the risk of over-hydrating the
patient.
• One way of avoiding this is to use a longer term trend such as the urine
output over the last 4 hours <2mL/kg (ie, a rolling average of <0.5mL/
kg/hour over 4 hours) to guide fluid management if the patient is not
acutely unstable.
• Alternatively, one can use 0.3mL/kg/hr lower limit on which to act,
whilst keeping 0.5mL/kg/hr as a “warning sign” – an indication that the
patient may be potentially hypovolaemia.
• The most common cause of oliguria in a postoperative patient is
hypovolaemia
• Therefore, the most common appropriate response is to increase
fluid input
• NOT frusemide
• Causes of oliguria
• Prerenal - Hypovolaemia
• Excessive output:
• Third space losses
• Visible losses (eg, GIT losses)
• Bleeding
• Inadequate replacement
• Renal
• Blood transfusion incompatibility
• Myoglobinuria after crush injuries
• Circulating nephrotoxins in sepsis
• Nephrotoxic drugs eg. Aminoglycosides
• Postrenal
• Catheter obstruction
• Bladder injury
• Ureteric ligation or obstruction (bilateral)
• Assessment:
• Clinical Assessment:
• Clinical fluid assessment
• Review operative site – evidence of bleeding?
• Chart review:
• Check fluid balance
• Do not forget pre-operative hydration, intra-operative
blood loss, continuing fluid loss.
• Check BP, HR – is the patient shocked inadequate renal
perfusion?
• Review patient medications
• If no catheter in situ, consider urinary catheterisation for hourly urine
output monitoring
• Investigations:
• Exclude acute urinary retention by examination and bladder
scan
• This may be true even if the patient has a catheter in situ
(it may be kinked or otherwise obstructed)
• Abrupt anuria is often a tell-tale sign of a blocked catheter
• Check pre-operative and current EUC.
• Check haemoglobin
• Can consider measuring ‘fractional excretion of Na (FENa)’
• This is a helpful guide to determining whether the
patient’s oliguria or renal impairment is due to
hypovolaemia or not.
• This is based on the fact that pre-renal renal
impairment results in sodium retention whereas
renal causes will result in the loss of the kidney’s
ability to reabsorb sodium.
• Clearly then, it is influenced by the use of diuretics,
which work by inhibiting tubular absorption.
• Requires the measurement of urinary creatinine and
sodium concentrations
• If FENa<0.01, a pre-renal cause is likely
• Calculation:
• FENa = ([Cr]Serum × [Na]Urine ) / ([Na]Serum ×
[Cr]Urine) × 100%
Confusion (Please also see the “Geriatric Medicine” section for details)
• This is a common problem postoperatively
• However, common causes in postoperative patients include:
• Hypoxia and hypercapnea - Full respiratory examination is necessary
to exclude fluid overload, embolism and worsening chronic respiratory
disease.
• Drugs – this can either be due to withdrawal, over-dosage (eg, opioid
analgesia) or as a consequence of metabolic disturbance (eg,
hyponatraemia from diuretic use).
• Sepsis – Surgical site, chest, urine, line infections are common causes.
Appropriate cultures and investigations are necessary. Early empirical
antibiotic use may be warranted if sepsis is suspected.
• Hypoglycaemia – often as a result of iatrogenic causes.
• Other causes include cerebrovascular disease, other organic brain
syndromes, fat embolism, etc.
• Treatment is directed at the cause. Supportive measures, eg. reassurance,
bed-side light, relatives are important.
• Early geriatric liaison team input is suggested.
Fever
• Most post-operative fevers have an easily identifiable cause.
• Immediate post-operative fever:
• Usually metabolic response to injury.
• Day 1 - 3:
• Trauma, haematoma, atelectasis.
• More than 3 days:
• Early collection
• Anastomotic leak
• Sepsis:
• Chest
• Urine
• Lines
• More than 5 days:
• Wound or cavity collection
• Anastomotic leak
• Sepsis
• Pulmonary Embolism
• Examine:
• Check pulse and BP
• Examine the operative site
• Auscultate lungs
• Examine abdomen
• Check IV line sites (old and new),
• Check calves for DVT
• Check urine
• Investigations and management are directed at the cause
• As a routine - CXR, MSU and blood cultures
• Other investigations as directed by clinical examination
• Be wary of swinging fevers as they may indicate a collection of pus
Atelectasis
Generally occurs within 48 hrs
• Predisposing factors
• Obesity
• Smoking
• Opiates
• Drowsiness
• Nasogastric tubes
• Abdominal distension
• Prevention
• Stop smoking preoperatively
• Preoperative optimisation of respiratory diseases
• Deep breathing exercises
• Coughing
• Incentive spirometry
• Analgesia
• Treatment
• Physiotherapy
• Suctioning
• Provision of PEEP (eg, high flow nasal prongs, CPAP)
Pneumonia
• Usually due to either:
• atelectasis
• aspiration
• Prevention:
• NBM 6hrs preoperatively
• NGT – to aspirate a distended stomach.
• Note however, a blocked NGT may predispose the patient to
aspiration by allowing a passage through the lower oesophageal
sphincter and cricopharyngeus
• Antacids
• Cricoid pressure during anaesthetic induction
• The above preventative measures for postoperative atelectasis
• Treatment
• Antibiotics
• In addition to usual pneumonia cover, it should cover aspiration
(anaerobes):
• Ceftriaxone and metronidazole
• Ticarcillin + clavulanic acid
• Physical therapy
• Chest physiotherapy
• Incentive spirometry
Fat Embolus
• Causes
• Fractures and trauma
• Burns
• Severe infection
• Pancreatitis
• Clinical features
• SOB, hypoxaemia, cyanosis
• Altered LOC
• Focal cerebral signs
• Petechial haemorrhages (skin, fundi, mucosal surfaces) – this is
pathognomonic, although occurs in less than half of cases
• Fever
• Diagnosis
• Earliest = hypoxia
• CXR
• Scattered consolidation
• “snow storm”
• Fat in
• Sputum
• Urine
• Blood
• Elevated lipase
• Management
• Careful handling of fractures
• Early immobilisation of fractures
• Supportive management:
• Oxygen
Clostridium Difficile
• Common cause of postoperative diarrhoea – should always be considered
• Selected out and overgrows with the administration of many antibiotics
• In severe cases, may cause pseudomembranous colitis
• Investigations:
• Stool mcs - may demonstrate leucocytes
• Stool clostridium difficile toxin test
• Management
• First line agent is oral metronidazole (400mg tds). If an ileus is
present, intravenous metronidazole may also be used (note that
metronidazole works through mucosal concentration and secretion in
contrast to vancomycin where there is intraluminal retention from non-
absorption).
• If no response, then oral vancomycin (125mg qid po).
• Must be administered orally as vancomycin is not absorbed
orally and acts intraluminally
• Duration of treatment is 10-14 days
• Isolation, strict hand hygiene and PPE (personal protective equipment)
protocols
• Note that clostridium difficile spores are not killed by alcohol
hand cleansers alone and will require thorough hand washing
after contact with these patients.
Post-thyroidectomy bleed
• This is a surgical emergency
• Should be suspected in a patient with neck swelling post thyroid or
parathyroid surgery
• Potentially life threatening as haematoma leads to laryngeal oedema and
ultimately airway obstruction
• Clinical features:
• Neck swelling – often large and tense
• Features of airway obstruction (occurs late)
• Stridor
• Dysnpnoea
• Use of accessory muscles
• Desaturation and cyanosis
• Patients may be on anticoagulants/antiplatelets
• Investigations: Unnecessary investigations could potentially delay the
management of this emergency situation.
• Management:
• The surgical registrar, fellow or consultant must be contacted
immediately
• Sit patient up as much as possible
• Oxygen
• Contact the anaesthetics team – usually, the best way to do that in an
emergency is to activate the arrest call
• Do not leave the patient until senior help arrives
• The patient requires urgent OT for evacuation of haematoma
• Note: If the patient is in immediate respiratory distress, the wound
should be opened on the ward
• There is usually a dressing pack with a suture cutter at the end
of the bed.
• Opening the skin only partially decompresses the haematoma.
The platysmal sutures often need to be opened as well.
• However, as the haematoma is usually not liquid enough to
come out, cutting the sutures by themselves might not be
very effective and may in fact lead to delays in securing the
airway in the OT. Therefore, this should only be done if the
patient is has immediate respiratory distress from airway
obstruction.
• The decision to do this should generally be made by the
surgical registrar, fellow or consultant.
• Surgical Wounds and Drains

• Most wounds are covered by some form of dressing and require strict, regular
inspection.
• Problems with wounds include:
Wound problems
Pain
• If persistent (greater than 72 hours) suspect:
• Infection
• Early dehiscence
• Haematoma
• Narcotic addiction
• Entrapment of viscera, eg. omentum, bowel.
Inflammation
• May be due to
• Suture and staples kept in for too long
• Underlying haematoma or abscess (will need drainage, usually by the
bed side)
• Infection (cellulitis)
• Ischaemic wound edges
• Allergy to dressings
• Underlying prosthetic material.
Bleeding
• May require a local stitch or re-exploration.
• If the patient is unwell suspect D.I.C. or sepsis, coagulation problems, vitamin
K deficiency, etc.
Haematoma
• Observe if small,
• May require surgery if large or arterial bleeding present.
Sepsis/wound infections
• Numerous predisposing factors:
• Diabetes
• Ischaemia
• Malnutrition (Vit C def, Zn def)
• Steroids
• Cytotoxics
• Radiotherapy
• Long preoperative hospital admission
• Failure to debride devitalised tissues
• Large dead space
• Contamination of wound
• Cellulitis requires swab, aspiration and antibiotics.
• Underlying abscess/infected haematomas requires release of sutures to allow
drainage
• Antibiotics is required only if cellulitis is present
Dehiscence
• Can be divided into:
• Superficial – skin only
• Deep dehiscence – deep fascial dehiscence
• Usually occurs in second post-operative week
• Maybe associated with pain, low grade fevers and poor nutrition
• Wound can be packed with Normal saline soaked ribbon gauze if it is only
superficial (skin only)
• Deep fascial dehiscence of the abdominal wound classically presents with
large volume haemoserous discharge from the wound.
• If deep dehiscence, may require reoperation to close wound.
Surgical drain tubes
• Drains are often placed intraoperatively when collection of fluid within a cavity
is expected
• Drains are often measured in the French gauge. 1 French = 1/3 mm external
diameter
• Management:
• Drain position and management plan is usually documented within the
operative notes
• However, if in doubt, contact the team responsible for the patient
as drain management varies greatly amongst different
consultants
• Drain output must be documented daily, both volume and quality as
these two factors, in general, determine the timing of their removal.
• Drains and surgical tubes should not be removed without permission of
the registrar or consultant.
• There are many types of drains, a few are described below.
Closed Suction Drains
• Are used in large, flexible cavities or under flaps.
• These are the most commonly used drains in abdominal surgery
• The drains are closed systems, which in theory protects from ascending
infections
• Generally, these drains remain on suction by squeezing the suction
compartment. As this compartment fills, the suction is lost and will need to be
recharged as necessary.
• Sometimes, these drains are left on free drainage which means leaving the
suction compartment expanded.
• Examples include: round and flat Blake drains, Bellovac and Jackson-Pratt
(JP) drains
“Pigtail” drains
• Radiologically inserted drains
• Has a wire inside which keeps the drain in a curled shape (hence “pigtail”)
• It is inserted in a straight configuration, then the wire pulled to deploy
the curl
• Therefore, to remove, the wire must be loosened first prior to removal,
otherwise the pigtail will prevent removal
Corrugated rubber
• Penrose or Yeates drains are sutured to skin and are removed gradually when
drainage subsides.
• This gradual removal is called “shortening” of the drain. A classic drain
management order is to “shorten the drain by an inch a day”.
• They serve to remove fluid through
• Holding the drainage site open
• By gravity and capillary action
• Generally, these are covered by sterile pads or drainage bags (Note that
these are convenient but can form a rich culture medium).
• Usually used for draining chronic abscess cavities.
Sump Drains
• These are less commonly seen now.
• Composed of 2 components:
• An outer fenestrated tube which prevents blockage of the inner tube.
• Inner suction tube
• The inner tube suction (high wall suction) creates a venturi effect on the outer
tube holes, so the space between the two tubes must be kept open and the
inner tube must be kept open.
• Inner tube may need to be replaced if it is no longer patent. Patency can be
assessed by auscultation of the abdomen with drain on suction, if drain is
patent a `sucking' sound should be present.
• Sump drains should generally be on `high' wall suction, ie. 80-100mmHg.
Chest Drains
• Used in cardiothoracic surgery or trauma.
• Require underwater seal to prevent air entering pleural space creating a
pneumothorax
• May be on suction. Modern underwater seal containers have an inbuilt
pressure regulator. The container can be placed on high wall suction
and the regulator can be adjusted to provide the required suction
pressure (typically 10-20 cmH2O)
• Position:
• When placed outside of theatres, it is traditionally placed in 5th
intercostal space in mid-axillary line (just above the 6th rib to avoid
neurovascular bundle which runs under each rib).
• When placed during surgery, it may be found in alternative positions
• Often in that case, 2 drains are placed – a straight one directed
to the apex (“apical drain”) and a curved one directed to the
base of the pleural space (“basal drain”). Classically, the
“Anterior” drain is “Apical” whereas the one at the “Back” is
“Basal”.
• Should be removed at height of inspiration and a stitch applied.
• Always perform CXR post-removal.
T-tubes
• Uses:
• Classically placed after open bile duct exploration to sit within the bile
duct.
• This is an increasingly uncommon operation and T-tubes are
rarely used in laparoscopic bile duct exploration
• It is now often also used to drain sepsis when a perforated viscus could
not be closed (ie, to create a “controlled fistula”)
• If used in the former, it may be sutured to skin and are removed when
cholangiogram films are satisfactory
• Cholangiograms are performed prior to removal
• Prior to T-tube cholangiogram, the T-tube is often clamped for at least
24 hours
• Average bile drainage is 250-350mls daily, and if larger volumes are
lost then IV replacement with Hartmann's solution is needed.
• Dislodgment is a problem and requires surgical replacement if dislodged
before day 5 or 6
• Contact surgical registrar/consultant if this occurs
• General Surgical Conditions

Appendicitis
• Occurs at any age (normally < 40)
• Differentials – Gastroenteritis, Meckel’s diverticulum, Mittelschmerz, ruptured
ovarian cyst, Diverticulitis
• Classically migratory pain which localizes to RIF
• Fevers
• Anorexia
• Examination:
• Peritonism over McBurney’s point (One third along line drawn between
ASIS and umbilicus)
• Rovsing’s sign – Palpation on left of abdomen elicits pain on right
• Obturator sign – Flexion and internal rotation of hip elicits pain
• Psoas sign – Extension of hip elicits pain
• Investigations:
• Elevated inflammatory markers (WCC, CRP)
• EUC, LFTs and Lipase
• Imaging – REMEMBER THAT APPENDICITIS IS OFTEN A CLINICAL
DIAGNOSIS AND IMAGING IS USUALLY NOT REQUIRED:
• Plain films are of limited value
• Should almost never be performed in young male patients
• Consider CT if atypical or patient >40 years (where the chance
of alternative diagnoses increase, such as diverticulitis or
perforated cancer)
• Consider Pelvic US if patient is female <40 years
• Investigations in preparation for theatres (ECG, CXR etc) as necessary
• Management:
• NBM
• IVF
• DVT prophylaxis
• Analgesia (regular and prn)
• IV antibiotics
• If clinical appendicitis, commence antibiotics
• If planning to monitor clinically, consider withholding antibiotics.
Unless:
• Septic
• Pregnant – some surgeons prefer initiating antibiotics in
pregnant patients as the settling of an appendicitis
episode with antibiotics alone is not necessarily an
undesirable outcome.
• Antibiotic choice:
• Ampicillin, Gentamicin, Metronidazole
• Ceftriaxone/Cefazolin, Metronidazole
• Consent
• OT for laparoscopic (or less commonly open) appendicectomy
Acute Cholecystitis
• Classically, 4 F’s – Fat, forty, female, fertile
• Often not
• Differentials – Cholangitis, Pancreatitis, Peptic Ulcer Disease, Gastritis
• RUQ or epigastric pain
• Associated fevers
• Usually not jaundiced (unless coexistent choledocholithiasis or Mirrizi’s
syndrome)
• Examination:
• RUQ tenderness
• Positive Murphy’s sign – Increased RUQ tenderness on inspiration
• Investigations:
• LFTs – Maybe non-specifically deranged
• EUC, Lipase
• Imaging:
• Plain films are rarely useful
• Upper abdominal US – thickened gallbladder wall, cholelithiasis,
pericholecystic fluid, sonographic Murphy’s sign. CBD calibre
should be normal.
• Management:
• Clear fluid diet
• IVF as necessary
• DVT prophylaxis
• Analgesia (regular and prn)
• IV antibiotics
• Ceftriaxone as single agent
• Gentamicin/Ampicillin
• Metronidazole generally not required unless previous biliary
interventions
• OT for laparoscopic cholecystectomy, preferably during the same
admission.
• (Biliary colic differs from Acute Cholecystitis in that the patient is likely to have
a normal WCC, negative Murphy’s sign and no fevers)
Acute Pancreatitis
• 80% caused by gallstones and alcohol
• Differentials – Perforated peptic ulcer, peptic ulcer disease, gastritis, bilary
colic, acute cholecystitis, other causes of peritonitis, ruptured AAA.
• Upper abdominal pain radiating to back
• Associated vomiting
• Possible jaundice
• Examination:
• Epigastric tenderness with possible peritonism
• Possible abdominal distension
• Tachycardia and shock depending on severity
• Investigations:
• LFTs often deranged; possible raised serum bilirubin
• EUC, CMP – Electrolytes may be deranged from fluid shifts;
hypocalcaemia from sequestration (fat saponification); hypercalcaemia
may also be a cause of pancreatitis
• BSL – Possible hyperglycaemia
• LDH, Coags – abnormal if severe
• Fasting lipids – to investigate for aetiology
• ABG – hypoxaemia if severe
• Lipase raised; above 3x upper limits of normal.
• Imaging:
• US abdomen to assess for gallstones (aetiology) and CBD
calibre (choledocholithiasis)
• Biliary imaging – MRCP/ERCP/Intraoperative cholangiogram
• CT – Usually performed at around 48h to assess for pancreatic
necrosis (if severe)
• Severity assessment:
• Mild – no organ dysfunction
• Moderate – organ dysfunction <48h
• Severe – persistent organ dysfunction
• Management:
• If organ dysfunction, then patient should be managed in critical care
area (ICU/HDU)
• IVF resuscitation
• IDC with strict fluid balance
• QID BSL
• NBM initially
• ERCP if high suspicions of CBD stone
• DVT prophylaxis
• Antibiotic is not indicated in initial stages unless concomitant
cholangitis is suspected
• Treat cause (if gallstone pancreatitis, will require laparoscopic
cholecystectomy during same admission)
Diverticulitis
• Due to inflammation/ perforation of colonic diverticula
• Diverticula occur in weak points of bowel wall (where blood vessels penetrate)
• Most commonly affects sigmoid colon
• Usually LIF pain
• Asians may have RIF pain from right sided diverticulitis
• Associated fevers
• Examination:
• Localised peritonism in the LIF
• Febrile
• Free perforation is suspected if generalized peritonitis
• Investigations:
• Elevated inflammatory markers
• EUC may be deranged if patient is dehydrated
• Imaging:
• Plain films are usually not helpful
• CT Abdomen/Pelvis (with oral and IV contrast) is the
investigation of choice and to delineate complications arising
from diverticulitis (abscess/perforation)
• Management:
• CF diet
• IVF
• IV antibiotics
• Ceftriaxone/cephazolin and metronidazole
• Or gentamicin, ampicillin, metronidazole
• DVT prophylaxis
• IDC if unwell (strict fluid balance)
• Non-operative treatment if uncomplicated
• OT/ percutaneous drainage if complications arise, the exact procedure
depending upon surgical team
Small Bowel Obstruction
• Common causes – Adhesions, hernia, intussusception, malignancy
• Clinical features – Vomiting, colicky abdominal pain, absolute constipation,
abdominal distension.
• Examination:
• Dehydrated patient
• Importantly, take note of the presence of:
• Peritonism (may indicate strangulation)
• Herniae
• Other signs suggestive of distended gastrointestinal tract:
• Central resonance to percussion
• Possible succusion splash
• Tinkling bowel sounds have been described
• PR examination
• Investigations:
• Inflammatory markers should not be elevated
• EUC may be deranged due to fluid losses and third space losses
• Possible prerenal acute kidney injury
• Imaging:
• Plain films
• Erect CXR – to exclude pneumoperitoneum
• AXR (supine and erect) –
• Multiple air fluid levels
• Dilated SB loops
• CT Abdomen/Pelvis (with oral and IV contrast) is often helpful to
look for:
• transition point and location
• closed loop obstruction
• evidence of ischaemia or perforation
• herniae (internal and external)
• Management:
• NBM
• NGT either on low wall suction of free drainage + q4h aspirates
• IDC (and commence strict fluid balance)
• DVT prophylaxis
• OT is generally indicated if:
• Patient has “virgin abdomen” (ie, no previous abdominal
complications), indicating the likely cause as a congenital band
• Signs of peritonism (indication of ischaemia/perforation)
• SBO secondary to abdominal wall herniae
• Failure of conservative management – generally after 48 hours
Large Bowel Obstruction
• Commonly due to cancer, strictures (eg, diverticular), volvulus
• Clinical features – Possible vomiting, abdominal pain, absolute constipation,
abdominal distension.
• Examination:
• Dehydrated patient
• Importantly, take note of the presence of:
• Tenderness
• Generalized – may indicate perforation/ischaemia
• RIF – may indicate impending caecal perforation (caecum
being the area most likely to perforate due to LaPlace’s
law).
• Always perform PR examination – there may be a rectal mass
• Investigations:
• Inflammatory markers should not be elevated
• EUC may be deranged due to fluid losses and third space losses
• Possible prereneal acute kidney injury
• Imaging – the role of imaging is to exclude complications (perforation/
ischaemia) and to rule out colonic pseudo-obstruction.
• CT abdomen (with rectal and iv contrast preferable)
• Contrast enema (water soluble)
• Plain films is often a helpful first step, but imaging as per above is
almost always required:
• CXR – to exclude pneumoperitoneum
• AXR (supine and erect films)
• Dilated large bowel loops
• Multiple air fluid levels
• Small intestines may be dilated if incompetent ileocaecal
valve
• Volvulus
• Management:
• NBM
• NGT either on low wall suction of free drainage + q4h aspirates
• IDC (and commence strict fluid balance)
• DVT prophylaxis
• OT is generally indicated in the case of large bowel obstruction.
Surgical consultation is mandatory.
Abdominal wall herniae
Inguinal herniae
• More common than femoral
• Types:
• Direct – hernia protrudes through posterior wall of inguinal canal,
medial to inferior epigastric vessels
• Indirect – hernia exits abdominal cavity via the deep inguinal ring and
courses through the inguinal canal, ie, lateral to inferior epigastric
vessels
• Important point to note is that the type of inguinal hernia does not
influence management at all. Furthermore, clinical diagnosis of the
type is unreliable.
• More important is to be able to distinguish an inguinal hernia
from other hernias, eg femoral
• Clinically, inguinal hernias arise above the inguinal ligament and
pubic tubercle.
Femoral
• Protrusion into potential space of femoral canal
• Clinically, arises inferior to the pubic tubercle. Usually found protruding
directly from the goin crease.
Paraumbilical/Umbilical
• More common in the obese
• Found within or around the umbilicus
Hernia warning signs: All of these warning signs require URGENT surgical referral
• Sudden onset persistent pain
• Irreducible
• Tender
• Firm lump
• Erythema over hernia
• Features of bowel obstruction on AXR
Pneumoperitoneum (ie, free gas on erect CXR)
• Most commonly due to:
• Perforated peptic/ duodenal ulcer
• Perforated diverticulitis
• Early postoperative period
• Diagnosis may be guided by history. eg:
• Location of initial pain:
• Epigastric – due to ulcer
• RIF – Appendicitis
• LIF – Diverticulitis
• Past medical history:
• Previous diagnosis of diverticular disease
• Previous diagnosis of peptic ulcer
• NSAID use
• Investigations:
• Investigations don’t usually help with making the diagnosis regarding
the cause
• Inflammatory markers may be raised (WCC/CRP)
• EUC may be deranged due to fluid and third space losses
• Imaging:
• Plain film - CXR demonstrates air under diaphragm but does not
identify source
• CT – pattern of intraperitoneal gas, presence of collection/
diverticulitis, or contrast extravasation may help identify cause.
• NOTE: if patient has a rigid abdomen or is unstable, CT is
not recommended. Rather, urgent surgical consultation
and operation is recommended.
• Management:
• NBM
• Urgent IVF resuscitation
• Early IV antibiotics
• Ceftriaxone/cephazolin and metronidazole
• Or gentamicin, ampicillin, metronidazole
• DVT prophylaxis
• IDC
• Notify surgical team immediately
• Proton pump inhibitor if thought to be due to perforated peptic/
duodenal ulcer
Skin abscesses
• Cutaneous or subcutaneous collection of pus
• Maybe due to foreign bodies
• When local defence mechanisms are overwhelmed, cellulitis results
• Will tend to ‘point’ to the nearest epithelial surface
• Investigations
• Usually unnecessary
• Management:
• NBM in preparation for surgery
• IVF
• Likely to need incision and drainage
• IV or oral antibiotics will only help surrounding cellulitis. May also be
considered if there is delay in theatre access
Necrotising soft tissue infection
• Also known as necrotizing fasciitis.
• Clinical Features:
• Local – rapidly spreading cellulitis
• Systemic – patient is septic
• Organ failure
• The presence of organ failure/impairment in association with cellulitis should
alert one to the possibility of a necrotising soft tissue infection.
• Predisposing factors include – diabetes, alcohol abuse, immunosupression
(including steroids and chemotherapy)
• Management:
• NBM in preparation for theatres
• Early IV antibiotics
• Clindamycin, meropenem and vancomycin as empirical therapy
• Further therapy to be directed by cultures or guided by the
infectious diseases team.
• Urgent surgical referral for radical debridement
• DVT prophylaxis
•
Other Surgical Problems
Trauma
Head Injury
• History
• Mechanism of accident
• Neurological state and vital signs at scene of accident and during
transport:
• Loss of consciousness/change in consciousness
• Confusion
• Amnesia to events
• Illegal or legal drugs,
• Other medical problems and other injuries
• Examination
• Level of consciousness - Glasgow Coma Scale
• Pupils
• Full neurological examination:
• Cranial nerves
• Upper and lower limbs
• External cranial assessment, eg. lacerations, periorbital or mastoid
haematoma, palpable bone depression or boggy swelling, CSF
rhinorrhea/otorrhoea, haemotympanum
• In the severe trauma setting, secondary survey to exclude other body
system trauma.
• Investigations
• Routine bloods, crossmatch, alcohol and drug levels
• Imaging: CT head +/- c-spine
• Depends on type of head injury:
• High risk head injury for CT head
• Focal neurological deficit
• Oral anticoagulants or bleeding disorder
• Penetrating skull injury
• Obvious depressed skull fracture
• GCS<13 at any time since injury
• Post-traumatic seizure
• Minor head injury for CT head if risk factors present
• Loss of consciousness, amnesia or disorientation;
but
• GCS≥13 on examination
• Plus risk factors:
• GCS<15 at 2h after injury
• Suspected open or depressed skull fracture
• Racoon eyes, battle’s sign, CSF rhinorrhea,
otorrhoea, haemotympanum
• Vomiting 2 or more times
• Age ≥ 65 years
• Retrograde amnesia >30min
• High mechanism of injury (pedestrian,
ejection from vehicle, fall>1m)
• If no risk factors, can observe
• Trivial head injury - If neither head injury categories
above are satisfied
• Discharge with head injury advice
• Management
• Basic resuscitation as required, particularly airway,
• Basic management algorithm as above
• If patient has high risk head injury, neurosurgical consultation is
recommended.
• If patient has GCS<8, definitive airway must be established.
Furthermore, patient’s physiology should be optimized to prevent
secondary injury:
• A – establish airway
• B – maintain pCO2 35-40mmHg, SaO2>95%
• C – Haemorrhage control and SBP>100mmHg
• 30 degree reverse Trendelenburg position
• Urgent neurosurgical consultation and CT head.
• Note that shock from blood loss is rarely due to head injury except in infants,
or extensive scalp lacerations.
• For trivial head injury, before discharging a patient from Casualty check
• that a patient is fully alert, orientated and can walk unaided.
• If any doubt, then admit.
• Be wary of attributing drowsiness to alcohol (may miss an intracranial injury)
• Reference: Westmead trauma service clinical algorithms
GLASGOW COMA SCORE:
Eye Spontaneous 3
Opens to voice 2
Opens to pain 1
None 0
Verbal Orientated 4
Confused conversation 3
Inappropriate response 2
Incomprehensible speech 1
None 0
Motor Obeys commands 5
Localizes to pain 4
Withdraws from pain 3
Abnormal flexion 2
Abnormal extension 1
None 0
Westmead trauma guidelines
• Westmead trauma guidelines is available as a smart phone app:
• Android:
• https://play.google.com/store/apps/details?
id=air.au.com.lpn.WestmeadApp&hl=en
• iOS:
• https://itunes.apple.com/au/app/westmead-trauma/
id785943004?mt=8
Urological Problems
Macroscopic haematuria
• Haematuria may be broadly divided into glomerular and extra-glomerular in
origin
• History
• Pyuria/dysuria – suggest urinary tract infection
• Loin to groin pain – ureteric obstruction
• Lower urinary tract symptoms (hesitancy, dribbling, etc) – Prostatic
cause including BPH
• Bleeding disorder
• Passage of clots – suggest extraglomerular origin
• Cyclic haematuria in women – suggest endometriosis
• Recent vigorous exercise
• The following may suggest glomerular causes:
• Recent URTI
• Personal or family history of renal disease, sickle cell disease
• Medications which may cause nephritis
• Investigations:
• FBC – anaemia
• EUC – renal dysfunction
• Coagulation studies – coagulopathy as cause
• Urine microscopy and culture – Urine infection, casts, red cell
morphology
• U/S KUB or CT Renal – Triple phase (after discussion with Urology
team)
• Cystoscopy and urine cytology usually necessary after referral.
• Urology consultation should be sought
• Emergency admission if:
• Haemodynamic instability
• Anaemia
• Persistent gross haematuria (especially if anticoagulated)
• Clot retention
• This requires a 3 way IDC with normal saline irrigation. Stat
dose of gentamicin should be given.
Renal colic
• Presentation:
• Loin to groin pain
• Haematuria
• Dysuria/urgency (especially lower ureteric stones)
• Investigations:
• EUC – looking for impaired renal function
• CMP, Uric acid
• Urinalysis
• Urine culture
• Imaging:
• CT KUB (ie, non-contrast CT abdomen/pelvis)
• Can identify the stone, provide information regarding
stone size
• Ureteric and collecting system dilatation
• Plain AXR (to see if stone is radio opaque)
• Renal drainage indications:
• Absolute:
• Sepsis - Requires blood and urine cultures, antibiotics
• Urinary tract infection
• Single kidney
• Acute renal failure
• Relative:
• Pain
• Social reasons (eg. Airline pilot)
• In general if stone is less than 5mm (and no acute indications for drainage),
can trial medical expulsion therapy - analgesia, high oral fluid intake, and
Flomaxtra 400 mcg daily
Acute Urinary Retention
• History and examination :
• Establish cause, eg prostatomegaly, constipation, infection, drugs (anti
Parkinson, atropine, etc)
• Per rectal examination to assess prostate
• Management – perform bladder scan:
• If < 500ml, perform trial of void. If unable to void, needs IDC.
• If > 500ml, then insert IDC
• start with 16F Idc (18fr if large prostate or 12/14fr if history
stricture) for men and 12-14F for women then if fails trial coude
tip or call urology reg on call. Contact Urology CNC for
outpatient trial of void.
• Do not drain the bladder, remove catheter, and discharge patient from
casualty.
• If catheterisation is difficult (avoid excessive trauma), then the urology
registrar should be contacted. Options at this point (by urology) may include
suprapubic cystostomy or urethral dilatation.
Renal Trauma
• Usually picked up either by:
• CT abdomen during trauma evaluation
• Macroscopic haematuria
• Investigations:
• FBC, EUC, Coags are usually performed as part of trauma evaluation
• CT Abdo/Pelvis (with iv contrast) – first line investigation
• If CT abdomen/pelvis with iv contrast detects renal injury, delayed-
phase CT may be performed.
• Management:
• Resuscitation as per usual trauma protocol
• Urgent urology review
• Urgent surgical intervention may be indicated depending upon grade of
injury
Post Transurethral Surgery Bleeding
• Notify urology registrar or urologist on call.
• Clot flushing can be attempted but catheters should NOT be changed.
• DO NOT deflate balloon.
• Persistent bleeding requires monitoring of vital signs, FBC, group and hold
and coagulation studies
• If TURP – can place catheter on mild traction
Testicular Torsion
• Occurs when testis become twisted around its axis causing initially venous
then eventually arterial infarction
• Increased risk in patients with “bell clapper” deformity, which may be bilateral
• Usually younger, pubertal males
• Differentials – Epididymo-orchitis, torsion of hydatid of Morgagni
• Sudden onset testicular pain.
• May have associated lower abdominal pain
• Nausea/vomiting
• Possibly previous episodes of pain
• Examination:
• Exquisitely tender testicle
• Swollen, indurated
• Elevated (“high riding testis”)
• Horizontal lie
• Absent cremesteric reflex
• Note that this is a clinical diagnosis. Imaging with testicular US only in
patients with equivocal clinical features and if US can be performed without
delaying treatment of the patient.
• Management:
• NBM + IVF
• Analgesia
• Urgent urology consultation for scrotal exploration + bilateral
orchidopexy (even if there is ANY doubt).
Vascular Conditions
Acute limb ischaemia
• Occurs when an extremity is deprived of adequate blood flow and
oxygenation
• The extent of collateral flow determines severity of symptoms
• Cardiac emboli account for 90% of acute limb ischaemia
• 5 P’s – Parasthesia, pain, pallor, pulselessness and paralysis
• History
• Identify location, duration and onset of pain. Ask whether it improves
with rest. (embolic occlusions are sudden and of great intensity)
• Identify risk factors including previous vascular operations, cardiac
arrhythmias, aneurysms and atherosclerotic risk factors (smoking,
hypertension, diabetes, hypercholesterolaemia)
• Examination:
• Inspect - Identify signs of chronic ischaemia (hair loss, muscle wasting,
pallor, ulcers)
• Check for capillary return (normal < 3 sec). Palpate for warmth/
perfusion.
• Palpate pulses (use doppler U/S if necessary)
• Check for arrhythmias
• ALWAYS compare both sides – will give you a clue as to whether this is
chronic or acute ischaemia
• Examine abdomen for AAA.
• Also include general cardiorespiratory examination
• Ankle-Brachial index should be performed
• Investigations:
• FBC, EUC, CMP, LFTs, Coags, BSL, Group and hold
• ECG and CXR
• Further imaging including arterial duplex, CT Angiogram, conventional
angiogram as per vascular team
• Management:
• NBM + IVF
• Heparin infusion
• OT as per vascular team (Embolectomy/bypass/thrombolytic therapy/
amputation)
• NUTRITION
Nutrition screening
Nutrition screening is a key to early identification of patients with nutritional problems
which may go unrecognised and therefore remain untreated during the patient’s
hospital stay. Malnutrition, if untreated, can cause a wide range of adverse outcomes
for the patient and the health system. These include:
• Delayed wound healing

• Apathy and depression
• Increased risk of pressure areas
• Increased lengths of stay
• Muscle wasting and weakness
• Increased rates of readmission
• Increased prevalence of both
• Greater antibiotic use
adverse drug-reactions and drug
• Increased complications
interactions
• Increased clinical intervention
• Infection
• Impaired mobility
Nutrition screening should occur for all hospital inpatients on admission and then
weekly during the patient’s episode of care, or if the patient’s clinical condition
1,2
changes . All patients should have their weight and height documented on
admission and weight should continue to be recorded at least weekly1.
Use the Nutritional Risk Screening (NRS 2002) tool during the patient’s
3
hospital stay .
Table 1 Initial screening
1 Is BMI <20.5kg/m2? Yes No
Has the patient lost
2 weight within the last 3
months?
Has the patient had a
3 reduced dietary intake in
the last week?
Is the patient severely
4 ill? (e.g. in intensive
therapy)
Yes: If the answer is ‘Yes’ to any question, the screening in Table 2 should be performed.
No: If the answer is ‘No’ to all questions, the patient is re-screened at weekly intervals. If the patient e.g. is
scheduled for a major operation, a preventive nutritional care plan is considered to avoid the associated risk
status.
Table 2 Final screening

Impaired nutritional status Severity of disease (= increase in requirements)
Absent Absent Normal nutritional
Normal nutritional status
Score 0 Score 0 requirements
Hip fracture* Chronic
Wt loss >5% in 3 mths or
patients, in particular
food intake
Mild Mild with acute complications:
below 50–75% of normal
Score 1 Score 1 cirrhosis*, COPD*.
requirement
Chronic haemodialysis,
in preceding week
diabetes, oncology
Wt loss >5% in 2 mths or
BMI 18.5 – 20.5 +
Major abdominal
impaired general
surgery* Stroke*
Moderate Score 2 condition or food intake Moderate Score 2
Severe pneumonia,
25–60% of normal
hematologic malignancy
requirement in preceding
week
Wt loss >5% in 1 mth
(>15% in 3mths) or BMI
Head injury* Bone
<18.5 + impaired general
Severe marrow transplantation*
Severe Score 3 condition or food intake
Score 3 Intensive care patients
0-25% of normal
(APACHE>10).
week.
Score: + Score: =Total score
Age: if >70 years: add 1 to total score above =age-adjusted total score
Score ≥3: the patient is nutritionally at-risk and a nutritional care plan is initiated
Score <3: weekly rescreening of the patient. If the patient e.g. is scheduled for a major operation, a
preventive nutritional care plan is considered to avoid the associated risk status.
NRS-2002 is based on an interpretation of available randomized clinical trials.
*indicates that a trial directly supports the categorization of patients with that diagnosis.
Diagnoses shown in italics are based on the prototypes given below.
week
Wt loss >5% in 1 mth
(>15% in 3mths) or BMI
Head injury* Bone
<18.5 + impaired general
Severe marrow transplantation*
Severe Score 3 condition or food intake
Score 3 Intensive care patients
0-25% of normal
(APACHE>10).
week.
Score: + Score: =Total score
Age: if >70 years: add 1 to total score above =age-adjusted total score
Score ≥3: the patient is nutritionally at-risk and a nutritional care plan is initiated
Score <3: weekly rescreening of the patient. If the patient e.g. is scheduled for a major operation, a
preventive nutritional care plan is considered to avoid the associated risk status.
NRS-2002 is based on an interpretation of available randomized clinical trials.
*indicates that a trial directly supports the categorization of patients with that diagnosis.
Diagnoses shown in italics are based on the prototypes given below.
Nutritional risk is defined by the present nutritional status and risk of impairment of present status, due to increased
requirements caused by stress metabolism of the clinical condition.
A nutritional care plan is indicated in all patients who are: 1: severely undernourished (score=3), or 2: severely ill (score=3),
or 3: moderately undernourished + mildly ill (score 2 +1), or 4: mildly undernourished + moderately ill (score 1 + 2).
Prototypes for severity of disease:
Score=1: a patient with chronic disease, admitted to hospital due to complications. The patient is weak but out of bed
regularly. Protein requirement is increased, but can be covered by oral diet or supplements in most cases.
Score=2: a patient confined to bed due to illness, e.g. following major abdominal surgery. Protein requirement is
substantially increased, but can be covered, although artificial feeding is required in many cases.
Score=3: a patient in intensive care with assisted ventilation etc. Protein requirement is increased and cannot be covered
even by artificial feeding. Protein breakdown and nitrogen loss can be significantly attenuated.
Nutrition Assessment
Patients who are identified as malnourished or at risk of malnutrition should be
referred to a dietitian for a full nutrition assessment and implementation of a nutrition
1
care plan . Dietitian referrals should be made via Cerner Powerchart.
Components of a comprehensive nutritional assessment include: diet and weight

history, medical and social history, current diagnosis and clinical status, laboratory
assays, and physical examination.
Serum transport proteins—albumin, transferrin and pre-albumin should not be relied

on as direct indicators of nutritional status or recovery as levels of these negative
acute-phase proteins decrease during stress, injury, infection, inflammation, and
organ failure. They are useful indicators of severity of illness, and may help identify
patients who are at increased risk of malnutrition4.
Nutrition Support
Algorithm5
Is the gut functional and accessible?
Is the gut functional and accessible?
Yes
Yes
No
No
No
No
Yes
Yes
No
No
Is the likely duration of parenteral nutrition 5 days or longer?
Is the likely duration of parenteral nutrition 5 days or longer?
Oral or enteral nutrition is indicated as soon as possible. Parenteral nutrition is not recommended.
Oral or enteral nutrition is indicated as soon as possible. Parenteral nutrition is not recommended.
Yes
Yes
No
No
Yes
Yes
Is the patient malnourished and/or at high nutritional risk (e.g. critically ill)?
Is the patient malnourished and/or at high nutritional risk (e.g. critically ill)?
Early commencement of parenteral nutrition (within first 24-48 hours) may be beneficial irrespective of likely
duration of use. Central PN is preferred.
Parenteral nutrition may not be appropriate in patients whose prognosis is inconsistent with aggressive nutrition
support strategies.
Early commencement of parenteral nutrition (within first 24-48 hours) may be beneficial irrespective of likely
duration of use. Central PN is preferred.
support strategies.
Parenteral nutrition may be indicated. Note that providing even a small amount of enteral or oral nutrition,
wherever possible, may be beneficial for patients who are receiving parenteral nutrition, by stimulating normal
intestinal functioning (including motility, secretions, gut barrier against bacteria and endotoxin, and immune
function of the gut).
support strategies.
Parenteral nutrition may be indicated. Note that providing even a small amount of enteral or oral nutrition,
wherever possible, may be beneficial for patients who are receiving parenteral nutrition, by stimulating normal
intestinal functioning (including motility, secretions, gut barrier against bacteria and endotoxin, and immune
function of the gut).
support strategies.
Can full nutrition needs be met with oral or enteral nutrition within the next 5 days?
Can full nutrition needs be met with oral or enteral nutrition within the next 5 days?
• The refeeding syndrome is a potentially lethal complication of refeeding in
patients who are severely malnourished from whatever cause. Clinical
manifestations include hypokalaemia, hypophosphataemia,
hypomagnesaemia, depletion of thiamine leading to Wernicke’s
encephalopathy, and salt and water retention leading to oedema and heart
failure6.
• A patient is defined as being at high refeeding risk if he/she has one or more
7
of the following :
• BMI less than 16 kg/m2
• unintentional weight loss greater than 15% within the last 3–6 months
• little or no nutritional intake for more than 10 days
• low levels of potassium, phosphate or magnesium prior to feeding
• The effects of refeeding syndrome can be minimised by administering
thiamine, close monitoring and replacement of electrolytes, starting enteral or
parenteral feeding at a reduced amount of calories (e.g. 10kcal/kg/day) and
increasing caloric input slowly.
• Give thiamine 300mg intravenously before initiating nutrition therapy, and
continue with 100mg tds to 300mg tds for at least 3 days6,8. Oral dosing is
not appropriate as the maximum amount of thiamine which is absorbed from a
single oral dose is approximately 4.5mg. Larger oral doses do not increase
8
the amount absorbed .
Oral nutrition support
• For patients who are malnourished or at risk of malnutrition, check for
dysphagia. If the patient can swallow safely, provide oral nutrition support
such as fortified food with protein, carbohydrate and/or fat, plus minerals and
vitamins; snacks; oral nutritional supplements; altered meal patterns; and
dietary advice7.
• In cancer patients undergoing upper major abdominal surgery preoperative
oral nutrition supplements enriched with immune modulating substrates
(arginine, -3 fatty acids and nucleotides) is recommended for 5–7 days
9
independently of their nutritional risk .
• Contact the dietitian.
Enteral Nutrition
• For patients who have inadequate or unsafe oral intake, and has a functional
& accessible GIT, consider enteral tube feeding7.
• In patients with upper gastrointestinal dysfunction (or an inaccessible upper
GIT) consider post-pyloric (duodenal or jejunal) feeding.
• Consider insertion of a PEG or PEJ for long-term (6 weeks or more) enteral
tube feeding.
• For detail information on the provision of enteral nutrition, refer to the ESPEN
Guidelines on Enteral Nutrition9 (http://www.espen.org/education/espen-
guidelines), the Summary points and consensus recommendations from the
10
North American Surgical Nutrition Summit , and the WSLHD procedure:
Enteral Nutrition - Adult Patient - Westmead Hospital WSYD-PROC201905.
• Contact the ward dietitian or the Nutritional Support (Intestinal failure) Service
NSS(IF) CNC/CNS for advice on enteral feeding and enteral tube care.
Intestinal failure
• Intestinal failure is defined as the reduction of gut function below the minimum
necessary for the absorption of macronutrients and/or water and electrolytes,
such that intravenous supplementation is required to maintain health and/or
growth.
• The functional classification of intestinal failure is as follows18:
• Type I - acute, short-term and usually self-limiting condition
• Type II - prolonged acute condition, often in metabolically unstable
patients, requiring complex multi-disciplinary care and intravenous
supplementation over periods of weeks or months.
• Type III - chronic condition, in metabolically stable patients, requiring
intravenous supplementation over months or years. It may be
reversible or irreversible.
Parenteral Nutrition (PN/TPN)
• For patients who are malnourished or at risk of malnutrition, and has a non-
functional, inaccessible or perforated (leaking) GIT, consider parenteral
nutrition7.
• Pre-operative TPN for 7-10 days may improve post-operative outcomes in
severely undernourished patients who cannot be adequately orally or enterally
14
fed .
• Consultation for TPN should be made to the NSS(IF) Monday to Friday 08:00
– 16:00. Commencement of TPN without prior assessment by the NSS(IF)
(e.g. during weekends and public holidays) is not recommended.
• The NSS(IF) will contact the dietitian to perform a full nutrition assessment on
all TPN patients.
• When a decision is made to start TPN, document this in the medical records,
then:
• Check that the patient has a functional multi-lumen central venous
access device (CVAD). If not, contact the NSS(IF) CNC and the
Vascular Access CNC to organise placement of a CVAD. Complete a
Central Venous Access Nurse Consult via PowerChart.
• Page the NSS(IF) CNC on 09191 as soon as possible and provide the
following information:
• Your Full Name and page number
• Patient’s Full Name, MRN, DOB, ward
• Brief history, current problem, and indication for TPN
• CVAD – in-situ or not, type of line, date of insertion, tip position,
is there a dedicated lumen for TPN.
• Fill out the medical consult sheet and place in front of the medical
records.
• Make sure the following blood results are available on the day of
request: EUC, CMP, LFT, FBC, Coags
• Check that the patient is prescribed medications for stress ulcer
prophylaxis, and heparin or LMWH for prevention of venous thrombosis
due to CVAD (unless contraindicated).
Venous Access
• A central venous access device (CVAD) is required for the administration of
TPN due to the high osmolarity of the solution.
• Peripherally inserted central catheters (PICC) inserted via the basilic vein is
the catheter of choice for TPN therapy, followed by subclavian and internal
11
jugular veins. The femoral vein is used as a last resort .
• The choice of insertion site may depend on:
• previous surgery at or near the insertion site
• history of vein thrombosis or infection
• previous central line insertion sites
• coagulation status
• relative risk of mechanical, thrombotic and infective complications
• ease of site care
• A minimum of two lumens are required as one lumen is dedicated to the TPN
infusion. More lumens may be required depending on the number of
intravenous infusions/medications to be given and the compatibility between
the medications. If unsure, contact your ward pharmacist or the NSS(IF)
Pharmacist.
• The tip of the CVAD should be at the lower third of the superior vena cava or
at the atrio-caval junction as this is associated with the least incidence of
mechanical and thrombotic complications12. In most cases, the intracavitary
ECG method is used for real-time positioning of the catheter tip. If the
radiological method is used, the final tip position must be confirmed by a CXR
or intensive imaging. Regardless of insertion method, the tip position must be
documented on the Central Venous Line Insertion Record Form.
• Complications:
• Pneumothorax, haemothorax
• Catheter-related thrombosis
• Catheter-related blood stream infection
• Catheter occlusion
• Pericardial effusion
13
• Cardiac perforation or tamponade
Nutritional Requirements
• Approximate fluid requirements for routine maintenance is 25–30mL/kg/day
15
(this does not include GIT/drain losses and third spacing).
• When prescribing maintenance fluids for patients on TPN, take into account
the amount of fluid from the TPN and lipid infusion. Sodium chloride 0.9%
should be prescribed except in conditions where administration of sodium or
chloride is undesirable (e.g. hyperchloremic metabolic acidosis,
hypernatremia, liver failure).
• Approximate energy requirements for a patient in the perioperative period is
25-30kcal/kg/day (based on ideal body weight).14
• Approximate protein requirements range from 1.2-1.5g/kg/day. This is
influenced by the presence of stress, trauma, or infection; the patient’s BMI;
kidney and liver function.
• The maximum dose of lipid is 2g/kg/day and maximum infusion rate is 0.15g/
kg/hour. Higher doses or infusion rates may cause fat overload syndrome.
Check for allergies to egg, soy, peanuts (or fish) before commencement of
lipid infusion.
• A full range of vitamins and trace elements should be supplemented on a daily
14
basis .
TPN prescription and blood tests11

• The TPN prescription is ordered by the NSS(IF) Pharmacist and CNC during
a daily morning round (Mon - Fri).
• Cernevit®, vitamin K, thiamine, trace elements, folate, and vitamin B12 are
ordered according to the patient’s requirements and severity of malnutrition.
• Electrolytes replacements are also ordered by the NSS(IF). Requirements
depends on factors such as serum level, renal function, weight, severity of
depletion, medical history and medications. The total amount of electrolytes
provided from the TPN solution is documented in the patient’s progress notes.
Discuss with the NSS(IF) Pharmacist or CNC if you have special requests for
electrolyte replacement.
• Actrapid 50 units in Sodium Chloride 0.9% 50mL is ordered by the NSS(IF) on
the NIMC. The infusion rate is adjusted to maintain BSL between 5-8mmol/L.
• The following blood tests are ordered by the NSS(IF):
• Daily: EUC, CMP, random glucose, LFT, FBC
• Weekly and/or on consultation: zinc, red cell folate, vitamin B12, 25-
OH-Vit-D, Chol, TG, coags, iron studies, transferrin, pre-albumin.
• When required: Vitamins A, B1, B6, B12, C, D, E, serum folate, red cell
folate, trace elements (Cr, Se, Mn, Cu, Al)
Weaning TPN
• Weaning is commenced once the patient is tolerating 50% or more of their
caloric needs orally / enterally. Example of a standard weaning regimen:
• Reduce TPN rate to 63mL/hr for 4 hours then to 42mL/hr for 4 hours
then cease TPN and commence Glucose 10% at 42mL/hr for 4 hours.
• Emergency weaning may be necessary in the case of: removal of CVAD,
sepsis, or emergency surgery. Stop the TPN and commence Glucose 10% via
peripheral or central line at the same rate as the TPN.
• For patients with type 1 diabetes, the endocrine team should be contacted
when planning to commence TPN and when planning to cease TPN. This is
best done during business hours, concurrently with the NSS(IF), but the
endocrinologist on call can be contacted by the team in the case of an
emergency. When TPN is to be ceased, basal bolus insulin should be
commenced prior to cessation of the actrapid infusion. The actrapid infusion
should be continued for at least 1 hour until after a rapid acting insulin
analogue (e.g Novorapid®, Humalog®, Apidra®) is given and at least 3 hours
after other insulins. The plan for weaning should be discussed with the
endocrine team during business hours and at least 24 hours prior to weaning
to ensure a smooth transition.
• For patients with type 2 diabetes, oral hypoglycaemic agents and/or
subcutaneous insulin may need to be re-started.
• Consult the WSLHD Policy: Total parenteral nutrition (TPN) in adults
(Westmead) for details.
Complications of TPN16,17
• Refeeding syndrome (see above)
• Hyper- /hypo-glycemia
• Hypertriglyceridemia, azotemia
• Fluid & electrolyte disturbances
• Acid-base disturbances due to chloride/acetate content
• Hepatobiliary disorders: steatosis, cholestasis, gallbladder sludge/stones
• Metabolic bone disease (for patients on long term TPN)
For more information on parenteral nutrition:

• WSLHD Policy. Total parenteral nutrition (TPN) in adults (Westmead). WSYD-
POLY201329
• http://www.espen.org/education/espen-guidelines
References:
• NSW Ministry of Health Policy. Nutrition Care. PD2011_078
• Agarwal E, Ferguson M, Banks M, et al. Nutrition care practices in hospital wards: Results
from the Nutrition Care Day Survey 2010. Clinical Nutrition 2012;31:955-1001
• Kondrup J, Allison S.P, Elia M, Vellas B, Plauth M. ESPEN Guidelines for nutrition screening
2002. Clinical Nutrition 2003;22:415-421
• Fuhrman MP, Charney P, Mueller CM. Hepatic proteins and nutrition assessment. Journal of
the American Dietetic Association 2004;104:1258–1264.
• Dietitians Association of Australia. Nutrition Support Interest Group. Parenteral nutrition
manual for adults in health care facilities. Dietitians Association of Australia. 2009
• Stanga Z, Brunner A, Leuenberger M et al. Nutrition in clinical practice—the refeeding
syndrome: illustrative cases and guidelines for prevention and treatment. European Journal of
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Editor: Tony Pang

Contributors: Fredy Surianto (Preoperative investigations); Nari Aberdour
(Prevention of Venous Thromboembolism), Angela Poon (Nutrition), Sylvia Lim-Tio
(Endocrine Section)

MO Handbook Surgery

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SURGERY

• Prevention of Venous Thromboembolism

• Reference: Prevention of Thromboembolism: Best Practice Guidelines for

• Common Postoperative Problems

• Surgical Wounds and Drains

• General Surgical Conditions

• Delayed wound healing

Table 2 Final screening

Components of a comprehensive nutritional assessment include: diet and weight

Serum transport proteins—albumin, transferrin and pre-albumin should not be relied

TPN prescription and blood tests11

For more information on parenteral nutrition:

Editor: Tony Pang

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