Post-mortem There are two types of post-mortem (PM): Those man- dated by the coroner or pro curator fi scal, and those undertaken after a medical request (a hospital PM ). The coroner s PM (or procurator fi scal in Scotland) is undertaken to fi nd out how someone died and to inform the decision on whether an inquest is needed or not. The next of kin is informed, but not asked for permission, as the law requires a PM to be performed. A hospital PM is usually undertaken at a doctor s request to provide more information about an illness or the cause of death. Consent must be given by the patient before they died, o r by the next of kin after their death. The hospital bereavement offi ce can assist with th is should you be asked to gain consent. Table 2.8 Causes and modes of death Modes of death (avoid these terms) Causes of death (use these terms) Cardiac arrest, syncope Myocardial infarction, cardiac arrhythmia Sepsis, hypovolaemia, hemorrhage, anaphylaxis Con gestive cardiac failure, pulmonary oedema Bronchopneumonia, pulmonary embolism, asthma, chr onic obstructive pulmonary disease Cerebrovascular accident Cirrhosis, glomerulonephritis, diabetic nephropathy Carcinomatosis, carcinoma of the \200 Hypotension, shock, off -legs Heart failure, cardiac failure, ventricular failure Respiratory failure, respiratory arrest Collapse Liver failure, renal failure, uraemia Cachexia, exhaustion _OHFP.indb 97 _OHFP.indb 97 30/05/2014 16:17 30/05/2014 16:17 98 CHAPTER 2 Life on the wards Cremation forms1 Statute While individual crematoria or regions may have slightly diff eren t looking cremation forms, they all follow a similar pattern and ask very similar questions . Guidance on how to complete cremation forms is freely available online,2 though the berea vement offi ce will also be able to guide you and answer your questions. Cremation form nom enclature The main form to be completed for adult cremation is Cremation 4 (Form B in Nor thern Ireland) \200\223 see box. The senior doctor (who must be fully registered for more than 5 years) who checks and verifi es the details in Cremation 4 subsequently completes C remation 5 (Form C in Northern Ireland). Other cremation forms are available for stillbirt hs, and for the cremation of body parts.1 Eligibility For deaths in hospital, it is expecte d that the person com- pleting Cremation 4 treated the deceased during their last illness a nd to have seen the deceased within 14 days of death. Medical practitioners completing Crem ation 4 must hold a license to practice with the GMC, which includes temporary or provision al registration. Examining the body If you are completing a cremation form you were previou sly required to see the body to check the patient \200\231s identity (wrist band and physic al appearance) and examine them to see if they have any implant which may cause a problem d uring cremation (see Table 2.9). Under the proposed 2014 reforms, this responsibility will transfer to the Medical Examiners. If you are required to view the body, check the notes, E CGs and X-rays for possible implants, but also examine the patient for scars or palpable im plants (pacemakers are usually, but not always, on the anterior chest wall). If you believe there is an implant talk to the mortuary staff who will be able to remove it. Remuneration Under arrangements prior to 2014, junior doctors were paid around 70 for completing the form (see b p38); this fee is under review as part of the 2014 reforms. Any fee comes from the patient \200\231s relatives via the funeral director who keeps the money if you fail to take it. The reason you are paid is because this is not a standard NHS service and you are taking responsibility for the fact the body will not be able to be exhumed for evidence if there is any doubt in the future as to the cause of death. Table 2.9 Problematic implants for the cremation of human remains Pacemakers; implantable cardioverter defi brillators; cardiac resynchronisation therapy dev ices; implantable loop recorder Ventricular assist devices Implantable drug pumps including intrathecal pumps Neurostimulators and bone growth stimulators Hydrocephalus programmable shunts Any other battery powered implant Fixion nails (intramedullary nails for fi xing lon g bone fractures) Brachytherapy implants 1 In Scotland, the information previously contained on the cremation form will be included on the revised MCCD from 2014 onwards. Arrangements in the rest of the UK are under review. 2 eg For England and Wales: (cid:27)www.justice.gov.uk/downloads/burials-and-coroners/crema - tions/cremation-doctors-guidance.pdf OHFP.indb 98 OHFP.indb 98 30/05/2014 16:17 30/05/2014 16:17 99 DEATH Completing Cremation 4 Most of the questions are self-explanatory: \200 Details of the de ceased: Name, address, occupation \200 Date and time of death, place of death \200 Are you a relative of the deceased? \200 Have you, so far as you are aware, any pecuniary int erest in the death of the deceased? Were you the deceased s usual medical practitioner? Generally it is the patient s GP who is regarded as the usual medical practitioner. \200 Please state for how long you attended the deceased during their last illness? eg 5 days Please state the number of days and hours before the deceased s death that you last saw them alive? eg 1 day, 12 hours Please state the date and time that you saw the body of the deceased and the examination that you made of the body? eg date, time, external examination to confi rm identify and check for implantable devices From your medical notes, and the observations of yourself and others immediately before and at the time of the deceased s death, please describe the symp toms and other conditions which led to your conclusions about the cause of death. Outline t he symptoms in the period leading up to the patient s death; include the date of admission to hospital Has a post-mortem examination been made? Usually the answer to this is no, but if it has, tick yes and give details Please give the cause of death. Copy what appears on the MCCD \200 Did the deceased under go any operation in the year before their death? If yes, give brief details Do you have any reasons to believe that the operation(s) shortened the life of the deceased ? If yes, the case should be discussed with your seniors/Medical Examiner/coroner s offi ce /procurator fi scal Please give the name and address of any person who nursed the deceased during their last il lness. Usually enter the name of the sister responsible for the ward where the patient died , eg Sister Jayne Smith, Ward 26 \200 Were there any persons present at the moment of dea th? If yes, give details, as above If there were persons present at the moment of death, did those persons have any concerns regarding the cause of death? If yes, give details \200 In view of your knowledge of the deceased s habits and constitution do you have any doubts whether about the character of the disease or condition which led to the death? Yes or no Have you any reason to suspect the death of the deceased was: violent (yes or no) or unnatural (yes or no)? Have you any reason at all to suppose a further examination of the body is desirable? If yes, give details Has the coroner been informed about the death? If yes, give details \200 Has there been a ny discussion with a coroner s offi ce about the death of the deceased? If yes, give details Have you given the certifi cate required for the registration of death? If no, give the details of who has completed the MCCD \200 Was any hazardous implant placed in the body? See Table 2.9. \200 If yes, has it been removed? Yes or no \200 Sign, date and enter your contact details. _OHFP.indb 99 _OHFP.indb 99 30/05/2014 16:17 30/05/2014 16:17 100 CHAPTER 2 Life on the wards Death certi \201 cation, registrars, examiners and the coroner1 Steps involved in register ing a death If a medical practitioner completes the MCCD, this is given to the next of kin, usually by the bereavement offi ce; if the doctor cannot complete a MCCD, the coroner send s the relevant paperwork directly to the registrar after establishing a cause of death to t he best of his/her satisfaction, through a post-mortem and/or investigation and/or inquest. Only once the registrar has the relevant paperwork can the death be entered into the regis ter and a death certifi cate issued to the next of kin, permitting a burial or cremation to take place. Death Certi \201 cation Reforms In response to the Shipman Inquiry and more r ecently the Francis Inquiry, a new system is being introduced. All MCCDs will be scrutinize d by a Medical Examiner, who will be able to make certain changes to the MCCD after examini ng the case notes or talking to staff involved in the patients care and to the individual w ho initially completed the MCCD, if the cause of death is inaccurate. Junior doctors may sp eak to their local Medical Examiner before completing the MCCD for guidance. Any case which would normally have been referred to the coroner will still be referred to the coroner, bu t if not accepted by the coroner will then be subsequently scrutinized by the Medical Exami ner. The purpose of the Medical Examiner system is to: ensure more accu- rate reporting of disease processes; to better identify unusual patterns of death which may have public healt h or local clinical governance impli- cations; to ensure the individual completing the MCCD understands the cause of death, and to provide an opportunity to raise other matters which might require the death to be reported to the coroner. Medical Examiner These are medical practitioners from any specialty background who are licensed to practice by the GMC and wit h at least 5 years experience. As well as scrutinizing MCCD and guiding doctors to complet e these, they will also discuss the cause of death with the family and act on any additiona l information the family provides. They will work closely with the coroner s service and re gistrations services, and feed information back to clinical governance structures to aid in future health- care planning and provision. The Coroner The coroner is a government offi c ial and is usually a lawyer but may have joint degrees in law and medicine; their job is to investigate a death when the cause of death is unknown or cannot readily be certi- fi ed a s being due to natural causes (see box b p101). The Coroner s Offi ce This is staff ed by C oroner s Offi cers. They are not usually medically or legally qualifi ed and are often serv ing, or ex-police offi cers. They take the majority of enquiries, and will fi lter which ca ses are escalated to the coroner. 1 The term coroner as used here applies to the coronial service in use in England and Wal es and Northern Ireland, as well as the role of the Procurator Fiscal in Scotland. Although these are all covered by diff erent legislation, the same basic roles and rules apply. Lik ewise the new role of Medical Examiner in England and Wales is equivalent to Medical Rev iewer in Scotland. OHFP.indb 100 OHFP.indb 100 30/05/2014 16:17 30/05/2014 16:17 101 DEATH Making a referral to the coroner Any case which meets the criteria in the box should be ref erred to the coroner s offi ce for their consideration; after discussing the case, the coro ner s offi cer may suggest it is appro- priate for the referring doctor to complete the MCC D. Occasionally the coroner s offi cer will either take over the case, or wish to discuss i t directly with the coroner fi rst, and in these situations the MCCD should not be complete d by the referring doctor unless instructed to do so. To refer, or not to refer? If you are in any doubt about whether to refer to the coroner or not, speak fi rst to your seniors, or the local Medical Examiner for advice. A death should be referred to HM Coroner if either:1 \200 the cause of death is unknown; \200 it cannot be readily certifi ed as being due to natural causes; \200 the deceased was not attended by the doctor during his last illness or was not seen within the last 14 days or viewed after death; \200 there are any suspici ous circumstances or history of violence; \200 the death may be linked to an accident (wh enever it occurred); \200 there is any question of self-neglect or neglect by others; \200 the death has occurred or the illness arisen during or shortly after detention in police or prison custody (including voluntary attendance at a police sta tion); the deceased was detained under the Mental Health Act; \200 the death is linked with an a bortion; \200 the death might have been contributed to by the actions of the deceased (such as a history of drug or solvent abuse, self injury or overdose); the death could be due to industrial disease or related in any way to the deceased s employment; the death occurred during an operation or before full recovery from the eff ects of an anesthetic or was in any way related to the anesthetic (in any even t a death within 24 hours should normally be referred); the death may be related to a medical procedure or treatment whether invasive or not; the death may be due to lack of medical care; \200 there are any other unusual or disturb ing features to the case; \200 the death occurred within 24 hours of admission to hospita l (unless the admission was purely for terminal care); it may be wise to report any death where there is an allegation of medical mismanagement. This note is for guidance only, it is not exhaustive and in part may repre- sent desired lo cal practice rather than the statutory requirements. If in any doubt contact the coroner s offi ce for further advice. 1 Taken from: Dorries, C. Coroners Courts: a guide to law and practice, 2nd edition, Oxfor d University Press, 2004. _OHFP.indb 101 _OHFP.indb 101 30/05/2014 16:17 30/05/2014 16:17 102 CHAPTER 2 Life on the wards Nutrition A patient \200\231s nutritional state has a huge eff ect on their well-being, moo d, compliance with treatment, and ability to heal. You should consider alternative nutritio n for all patients without a normal oral diet for over 48h. IV fl uids are only for hydrati on, they are not nutrition. See Table 2.10 for nutritional requirements. Enteral feeding (via the gut) Oral Most patients manage to consume suffi cient quantities of hospital food to stay health y. If not (eg due to inability to feed self, increased demand due to malnutrition) consider simple remedies, eg assisted feeding, favorite foods from home, medications for refl ux/he artburn (b p294) or nausea (b p185). If they are still not consuming adequate nutrition the n discuss with the dietician who can advise on nutritional supplements and high-energy drin ks. Nasogastric (NG) See b p549 for insertion procedure. This is a good short- term measure , however placing the tube may be uncomfortable and some people fi nd the sensation of the tube uncomfortable once it is in. Liquid foods and most oral medicines (except slow release and enteric coated preparations) can be given via NG tube; advice regarding medications vi a this route may be required from a pharmacist. Tubes can also be endoscopi- cally placed n aso-jejunally if required, eg gastric outlet obstruction. Gastrostomy Often called \200\230PEGs \200\231 (percutaneous endoscopic gastrostomy) these are a good long-term method of feeding in patients who cannot feed orally. They are typica lly sited endoscopically, though surgical and radio- logical approaches are possible (a rad iologically inserted gastrostomy is referred to as a RIG). It is also possible to place a j ejunostomy if required. Parenteral feeding (via the blood) Parenteral nutrition (PN) or total parenteral nutrition (TPN) requires central access because extravasation of the feed causes severe skin irri- ta tion. Central access can be via a long-line (eg PiCC) or central line (eg Hickman). It is u sed when the patient cannot tolerate suffi cient enteral feeds, eg short gut syndrome or wh en gut rest is required. There is signifi cant risk associated with PN use including line insertion, line infection, embolism/thrombosis, and electrolyte abnormalities. It is 3 \200\223, essential to monitor blood electrolytes regularly including Ca2+, PO4 Mg2+, zinc, and trace elements, particula rly in those starting PN after a period of malnutrition (see below). Refeeding syndrome After a prolonged period of malnutrition or parenteral nutrition, feeds must be reintroduced slowly (over a few days) to prevent electrolyte imbalance, particularl y dPO4 3 \200\223. It can be fatal but is entirely avoidable if blood tests are checked dai ly during the at risk period (for 3 \200\2235d, until full feeding rate estab- lished) and any electrolyte abnormalities are corrected promptly. OHFP.indb 102 OHFP.indb 102 30/05/2014 16:17 30/05/2014 16:17 103 NUTRITIONAL REQUIREMENTS Nutritional requirements Table 2.10 Nutritional requirements Name Sources Daily requirement De \201 ciency Carbohydrate Almost all foods Protein 300g 50g Malnutrition Kwashiorkor Meat, dairy, vegetables, grain Nuts, meat, dairy, oily foods Dairy, leafy vegetables Fish, seafood, enriched salt Meat, vegetables, grains 15mg 420mg Dairy, leafy vegetables, meat Fr uits, vegetables Meat, fi sh, vegetables Processed foods, salt Cereals, meat Fat 56g Malnutrition Calcium Iodine 1g 150micrograms Osteoporosis Hypothyroid Iron Magnesium Anemia Cramps Potassium Selenium Sodium Zinc 3.5g 55micrograms 2.4g 11mg Hypokalaemia Keshan disease Hyponatraemia Hair/skin problems Night blindness Beri Beri Vitamin A (retinoid) Vitamin B1 (thiamine) Vitamin B2 (ribofl avin) Vitamin B3 (niacin) Vit amin B5 (pantothenic acid) Vitamin B6 (pyridoxine) Vitamin B7 (biotin) Vitamin B9 (folate) Vitamin B12 (cobalamin) Vitamin C (ascorbic acid) Vitamin D Dairy, yellow or green leafy vegetables, liver, fi sh 900micrograms Bread, cereals 1.2mg Meat, dairy, bread 1.3mg Aribofl avinosis Meat, fi sh, bread 16mg Pellagra Meat, egg, grains, potato, vegetables 5mg Neurological problems, paraesthesia Anemia Meat, fortifi ed cereals 1.7mg Liver, fruit, meat 30micrograms Dermatitis Bread, leafy vegetables, cereals 400micrograms Anemia Meat, fi sh, fortifi ed cereals 2.4micrograms Anemia Citrus fruits, tomato, green vegetables 200mg Scurvy Fish, liver, fortifi ed cereals Vegetables, nuts, fruits, cereals Green vegetables, cereals 120micrograms 5 \200\22315micrograms Rickets/ osteomalacia None Vitamin E 15mg iPT Vitamin K _OHFP.indb 103 _OHFP.indb 103 30/05/2014 16:17 30/05/2014 16:17 104 CHAPTER 2 Life on the wards Diffi cult patients Alcoholism1 Many patients will drink over the recommend limits (3-4 uni ts/d for 4 and 2 \200\2233 units/d for 5), but not all of these will be \200\230alcoholics \200\231. Defi ning alcoholism is hard, but if drinking, or the eff ects of drinking, repe atedly harms work or social life it is clearly a problem. Answering \200\230yes \200\231 t o three out of four of the CAGE questions suggests alcoholism: Ever felt you should Cut dow n on your drinking? Have people Annoyed you by criticizing your drinking? Ever felt Guilty about your drinking? Ever had an Eye-opener in the morning? The medical aspects of alcohol excess and withdrawal are covered on b p348. Excessive drinking can be a psychiatric issue in its own right but can also complicate many psychiatric diseases. Modifying drinking beha v- iour is diffi cult and only of benefi t in patients who want to change. \200 Abuse Exc essive drinking despite mental or physical harm \200 Dependence Alcohol tolerance, withdr awal symptoms if not drinking. Alcoholism management Have a low threshold for commencing ben- zodiazepine therapy to avoid alcohol withdrawal (see suggested regimen in Table 2.11 or your trust \200\231s own protoc ol). In addition, start vitamin B1 sup- plementation with either IV preparations (Pabrinex 2 pairs/8h IV for 2d) or oral thiamine 200mg/24h PO and multi-vitamins (1 \200\2232 table ts/24h PO). Table 2.11 Chlordiazepoxide regimen for alcohol withdrawal Day 1 Day 2 Day 3 Day 4 20mg/6h PO 20mg/8h PO 10mg/6h PO 10mg/8h PO Day 5 Day 6 Day 7 Day 8 5mg/6h PO 5mg/8h PO 5mg/12h PO STOP If not treated, thiamine defi ciency can lead to Wernicke \200\231s encephalop- athy (see b p363). This is characterized by a triad of nystagmus, oph- thalmoplegia, and ataxia, but c an also present with confusion, altered consciousness, vomiting, and headache. Untreated it can progress to Korsakoff \200\231s syndrome characterized by an irreversible inability t o acquire new memories associated with a tendency to confabulate to fi ll in the gaps. Both are treated with Pabrinex or oral thiamine, but the memory loss in Korsakoff \200\231s is usually permanent. Other management Alcohol diaries, reduced intake or abstinence plans, indi- vidual and group counseling, eg Alcoholics Anonymous, pharmacological assistance, eg disulfi ram, address underlying social and psychiatric problems. Elderly patients often take many medications, making interactions and side eff ects more co mmon. Declining renal function means lower doses may be needed for renally excreted drugs. Likewise, elderly patients are more prone to heart failure from fl uid boluses/excessive IV fl uids. Other prob- lems include: increased susceptibility to infections; higher pain thr eshold (can mask fractures or other acute pathology); atypical disease presentations; poor thermoregulation (easily develop hypothermia); malnourishment (if unable to obtain/prepare food); history taking can be diffi cult if hard of hearing. Elderly patients can suff er wi th depression and other psychiatric illness (b p367) and social circumstances must always b e considered prior to discharge \200\223 liaise with OT, physiotherapy, and social service s. 1 NICE guidelines available at (cid:27)guidance.nice.org.uk/CG115 OHFP.indb 104 OHFP.indb 104 30/05/2014 16:17 30/05/2014 16:17 105 AGGRESSION AND VIOLENCE Aggression and violence The majority of patients have respect for NHS staff ; however under certain circumstances anyone can become aggressive: \200 Pain (b p86) \200 Reversible confusion or delirium, eg hypoglycaemia (b p341) \200 Dementia (b p342) \200 Inadequate communication/fear/frustration (b p19) \200 Intoxication (medications, alcohol, recreati onal drugs) \200 Mental illness or personality disorder (b p364 \200\223369). The aggress ive patient Ask a nurse to accompany you when assessing aggressive patients. Position yours elves between the exit and the patient and ensure that other staff know where you are. The majority of patients can be calmed simply by talking; try to elicit why they are angry and ask specifi cally about pain and worry. Be calm but fi rm and do not shout or make threats. If this does not help, off er an oral sedative or give emergency IV sedation (see b p364) or call hospital security. The aggressive relative Relatives may be aggressive through fear , frustration, and/or intoxication. They usually respond to talking, though make sure you o btain consent from the patient before discussing their medical details. Consider off ering to arrange a meeting with a senior doctor. If the relative continues to be aggressive, reme mber that your duty of care to patients does not extend to their relatives; you do not have to tell them anything or listen to threats/abuse. In extreme cases you can ask security or police to remove the relative from the hospital. Violence Assault (the attempt or threat o f causing harm) and battery (physical contact without consent) by a patient or relative is a criminal off ence. If you witness an assault or are assaulted yourself, inform your senio rs and fi ll in an incident form including the name and contact details of any witnesses. I f no action is taken on your behalf inform the police yourself. Abuse Abuse is a violation of an individual \200\231s human and civil rights and may consist of a single act or repeat ed actions. It may be physical, sexual, fi nancial, psychological or through neglect. Patie nts of any age can be abused. Do not be afraid of asking patients how they sustained injuri es or asking directly if someone caused them. Inform a senior if you ) suspect a patient ha s been abused (see box). p p ( Safeguarding and protection As a doctor you will often meet your patients at their most vul nerable moments. In most instances, the forces of nature will have conspired to weaken the individual to bring them to this point. But in sad and rare cases, vulnerable individuals a re not aff orded the protection they need, and a presentation to acute healthcare services may be a manifestation of abuse. Two groups are particularly at risk: vulnerable adults (th ose in need of community services because of mental or other illness, disability or age) an d children. Whilst government policy on protecting these groups continues to evolve, and ne w statutory regulations are likely to be intro- duced, your local healthcare organization s hould have clear policies on child protection and adult safeguarding. In all instances, you r fi rst and most important action if you believe a patient may be subject to any form of a buse is to bring your concerns to the attention of your consultant. _OHFP.indb 105 _OHFP.indb 105 30/05/2014 16:17 30/05/2014 16:17 106 CHAPTER 2 Life on the wards Needle-stick injuries Many doctors have received needle-stick injuries without serious cons e- quences (see Table 2.12). However, if you have just been exposed get advice as soon as p ossible. Immediately Stop what you are doing. If it is urgent, phone your senior/colleague to do it. Your future health is your top priority. \200 Percutaneous exposure (needle or sharp) sq ueeze around the wound so that blood comes out and wash with soap and water; avoid scrubbing or pressing the wound directly Mucocutaneous exposure (eyes, nose, mouth) rinse with water (or 1l of 0.9% saline through a giving set for eyes/nose). Within an hour A colleague should: \200 Talk to the patient alone, explain what has happe ned and ask about risk factors: \200 injecting drugs, blood transfusions, tattoos or piercings in foreign countries, unprotected sex (particularly in last 3mth, in a developing country or, if male, with a man), prior testing for hepatitis B+C or HIV and the results Ask to take a blood sample for testing for hepatitis B+C and HIV. You should: \200 Phone occupational health if during offi ce hours or go to the ED and follow their advice exactly Document the event in the patient \200\231s notes and complete an incident form. Post-expos ure prophylaxis You may be prescribed antiretrovirals (triple therapy, within 1h), hepa- ti tis B immunoglobulin (within 24h), or hepatitis B booster (within 24h) according to the sig nifi cance of the exposure. There is currently no post- exposure prophylaxis for hepatitis C. Table 2.12 Viruses associated with needle-stick injuries Hepatitis B Hepatitis C HIV UK prevalence <0.5% <0.5% <0.1% Transmission risk 1 in 3 (without vaccine) Vaccination Post-exposure 1 in 50 Vaccines at 1, 2, + 12mth None Immunoglobulin or booster None 1 in 300 None Triple therapy Over the next few weeks The patient \200\231s blood tests should take <2d for HIV and hepat itis B+C results. Following high-risk exposure you may be advised to have a blood test in t he future (2 \200\2236mth); during this time you should practice safe sex (condoms) and not donate blood. You cannot be forced to have an HIV test. Discuss with occupational health a bout involvement in surgery. OHFP.indb 106 OHFP.indb 106 30/05/2014 16:17 30/05/2014 16:17 107 PRE-OP ASSESSMENT Pre-op assessment Elective patients generally attend pre-admission clinics a few weeks befo re their operation. This enables you to: \200 Assess the patient \200\231s problem (ie do they still need the operation?) \200 Gauge their medical fi tness for an anesthetic and surgery \200 Request any pre-op investigations (see NICE guidelines, Table 2.13) \200 C heck consent (this should only be obtained by the surgeon performing the procedure or a per son competent to undertake it, see b p129) Answer any questions the patient may have. Pre-op investigations Table 2.13 Pre-operative investigations1 Investigation Indication To exclude infection or anemia FBC Sickle-cell screen African/Mediterranean patients, +ve family history U+E Age >60yr, cardiac/renal disease, patients on steroids, diuretics, ACEi Previous/suspected abnormal liver function, biliary surgery Established/suspected abnormal liver function or c lotting disorder Women of child-bearing age Age >60yr, cardiorespiratory disease, malignanc y, major thoracic and upper abdominal surgery, unexplained SOB Age >50yr, cardiovascular di sease, DM, smokers LFT Clotting Urine B-hCG CXR ECG 1 NICE guidelines: (cid:27)guidance.nice.org.uk/CG3 Requesting blood pre-op Each hospital will have guidelines on the transfusion requirements for most elective operations; become familiar with these. Blood for transfu- sion is in lim ited supply and should only be cross-matched when neces- sary. Table 2.14 shows common bloo d requirements for elective surgery. Table 2.14 Summary of operations and blood requirements Blood request Operation No request Minor day-case surgery (carpal tunnel release, peripheral lipoma excision, etc) Laparoscopy , appendicectomy, cholecystectomy, hernia repair, simple hysterectomy, liver biopsy, mastec tomy, varicose veins, thyroidectomy Colectomy, hemiarthroplasty, laparotomy, TURP, total hi p replacement Abdominoperineal resection, hepatic/pancreatic surgery Aneurysm repair (book ICU bed post-op) Group and save X-match 2units X-match 4units X-match 6units _OHFP.indb 107 _OHFP.indb 107 30/05/2014 16:17 30/05/2014 16:17 108 CHAPTER 2 Life on the wards Patients with medical problems \200 DM See b p328, put the patient fi rst on the operatin g list \200 CVS Inform the anesthetist if patients have had recent chest pain, an undiagn osed murmur, or symptoms of heart failure. The anesthetist may want you to request an echo or may see the patient personally \200 Rheumatoid arthritis/ankylosing spondylitis Inform the anesthetist as these patients may be diffi cult to intubate or have an unstable C-spin e \200\223 the anesthetist may want to see the patient or request radiological imaging. Contacting the anesthetist/ICU Find out who the anesthetist is for your list and inform the m as soon as possible about any patients who may need further investigations or review prio r to surgery. If a patient needs an ICU bed post-op, inform ICU well in advance with the da te the bed is required (contact details should be available from the anesthetic department offi ce). Phone to confi rm that the bed is still available on the day of the operation; if it is not the operation may be canceled. Special circumstances \200 Steroids (b p177) Pa tients taking regular steroids must have extra steroid cover during surgery and be converte d to IV preparations if NBM. Discuss each patient \200\231s needs with your team and the an esthetist Warfarin should be stopped at least 5d pre-operatively. The INR should be <1.5 for most operations and lower if spinal or epidural anesthetic techniques ar e to be used; warn the anesthetist. Patients with prosthetic heart valves may need IV or SC heparin whilst warfarin is omitted (b p406) Clopidogrel must be stopped 7 \200\22310d prior to surgery, aspirin is usually continued un less otherwise instructed by senior surgeon (if in doubt check with the operating surgeon/n amed consultant) Oestrogens and progestogens HRT can be continued as long as DVT/ PE prophylaxis is undertak en. Progestogen-only contraceptives can be continued, but combined oral contraceptives shou ld be stopped 4wk prior to surgery and alternative means of contraception used Bowel preparation see table 2.15 b p109. Writing the drug chart Try and do this at pre-admi ssion clinic to save yourself time later. Document any allergies. Things to check include: \200 Prophylactic anticoagulation (b p406) \200 Antibiotics Consider pre-op antibiotics (check local guidelines) \200 Bowel preparation and IV \202 uid (b p109) \200 Regula r drugs Review these and write up those which should be continued in hospital (stop COCP, c lopidogrel as above, etc) \200 TED stockings Prescribe these under regular medications fo r all patients Analgesia and anti-emetics (b p86 and b p304) The anesthetist will usually write these up during the operation. Instructions for the patient \200 Where and when to go for admission (write this down for them) \200 If they are to have bowel prep, they should usually be on clear fl uids at least 24h before the operation (see b p111) Tell the patient about any drains, NG tubes or catheters which may be inserted during the operation Tell them if they are being admitted to ICU post-op. OHFP.indb 108 OHFP.indb 108 30/05/2014 16:17 30/05/2014 16:17 109 BOWEL PREPARATION Bowel preparation Before endoscopy and some GI surgery procedures patients are given laxati ves to clear the bowel (Table 2.15). For surgery the aim is to reduce the risk of post-op a nastomotic leak and infections. Accumulating evi- dence suggests that it does not improve c omplication rates and may even be harmful,1 hence use of bowel preparation prior to surgery is declining. Check your local policy for guidance. Where bowel prepara- tion is required, it is vital that patients are instructed properly and the importance of good compliance is stressed. For example, during colon- oscopy inadequate bowel preparation can lead to patho logy being missed or the procedure being aborted. Table 2.15 Procedures and the potential need for bowel preparation Bowel preparation Procedure None Phosphate enema (on day of surgery) OGD, ERCP, closure (reversal) ileostomy Anal fi ssure, haemorrhoidectomy, examination under anesthetic (sigmoid colon/rectum/perianal area), fl exible sigmoidoscopy Colonoscopy, rect opexy, right hemi-/left hemi-/ sigmoid/pancolectomy, anterior resection, abdominoperineal r esection, Hartmann \200\231s reversal Full bowel prep (see below) Full bowel preparation A variety of oral bowel cleansing products are available in the UK. In 2009 the National Patient Safety Agency issued an alert in response to safety incidents including a reported death following bowel prepara- tion. In particular, patients at risk o f renal impairment and electrolyte imbalance need careful identifi cation and prescribing. \200 Sodium picosulfate/Magnesium citrate combinations (eg Picolax ) give excellent bowe l preparation and are relatively acceptable to patients; they are relatively contraindicate d in those with stage 4 or 5 CKD or those at risk of electrolyte imbalance, cardiac or live r failure \200 Polyethylene glycols/macrogols (eg Klean-Prep , MoviPrep ) require large volumes of liquid to be drunk, but are safer in at-risk groups. Consider admitting elderly patients and those with comorbidities for IV fl uids and monitor ing during bowel preparation. Oral medica- tions should not be taken 1 h before or after ad ministration of bowel cleansing preparations; where reduced absorption could prove cata- st rophic (eg immunosuppressives post-transplant) consider admission for IV administration. Ad vise patients taking the OCP to take alternative precautions during the week following taki ng the bowel preparation. Off er patients written dietary advice on low-residue foods for t he 2d prior to their procedure (local documents should be available); those taking insulin will require specifi c advice and guidance for management. 1 Guenaga, K. et al. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD001544. _OHFP.indb 109 _OHFP.indb 109 30/05/2014 16:17 30/05/2014 16:17 110 CHAPTER 2 Life on the wards Surgical terminology Pre \201 x/suffi x Meaning and example Angio- Relating to a vessel Angioplasty \200\223 reconstruction of a blood vessel Relating to the biliary system Cholecystitis \200\223 infl ammation of the gallbladder Meaning half of so mething Hemicolectomy \200\223 excising half the colon Relating to the uterus Hysterectomy \200\223 removal of the uterus Relating to the abdomen Laparotomy \200\223 opening the a bdomen Relating to the kidney Nephrotoxic \200\223 damaging to the kidney Total/every Panc olectomy \200\223 complete removal of the colon Going through a structure Percutaneous \200\223 going through the skin Near or around a structure Perianal \200\223 near the anus /around the anus Relating to the rectum Proctoscopy \200\223 examination of the rectum Rel ating to the renal pelvis Pyelonephritis \200\223 infl ammation of the renal pelvis Relati ng to the thorax Thoracotomy \200\223 opening the thorax Going across a structure Transoes ophageal \200\223 across the esophagus Surgical excision Nephrectomy \200\223 removal of a kidney A radiological image often using contrast medium Angiogram \200\223 contrast stud y of arteries Infl ammation of an organ Pyelonephritis \200\223 infl ammation of the renal pelvis Stone-like Faecolith \200\223 solid, stone-like stool A device for looking inside the body Sigmoidoscope \200\223 device for looking into the distal colon An artifi cial op ening between two cavities or to the outside Colostomy \200\223 opening of the colon to th e skin Cutting something open Craniotomy \200\223 opening the cranium (skull) Reconstructi on of a structure Myringoplasty \200\223 repair of the tympanic membrane Chol- Hemi- Hystero- Lapar- Nephr- Pan- Per- Peri- Proct- Pyelo- Thoraco- Trans- ectomy gram itis olith oscope ostomy otomy plasty OHFP.indb 110 OHFP.indb 110 30/05/2014 16:17 30/05/2014 16:17 111 PREPARING IN-PATIENTS FOR SURGERY Preparing in-patients for surgery Checklist Before your patient goes to theater, you have a responsibility to check the follo wing have been done: \200 The consent form has been signed by the patient and surgeon \200 The patient has been seen by the anesthetist \200 The operation site has been marke d by the surgeon (imperative if the operation could be bilateral, eg inguinal hernia repair) The pre-operative blood results are in the notes \200 The pre-operative ECG and/or CXR ar e available \200 Prophylactic LMWH, TED stockings and antibiotics have been prescribed where relevant (do not give heparin <12h pre-op if having spinal/epidural) The patient has received bowel preparation if necessary \200 The patient has been adequat ely fasted (see next section) \200 Blood has been crossmatched and is available if requir ed (b p398) \200 Check if the patient has any last minute questions or concerns and is still happy to proceed with the operation. Oral \202 uids pre- and post-op In general, patients should not eat for at least 6h befor e going to theater but can have clear fl uids until 2h. In emergencies this rule may be ove r- ruled, but the risk of aspiration of gastric contents will be increased.