Return to Scenario ListShow Learning Points most relevant to Phase 1:

Postoperative complications

Clinical Discipline(s)/Organ System(s)
General Surgery, Infectious Diseases, Anaesthesiology, Cardiovascular System, Digestive System, Urology, Ethics
Progress Test Topic(s)
General duties, Homeostasis
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.
Progress Test-Type Questions:   Question 1 | Question 2 | Question 3
Applied Science for Medicine 
   - Anatomy of abdomen, thorax and pelvis, kidneys, ureters, bladder, spinal cord
   - Physiological changes following surgery, including consequences of fasting, changes in body fluid compartments, nerve and pain conduction
   - 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, gentamicinmeropenemmetronidazole, 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)
   - Pharmacology of opioids, paracetamol, non-steroidal anti-inflammatory drugs
Clinical and Communication Skills 
   - History from a patient with postoperative complications including urinary retention, pain assessment (communicative and non-communicative), respiratory distress, sepsis features
   - Recognise and assess a critically unwell surgical patient examination of cardiovascular, respiratory and neurological and abdominal systems
   - Describe the range of potential postoperative complications (distended bladder, shock, respiratory distress, delirium, ischaemic heart disease, cardiac arrthymias)
   - Classify types and severity of shockcriteria for SIRS (systemic inflammatory response syndrome) and septic 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, electrolytes, renal function tests, liver function tests, coagulation screen, C-reactive protein, troponin
   - 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, ischaemic heart disease, wound infection, ileus, cardiac arrhythmias, acute alcohol withdrawal, urinary retention, delirium, electrolyte abnormalities, reduced Glasgow Coma Score (GCS and respiratory distress
   - Antimicrobial stewardship: rational empirical antibiotic choices including perioperative antibiotic prophylaxis
   - Prescribing intravenous fluids and complications of iv fluids
   - Perioperative care of diabetic patients
   - Management of septic shock, complications following abdominal surgery
   - Indications for removal of iatrogenic devices
   - Perioperative nutritional and metabolic needs of the patient
   - Post-operative analgesia, pain management, drug and administration options Outline management of patient-controlled analgesia (PCA), nerve blocks and nausea
   - Role of anaesthetist, pain team, surgeon, high dependency unit nursing and geriatrician
Personal and Professional Skills 
   - Empathise about a major operation with complications involving unpleasant symptoms and a longer hospital stay, empathise with a patient in pain
   - 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, awareness of appropriate medical roles with a severely unwell patient, including when to contact team for assistance
Hauora Māori 
   - Appropriate engagement and consultation with whānau and 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
   - Consider ethnic disparities in adverse events during hospitalisation and the management of pain in New Zealand
Population Health 
   - Burden of post-operative complications to society and healthcare
   - Importance of hospital 'morbidity and mortality' meeting and clinical governance
   - Epidemiology in New Zealand of postoperative complications
   - Epidemiology in New Zealand of thromboembolic disease occurring in hospitalised patients
Conditions to be considered relating to this scenario
peritonitis, anastomotic leak, healthcare-associated infection (including surgical site infection, pneumonia, peripheral and central intravenous cannula infection, urinary tract infection), bleeding, other causes of postoperative fever (including atelectasis, deep venous thrombosis, pulmonary embolus, drug reaction), electrolyte imbalance, postoperative ileus, acute coronary syndrome (STEMI, NSTEMI, cardiac arrhythmias and unstable angina), cardiac arrhythmias, dehydration, delirium tremens postoperative nausea and vomiting, acute urinary retention, inadequate analgesia
Less common but 'important not to miss'
pseudo-obstruction, diabetic ketoacidosis, ischaemic bowel, perforation, wound dehiscence, epidural haematoma