Post-operative review OSCE

How to Assess the Post-operative Surgical Patient – OSCE Guide

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Introduction

The ability to assess a post-operative surgical patient is an important skill to develop during medical school and your foundation years. It is commonly tested in OSCEs and almost all foundation year doctors will have at least one surgical rotation. Furthermore, assessing the post-operative surgical patient is also assessed at postgraduate surgical interviews.

This article will provide you with:

  • A structured format for carrying out a thorough review of the surgical patient – with a worked example for use in an OSCE setting.
  • A structure for categorising post-operative complications.

OSCE stations vary in their focus:

  • A-E assessment of an acutely unwell surgical patient [ABCDE approach]
  • A broader assessment of a post-operative surgical patient [SHE BOXED approach]

A-E assessment of an acutely unwell surgical patient 1,2,3

As with all OSCE stations, you should first introduce yourself, confirm the patient’s details and gain consent to proceed. The examiner of the station may then ask you to describe how you would approach an acutely unwell surgical patient.

An example of a response could be:

“I would approach the patient using a structured A-E approach according to Advanced Life Support guidelines, initiating immediate management as required and escalating appropriately.”

The A-E assessment is not in the scope of this article, however, it is an essential skill that all doctors should possess. A thorough guide for A-E assessment can be found here.

Once the A-E assessment has been completed and the patient has been stabilised, it is important to think more broadly about a thorough surgical assessment.

In an OSCE, after performing an A-E assessment, it is often sensible to suggest escalating to a senior member of the team.

The examiner will then often state “Your senior is on the way”.

Having been through the A-E assessment, you may have decided the patient needs to return to theatre urgently. You may be asked at this point “What would you do whilst you wait for your senior?”

A good answer in this situation would be:

  1. Consent utilising the correct consent form (if you are trained to do so)
  2. Book the patient onto the emergency theatre list
  3. Inform the theatre coordinator and on-call anaesthetist

A broader assessment of a post-operative surgical patient [SHE BOXED approach] 2,4

It may be that in an OSCE scenario you complete your A-E assessment and the examiner then asks you “now what would you do?”. If there is no clear indication to take the patient to theatre for an emergency operation, a further, more detailed assessment is required. In this situation, the SHE BOXED approach can be utilised.

SHE = Summary of History and Examination findings

History

I would take a focused history from the patient and ask particularly about…”

A useful structure for quickly covering the salient features of a surgical history is the acronym AMPLE:

  • A – allergies
  • M – medications
  • P – past medical history
  • L – last eaten/had something to drink (patients should not have had something to eat in the 6 hours prior to an operation and should not have had water in the 2 hours before an operation)
  • E – events leading up to admission/current situation/current positive examination findings (e.g tender at McBurney’s point)

Tip for surgical patients: Review the operation note and anaesthetic chart. Was the operation straightforward? Were there any complications? What were the post-operative instructions? What drugs were used during the operation? How has the patient been in recovery?

Examination

You then need to complete a focused examination of the relevant system. For example, if the patient is post-thyroidectomy then it would be worth stating that you would want to carry out a complete neck examination, inspecting for any visible swelling/airway compromise (e.g. in the event of a haematoma).

BOXED

B = Bedside tests & bloods

Bedside:

  • Basic observations
  • ECG

Bloods:

  • Laboratory tests (e.g. FBC,U&Es,LFTs,Clotting, Group & Save)
  • Blood cultures
  • Gases (e.g. arterial blood gas or venous blood gas)

Tip: Isolated figures often are difficult to interpret. Therefore the TREND in blood test values and observations is important to pay attention to.

O = Orifices

Are there any results for:

  • Sputum culture
  • Swab results (e.g. from surgical site/MRSA status/previous operations)
  • Urine culture
  • Urine output
  • Stool output
  • Drain output

Tip: Work from the head downwards to help remember these! Also, don’t forget the TREND in the drain or catheter output.

X = Xray, imaging and special tests

  • X-ray
  • Ultrasound/Doppler
  • CT
  • MRI
  • Endoscopy

E = Escalation plan

Is there a documented escalation plan? Would this patient be appropriate to receive HDU or ITU level care?

Who should you escalate to within your team? What other specialities should you escalate to (for example critical care team, medical registrar, anaesthetics etc)?

Tip: What organ support may be required from HDU/ITU (e.g. non-invasive ventilation/inotropic support/intubation)? 

D = Do not attempt CPR (DNACPR) status

Does the patient have a valid DNACPR form in place? Is this something worthwhile highlighting with seniors to discuss?


Example

You are the on-call doctor and are asked to see a 61-year-old male who is day 3 post laparoscopic cholecystectomy. He has spiked a temperature of 38 degrees celsius and is tachycardic at 120bpm.

How would you approach this situation?

In an OSCE you may initially state…

“I would approach the situation using a structured A-E approach, initiating immediate management to stabilise the patient. If required, I would also escalate appropriately.”

After a provisional A-E assessment, the patient is deemed stable. How would you now approach performing a comprehensive post-operative assessment?

Summary of history and examination findings (SHE)…

“I would take a history, focusing on the patient’s allergies, medications, past medical history and when they had last eaten or had something to drink. In addition, I would clarify the recent events of the hospital stay, including admission date, the current diagnosis and any operation that has taken place. With regard to the surgery, I would want to review the operation note for post-operative instructions and evidence of complications. In addition, I would want to read over the most recent ward review. Given that this patient has undergone gastrointestinal surgery, I would focus my examination on their gastrointestinal system.”

BOXED…

“I would review the patient’s recent bedside observations, input/output charts, imaging and laboratory results (including blood tests and microbiology results). I would also ensure the patient had a valid group and save, should they need to return to theatre.”

“If the patient was potentially in need of HDU/ITU input, I would clarify the escalation plan with senior team members and ensure it was discussed with the patient and family as appropriate. I would also check if a DNA CPR form was present and if not, consider if this needed further discussion with senior team members and the patient/family.:

“Based on the findings of my assessment, I would then formulate a differential diagnosis and management plan accordingly.”

Documentation example

Date: 05/01/19

Time: 18:30  

Title: General Surgery Review             

Doctor name and role: Rakesh Mistry FY2

Asked to see patient regarding temperature (38 °C) and tachycardia (120bpm).

A:

  • Able to complete sentences
  • No added breath sounds

B:

  • RR 23
  • SpO2 96% on 15L O2
  • Reduced breath sounds at both lung bases
  • Portable chest x-ray ordered

C:

  • Peripheral capillary refill time approx 3 seconds
  • Pulse 120 bpm regular
  • BP 97/63 mmHg
  • Temperature 38 ºC
  • 2 large IV bore cannula inserted – 500mls Hartmann’s bolus administered
  • FBC/U&E/CRP/LFT/Clotting/Group and Save
  • Heart sounds normal on auscultation
  • ECG – sinus tachycardia 120bpm

D:

  • AVPU: Alert
  • Blood sugar 6
  • Pupils equal and reactive

E:

  • Abdomen tender around surgical site with associated guarding
  • Surgical site looks healthy with no evidence of breakdown

Summary of History and Examination  

61-year-old male

Allergies – NKDA

Medications:

  • Amlodipine
  • Metformin
  • Salbutamol
  • Omeprazole

Past medical history:

  • HTN
  • Type 2 diabetes mellitus
  • Asthma
  • Hyperlipidaemia
  • GORD

Last intake of food/fluid:

  • Last ate 7 hours ago
  • Last had water 3 hours ago

Events

Admitted 01/01/19:

  • Admitted with epigastric discomfort and vomiting, Murphy’s positive
  • CT abdomen: likely cholecystitis secondary to gallstones
  • Started on IV Abx, analgesia and IV fluids

03/01:

  • Underwent laparoscopic cholecystectomy on emergency list under Mr Wan
  • Operation note: Difficult procedure – extended operative time however no complications. No drain in situ.
  • Post-operative instructions: Abx for 1/52, analgesia, can eat and drink, home when mobilising

06/01:

  • Day 3 post laparoscopic cholecystectomy for gallstone cholecystitis
  • Seen on ward round – some mild abdominal tenderness
  • FY1 review (evening): patient vomiting, bloated and becoming tachycardic 110bpm. Patient yet to mobilise.

Bedside (previous results in brackets):

  • SpO2 96% 15L O2 (SpO2 86% 2L O2)
  • RR 23 (16)
  • BP 97/63 mmHg (105/70 mmHg)
  • HR 120 sinus tachycardia (95 bpm)

Bloods:

  • 06/01: Hb 130, WCC 15, U&Es and clotting awaited from this afternoon
  • Blood cultures – taken earlier this afternoon. No previous results.
  • Arterial blood gas on 15L O2:
    • pH 7.28
    • PO2 19.3 kPa
    • pCO 5.9 kPa
    • HCO3 27 mmol
    • Lactate 4.0

Orifices:

  • No sputum, wound or faeces samples
  • Catheter in situ – urine output past 3 hours in ml/kg: 1/0.8/0.4
  • No drain in situ

Imaging:

  • Portable CXR ordered now – awaited
  • CT abdomen 01/01: cholecystitis secondary to gallstones
  • Previous endoscopy (2002): gastritis

Escalation plan:

Discussed on ward round this morning – would be for HDU care and potentially inotropic support if required 

DNACPR status: No DNACPR status recorded 

Issues:

  1. Day 3 post laparoscopic cholecystitis – hypotensive, tachycardic, pyrexial and vomiting (guarding around surgical site).
  2. Elevated WCC
  3. Lactic acidosis
  4. Oliguric

Impression: Likely anastomotic leak post laparoscopic cholecystectomy

Plan:

  1. Ensure “Sepsis 6” has been completed in light of septic picture
  2. Assess response to 500mls IV Hartmans
  3. Inform surgical registrar – will need senior review ?return to theatre
  4. Inform anaesthetics and theatre co-ordinator if surgical registrar believes likely to return to theatre – may need HDU/ITU bed post-operatively for possible inotropic support
  5. Get consent form ready for registrar arrival

Rakesh Mistry

FY2 General Surgery

GMC: 1234567

Bleep: 1311


Surgical risk factors 4,5

When assessing any patient, it is important to have an awareness of possible surgical complications that may affect them. Each patient’s risk of surgical complications differs depending upon the presence or absence of various factors. Below are two different ways of applying a structured approach to considering surgical risk factors.

Method A

  • Pre-operative
  • Peri-operative
  • Post-operative

For example: “You are called to see an obese diabetic 50-year-old patient following their open mesh inguinal hernia repair. The patient is 3 days post-op and is complaining of pain around his surgical site in his groin. The nurse reports some swelling at the site and a foul odour.”

  • Pre-operative factors – diabetic and obese patients are more likely to develop surgical site infections and wound breakdown
  • Peri-operative – the operation was completed open and with a mesh. An open wound is more likely to breakdown in an obese patient and the mesh is a foreign material which increases the possibility of infection.
  • Post-operative – What were the post-operative instructions on the operation note? Did the patient receive antibiotics?

Method B

Another simple way of categorising these risk factors is:

  • Patient factors – patient risk factors
  • Operation factors – surgical technique, post-operative care/instructions

For example, risk factors for a post-operative infection may be categorised into:

Patient factors Operation factors
  • Obesity
  • Diabetes
  • Steroids
  • Immunosuppression
  • Malnutrition
  • Contaminated/dirty operation
  • Foreign materials
  • Vascular grafts
  • Joint replacement

 


Post-operative complications

In an OSCE, you may be in a situation whereby you need to identify the most likely post-operative complication and manage the patient appropriately.

Complications may be classified by time or underlying cause.

Time

  • Immediate: <24 hours
  • Early: within 30-days (usually within 1 week)
  • Late/long term: after 30 days or after discharge

Underlying cause

General Specific
Reaction to anaesthesia Adjacent structure damage
Haemorrhage Gastrointestinal: anastomotic leak, visceral injury, strictures
Pyrexia Vascular: ischaemic colitis, endoleaks, graft migration
Wound infection/surgical site infection Plastic surgery: scarring, flap failure
Thromboembolism

The above may be combined and summarised into the following table:

General Specific
Immediate Haemorrhage

Broken tooth

Anaesthetic reaction

Asphyxia

Haemorrhage

Adjacent structure damage

Early Pyrexia – chest/urine/line

Bedsore

VTE – PE/DVT

Wound complication

Anastomotic leak

Deep collection

Paralytic ileus

Prosthetic infection

Late Weight loss

Osteoporosis

Anaemia

Inability to eat

Dumping syndrome

Recurrence


Post-operative pyrexia

Post-operative pyrexia is a common issue and the differential diagnosis for post-operative pyrexia is highly dependent on the timescale.

The trend of the pyrexia is also very important (i.e. new, persistent, swinging).

The 7 C’s of post-operative pyrexia – these are potential sources of post-operative pyrexia:

  • Chest
  • Catheter
  • CVP Line
  • Cannula
  • Cut (surgical wound)
  • Collections
  • Calves

Timeline

Days Possible cause
1 – 3 Atelectasis

Metabolic response to trauma

Drug reaction – IV fluids/transfusion

SIRS

Line infection

Instrumentation of viscus – transient bacteraemia

4 – 6 Chest infection

Superficial wound infection

UTI

Line infection

Compartment syndrome

= />7 Chest infection

Suppurative wound infection

Anastomotic leak

Deep abscess (swinging pyrexia)

DVT


Reviewer

Mr Mustafa Jaffar

ENT Registrar

St. Mary’s Hospital, Imperial College Healthcare Trust


References

  1. Farrington G. ABCDE approach. Geeky Medics. Available from: [LINK].
  2. Edwards P, Stechman M, Green J. How to pass the emergency OSCE station. BMJ Online 2019; 367: I2414. Available from: [LINK].
  3. Frost P, Wise M. Early management of acutely ill ward patients. BMJ online 2012; 345: e5677. Available from: [LINK].
  4. Goldberg A, Stansby G. Surgical Talk, 2nd Edition ed: ICP, 2005

 

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