Atelectasis

You are the General Surgery CT1 and are asked to see a 35 year old patient who is day 1 post laparotomy. The nurses call you as he is complaining of a lot of pain. His temperature is 38.1oC and saturations are 92%.

Example answer introduction

In this scenario, in a patient who is day 1 post op with a pyrexia and low saturations, I would be concerned about potential chest cause such as atelectasis. I would attend immediately and assess this patient using an A-E approach according to the CCRISP algorithm followed by a focused history and examination. I would arrange further investigations to confirm my diagnosis and escalate to the general surgery registrar. 

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

  • Disability - GCS, pupillary response, blood sugar, temperature

  • Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!

 

During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, CRP. I would send Lactate, blood glucose, and blood and urine cultures if spiking a temperature. 

Focused history​

  • Allergies

  • Medications - VTE prophylaxis, what analgesia is the patient on – is it sufficient

  • Past medical history – any pre-existing lung problems e.g. asthma. Is the patient a smoker?

  • Last meal

  • Events leading up to this point –

    • Indication for surgery

    • Review operation notes – any high risk of complication, was the operation difficult

    • Has the patient been taking deep breaths?

    • Is their pain well controlled as this may be affecting their breathing

    • Has the patient been eating? Are they at risk of aspiration pneumonia

Examination

  • Chest examination 

  • Look for possible signs of pulmonary collapse e.g. rapid respiration, tachycardia and mild pyrexia, with diminished breath sounds and dullness to percussion over the affected segment

  • Assess patients pain

  • Examine wounds and drains

Investigations 

  • Blood tests– FBC, CRP, U&Es

  • Cultures– blood, sputum sample

  • Imaging– Chest X-ray

  • Arterial Blood Gas

Initial management

The patient describes being in significant pain and is taking small shallow breaths. You give oxygen and their saturations improve. The X-ray shows evidence of atelectasis

 

  • Sit patient up

  • Encourage patient to take deep breaths and cough

  • Oxygen to maintain saturations >96%

  • Optimise analgesia. 

  • Consider the requirement for PCA/ epidural

  • An epidural in patients undergoing major abdominal surgery may help with post-operative wound pain

  • Chest physio

  • If evidence of infection – start empirical antibiotics according to microbiology guidelines

  • If evidence of bronchospasm – give nebulised salbutamol

  • Regular observations

  • Ensure DVT prophylaxis

  • Inform patient and family

  • Document

  • Discuss with surgical registrar

Example questions to progress the station

Q1 - Describe peri-operative measures that can reduce the risk of atelectasis and pulmonary collapse.

 

Preoperatively

  • cessation of smoking

  • physiotherapy if co-existing chest disease e.g. COPD

  • Deferring elective surgery for at least 2 weeks in patients with chest infection

 

Postoperative

  • Encouraging deep breaths, cough

  • Early mobilisation

  • Adequate analgesia

  • Regular chest physio

Have an understanding of ERAS pathways 

Escalation

​Consider discussion with:

  • ​General Surgical registrar

  • Medical Registrar on call

  • Critical care – if no improvement with management 

    • When hypoxia is severe, the patient may requireendotracheal intubation, assisted ventilation and repeated bronchial aspiration

 

Note:

Atelectasis is a very common complication of surgery and  usually occurs within the first 24 hours. It can increase the work of breathing and lead to impaired gas exchange. If untreated this may precipitate secondary bacterial infection causing lobar or broncho-pneumonia. 

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