11/13/24, 7\:26 PM Guide | Post-operative assessment

Post-operative assessment

Table of contents

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 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

As with all OSCE stations, you should
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 w o u l d a p p r o a c h t h e p a t i e n t u s i n g a s t r u c t u r e d A-E a p p r o a c h a c c o r d i n g t o A d v a n c e d L i f e S u p p o r t g u i d e l i n e s , i m m e d i a t e m a n a g e m e n t a s r e q u i r e d a n d e s c a l a t i n g a p p r o p r i a t e l y .
"
i n i t i a t i n g
The A-E assessment is not in the scope of this article, however, it is an essential skill that all doctors should possess. See our A-
E assessment guide for more details.
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\:
" Y o u r s e n i o r i s o n t h e w a y
"
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\:
" W h a t w o u l d y o u d o w h i l s t y o u w a i t f o r y o u r s e n i o r ?"
A good answer in this situation would be\:
Consent utilising the correct consent form (if you are trained to do so)
Book the patient onto the emergency theatre list
Inform the theatre coordinator and on-call anaesthetist

SHE BOXED assessment

It may be that in an OSCE scenario you complete your A-E assessment and the examiner then asks you
" N o w w h a t w o u l d y o u
d o ?"
. 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.
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SHE = Summary of History and Examination

History
" I w o u l d t a k e a f o c u s e d h i s t o r y f r o m t h e p a t i e n t a n d a s k s p e c i
"
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
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
pay attention to.
O = Ori
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
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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
Examples include\:
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 w o u l d a p p r o a c h t h e s i t u a t i o n u s i n g a s t r u c t u r e d A-E a p p r o a c h , r e q u i r e d , I w o u l d a l s o e s c a l a t e a p p r o p r i a t e l y .
"
i n i t i a t i n g i m m e d i a t e m a n a ge m e n t t o s t a b i l i s e t h e p a t i e n t . I f
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
" I w o u l d t a k e a h i s t o r y , f o c u s i n g o n t h e p a t i e n t’ s a l l e r gi e s , m e d i c a t i o n s , p a s t m e d i c a l h i s t o r y a n d w h e n t h e y h a d l a s t e a t e n o r
h a d s o m e t h i n g t o d r i n k . I n a d d i t i o n , I w o u l d c l a r i f y t h e r e c e n t e v e n t s o f t h e h o s p i t a l s t a y , i n c l u d i n g a d m i s s i o n d a t e , t h e c u r r e n t
d i a g n o s i s a n d a n y o p e r a t i o n t h a t h a s t a k e n p l a c e . W i t h r e g a r d t o t h e s u r ge r y , I w o u l d w a n t t o r e v i e w t h e o p e r a t i o n n o t e f o r
p o s t-o p e r a t i v e i n s t r u c t i o n s a n d e v i d e n c e o f c o m p l i c a t i o n s . I n a d d i t i o n , I w o u l d w a n t t o r e a d o v e r t h e m o s t r e c e n t w a r d r e v i e w .
G i v e n t h a t t h i s p a t i e n t h a s u n d e r g o n e g a s t r o i n t e s t i n a l s u r ge r y , I w o u l d f o c u s m y e x a m i n a t i o n o n t h e i r ga s t r o i n t e s t i n a l s y s t e m .
"
BOXED
" I w o u l d r e v i e w t h e p a t i e n t' s r e c e n t b e d s i d e o b s e r v a t i o n s , i n p u t / o u t p u t c h a r t s , i m a gi n g a n d l a b o r a t o r y r e s u l t s ( i n c l u d i n g b l o o d
t e s t s a n d m i c r o b i o l o g y r e s u l t s ) . I w o u l d a l s o e n s u r e t h e p a t i e n t h a d a v a l i d gr o u p a n d s a v e , s h o u l d t h e y n e e d t o r e t u r n t o
t h e a t r e .
"
" I f t h e p a t i e n t w a s p o t e n t i a l l y i n n e e d o f H D U / I T U i n p u t , I w o u l d c l a r i f y t h e e s c a l a t i o n p l a n w i t h s e n i o r t e a m m e m b e r s a n d
e n s u r e i t w a s d i s c u s s e d w i t h t h e p a t i e n t a n d f a m i l y a s a p p r o p r i a t e . I w o u l d a l s o c h e c k i f a D N A C P R f o r m w a s p r e s e n t a n d i f n o t ,
c o n s i d e r i f t h i s n e e d e d f u r t h e r d i s c u s s i o n w i t h s e n i o r t e a m m e m b e r s a n d t h e p a t i e n t / f a m i l y .\:
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" B a s e d o n t h e
"
Documentation example
D a t e \: 0 5 / 0 1 / 1 9
T i m e \: 1 8 \: 3 0
T i t l e \: G e n e r a l S u r g e r y R e v i e w
D o c t o r n a m e a n d r o l e \: R a k e s h M i s t r y F Y 2
A s k e d t o s e e p a t i e n t r e g a r d i n g t e m p e r a t ur e ( 3 8 A \:
° C ) a n d t a c h y c a r d i a ( 1 2 0 b p m ) .
A b l e t o c o m p l e t e s e n t e n c e s
N o a d d e d b r e a t h s o u n d s
B \:
R R 2 3
S p O 2 9 6 % o n 1 5 L O 2
R e d u c e d b r e a t h s o u n d s a t b o t h l u n g b a s e s
P o r t a b l e c h e s t x-r a y o r d e r e d
C \:
P e r i p h e r a l c a p i l l a r y r e
P u l s e 1 2 0 b p m r e g u l a r
B P 9 7 / 6 3 m m H g
T e m p e r a t u r e 3 8 º C
2 l a r g e I V b o r e c a n n u l a i n s e r t e d - 5 0 0 m l s H a r t m a n n' s b o l u s a d m i n i s t e r e d
F B C / U & E / C R P / L F T / C l o t t i n g / G r o u p a n d S a v e
H e a r t s o u n d s n o r m a l o n a u s c u l t a t i o n
E C G - s i n u s t a c h y c a r d i a 1 2 0 b p m
D \:
A V P U \: A l e r t
B l o o d s u g a r 6
P u p i l s e q u a l a n d r e a c t i v e
E \:
A b d o m e n t e n d e r a r o u n d s u r g i c a l s i t e w i t h a s s o c i a t e d gu a r d i n g
S u r g i c a l s i t e l o o k s h e a l t h y w i t h n o e v i d e n c e o f b r e a k d o w n
S u m m a r y o f h i s t o r y a n d e x a m i n a t i o n
6 1- y e a r-o l d m a l e
A l l e r g i e s - N K D A
M e d i c a t i o n s \:
A m l o d i p i n e
M e t f o r m i n
S a l b u t a m o l
O m e p r a z o l e
P a s t m e d i c a l h i s t o r y \:
H T N
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T y p e 2 d i a b e t e s m e l l i t u s
A s t h m a
H y p e r l i p i d a e m i a
G O R D
L a s t i n t a k e o f f o o d /
L a s t a t e 7 h o u r s a g o
L a s t h a d w a t e r 3 h o u r s a g o
E v e n t s
A d m i t t e d 0 1 / 0 1 / 1 9 \:
A d m i t t e d w i t h e p i g a s t r i c d i s c o m f o r t a n d v o m i t i n g , M u r p h y’ s p o s i t i v e
C T a b d o m e n \: l i k e l y c h o l e c y s t i t i s s e c o n d a r y t o ga l l s t o n e s
S t a r t e d o n I V A b x , a n a l g e s i a a n d I V
0 3 / 0 1 \:
U n d e r w e n t l a p a r o s c o p i c c h o l e c y s t e c t o m y o n e m e r g e n c y l i s t u n d e r M r W a n
O p e r a t i o n n o t e \: D i
P o s t-o p e r a t i v e i n s t r u c t i o n s \: A b x f o r 1 / 5 2 , a n a l g e s i a , c a n e a t a n d d r i n k , h o m e w h e n m o b i l i s i n g
0 6 / 0 1 \:
D a y 3 p o s t l a p a r o s c o p i c c h o l e c y s t e c t o m y f o r g a l l s t o n e c h o l e c y s t i t i s
S e e n o n w a r d r o u n d - s o m e m i l d a b d o m i n a l t e n d e r n e s s
F Y 1 r e v i e w ( e v e n i n g ) \: p a t i e n t v o m i t i n g, B e d s i d e ( p r e v i o u s r e s u l t s i n b r a c k e t s ) \:
b l o a t e d a n d b e c o m i n g t a c h y c a r d i c 1 1 0 b p m . P a t i e n t y e t t o m o b i l i s e .
S p O 2 9 6 % 1 5 L O 2 ( S p O 2 8 6 % 2 L O 2 )
R R 2 3 ( 1 6 )
B P 9 7 / 6 3 m m H g ( 1 0 5 / 7 0 m m H g )
H R 1 2 0 s i n u s t a c h y c a r d i a ( 9 5 b p m )
B l o o d s \:
0 6 / 0 1 \: H b 1 3 0 , W C C 1 5 , U & E s a n d c l o t t i n g a w a i t e d f r o m t h i s a f t e r n o o n
B l o o d c u l t u r e s - t a k e n e a r l i e r t h i s a f t e r n o o n . N o p r e v i o u s r e s u l t s .
A r t e r i a l b l o o d g a s o n 1 5 L O 2 \:
p H 7 .2 8
P O 1 9 .3 k P a
2
p C O 5 .9 k P a
2
H C O 3 -
2 7 m m o l
L a c t a t e 4 .0
O r i
N o s p u t u m , w o u n d o r f a e c e s s a m p l e s
C a t h e t e r i n s i t u - u r i n e o u t p u t p a s t 3 h o u r s i n m l / k g \: 1 / 0 .8 / 0 .4
N o d r a i n i n s i t u
I m a g i n g \:
P o r t a b l e C X R o r d e r e d n o w - a w a i t e d
C T a b d o m e n 0 1 / 0 1 \: c h o l e c y s t i t i s s e c o n d a r y t o g a l l s t o n e s
P r e v i o u s e n d o s c o p y ( 2 0 0 2 ) \: g a s t r i t i s
E s c a l a t i o n p l a n \:
D i s c u s s e d o n w a r d r o u n d t h i s m o r n i n g - w o u l d b e f o r H D U c a r e a n d p o t e n t i a l l y i n o t r o p i c s u p p o r t i f r e q u i r e d
D N A C P R s t a t u s \: N o D N A C P R s t a t u s r e c o r d e d
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1. 2. 3. 4. 1. 2. 3. 4. 5. I s s u e s \:
D a y 3 p o s t l a p a r o s c o p i c c h o l e c y s t i t i s - h y p o t e n s i v e , E l e v a t e d W C C
t a c h y c a r d i c , p y r e x i a l a n d v o m i t i n g ( gu a r d i n g a r o u n d s u r gi c a l s i t e ) .
L a c t i c a c i d o s i s
O l i g u r i c
I m p r e s s i o n \: L i k e l y a n a s t o m o t i c l e a k p o s t l a p a r o s c o p i c c h o l e c y s t e c t o m y
P l a n \:
E n s u r e " S e p s i s 6" h a s b e e n c o m p l e t e d i n l i g h t o f s e p t i c p i c t u r e
A s s e s s r e s p o n s e t o 5 0 0 m l s I V H a r t m a n s
I n f o r m s u r g i c a l r e g i s t r a r - w i l l n e e d s e n i o r r e v i e w ? r e t u r n t o t h e a t r e
I n f o r m a n a e s t h e t i c s a n d t h e a t r e c o-o r d i n a t o r i f s u r gi c a l r e gi s t r a r b e l i e v e s l i k e l y t o r e t u r n t o t h e a t r e - m a y n e e d H D U / I T U
b e d p o s t-o p e r a t i v e l y f o r p o s s i b l e i n o t r o p i c s u p p o r t
G e t c o n s e n t f o r m r e a d y f o r r e g i s t r a r a r r i v a l
R a k e s h M i s t r y
F Y 2 G e n e r a l S u r g e r y
G M C \: 1 2 3 4 5 6 7
B l e e p \: 1 3 1 1

Surgical risk factors

When assessing any patient, it is important to have an awareness of possible surgical complications that may a
patient's risk of surgical complications di
di

Method A

Risk factors can be broken down into the following categories\:
Pre-operative
Peri-operative
Post-operative
For example\:
" Y o u a r e c a l l e d t o s e e a n o b e s e d i a b e t i c 5 0- y e a r-o l d p a t i e n t f o l l o w i n g t h e i r o p e n m e s h i n gu i n a l h e r n i a r e p a i r . T h e
p a t i e n t i s 3 d a y s p o s t-o p a n d i s c o m p l a i n i n g o f p a i n a r o u n d h i s s u r g i c a l s i t e i n h i s gr o i n . T h e n u r s e r e p o r t s s o m e s w e l l i n g a t t h e
s i t e a n d a f o u l o d o u r .
"
Pre-operative\: 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 (i.e. patient risk factors)
Operation factors (e.g. surgical technique, post-operative care/instructions)
For example, risk factors for a post-operative infection may be categorised as shown below.
Patient factors Operation factors
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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 classi

Time

Complications can be classi
Immediate\: \<24 hours
Early\: within 30-days (usually within 1 week)
Late/long term\: after 30 days or after discharge

Underlying cause

Complications can be classi
General Speci
Reaction to anaesthesia Adjacent structure damage
Haemorrhage Gastrointestinal\: a n a s t o m o t i c l e a k , v i s c e r a l i n j u r y , s t r i c t u r e s
Pyrexia Vascular\: i s c h a e m i c c o l i t i s , e n d o l e a k s , g r a f t m i g r a t i o n
Wound infection/surgical site infection Plastic surgery\: s c a r r i n g ,
Thromboembolism
Both time and aetiology may also be combined to categorise complications as shown in the table below.
General Speci
Haemorrhage
Broken tooth
Immediate
Anaesthetic reaction
Asphyxia
Pyrexia – chest/urine/line
Bedsore
Early
VTE - PE/DVT
Wound complication
Weight loss
Late
Osteoporosis
Anaemia
Haemorrhage
Adjacent structure damage
Anastomotic leak
Deep collection
Paralytic ileus
Prosthetic infection
Inability to eat
Dumping syndrome
Recurrence
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Post-operative pyrexia

Post-operative pyrexia is a common issue and the di
The trend of the pyrexia is also very important (i.e. new, persistent, swinging).
The 7 C’s of post-operative pyrexia is a helpful way to remember potential sources of post-operative pyrexia\:
Chest
Catheter
CVP Line
Cannula
Cut (surgical wound)
Collections
Calves

Timeline of pyrexia

Days Possible cause
Atelectasis
1 - 3
Metabolic response to trauma
Drug reaction – IV
SIRS
Line infection
Instrumentation of viscus – transient bacteraemia
Chest infection
4 - 6
Super
UTI
Line infection
Compartment syndrome
Chest infection
= />7
Suppurative wound infection
Anastomotic leak
Deep abscess (swinging pyrexia)
DVT

Reviewer

Mr Mustafa Ja
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].
https\://app.geekymedics.com/osce-guides/clinical-procedures/post-operative-assessment/ 8/911/13/24, 7\:26 PM Guide | Post-operative assessment
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
Source\: geekymedics.com
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