Initial Management of the Acute Surgical Admission

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 requirements for the junior members of the team to undertake.

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


System of Five

In the initial management of any acute surgical admission, a systematic approach is vital. The ‘System of Five’ approach (Table 1) is one such method that 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.

The first decision when you first see any patient is “Are they critically unwell?”.  A 10-second assessment of their clinical state can be made by a general look (the “end-of-bed-o-gram”), their observations, and whether they are fully alert and orientated.

If they are critically unwell, start initial steps to stabilise the patient, and then call for help early before going into detail on the history and examination.

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 Five

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 redone during any examination
  • Microbiology
    • Where clinically indicated, a patient should have samples sent for culture (e.g. wound swabs, urine culture, or blood cultures)
    • All acute admissions should be screened for MRSA. Elective patients who are MRSA positive and have not received decontamination treatment should not be taken to theatre (unless they need emergency surgery)
  • 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.
      • A Group and Save (G&S) should be taken for anyone who may need a significant operation (depending on local protocols)
    • Think about any specialist blood tests that may be required, depending on the presenting symptoms or likely underlying cause
  • Imaging
    • Basic imaging (such as an ECG or CXR) can be used to assess the baseline health of the patient pre-operatively or to further investigate potential diagnoses
  • Specialist tests
    • Depending on the underlying suspected pathology, discussion with your seniors may lead to further specialist tests being required (e.g. CT imaging or endoscopy)

Figure 1 – Specialist tests, such as upper GI endoscopy, may be warranted in some patients and your senior colleagues will usually inform you if these are required

Management

Using the ‘System of Five‘, 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 undergoing surgery for malignancy or in those who have had orthopaedic surgery involving the lower limbs
    • All surgical patients should have TED stockings prescribed (as long as 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 16G 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 and recording hourly urine output
  • Oxygen
    • Oxygen saturations should be 94-98% in most patients, or 88-92% in known CO2 retainers (e.g. patients with COPD)
  • 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, however the following principles may be useful:

  • Your own team need to know about any patient that is under the care of your consultant:
    • 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 post-operative 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 address this, in an attempt to reduce 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.

Key Points

  • When you first see a patient, ask yourself “are they critically unwell”?
  • Using the System of Fives can ensure you cover all the required initial investigation and management steps for every new surgical patient
  • Discuss with your senior in cases where the patient becomes acutely unwell, diagnosis is uncertain, or prior to referral to another team
  • Ensure suitable involvement of the multidisciplinary team as required

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