Post-Operative Pyreia

You are the General Surgery CT1 and are asked to see a 65year old gentleman who is day 5 post right hemi colectomy who is complaining of abdominal pain and has a temperature of 39oC .The nurse asks you to review the patient.

Example answer introduction

In this scenario, I would be most concerned about a possible post operative infection, possible collection given the patient is pyrexial and complaining of abdominal pain.  I would 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 depending on my clinical suspicions 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 CCISP Algorithm:

A - Patent, no stridor or stertor

B - Check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns give high flow oxygen 

C – Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output 

  • Bloods - FBC, U&E, LFTs, clotting, Group & Save, lactate, blood cultures

  • IV access - large bore 

  • IV fluid resuscitation with crystalloids

  • Catheterise patient to assess urine output urine output >0.5L/kg/hr

D – Glasgow Coma Score, temperature, pupillary response, blood glucose

E – Expose patient and look for rashes, systemic signs of shock. 

During this acute phase state remember to provide constant reassessment

Focused history​

  • Allergies

  • Medications - anticoagulants, antiplatelets, VTE prophylaxis, is the patient on antibiotics?

  • Past medical history – previous bowel surgery

  • Last meal

  • Events leading up to this point:

    • Indication for surgery

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

Examination

Examine to determine source of infection

  • Chest examination 

  • Abdominal Examination

  • Examine all wounds and drains (remember there may be multiple wounds and multiple drains)

  • Assess for possible DVT

Initial investigations: Septic screen

  • Blood tests– FBC, CRP, U&Es.

  • Urine dipstick

  • Cultures– blood, urine, sputum, and wound swab

  • Imaging– Chest X-ray, CT abdomen

Initial management

  • Empirical antibiotics as per local guidelines

  • IV fluids

  • Analgesia

  • Ensure DVT prophylaxis

  • Monitor fluid input/output

  • Catheter if septic 

  • Reassessment

Escalation

Consider discussion with:

  • ​General Surgical registrar

  • Radiologist

  • Anaesthetics and theatres – if drainage/exploration required

Questions testing further knowledge

Q1 What are the common causes of post operative pyrexia and timings of these?

Days 0-2

  • Physiological as response to tissue injury: low grade

  • Pulmonary collapse, atelectasis

  • Blood transfusion

  • Thrombophlebitis

 

Days 3–5

  • Sepsis: wound infection

  • Biliary or urinary infection: catheter

  • Intra-abdominal collection

  • Pneumonia

 

Day 5–7

  • Deep-vein thrombosis (DVT)

  • Enteric anastomotic leak 

>7 days

  • Intra-abdominal collection

  • DVT

  • Septicaemia.

core surgical training interview

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