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Postoperative complications

Clinical Discipline(s)/Organ System(s)
Cardiovascular System, Digestive System, General Surgery, Infectious Diseases, Ethics
Progress Test Topic(s)
General duties, Homeostasis
Description
A 75 year old Chinese woman had an anterior resection (large bowel operation) 4 days ago. She develops fever, abdominal pain and has not opened her bowels since surgery. She has an intravenous cannula in her forearm and one in her foot. She also has an indwelling urinary catheter. Her heart rate is 130 beats per minute, her blood pressure has fallen to 90/50 mmHg, and her temperature is 38.3°C. She is breathing rapidly. You are the on call junior doctor and are asked to review her.
Applied Science for Medicine 
   - Anatomy of abdomen, thorax and pelvis
   - Physiological changes following surgery, including consequences of fasting
   - The spectrum of healthcare-associated infections
   - Pathogenesis of systemic inflammatory response syndrome (SIRS), atelectasis, deep vein thrombosis and pulmonary embolism
   - Microbiology of peritonitis and surgical site infection; microorganisms associated with venous lines and urinary catheters
   - Pharmacology of beta-lactam antimicrobials, metronidazole, aminoglycosides, paracetamol and opioids
   - Principles of repeated drug dosing, pharmacokinetic variability in the response to drugs, monitoring drug concentrations, rational prescribing (calculation of drug dosage)
Clinical and Communication Skills 
   - History from a patient with postoperative complications
   - Recognise and assess a critically unwell surgical patient
   - Describe the range of potential postoperative complications
   - Classify types and severity of shock
   - Perform arterial blood gas, venepuncture, central line and peripheral blood cultures, urinary catheter placement, peripheral intravenous cannulation, ECG, placement of nasogastric tube
   - Recognise infectious and non-infectious complications of medical devices
   - Interpret chest X-ray, ECG, abdominal X-ray, full blood count, renal function tests, liver function tests, coagulation screen, C-reactive protein
   - Indications for CT abdomen/pelvis, CT pulmonary angiogram, ventilation/perfusion (V/Q) scan
   - Management, in the postoperative setting, of fluid resuscitation, early sepsis, thromboembolic disease, acute coronary syndrome, wound infection, ileus, cardiac arrhythmias, acute alcohol withdrawal
   - Antimicrobial stewardship: rational empirical antibiotic choices including perioperative antibiotic prophylaxis
   - Prescribing intravenous fluids
   - Perioperative care of diabetic patients
   - Management of septic shock, complications following abdominal surgery and perioperative nutrition
   - Indications for removal of iatrogenic devices
   - Perioperative nutritional and metabolic needs of the patient
   - Post-operative analgesia, drug and administration options
Personal and Professional Skills 
   - Empathise about a major operation with complications involving unpleasant symptoms and a longer hospital stay
   - Ethics regarding consent and advance directives
   - Awareness of cultural issues when discussing a patient's health status
   - Self-care: coping with stressful situations
   - Understand your limitations and when to call for help
Hauora Māori 
   - Engage appropriately with whānau, as well as patient
   - Involve cultural/spiritual support team when appropriate
   - Ability to cater for differential health literacy needs of Māori patients and whānau
   - Consideration of patient and whānau needs when delivering life-changing news
Population Health 
   - Burden of post-operative complications to society
   - Importance of hospital 'morbidity and mortality' meeting and clinical governance
   - Epidemiology in New Zealand of thromboembolic disease occurring in hospitalised patients
Conditions to be considered relating to this scenario
Common
peritonitis, anastomotic leak, healthcare-associated infection (including surgical site infection, pneumonia, peripheral and central intravenous cannula infection, urinary tract infection), other causes of postoperative fever (including atelectasis, pulmonary embolus, drug reaction), electrolyte imbalance, postoperative ileus, acute coronary syndrome (STEMI, NSTEMI and unstable angina), cardiac arrhythmias, dehydration, delirium tremens
Less common but 'important not to miss'
pseudo-obstruction, diabetic ketoacidosis, ischaemic bowel, perforation, wound dehiscence, septic shock
Related Scenarios
[Postoperative care]