Initial Management of the Acute Surgical Admission

Original Author: Ollie Jones
Last Updated: September 3, 2016
Revisions: 9

Once a patient has been clinically assessed and a decision has been made to admit them to a surgical unit, there are a number of generic requirements for the junior members of the team.

In this article, we shall look at a system by which you can approach the management of any acute surgical admission.


System of 5

In the initial management of any acute surgical admission, a systematic approach is vital. The ‘System of 5’ approach (Table 1) will ensure that you do not miss out any vital investigations or management steps.

This system can be applied to any surgical patient, regardless of their diagnosis, and can be used as a checklist for whenever you are required to admit a patient or prepare them for theatre.

Investigations Management
  • Bedside observations
  • Microbiology
  • Blood tests
  • Imaging
  • Specialist tests

 

  • Oxygen?
  • IV access, Inputs & Outputs: IV fluids? Urinary catheter? NBM or NG tube?
  • Drug Chart: Analgesia, Anti-emetic, Antibiotics, Regular Medication
  • VTE prophylaxis
  • Escalation & involvement of the MDT

Table 1: The System of 5

Investigations

There are five groups of investigations that should be considered:

  • Bedside observations
    • These should have been recorded by the nursing staff on admission, but should be checked and restated at the start of any examination.
  • Microbiology
    • Where clinically indicated, a patient should have samples sent for culture (e.g. wound swabs, urine MSU/CSU, or blood cultures).
    • All acute admissions should be screened for MRSA. Elective patients who are MRSA positive (and have not received treatment to decontaminate them) should not be taken to theatre.
  • Blood tests
    • Obtain a set of baseline blood tests, normally including Full Blood Count (FBC), Urea & Electrolytes (U&Es), Liver Function Tests (LFTs), Amylase, and a Clotting profile.
    • Think about any specialist blood tests that may be required – depending on the presenting symptoms or likely underlying cause.
    • A Group and Save (G&S) or a Crossmatch may be warranted.
  • Imaging
    • Basic imaging (such as an ECG or CXR/AXR) can be used to assess the baseline health of the patient, or to determine a diagnosis.
  • Specialist tests
    • Specialist tests vary by surgical specialty, but patients may require an ECHO or lung function test to determine their suitability for surgery.
    • Your seniors will normally inform you of the instances in which the patient requires further specialist tests (e.g. CT/MRI/endoscopy).
Fig 2 - Features of peptic ulcers on endoscopy (A) peptic ulcer located in the gastric antrum (B) haemorrhaging gastric ulcer

Fig 1 – Specialist tests, such as upper GI endoscopy, may be warranted in some patients. Your senior colleagues will usually inform you if they need requesting.

Management

Using the ‘System of 5’, consider the five aspects to the management of the acute surgical admission:

  • VTE prophylaxis
    • Low molecular weight heparin (LMWH) should be prescribed as per local trust guidelines for pre- and post-op prophylaxis of VTE.
    • An extended course of prophylaxis is usually required in patients with ongoing cancer, or those who have had orthopaedic surgery involving the lower limbs.
    • All surgical patients should have TED stockings prescribed (as long as ABPI > 0.9 and no history of arterial disease).
  • Start a Drug Chart
    • In all patients (following local guidelines as necessary) consider:
      • Analgesia
      • Anti-emetics
      • Antimicrobials
      • Any normal regular medications
  • IV access and consider Inputs and Outputs
    • When taking blood tests, place an IV cannula at the same time (all surgical patients should have a cannula sited, preferably 18G or larger).
    • Start a fluid balance chart and ensure that all inputs and outputs are charted:
Inputs Outputs
  •  Does the patient need to be Nil by Mouth (NBM)? This decision should be clearly documented in the notes, communicated to the patient and to the nurse, and displayed above the patient’s bed.
  • Do fluids need to be prescribed for maintenance, to replace a fluid deficit, or for ongoing losses?
  •  If the patient is intensely vomiting, you should consider passing a nasogastric tube to decompress the stomach
  • If a patient is critically unwell or hypotensive, you should consider placing a urinary catheter [link to catheterisation page] and recording hourly urine output
  • Oxygen
    • Oxygen saturations should be 94-98% in most patients, or 88-92% in patients known to retain CO2 (e.g. COPD patients)
  • Senior Referral & Involvement of the MDT
    • Always remember that no matter the clinical problem, there is only so much that you can do by yourself! Always consider seeking appropriate and timely senior support.

Senior Referral

Traditionally, medical students and junior doctors have difficulty knowing when to refer patients to the senior members of the team. For UK doctors, the following principles may be useful:

  • Your own team need to know about any patient that is under the care of your consultant:
    • For help with routine ward work, your SHO is your first point of call.
    • Your registrar should be made aware of anyone who is unwell. For example, a patient who has become septic, needs to go to theatre, or developed a complication.
  • If another specialty is to be made aware of a patient, this decision is usually taken by your registrar/consultant
    • However, you may be the person physically making the referral.
  • In an emergency, you should be aware of your local escalation protocol. These will generally include:
    • An outreach team, for unwell patients for whom you need help urgently, but they are not critically unwell.
    • The Cardiac Arrest (‘crash’) team, for patients who have had a cardiac arrest or are quickly heading towards one.
    • In these cases, you will need to make your Registrar and Consultant aware.

The Multidisciplinary Team

Major surgery is a significant physiological insult to the body, particularly in the elderly population. There is a real risk of functional decline in the post-operative period, and anticipatory therapy may be required.

To address this, the involvement of a multidisciplinary team (MDT) is often needed. This can occur pre-operatively, in order to optimise the patient and to anticipate any decline – or post-operatively if the decline was not anticipated. MDT members commonly include:

  • Physiotherapy (PT)
  • Occupational therapy (OT)
  • Speech & language therapy (SALT)

There is also an important role for dieticians in helping to manage the perioperative patient. Where patients are malnourished pre-operatively, dieticians can reverse this – thereby reducing the patient’s risk of perioperative complications. Post-operatively, if a patient is NBM for any significant period of time (usually ~5 days or so), dieticians can organise suitable dietary supplementation.

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