Surgerical Basics Study Reference

Surgical Basics Notes Surgical Record Keeping Learning Objectives 1. Can document and complete and concise history of surgical admission in the notes. 2. Can write preoperative and post-operative orders. 3. Can write an operation report. 4. Can prepare a discharge summary. 5. Can write entries of patient progress in the notes which must include date, time, printed name, and signature of the writer. Surgical Admission History 1. Presenting complaint:    Use SOCRATES Include positive and negative findings. If the patient has had a pervious episode like this. 2. Past Medical/Surgical History     Divide into medical and surgical history. Specifically ask about diabetes and hypertension so specifically ask about these co-morbidities. Specifically ask about ischemic heart disease and how that was managed. For example, if the patient has had a stent, then this needed to decide on stopping anti-platelet or anti-coagulant medications and consultations with the cardiology team. 3. Drugs and allergies    Get down the medication doses and frequencies. - IT IS EXTEREMLY IMPORTANT TO DOCUMENT ANY ANTI-COAGULANTS THAT THE PATIENT IS TAKING DUE TO A BLEEDING RISK WHICH MAY BE FATAL. Ask about allergies and what happens when the patient takes them. - For example, if the patient has vomited when they were younger when they took penicillin then this is not a true allergy. - Some patients are allergic to certain types of plastering and dressings -> make sure to ask about this. Latex allergy: - Remove all products containing latex. 4. Social history  Smoking:  Duration and amount. If they have quitted, when have they quitted? This is also important to know for anaesthetists, as the patient could have had COPD as a result. Alcohol: - Amount and what they drink. May need to assess for alcohol withdrawal using the CIWA score.  The score looks at:  Nausea and vomit.  Tremor: assess using arms extended and fingers spread out.  Paroxysmal sweats.  Anxiety.  Agitation  Tactile disturbances: ask the patient if they have had itching, pins and needles sensation, any burning, any numbness or do you feel bugs crawling on or under their skin.  Auditory disturbances: more aware of sounds around you, are they harsh, do they cause frightening, are they hearing things that are disturbing them, are they hearing things that they know are not there?  Visual disturbances: are there bright lights, is there a colour different, do the eyes hurt, are they seeing things that are disturbing them, are you seeing things that you known are not there?  Headache and head fullness: do not rate for dizziness or light headedness, but rate for severity.  Orientation/clouding of sensorium: ask about that day it is, where they are and who I am.  Rate out of 7 for all except orientation:  For orientation use the following rating:  If the patient scores more than 8, then they may need medications for withdrawal. 5. Family History      Cancer: - Document relation and age and they where diagnosed/died. - Appendectomies (general surgeries) and tonsillectomies (ENT), tent to run in families and may indicate a family history -> IMPORTANT TO DOCUMENT Strokes and histories of VTE events. Gynae history: - Early menopause, fibroids, recurrent miscarriages and endometriosis. IBD: Crohn’s disease and UC tent to run in families. Cardiac history. Important Pre-Surgical Examinations 1. GCS 6. Hands and fingers: - CRT Rheumatoid nodules Nicotine statins Clubbing Pulses (radio-radial delay/collapsing pulse) 2. Eyes: - Pallor in conjunctiva. - Jaundice in sclera. - Photophobia - Xanthelasma - Ptosis - Proptosis 3. Face: - Symmetrical - Dropping - Rash - Nerve palsies - Flushed cheeks 4. 5. 6. 7. 8. - Rhinorrhoea - Epistaxis - Drooling Ears: - Abnormalities in the outer ear - Otorrhea - Bleeding - Visualisation of the tympanic membrane - Weber’s and Rinne’s tests Neck - Tracheal tug - Central trachea - Thyroidectomy scar - Lymphoid nodes - Stiffness - Pain Mouth and throat: - dentition - hydration - cyanosis - appearance of the tongue - tongue deviation. - uvular deviation - tonsillar enlargement - peritonsillar mass - exudate - inflammation stones Chest: - Symmetrical expansion - Shallow/deep breathing - Rash - Breath sounds - Heart sounds - Wheeze/stridor/crepitation/crackles pain. - +/- palpations of the breast if irrelevant  Look for:  Appearance  Lumos  Nipple discharge - Excessive carinatum/excavatum Abdomen and the pelvis:    Palpate the nine regions. Look for: rashes, guarding, peritonism, distension, resonance, ascites, shifting dullness, masses, bowel sounds, hernial orifices, inguinal lymph nodes, abdominal aorta. Look for roving’s sign and psoas sign (specific for retrocecal appendicitis) 9. MSK examination:  10.  11.   Joints: - Examine the joint itself. - Examine above and below the joint. - Look for and comment on:  Appearances  Swelling  Redness  Warmth  Obvious wound overlying  Deformities  Pain on palpation  Pain on movement: both passive movements. - Look like specialist exams for different joints. and active Legs and feet: Look for signs of: - Pallor - Symmetry in appearance - Ulcers - Signs of vascular insufficiency - ABPI - Swelling of the ankles and feet. - Calves:  Softness  Firmness  Tenderness - Toenails:  Long/unkempt: may suggest self or carer neglect of elderly patient. - Pulses - Sensation and power PR examinations: Document the chaperone. Look for: - Blood - Mucus - Stool on the glove. - Painful - Difficult - Haemorrhoids - Firm stool in the rectum - Masses - Peri-anal discharge - Fissures - Fistulae 12. PV examination:  Document chaperone.  Look for: - Pain - Difficult - Masses - Location - Nature of pain - Visualisation of the cervix -> appearance of OS - Fistulae - Odour - Discharge - Bleeding Peri-operative Orders 1. Vitals 2. ECG  Abdominal pain may also be a feature of an MI. 3. Blood:  Complete blood count  CPR  U and E  LFTs  INR (if on warfarin)  VBG: for lactate, pH and glucose.  Amylase  Grouping  Thyroid function tests 4. Renal function tests 5. Urine  Urinalysis -> +/- MC&S  Pregnancy: for all women with a uterus and are at a child-bearing age. 6. Wounds:  Swaps -> MC&S  CXR: - An erect on is important in patients who have presented falls and who are elderly. - Generally, not needed for asymptomatic patients. - It is recommended for patients undergoing cardiorespiratory surgeries.  Speciality specific tests: - Vascular: ABPI. - Orthopaedics: compartment pressure - Ophthalmology: ocular pressure 7. CT scans  Generally, the imaging of choice for patients undergoing a general surgery. 8. MRIs:  Useful for neurosurgery -> improves outcomes for tumor resection, epiliepsy surgery and insertion of deep brain stimulators. Post Operative Orders  See post-operative management section. Writing a Discharge Summary 1. Dates 2. Times:  Must be presented in hours, minutes and seconds if possible.  In the 24-hour format.  Separate hours, minutes and seconds using “:”. 3. Names:  Present in the following order: i) Title ii) Prefix iii) First name iv) Last name v) Name suffix e.g. jr.  Include the correct tiles of healthcare providers. 4. Addresses 5. Telephone numbers. 6. Email address. 7. Patient details:    Display the patient details on the upper left corner of the discharge summary, within the banner section. Use the heading “patient details”. Display the patient’s name on a single line, in a larger bold font. Display the patients details in the following order with no preceding title: - Name - Date of birth (PRECENDING TITLE IN THERE IS A MUST). - Sex - Address - Telephone - MRN - Individual health identifier (IHI).  Ensure the patient’s details are always visible, regardless of whether the user scrolls up or down. 8. Hospital details:  Position: - Display the hospital details in the upper right corner of the discharge summary, within the banner section, next to the patient details.  Use the heading, “Hospital details”.  Display the hospital name on a single line, in bold, with a larger font.  Display the hospital details in the following order with no preceding title: - Local health district (if applicable). - Address - Telephone number. - Ensure always visible, regardless of whether once scrolls up or down. 9. Recipients:  Display the names all receipts under the document banner and the start of the document indicator.  Use the heading “recipient/s”. 10.Author:  Display the name of the document’s author next to the recipients’ names, underneath the start of the document indicator.  Use the heading “author”.  Clearly separate the name of the author from the rest of the document.  Include the author’s communication details, if different from the hospital communication details. 11.Presentation details:  Use the following headings: - Presentation date:  For admitted patients the day of presentation is the day of admission.  For non-admitted patients the date of presentation is the day of presenting to the hospital. - Discharge date. - Length of stay (at hospital).  - Clinical unit – the location from which the patient was discharge.  For admitted patients, the clinical unit is the ward from which the patient was discharged. For non-admitted patients, the clinical unit is the emergency department.  Avoid using abbreviations. - Episode type: specifically, in which the patient was treated.  Display the name of the speciality or the specialities in which the patient was being treated.  If the patient was treated under more than one speciality, display these in REVERSIBLE CHRONOLOGICAL ORDER.  Ensure the names of the specialties align with the speciality codes provided by the Australian Institute of Health and Welfare. - Senor clinician: the healthcare provider who was responsible for the patient’s care at the time of discharge. - Discharge destination.  Indicate the location to which the patient was discharged e.g. home, aged care facility etc.  If the patient is deceased, include “DECEASED” bold capital letters. 12.Problems and Diagnosis  Display problems and diagnoses immediately after presentation details.  Use the heading “Problems and Diagnoses” for this section and use the following headings: - Principle diagnosis: the diagnosis that cause the patient to come to the hospital. - Reason for admission: the symptoms that caused the patient to come to the hospital. - Secondary diagnosis: display a list of the problems and diagnosis (in addition to the diagnosis) that were treated at the hospital. - Complications: display any additional patient conditions or any adverse events that affected the hospital treatment. - Past medical history - If no information is available for one of the elements write Nill. 13.Procedures:  Should include clinical interventions including operations and procedures.  Display immediately after problems and diagnosis.  Use the heading “Procedures”.  Display the list of procedures and interventions performed in hospitals as bullet list in chronological order.  List the procedures and interventions in chronological order.  If no procedures were performed during the hospital stay, include the statement “Nill performed. 14.Clinical summary:  This is expected to the one of the largest sections in a discharge summary.  Display this section after the list of procedures and interventions.  Use the heading “clinical summary”.  Use the line breaks to separate topics.  Use bullet points or short sentences where appropriate rather, than full paragraphs.  Use bold letters and coloured font to highlight critical information.  Avoid abbreviations.  Avoid repeating information that occurs in other sections of the discharge summary.  Ensure this section is succinct but also provides all the relevant information.  Describe the abnormal investigation results in this section. 15.Allergies and adverse drug reactions:  Use the following heading “allergies/adverse reactions”.  Display this as a table.  Name the agent causing the patient to experience an adverse reaction.  Describe the type of reaction/allergy. - Describe the type of reaction. E.g. allergy. - Describe the negative effect. E.g. urticaria.  Use the following headings for the table columns: - Substance/agent - Reaction type - Clinical manifestation. 16.Medicines on discharge.  Use the heading “medicines on discharge”.  Use the following subheadings for the column table”: - Medicines - Directions - Duration/end date - Status: new, changed, or unchanged - Change reason/clinical indication. - Quantity supplied.     State the quantity of medicines provided to the patient before being discharged.  If no information is available, add a dash (-) to avoid the cell being left out. Group the medicines and display in the following order: - New medicines - Changed medicines. - Unchanged medicines. List medicines in each group alphabetically. Other important content to include: - For new medicines provide clinical indication. - For changed medications describe the reason as to why. - For unchanged medicines (or if a clinical indication is not deemed required) and a dash (-) to avoid leaving blank. 17.Ceased medications:  Use the heading “ceased medications”.  Use the following headings for the table columns: - Medicine - Reasons for ceasing.  The content that must be added includes: - Name of the new medicines - Provide reasons as to why the medication was stopped. - Include a comprehensive list of medicines that were ceased while in hospital. 18.Alerts:  Use the heading “alters”.  Display alerts as a bullet list using short sentences.  Include a list of alerts that may affect the patient’s continuity of care.  Be aware of the sensitivity of information that could be captured as an alert and be aware that the information could be made available to the patient or their carers in My Health Record. 19.Recommendations  Use the heading “recommendations”.  Use the following headings to the table columns: - Recommendations - Persons responsible.  Describe recommended actions.  Name the persons responsible for actioning the recommendations.  If investigation results are bending at the time of discharge, include a recommendation for the relevant healthcare provide.  Name the person responsible for actioning the recommendation. 20.Follow up appointments:  Use the heading “follow-up appointment”.  Use the following headings for the table columns: - Description - When. - Booking status - Name - Location - Contact details.  Present follow-up appointments in a table. 21.Information provided to the patient:  Use the heading “information provided to the patient”.  Display this section as a bullet list, using short sentences.  List the recommendations or actions that have been provided to the patient.  If the patient for whom the discharge summary was written is deceased, do not include any information provided to the patient, and instead write N/A. 22.Receipt details:  Use the heading “recipients”.  Use the following headings for the table columns: - Nam e - Contact details. - Address - Organisation - Department. - Name the receipt and indicate whether they are the primary or nominated recipient healthcare provider. 23.Selected investigation results:  Include selected investigations and associated results as the last element of the discharge summary.  Use the heading ‘selected investigation results”.  Use the following headings in the table columns: - Test name. - Date - Result  Indicate whether the results are available or pending.  Display this section in a table.  Group investigations and display them in the following order: - Pathology - Imaging - Other   List investigations in each group chronologically. Link the name of the test so that when it is clicked, so that the user directed to the relevant results (this applies to electronic forms”. Writing Patient Progress Notes Basic Structure           Date and time. Name of the patient Identification of the doctor who wrote the note. An overview of the general description of the patient. Clinical assessment Any incidents that occurred. Any changed noticed: - Behaviour - Wellbeing - Emotional state Consider the following: - Assessment - Diagnosis - Planning - Intervention - Evaluation. Any changed in the care: - Such as a shift change to a new doctor or nurse, or new orders placed. Recommendations for further care. Types of Documentation     Charting. This includes information such as: - Patient’s pain level - How their lungs sounded - What their pulses felt like etc. Progress notes: - If the patient’s conditions start to decline or there are any changed in the patient’s care. Handwritten notes: - When a computer is not handy. Vernal communication at shift change: - This is a handoff report that will be given and received at the end of and the start of each shift. - This is an overview of each patient what is shared between medical staff when a shift is changing. Importance of documentation    To keep track of patient care throughout their hospitalization. Used by all members of the healthcare team to get an idea of how a patient is progressing throughout their hospitalization. If for some reason the patient’s condition declines, documentation can be used to look back and determine whether any healthcare provider was fault or to track what went wrong. Important considerations   Be concise. Use the facts. Preoperative assessment and mandatory protocols Learning objectives 1. Understand the administrative protocols regarding recommendation for admissions and the minimum data sets required by the health service including: a. Personal information b. Medical information c. LMO name and contact details. d. Co morbidities and medications e. Urgency and expected length of stay. 2. Understand the rationale and principles behind obtaining informed consent and the permitted nomenclatures. 3. Understand the principles of preoperative investigations and preparations. a. Indications for preoperative investigations. b. Role of pre-admission clinics c. Indications for allied health interventions and preoperative discharge planning. d. Understand the indications and rationale for perioperative antibiotic prophylaxis. 4. Understand and discuss perioperative VTE prophylaxis. a. Discuss the risk assessment for patients undergoing surgery. b. Discuss the methods prophylaxis, both perioperatively, intraoperative and post operative. 5. Understand and discuss the immediate preoperative checks and protocols including: a. Marking of correct side, correct protocols b. Anaesthetic bay identification c. Time out protocol Obtaining Consent Rationale for obtaining informed consent in surgery. 1. Patient autonomy  Informed consent respects the autonomy of patients.  It empowers them to make decisions about their own healthcare.  Patients have the right to be fully informed about their conditions, proposed treatments, risks, benefits and alternatives. 2. Ethical and legal obligations  It is an ethical duty.  It is a legal duty to avoid potential liability. 3. Risk disclosure  It ensures that the patients are aware of the medical risks assscosiated with the medical procedur.  These allow a patient to consider before proceeding. 4. Shared decision making  Informed consent facilitates shared decision making between patients and doctors.  It allows patients to participate actively in their own care by understanding the implications of treatment choices. Principles of informed consent 1. Capacity The patient giving consent must have the capacity to understand the information provided.  Capacity refers to the ability to comprehend the relative details and make a rational decision. 2. Freely given.  Consent must be freely given without coercion or pressure.  Patients should not feel compelled to agree due to external factors. 3. Specificity  Consent must be sufficiently specific to the procedure or proposed treatment.  Patients should understand the nature of the intervention, its purpose and potential outcomes. 4. Informed  General effects of the procedure  Material risks associated with the procedure.  Benefits and alternatives.  Preoperative Assessment Importance of preoperative assessment    Structured approach of questioning, a targeted clinical examination and the careful consideration of the which investigations are needed to plan for the best patient outcomes. Helps with avoiding possible risks. Informs the need for further investigations and optimisation of patients with medical comorbidity to reduce the risk of perioperative problems. Basics Steps of Preoperative Assessment 1. Diagnosis.  Provisional diagnosis – how confident one is with it.  Any further investigations needed to confirm the primary diagnosis.  Important aspects of the history.  Findings of the examination.  Results of already performed investigations.  Is it appropriate and possible to obtain biopsies before the surgery. 2. Operation.  What operation or procedure is planned.  Have any circumstances relating to the surgery or procedure changed.  Has the patient gotten better or worse.  Has any new information from history, examinations or investigations been revealed?  Is the planned operation still appropriate?  Any special risks during and after the surgery? E.g. DVT following.  Any standard precautions that need to be done during the operation> 3. Anaesthesia  What type of anaesthesia should be used? Can the anaesthesia risks be anticipated? E.g. vomiting during induction. 4. Fitness for the operation  Any recurrent diseases and are they being appropriately treated or any that might posses a special risk?  Are any preoperative investigations or treatments needed for intercurrent diseases.  Dose the surgical condition has special problems?  Is the patient taking any drugs which might cause problems with anaesthesia or the operation?  Is the patient fit for the planned anaesthesia or operation? 5. High risk  Is the patient predisposed to anaesthetic or surgical complications? 6. After the operation  Can any special problems be anticipated during the post-operative period and after discharge? E.g. elderly patients living alone.  Any problems specific to this anaesthetic or operation regarding recovery and rehabilitation, and is any special planning required?  Methods of evaluating patient risks    Clinical judgement Risk scores or models. Evaluation of functional capacity. Basic Patient Preparation 1. Marking the operation site:  When obtaining the final consent, the surgeon should mark the surgery site on the patient’s skin with an indelible pen. - Especially important when the surgery is to be done on right or left or when the patient will be turned into prone position. 2. Preoperative fasting and fluid restriction:  General anaesthesia depresses the protective airway reflexes of gag and cough.  To minimise the risk of gastric content aspirations into the lung during anaesthesia induction or in early recovery, the patient should be fasting.  Guidelines on fasting: - Stop solids before 6 hours. - Stop liquids before 2 hours.  For patients at higher risk of aspiration e.g. GERD, intestinal obstruction and pregnancy, the anaesthetist may prescribe an antiacid medication.  Should CHECK IF THIS HAS BEEN FOLLOWED. 3. Liaison with Anaesthetist  Evaluation of patient.  The anaesthetist is responsible for ensuring that the patient is fit for surgery and assists in resus if needed. 4. Operating theatre arrangement The intern is responsible for informing the operating department about the operation any special arrangements needed.  A formal operating theatre list should include: - Name - Age - Sex - Ward - Proposed operation  The side of the body to be operated on should be clearly noted.  The presence of transmissible infections e.g. MRSA or HCV should document.  The amount of bank bloods ordered for the patient should be noted.  If changes are made, a completely new list must replace the old list. 5. Planning the order of the operating list:  Latex allergy -> remove all latex containing products.  Paediatric patients -> minimise the period of fasting and reduce anxiety.  Diabetic patients -> make perioperative management as smooth as possible to minimise fasting period and return to normal diet and management.  Preparation for a major surgery 1. History  Presenting complaint  Results of outpatient investigations. E.g. colonoscopy.  Systems review  Past medical history  Family history  Social history  Drug history. 2. Examination. Antibiotics Prophylaxis Perioperative antibiotic prophylaxis    Purpose: reduces the incidence of postoperative surgical site infections. Timing: ideally 30 to 60 minutes prior to skin incision: - Maximizing the tissue concentration before incision and during surgery minimises the risk of postoperative infections. Antibiotics use: - Gentamicin + penicillin + metronidazole - Gentamicin -> gram negative bacteria - Penicillin -> gram positive cocci  For patients with beta lactam allergy -> clindamycin or vancomycin. - Metronidazole -> anaerobic bacteria. Intraoperative Antibiotics Prophylaxis Postoperative Antibiotics Prophylaxis Markings, Anaesthesia Bays and Time out Marking of the Correct Side   Purpose: to prevent wrong side surgery. - Such as operating on the wrong limb. Protocol: 1. Before the surgery -> the surgical team verifies the correct surgical site by marking it directly on the patient’s skin. 2. The mark should be visible even after draping. 3. The surgeon, anaesthetist and nursing staff participate in this process. 4. The patient is actively involved in confirming the correct side. 5. The mark should be consistent with any preoperative imaging ot documentation. 6. If there is any doubt, the team pauses to reconfirm before proceeding. Anaesthetic Bay Identification   Purpose: to ensure proper patient identification and safety during anaesthesia induction. Protocol: 1. The anaesthetist verifies the patient identity, surgical procedure and relevant medical history. 2. The anaesthetist reviews any allergies, medications and special considerations. 3. The anaesthetist reviews any allergies, medications and special considerations. 4. The anaesthesia machine and equipment are inspected for proper functioning. 5. Emergency drugs and equipment are readily accessible. 6. The patient’s airway management plan is discussed. 7. The anaesthetist confirms the patient’s position e.g. supine, lateral) for induction. 8. The team ensures that monitors e.g. ECG, blood pressure are connected. Time Out Protocol   Purpose: to prevent errors during surgery by pausing to verify critical information. Protocol: 1. Just before the incision, the entire surgical team (including anaesthesia) participates in a time out. 2. The time out includes: - Verifying the patient’s identity, procedure and correct side using the marked area. - Confirming any allergies, special considerations and consent. - Reviewing any critical steps or concerns. - Ensuring that all necessary equipment and implants are available. - Addressing any discrepancies or concerns. - Only after consensus is reached does the surgery proceed. Post Operative Pain    Managed preoperatively and post-operatively. Patients vary in degree of pain tolerance. Pain counselling:  - Let the patient know the extent of pain. Intra-operative pre-emptive analgesia: - Long-acting analgesic drug given IV. - Local anaesthetic infiltration into the wound edges at the end of the operation with a long-acting agent e.g. bupivacaine. - Regional nerve blocks e.g. intercostal nerves for upper GI surgery using transverse abdominis plane block. - Epidural anaesthesia using local anaesthetics and often morphine during and after abdominal and pelvic surgery. - Nonsteroidal analgesics given before the patient waken by suppository or intravenous injection.  These must not be given to patients with a known allergy to aspirin or other nonsteroidal anti-inflammatory drugs, history of severe asthma or angioedema or pregnancy or patients with a high risk of haemorrhage.  Mild asthma is NOT a contradiction. Common Post Operative Manifestation Manifestation Description Pyrexia Tachycardia Collapse or rapid general deterioration Nausea and vomit  Drugs  Bowel obstruction  Systemic disorders  Hematemesis Diarrhoea Constipation Poor urine output Changes in mental state Jaundice The operating Room 1. Demonstrate an understanding of operating room etiquette and multidisciplinary nature of the operating suite. 2. Demonstrate the proper technique for surgical scrubbing and gowning and gloving. 3. Demonstrate aseptic technique and discuss the microbiological principles involved. 4. Identify areas in the operating room which are considered part of the sterile operative field. 5. Demonstrate the ability to function as an assistant in the operating room environment. Oxygenation and Acid and Base Balance Learning Objectives 1. 2. 3. 4. Define the physiological limits of normal blood gases. List the factors that affect oxygen delivery and consumption. Describe the criteria for intubating and extubating a patient. Describe the anticipated arterial blood gas changes that might be obtained in patients with acute metabolic acidosis, acute and chronic respiratory acidosis, acute respiratory alkalosis and compensated metabolic acidosis. Normal Blood Gas Limits Factors that affect oxygen delivery and consumption Factors that affect oxygen delivery     Changes in cardiac output Haemoglobin saturation Haemoglobin concentration Carbon dioxide, pH levels and body temperature. - Carbon dioxide:  When there is Co2 in the blood, it will react with water to form HCO3- and water.  This will cause more H+ being produced which will decrease the blood pH.  This will shift the oxygen-haemoglobin curve to the right -> decreases affinity for oxygen - - -> increased oxygen unloading to peripheral tissues and less oxygen uptake. Blood pH levels:  Same as above.  In alkalosis there is shifting to the left -> increased Hb affinity for oxygen. Body temperature:  Increases will shift the graph to the right -> decreased Hb affinity for oxygen and increased oxygen unloading.  Decreases will shift to the left -> increases Hb affinity for oxygen and decreased oxygen unloading. Factors that affect oxygen consumption        Metabolic demand Active tissues: - Such as muscles during exercise. Physical activity. - Higher intensity needs higher consumption. - Higher activity leads to increased oxygen ventilation. Body size and consumption: - Larger people have a higher oxygen demand and higher oxygen consumption as they have greater mass tissue and higher lead body mass (muscles). Age - Decreases with age by 2% per year after 30s. Gender - Males have greater consumption than females. Health conditions - Fever: increases metabolic demand as the body fights of the infection ot inflammation -> needs higher oxygen demands. - Hypothyroidism: this is because there is reduced metabolic rate and liver oxygen consumption. Criteria for intubating and extubating a patient. criteria for intubation           Respiratory failure -> hypoxic or hypercapnic Apnoea Reduced levels of consciousness -> less than or equal to 8. Rapid change of metal status Airway injury Impending airway compromise Upper airway obstruction. Higher risk of aspiration Trauma to the larynx Neuromuscular weakness. Contraindications for intubation           When not possible consider a surgical airway. Conditions that make it hard or impossible to pass an endotracheal tube. Severe airway trauma or obstruction. Laryngeal edema Laryngeal fracture Epiglottitis Laryngotracheobrnochitis Base of skull fracture and CSF rhinorrhoea. - Should be avoided as there is a risk of tube reaching the cranium or chasing CSF to leak through the nose. Bleeding disorders: - Coagulopathies - Bleeding disorders. - All of these increase the risk of bleeding during intubation. Nasal polyps, abscess or foreign body: - These conditions obstruct the tube and may make intubating challenging. - Previous nasal surgery can be a relative contraindications. Criteria for Extubating       Disease resolution Adequate oxygenation and gas exchange (PaO₂ > 60 mmHg on FiO₂ < 40%, stable chest X-ray). Stable hemodynamic: - Minimal vasopressor use is needed. - Stable cardiac rhythm. Stable mentation: - Rousable no continuous sedation. Spontaneous breathing trial: - Criteria for successful for spontaneous breathing trial:  Awake and easily arousable.  Able to follow commands.  Minimal respiratory secretions.  Intact gag and cough reflex. Cuff leak test: - Cuff leak test to check for laryngeal edema.  Laryngeal edema can cause upper airway obstruction following extubating. Laparoscopic Surgery Basics      Was initially called minimally invasive surgery. Less tissue damages. Minimisation of surgical incisions. Less pain afterwards. Physiological responses to injury which slow recovery are reduced. Advantages Surgical Advantages Postoperative advantages  Improved access and  Fewer post-operative vision to difficult areas chest complications. such as the pelvis organs  Lower analgesia and gastro-oesophageal requirements. junction.  Sometimes even a  Avoid handling, exposure, shorter hospital stay. desiccation and cooling of the abdominal tissue, which may reduce adhesion formation.  Reduced contact with patient’s blood and body fluids.  Fewer wound infections, adhesions and incisional hernias. Risks and Complications    Induction of pneumoperitoneum: - Due to possible cause of subcutaneous emphysema and injury to the bowel or major blood vessels. Trocar insertion: - May injure abdominal wall, intra-abdominal organs and blood vessels. The raised intraabdominal pressure and head down position mean that patients have to be ventilated at higher inflation pressures. - This reduces the venous return and cardiac output -> may cause circulatory compromise in patients with cardiac ischemia. WILL FINISH THIS OFF LATER AS I MY BRAIN IS NOT BRAINING AT THIS MOMENT FOR THIS Laparoscopic applications in the colorectal setting Component Diagnostic Therapeutic Abdomen -> CT  Diagnosis of fluid  Guiding drainage of or ultrasound collections for example, fluid collections by ascites, pancreatic aspiration or pseudocysts, abscess. drainage insertion.  Percutaneous guided  Guiding sampling of biopsy of enlarged lymph suspected nodes, liver, or pancreatic necrosis pancreatic masses or for infection in other masses. acute pancreatitis.  Diagnosis of acute or  Stent placement for chronic abdominal obstructing colonic symptom’s including lesions. detection of colorectal cancer. Anal canal  Proctoscopy to inspect  Injection or banding the anal canal and if of haemorrhoids. necessary to biopsy  Perineal operations lesions. for rectal prolapse.  Trans anal total mesolectal excision (TaTME)of the rectum. Rectum and the  Diagnostic flexible  Snare excision of colon sigmoidoscopy or polyps and colonoscopy (including adenomas. biopsy) for bleeding,  Diathermy of suspected tumours, IBD, bleeding surveillance after polyp angiodysplasia. or cancer removal,  Diathermy loop tumours for palliation or resection of begin rectal structures. inoperable rectal  Endoluminal U/S imaging cancer. for staging rectal cancer  Argon beam laser and determining ablation after rectal sphincter damage. caner (palliative).  MRI for detailing the anatomy of complex fistula  Has been long used by surgeons for the assessment of chronic liver diseases and ascites of unknown origin. Technique of Laparoscopy Basics   Usually performed under general anaesthesia. Most often with muscle relaxation to allow full and safe insufflation of the abdominal cavity. Techniques 1. A pneumoperitoneum is created by introducing carbon dioxide under controlled pressure to lift the abdominal cavity away from the viscera -> allows inspection of the peritoneal cavity. - Gas is most safely introduced via a blunt cannula placed via an open technique to allow the visualisation of the peritoneal contents. - The gas pressure should be kept as low as possible while maintaining a satisfactory view to minimise cardiac and respiratory risk. 2. A 5 to 10 mm diameter laparoscopy with video camera is then introduced into the abdominal cavity. 3. Additional cannulae (trocars) are made to which pass the diathermy hooks, graspers, needle holders, clip appliers and linear staplers. - These secondary trocars are inserted through a new access point under direct vision within from within the abdomen to prevent injury to the bowel and other viscera. - Port sites differ with according to the nature and type of operation. For example, a patient undergoing cholecystectomy who is obese, requires different port sites than a thin patient. Sharp vs blunt dissections    May be used in an open surgery. Sharp dissections - Sharp dissections use laparoscopic scissors. Blunt dissections - Blunt dissections is carried using a fine dissecting forceps (Petelins or Marylands), laparoscopic gauze pledgets or the tip of a suction probe. - Tears rather than cuts small blood vessels -> deliberately causing a minor tissue damage -> rapidly actives a coagulation cascade -> spontaneous cessation of bleeding. - This is safer than sharp dissections which may require (potentially excessive) use of diathermy.  Haemostasis still requires diathermy, and this must be cautiously used to prevent the arcing to adjacent organs. - Increasingly safer alternatives are being used such as bipolar diathermy forceps or the harmonic scalpel, which uses ultrasound to coagulate and cut vessels and tissue. Important Points     In laparoscopy-assisted surgery such as colectomy, a large part of the dissection is performed laparoscopically and then a small incision is made to deliver the bowel for anastomosis outside the abdomen or to remove the resected specimen. After the operation, patients experience abdominal discomfort at trocar insertion sites, shoulder discomfort from retained gas in the peritoneal cavity. Fre restrictions are placed on the patient after discharge. The patient can return to work as soon as comfortable, often after a few days. Laparoscopy in the Colorectal Setting in Depth Laparoscopic appendectomy      Offers improved diagnostic accuracy and the ability to examine entire abdomen if the appendix is normal, as compared to open appendectomy. Lower rate of wound complications. Reduce post operative pain. Shorter hospital stays and more rapid return to normal activities. May offer a lower rate of pelvic adhesions because of reduced trauma. - This is an advantage in young women. Laparoscopic Inguinal Hernia Repair      Can be repaired laparoscopically using a transperitoneal or an extraperitoneal approach. Both involve less dissection than the open approach and are believed to reduce the likelihood od damage to the testicular vessels and ilioinguinal nerve (especially for recurrent hernias) -> lower incidence od long-term chronic groin pain. Particularly of value for recurrent hernias, allowing the surgery to performed in tissue planes free from scarring. It is also recommended for bilateral hernias, when both sides can be repaired through three small incisions. However, the Lichtenstein open mesh hernia repair remains the standard operation alongside laparoscopic operations. Laparoscopically assisted colectomy   Can be used for benign and malignant colorectal cancers. Short term benefits have been demonstrated along with reduced wound related long term complications for both rectal and colonic surgery. Nutrition Learning Objectives 1. Identify the parameters from a patient’s medical history that might indicate the presence of malnutrition. 2. List the anthropometric objective laboratory tests that is helpful in ascending a patient’s nutrition state. 3. List the daily requirements for fat, protein and carbohydrates. 4. List the metabolic changes that occur in both long term and short-term starvation. 5. Discuss the relationship between a patient’s ability to respond to immune challenged and their nutritional status and the impact of nutritional status on peri and post operative morbidity. 6. List indications for nutritional support and the various routes for supporting nutrition in the malnourished patient. 7. Describe the options for delivery of enteral nutrition in the surgical patient. 8. Describe the methods of parenteral nutrition. 9. List water soluble vitamins, non-water-soluble vitamins, and trace elements that must be replaced in a patient long-term parenteral nutrition. 10.Contrast the risk and benefits of enteral and parenteral nutritional support. 11.List the adverse sequelae of TPN catheter. Parameters from history indicating malnutrition.      Unintentional weight changes. Dietary history: - Inquire about the patient’s usual dietary intake. - Assess for any restrictions, food preferences or difficulty eating. Gastrointestinal symptoms: - Ask about nausea, vomiting, diarrhea or constipation. Functional status: - Evaluate the patient’s ability to perform daily activities. Malnutrition can lead to weakness and reduced functionality. Hospitalisation and medical history.  Consider any recent hospitalisation, surgeries or chronic illness. Inflammation - Chronic inflammation (e.g. due to infection or autoimmune conditions). - Assess for elevated CRP levels. Anthropometric Objective Laboratory Tests    Body weight - Current body weight compared to previous body weight. - Assess for underweight, overweight and obesity. BMI Waist circumference -  measured in cm or inches just above the hip bones. A large circumference is associated with higher mortality, especially due to cardiovascular disease. Skin fold thickness: - Measures subcutaneous fat at specific sites within the body. Estimates total body fat percentage.  Mid-upper arm circumference: -  Waist to hip ratio: -     - Can help differentiate between malnutrition and inflammation related hypoalbuminemia. - Can detect anaemia which can result from poor nutrition. - Assess the overall metabolic and nutritional status. CBC Electrolytes Blood glucose Includes cholesterol, LDL, HDL and triglycerides and helps assess fat metabolism. Micronutrition levels: -  Indicator of carbohydrate metabolism and can reflect nutritional status. Lipid profile: -  Shorter half-life than albumin -> provides immediate indicator of nutritional status. Total protein. CRP  Estimates body composition including far mass, lean body mass and body water. Serum albumin. Prealbumin -   Ratio of waist circumference to hip circumference. Indicates fat distribution and associated health risks. Bioelectrical impedance analysis (BIA): -   Assess muscle and fat stores -> especially in malnutrition screening. Vitamin and mineral levels -> vitamin D, B12, calcium, omega-3 fatty acids iron and folate. Normal ranges vary by specific micronutrients. Nitrogen balance: - Assess protein status by comparing nitrogen intake (from dietary protein) to nitrogen excretion (in urine). Positive balance indicates an anabolic state, while a negative balance indicates a catabolic state.  Nutritional Risk Screening 2002 score. - -  Used to determine the need for specialised nutrition support. Points are based on BMI, weight loss in the last three months, decrease oral intake in the last week and being an ICU patient. Patient with a score of greater than or equal to 5 is considered to be at a high nutritional risk. Nutrition Risk in the Critically Ill Score. - - Used to determine the need for specialised nutritional support. Points are based on age, number of comorbidities, number of days in hospital prior to ICU admission, IL-6 level, APACHE II score and the SOFA score on admission. A patient with a NUTRIC score of greater than or equal to 6 is considered at high nutritional risk. Daily requirements for fat, protein and carbohydrates. Metabolic Responses to Starvation   Short term responses: - The body adapts to the absence of food by utilising stored energy sources. - Glycogen depletion: initially, the stored glycogen is depleted. Glycogen is a rapidly available energy sources and mainly stored in the liver and muscles. - Increased gluconeogenesis: within the first 24 to 48 hours gluconeogenesis increases in attempt to maintain blood glucose levels. - Ketogenesis: the body switches to ketone bodies and free fatty acids as an alternative fuel source. Ketones are produced in the liver can be used in the nervous system and muscles. Long term responses: - As starvation persists more significant metabolic changes occur. - Ketone utilisation: ketone bodies become the preferential fuel for the heart and other organs, allowing the brain to continue to use glucose. - Increased fatty acid oxidation: the body heavily on fat oxidation to meet energy demands. - Decreased glucose oxidation: glucose utilisation decreases sparing it for essential function such as the brain function. - Protein catabolism: over prolonged starvation, protein breakdown occurs. This leads to the degradation of structurally important proteins and dysfunction in various organ systems. Relationship between the immune system and the nutritional status 1. Nutritional status and the immune response:  Malnutrition: malnutrition is common in patients with GI malignancies undergoing cancer related surgeries. - Studies report malnutrition in 19 to 50% of surgical patients.  Impact on immune response poor nutritional status adversely affects the immune response. - Surgery itself induces a significant stress response which can further impair immune function.  Reversed immune suppression: clinical research suggests that post-operative infections may result from immune suppression. - Specialized nutritional support can partially reverse the immune suppression, regardless of the nutritional status. 2. Impact of nutritional status on morbidity:  Post-operative outcomes: nutritional status significantly influences various post-operative status.  Morbidity: malnourished patients are at a higher risk of complications after surgery.  Hospital length of stay: poor nutrition status prolongs hospital stay.  Mortality: malnutrition contributes to increased mortality risk. 3. Immunonutrition (IMN):  This involves specialised nutritional support designed to enhance the immune response.  Recent meta-analysis has shown that IMN is associated with reduced post-operative complications in GI surgery.  Peri-operative administration of IMN appears to the preferred strategy for reducing infectious complications, anastomotic leaks, surgical site infections and hospital length of stay. Nutritional Support Indications and Routes Indications for nutritional support        Patient who cannot eat. Patient who should not eat. Patients who will not eat. Patient who cannot eat enough. All severely malnourished patients on hospital admission. This includes: - Patients with a BMI of less than 18.5 kg/m^2. - Unintentional weight loss greater than 10% within the last 3 to 6 months. - BMI less than 20 kg/m^2 and unintentional weight loss greater than 5% within the last 3 to 6 months. Moderately malnourished patients who because of their physical illness are not expected to eat for more than 5 days. Normally malnourished patients expected not to eat for more than 5 days or expected to eat less than half their intake fore more than 8 to 10 days. Routes for nutritional support Oral nutritional support Enteral tube feeding Parenteral nutrition  Providing  Delivers nutrients  Provides nutrients adequate directly into the intravenously nutrients GIT via a tube. (directly into the through regular Such as bloodstream). foods or oral nasogastric tube,  Reserved for supplements. nasoenteric, patients with  Suitable for gastrostomy or severe patients who can jejunostomy. malnutrition, gut swallow and  Indicated when dysfunction or tolerate oral oral intake is inability to tolerate intake. insufficient or not enteral feeding.  Includes feasible.  Required central modified diets,  Commonly used venous access. fortified foods, in hospitalised  Used when the and oral patients or those enteral routes are nutritional with impaired contraindicated or supplements. swallowing. insufficient. Options for Delivery of Enteral Nutrition in the Surgical Patient Option Placement Nasogas tric Tube (NGT) A flexible tube is inserted through the nose and down the esophagus into the stomach. Indication s NGT is commonly used for short-term EN, especially in patients who can tolerate gastric feeding. Advant ages Easy placem ent, costeffectiv e, and suitable for most patients . Contraindicati ons Risk of dislodgement, nasal irritation and aspiration. Surgery and Personal Safety 1. Understand the principles of universal precautions. 2. Protocols for needle stick injuries or other exposure to body fluids including understanding of procedures and consent issues. 3. Describe the steps of prevention of transmission of blood and other body fluid infections such as HIV and Hepatitis B. 4. Understand the protocols and principles of precautions in high-risk patients with resistant infections. 5. List the measures followed to avoid radiation exposure. Principles of Universal Precautions in Surgery  Hand hygiene. - Hand washing - Hand rubbing with an alcohol-based hand rub. - The five moments of hand hygiene.         Wear a mask and eye protection. Wear protective clothing -> PPE. Aseptic technique Cleaning and disinfection. Waste disposal. The safe use and disposal of sharps. Appropriate handling of linen. Respiratory hygiene and cough etiquette. Protocols of Needle Stick Injuries or other exposure to bodily fluids. Protocols of needle stick injuries 1. Wash hands with soap and water/ wash mucous membrane -> wash with water. 2. Report to the manager/supervisor. 3. Proceed immediately to ED for consultation, screening, counselling and treatment. 4. Any questions page or call infection control consultant, out of hours call. Treatment of the exposed health care worder.       Report incidence of occupational exposure. Medical history of: - The seize of needle used. - Site and depth of the injury. - What the needle has been used for. - Was any blood or body fluid injected during the injury. - Is the source known and does the HCW have any reason to suspect that their own HIV/hepatitis C test may be positive? Bloods need to be taken from the health care worder. Consent from the source must be obtaining by the treating medical officer. - The patient must sign a consent for HIV testing. Blood testing should be performed at 6 weeks, 3 months and 6 months. Pre and post test counselling must be given. When to notify NSW Health Steps of prevention of transmission of blood and other body fluid infections such as HIV and Hepatitis B.        Avoid sharing needles or injection equipment: - Do not share needles, syringes or any equipment used for injecting. Hand hygiene Hepatitis B vaccinations. Avoid sharing personal items such as razors and toothbrushes. Safe handling of blood and sharps: - Handle blood and sharp objects carefully to prevent accidental picks or cuts. - Use appropriate precautions when dealing with contaminated needles or other sharp objects. Always wearing PPE. Immediate clean ups of spillages: - Contaminated surfaces or spillages with blood or other bodily fluids should be dealt with immediately. - Use spillage kits appropriate for the type of spills e.g. blood/blood stained body fluids or non-blood body fluids. Protocols and principles of precautions in high-risk patients with resistant infections. For detailed guidelines refer to: https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2023_025.pdf 1. Screening for MROs: Targeted screening plans based on the level of risk and local epidemiology.  Factors to consider include local prevalence, reason for patient admission, potential risk of transmission and functional status of the unit. Patient placement and isolation:  Single-patient rooms are recommended for those requiring transmission-based precautions.  Placement decisions are made based on risk assessment and should involve infection prevention and control services and the infectious disease team.  Cohorting patients with the same infectious agent may be needed ot singe rooms are unavailable. Hand hygiene and precautions:  Emphasis on hand hygiene and the use of standard and transmission-based precautions (contact, droplet and airborne).  Appropriate use of PPE based on risk assessments. Communication and staffing:  Prompt and effective communication of patient’s MRO status, including electronic medical record alerts.  Adequate staffing levels to meet patient care requirements. Infection prevention and control involvement:  IPC should involve the analysis, structure, process and outcomes of interventions.  Monitoring compliance and providing timely feedback on adherence to recommended precautions. Antimicrobial stewardship:  Implementation of antimicrobial stewardship programs to ensure judicious use of antimicrobials.  Policies should include guidelines for prescribing and monitoring antimicrobial use. Educational interventions:  Training health workers, patients, family and carers about infection prevention measures and precautions. Environmental cleaning and monitoring:  Religious cleaning and disinfection of the patient environment and care equipment.  Regular environmental monitoring to prevent the spread of infections. Decolonisation programs:  Programs aimed at reducing the carriage of resistant organs in highrisk settings.  2. 3. 4. 5. 6. 7. 8. 9. Measures to avoid radiation exposure. 1. Distance:  Keep the X-ray tube as far away from the patient as feasible.  Keep the image receptor (e.g. X-ray film or digital detector) as close to the patient as possible. 2. Collimation:  Collimate the X-ray beam to focus only on the area of interest. - This helps reduce surrounding tissues. unnecessary exposure to 3. Limiting runs:  Reduce the number of X-ray images acquired to the essential ones needed for diagnosis or treatment. 4. Pulsed fluoroscopy:  Used pulsed fluoroscopy instead ot continuous fluoroscopy when performing procedures that require real time imaging.  Pulsed mode reduces overall exposure. 5. Last image hold:  Utilise the last image hold feature which freezes the last acquired image on the screen.  This allows the surgeon to review the image without continuous exposure. 6. Minimise magnification:  Avoid excessive use of magnification, as it increases radiation exposure.  Use magnification only when necessary. 7. Radiosensitive organs:  Be mindful of radiosensitive organs such as the breast and try to minimise exposure in these areas. 8. Oblique view:  Redice the use of oblique views unless essential for diagnosis or surgical planning. Surgical infections Learning Objectives 1. Define “clean”, “clean-contaminated” and “dirty” operative cases and the risk of infection in each. 2. List the factors which contribute to infection following a surgical procedure. 3. Differentiate between the clinical features of cellulitis, lymphangitis and abscess. 4. Describe the diagnostic features and treatment and treatment for common wound infections. 5. Describe the clinical features and treatment of clostridial. Anaerobic and synergistic gangrene. 6. List the causes of early and late post-operative fever and discuss the diagnostic steps for evaluation. 7. Describe the diagnostic evaluation and treatment options for a suspected intra-abdominal collection. 8. Define nosocomial infection and describe the most common causes of this in the surgical intensive care unit (esp. multi resistant staphylococcus and vancomycin resistant enterococci). 9. Discuss the rationale for prophylactic antibiotics in common surgical operations. 10.Define endotoxaemia and its role in infections. 11.Differentiate between antisepsis, asepsis and sterile techniques. Clean, Clean Contaminated and Dirty. Concept Clean wound Definition    Clean contamin ated wound   Contamin ated wound     Dirty Wound   Is non traumatic and lacks inflammation. There is no break in the aseptic technique during the procedure. GIT, resp trat and GU tracts are not entered. Non-traumatic. Has minor breaks in the aseptic technique. GI, rep and GU tracts entered but within minimal spillage of after prior decolonisation. Is a traumatic and exhibits inflammation or gross purulence. There is a major break in aseptic technique during the procedure. GIT, resp or GU tract is entered with gross spillage. Associated with a significant contamination. May involve open, fresh, accidental wound or spillage from GI, resp or GU tracts. Risk of infection postoperatively for Surgical Site Infections.  1% - 5%.  3% -11%.  10 – 17%.  Over 27%. Factors that contribute to infection following a surgical procedure. 1. Germs and contamination:  Germs can enter a surgical wound through various forms of contact. Such as: - Contaminated caregivers. - Surgical instruments - Air.  Exiting germs on or in the body can also spread into the wound during a surgery. 2. Wound classification:  The degree of risk for a surgical site infection is linked to the type of surgical wound: - Clean wound -> 1 – 5 % - Clean contaminated wound -> 3 – 11%. - Contaminated wound -> 10 to 17%. - Dirty wound -> more than 27%. 3. Patient related factors:  Age -> especially over 65.  Overweight or obesity.  Smoking  Diabetes  Immunosuppressive conditions.  Other chronic medical problems or diseases. 4. Surgery related factors:  Duration of surgery  Blood loss  Use of antimicrobial prophylaxis.  Wound management practices.  Post-operative hematomas.  Preoperative skin preparation.  Type of procedure.  Glove changes.  Topical antibacterial preparations. Diagnostic Features and Treatment for Common Wound Infections. Visual Observations      Before doing any diagnostic tools, most doctors will suspect a wound infection via visual inspections. Typical signs of a wound acute wound infection include: - Pain - Erythema - Warmness - Purulent exudate.  These may be modified in chronic wounds by underlying comorbidities. Additional signs include: - Delayed healing - Discolouration - Friable granulation tissue - Serous exudate - Epithelial bridging/pocketing in granulation tissue. - Foul Odor. - Wound breakdown.  Signs such as changes in exudate, granulation tissue, discolouration of wound bed and wound brigading can be associated with colonisation rather than infection. Acute wound infection has apparent signs and symptoms since it is generally cause by a single organism while, while chronic wound infections has less obvious signs due to multiple pathogens. The visual inspection DOES NOT provide any definite determination. Signs and symptoms at different stages of the wound infection continuum. Contaminat ion    Colonisatio n Local Infection    Spreading Infections   Systemic Infections     All open wounds may have microorganisms. They will not multiple or persistent until a suitable nutritive and physical conditions are available for each microbial species. Thus, their presence is only transient and wound healing is not delayed. Microbial species successfully grow and divide, but do not damage the host or initiate wound infection. Covert subtle signs of local infection: - Hyper granulation - Excessive vascular tissue - Bleeding - Friable granulation - Wound breakdown - Enlargement - Delayed wound healing beyond expectations. - New or increasing pain - Increasing malodour. Overt classical signs of local infection: - Erythema - Local warmth - Swelling - Purulent discharge - Delayed wound healing beyond expectation - New or increasing pain - Increasing malodour. Extending in duration +/- erythema, lymphangitis, crepitus, wound breakdown/dehiscence with or without satellite lesions, malaise/lethargy or non-specific general deterioration, loss of appetite, inflammation, swelling of lymph glands. Severe sepsis Septic shock Organ failure Death IMPORTANT NOTE Since a delayed wound healing process in an important indicator for wound infection, wound mapping tools such as wound tracing, scaled photographs, planimetry can be used to indirectly detect wound infection by monitoring wound size changes. Odor Sensing and Pain Assessment Clinical and Laboratory Assessments Intra-abdominal Collections Definition   An intra-abdominal abscess is a collection of pus or infected fluids that is surrounded by an inflamed tissue inside the abdomen. It can involve any abdominal organ or can settle in the folds of the abdomen. Causes    Can sometimes happen because of a medical issue such as appendicitis or diverticulitis. Can happen as a complication after surgery. Can be caused by a bacterial infection. - The most common bacteria that causes them is in the stomach and the intestines. Examples, include E. coli.  If left untreated the bacteria will multiply.  They can cause inflammation and kill healthy tissues. People who are at risk of developing intra-abdominal abscess    Abdominal surgery Abdominal abscess. Additional concerns include diabetes and IBD. Symptoms         Fever Abdominal pain Chest pain or shoulder pain Lack of appetite Nausea and vomit. Changes in bowel movements. Rectal tenderness or fullness. Malnourishment Diagnostic evaluation      Physical examination: - High temperature - Abdominal tenderness - Sometimes can be felt as a mass in the midsection. - Tachycardia Blood tests - Increase in the number of WBC - Increased CRP levels. - Possible signs of anaemia - Liver enzymes and hypergammaglobulinemia. - Abnormal platelet counts Blood cultures - More than 90% of intra-abdominal abscess contain anaerobic organisms such as B. fragilis, postoperative Bacteroides - Bacteria suggests intra-abdominal abscess Other factors: - Tachycardia - Change in bowel habits or abnormal bowel function. - Prolonged ileus -> delayed bowel movements. - Anorexia (lack of appetite) - Nausea and vomit - Signs of sepsis Ultrasonography: - Can be specific when correlated with the clinical picture. -  Can have an assurance of greater than 90% of diagnosing intra-abdominal abscess. Disadvantages include:  Obesity  Bowel gas  Intervening viscera  Surgical dressings  Open wounds  Stomas  These can create issues with definition.  These disadvantages may limit the efficacy of this modality in post-operative patients. CT: - Has an accuracy of more than 95% in this scenario. Best diagnostic modality of intra-abdominal abscess. The presence of ileus, dressings, drains or stomas does not interfere with the reliability. Good for anatomic resolution. Contrast may help differentiate a fluid filled extraluminal structure from a normal intestine. Management   Pharmacological therapy: - Empiric administration of parenteral empiric antibiotics. - This should be initiated before abscess fluid drainage and concluded when all systemic signs of sepsis have been resolved. - This is because fluid abscess usually contain a mixture of aerobic and anaerobic organisms hence empiric therapy must be directed against both. Percutaneous abscess drainage: - This is the first line of treatment against progressive sepsis. - Percutaneous CT guided catheter drainage has become the standard treatment of most intraabdominal abscess.  This helps avoid anaesthesia and laparoscopy and prevents the possibility of wound complications from open surgery and may reduce the length of hospitalisation.  It helps obviating the possibility of contaminating other areas within the peritoneal cavity.  When feasible it is preferred to open drainage. - A diagnostic needle aspiration is initially performed to confirm the presence of pus -> this makes gram staining and culture possible. -  After drainage clinical improvement should occur within 48 to 72 hours.  Lack of improvement within this time mandates a reap CT to check for additional abscesses. - Persistent drainage usually reflects the presence of an enteric fistula. - Complications include bleeding, or inadvertent puncture of the GIT. - Percutaneous drainage is effective in 90% of patients who have a single unilocular abscess with no enteral communication. - Complex abscesses that include multiple loculations or interloop abscess or those associated with an enteric fistula may require surgery. Laparoscopic open drainage: - When then percutaneous drainage fails or if collections are not amenable to catheter drainage. - Laparoscopic drainage for a massive intra-abdominal abscess is minimally invasive, permitting exploration of the abdominal cavity without the use of a wide incision; purulent exudate can be aspirated under direct vision.