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MRCOG PART 2 SBAs and EMQs

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Essay 266 - Peri-operative care

Posted by Asma kamal K.
The risk of venous thrombo-embolism(VTE) in a woman undergoing hysterectomy for gynecological malignancy is 45%.This patient is a high risk case for developing VTE because of her age, BMI,indication of surgery and nature of surgery(major surgery).To minimize the risk of VTE very unit should have clear protocol for VTE prophylaxis. She needs full VTE prophylaxsis. Anticoagulation with Low Molecular weight heparin (LMWH) Enoxaperin 40mg once a day or Unfractionated Heparin (UH) 5000iu subcutaneous 8 hourly. In this patient anticoagulation should be started 12-24 hours before surgery and continued till she is fully mobilized post operatively.UH is associated with more Hemorrhage(wound heamatoma) than LMWH because it causes both anticoagulation and anticlotting effect and LMWH has only anti-clotting effect.during surgery and post operatively intermittent pneumatic compression or graduated elastic stocking should be used. Post operatively good hydration and early mobilization should be done.

Postoperative infection in form of chest infection,wound infection, urinary tract infection and unexplained pyrexia can occur.
Measures taken pre-operatively ,intraoperatively and postoperatively will reduce the risk of post operative infection.preoperatively advise the patient to stop smoking at least 24 hours before surgery, correct anemia if present. well kept clean theaters and wards ,sufficiently sterilized instruments and scrupulous sterile technique help in reducing postoperative infection. moring shower before surgery and aseptic skin preparation will help.evidence shows that hair removal from the incision site other than esthetically does not help, if at all necessary clipping/cutting rather than shaving should be done. Antibiotic prophylaxis at the time of induction of anesthesia gives optimum tissue levels during surgery when bacteraemia is more likely to occur. single dose will adequately cover for surgery that lasts for 1 hour but if more time passes than 2 more doses postoperatively 8 hours apart can be given.this antibiotic prophylaxis is as effective as 24 hours or 5 day course. If patient not allergic to pencillinc than augmentin and metronidazole or cefuroxime/metronidazole should be given
Intraoperatively minimal tissue handling, meticulous haemostasis ,minimal use of cautry and less wound contamination will help in minimizing risk of infection. appropriate suture material and suturing technique not only help in good haemostasis and healing but also help in decreasing risk of infection. Postoperatively good analgesia, chest physiotherapy ,early mobilization, good hydration and good hygiene will help in decreasing risk of postoperative infection.

Sudden onset of pleuritic chest pain and shortness of breath in this particular patient points towards pulmonary embolism,and she should be managed on the lines of pulmonary embolism until specified otherwise.
This is an emergency,a call for help from nurses,midwife,doctors around should be made.patients airway should be assessed for patency and should be maintained with chin lift and head tillt.breathing assessed and if needed supported with high flow face mask oxygen or assisted with embo baging.if no breathing and no response than direct CPR should be started.senior anesthetist,obstetrician,intensivist and haematologist should be called and involved in the management of the patient.
Intra venous line maintained with two large bore cannula 14G or 16G,blood samples for full blood count ,clotting profile ,urea and electrolyte should be send. Arterial blood gases should be done. .Patient should be shifted to high dependency unit or intensive care unit and continuous monitoring of ECG, oxygen saturation blood pressure,input output record maintained.for confirmation of the diagnosis of pulmonary embolism x-ray chest and ventilation perfusion scan can be done, these test may or may not confirm the diagnosis but on strong clinical suspicion anticoagulation in the therapeutic dose should be started and continued 6 months postoperatively.
Posted by Lai Wai Man Son L.
a) how would u minimise risk of VTE (5marks)
To minimise the risk of venous thromboembolism (VTE), early mobilisation is encouraged post-operatively
Dehydration is avoided and intravenous fluids is given after fasting and througout post-operative course
Thromboembolic deterrent stockings are prescribed
Pneumatic compression devices is used postoperatively to prevent VTE of lower limbs
Low molecular weight heparin (LMWH) is given at prophylactic doses at 1mg/kg every 24 hours, once no sign of active bleeding post-operatively, until patient is fully mobilised
Watch out for infection which aggravates the risk of VTE
b) How will you minimise risk of post-operative infections (8marks)
Infection occurs in the wound, pelvic cavity, as vault cellulitis, urinary tract infection and chest infection
During the operation, aseptic technique is closely adhered to
Proper cleansing of skin with antiseptic solution for example iodine can prevent skin wound infection by reducing the bacterial load on the skin at time of incision
Prophylactic antibiotics is given at time of induction of anesthesia, this is shown to reduce risk of skin wound, urinary tract infections. if the operation is prolonged (>4 hours), use of antibiotics should be extended into postoperative period
Anatomical knowledge is required to minimise tissue damage. hemostasis should be meticulous. There should be minimal tissue handling . These surgical techniques help reduce risk of pelvic infection and vault cellulitis
Chest physiotherapy post-operatively helps lung re-expansion and reduce risk of atelactasis and chest infection
Proper Foley urinary catheter care with free drainage of urine can prevent urinary retention and UTI. However prolonged catheterisation should be avoided as it increases the risk of UTI
Regular audit of post-operative infection and review of department protocol is needed to improve the standard
C) Justify your initial management (7 marks)
The diagnosis is pulmonary embolism (PE) until proven otherwise.
Consultant gynecologist, anesthetists, physicians, hematologists are informed and the patient is managed in multidisciplinary approach
History is taken to exclude other possibilities e.g. exertional chest pain may suggest ischemic heart disease.
Assessment of patient includes her hemodynamic status, her blood pressure, pulse, oxygen saturation, to note signs of shock; chest examination is done to note respiratory distress. Lower limbs are examined for signs of VTE
Low molecular weight heparin is started at therapeutic dose 1mg/kg every 12 hours if clinical suspicion of PE is high. If patient is in shock, intravenous unfractionated heparin is given, with a loading dose of 80mg/kg followed by infusion at a rate of 18mg/kg/hr.
Investigations are arrange to confirm the diagnosis including CT pulmonary angiogram or ventilation-perfusion scan, depending on availability and patient\'s choice after counselling. Other investigations include FBC, clotting profile, arterial blood gases, to monitor progress and ensure dosage is adequate. CXR (may show lobar collapse and pulmonary edema) and ECG (showing right heart strain pattern) help to confirm the diagnosis
Patient is transferred to high dependency unit for close monitoring after stabilisation
Posted by Sam M.
The risk of thromboembolism in this patient is high because of v high bmi and a major surgey for carcinoma of pelvic organ.this can lead to prolong bed rest and lesser mobility .she will be councelled in a preoperative clinic about potential danger of the condition and prophylaxis and care provided.she should be seen by consultant anaesthetist and gynaecologist before surgery .there could be anaesthetic complications especially for general anaesthesia as difficult intubation can happen.
Thromboprophylaxis should be started ,drugs are unfractionated heparin 8000 iu every8 hourly 24 hrs before surgery or low molecular weight heparin as enoxaprin 40mg perday.she should be told that she had to wear graduated elastic stockings ,and early mobility postoperatively will reduce risk of thromboembolism..
Thromboprophylaxis should continue postoperatively till patient is completely mobilized and no signs and symptoms of DVT or thromboembolism are there.
To minimise the risk of infections prophylactically a single dose of apmicillin 1gm and metronidazole 50mg will tackle acute infection , further doses can be given according to individual circumstances and length of time surgical procedure lasts.penicillin resistant or allergic can be given a combination of cephalosporin and metronidazole.preoperatively .shaving of operative field be done if necessary just before surgey .a good asepsis can prevent infection ,so operative field ,instruments ,theatre and any equipment used must be meeting the aseptic requirements,disposable draps are better than linens which needs sterlization.time of surgery should be kept to miminum but with best haemostasis from incision to closure,residual blood in any area from skin to pelvis is a nidus for infection ,surgery must be by consultant gynaecologist or gynaecological oncologist.post operative wound care ,early mobility and chest physiotherapy can safeguard against infections .an early suspicion of infection if present with bleeding through vagina,or serous discharge through wound.
If condition of chest pain and breathlessness is associated with hypotension and tachycardia ,syncope and deep vein thrombosis ,a strong cilical suspicion of pulmonary emobolism be made and started with therapeutic doses of unfrationated heparin or low molecular weight heparin ,mean while be given oxygen therapy and arrange ECG.send blood for complete examination ,arterial bloodgas analysis.,clotting profile.arrange for ventilation perfusion scane ,though this doesnot confirm pulmonaryembolism but if ventilation perfusion scane is normal ,heparin can be stopped,Doppler studies for DVT should be done if there is c linical suspicion.if Doppler studies are normal and clinical suspicion is strong continue treatment for one week and then repeat dopplerstudies.for pulmonaryembolism definitive test is CT pulmonary angiography and/ spiral MRI Of chest.when pulmonary embolism is confirmed then treatment need to be continued for 6 months replacing heparin with warferrin.
If symptoms are associated with arrhythmias ,because of high BMI myocardial ishmia or infaction should be ruled.early consultation with cardiologist should be taken. Patient should be cared and monitored in a high dependence unit or intensive care.
Posted by Srivas  P.
a) This woman with surgery for malignant disease which is likely to last more than 30mins is high risk for VTE. Any Family or personal History of VTE, thrombophilia, long term immobilization also are considered as high risks and this should be enquired prior to surgery. Moderate risk factors like her age at 57 years and BMI 48 further increase her risks.

But the risk of VTE is to be balanced against better and almost 86% 5 year survival rates with surgery for early stage 1 cancer and long term morbidly too is lesser with surgery compared with radiotherapy. For stage2 and stage3 endometrial cancers, benefits of surgery should be balanced against full radiotherapy for this woman with high risk for VTE and joint decision should be taken in consultation with her oncologist, anesthetist and the hematologist.

Surgery for endometrial carcinoma is to be done on urgent basis and hence preventive measures like weight loss before surgery cannot be applied to her. Stop smoking does decrease the risk of VTE. Thromboprophylaxis should be started 12 hrs pre-operatively and should be continued until she is fully mobile post operatively. Use of pneumatic compression stockings preoperatively, during and post operatively should be encouraged. Post op hydration should be good and she should be mobilized early.

Patients would be closely monitored for symptoms and signs of leg and chest symptoms and appropriate treatment offered.

b) There should be minimum possible interval between admission and surgery to prevent colonisation with hospital flora. Any intercurrent infection if present should be treated prior to surgery. Shaving the operative field the day before surgery should be avoided as it has been found to be associated with increased risk of wound infection and is preferably done just before surgery.
Use of prophylactic antibiotics, decrease risk of infection. Bladder catheterisation should be under aseptic conditions. There is increased risk of injury to urinary tract hence senior oncologist should operate on her. Use aseptic surgical techniques like good hand washing, minimizing blood loss and excessive tissue handling and avoiding haematoma formation help decrease sepsis. Excessive use of cautery should be avoided.

c)These symptoms are suggestive of a pulmonary TE and treatment for thromboembolism with LMW heparin should be started immediately while objective testing is urgently done to rule out PTE. Myocardial Infarction should be another possibility in this grossly obese woman.

Resuscitation should be instituted immediately with emergency call for help. This should include the cardiologist, anesthetist, Consultant gynecologist, hematologist and senior nurses. Airway and breathing should be assessed immediately and high flow oxygen should be started.
Two large bore I/V drips with 14G or 16G cannula should be started and blood samples should be sent for FBC, clotting profile ,urea and electrolyte, Blood gases. She should be monitored for vitals –Pulse , B.P. Pao2, continuous monitoring of ECG, intake output record and CVP monitoring as decided by intensive care team. Patient should be shifted to high dependency unit when stabilized.

Hospital agreed protocol should be instituted for diagnosis and management of suspected PTE and her hematologist, radiologist and physician should be involved early. If the tests are negative but clinical suspicion of PTE remains high, the treatments should continue until repeat tests prove negative.
Posted by J P.
a.Venous thrombo embolism occurs in 40% of major pelvic surgeries .Hence careful risk assessment jointly by consultant anaesthetist and gynaecologist is necessary.Since the patient is morbidly obese BMI 48,age more than 35 and surgery being done for malignancy she comes under high risk and thrombo prophylaxis as unfractionated heparin 5000 u tds or low molecular wt heprain-enoxaparin 40 mg bd will be given 12 hrs preoperatively.Heparin will be continued 5 days after surgery or until patient is fully mobile.Platelet count will be monitored if heparin continued >5 days.Regional anaesthesia to be favoured in consultation with anaesthetist.Postoperatively early mobilisation and hydration should be ensured.I will give graduted TED stockings.
b.post operaively infection may be in the form of pulmonary,urinary tract infection or wound infection.Hence I will treat any minor respiratory or urinary infection preoperatively but this will not delay surgery since it is done for malignancy.Regional anaethesia preferred in consultation with anaesthetist in view of pulmonary atelectasis associated with general anaesthesia.Prophylactic antibiotics as augmentin/metro or cefurxime/ metro given at the time of induction is as effective as 5 days course,One more dose will be given if surgery is prolonged >1 hour.Strict asepsis and proper scrubbing before the case will be done.Intraoperatively fastidious haemostasis will be attained to prevent wound hematoma formation and subsequent infection.Though the use of drains is controversial in prevention of infection, since heparin is used in this case it should be use.Skin sutures will be interrupted to let out any oozing.Heparin administration should be away from wound or flank site.Early mobilisation aand removal of urinary catheter 24 hrs post operatively will minimise infection
c.This should suggest the possibility of pulmonary embolism which occurs in 1-10% in major pelvic surgery inhigh risk case.I will have a quick assessment of symptoms.I will look for airway ,breathing,circulation.Initial intravenous access and bloodwill be sent for full blood count,cloting profile, urea and electrolytes,liver fn test.I will call for help by consultant gynaecologist,physician ,anaesthetist and hematologist in high risk case.Patient will be manaaged in high dependency ITU as per local hospital guidelines.Initially unfractionated heparin as iv infusion started as per guidelines where low molecular wt heparin may be started in mild cases where monitoring by APTT and anti Xa accordingly.Initial ECG taken wiill show right ventricular strain and chest x ray may not show much features except pulmonary oligemia.Ventilation perfusion sca n will be done urgently which will show hypoperfusion in normal ventilated lungs but findings may be eqivocal post operative due to atelectasis.If available CT pulmonary angiogram to be arranged immdiately but needs expertise to interpret but this is the gold standard.Arterial blood gas analysis to be done for monitoringl show hypoxemia wiyh normal carbondioxide tension.Where needed in high risk ,thrombolysis[generally contraindicated post operatively],surgical embolectomy and vena caval filters to be placed in consultation with appropriate specialities.
Posted by Farina A.
In order to minimise the risk of VTE in this pt she should be catogorised accordind to the risk factors she has which include her age 57ys, BMI 48, having malignancy and and going to have a major surgery.other risk factors like use of HRT, personal or first degree relative with throboembolic disease, hx of thrombophilia,and sedentary life style pattern should be enquired for appropriate remedy.Gross varicosities should be looked for.
Pre op advise against smoking is useful. Wt reduction may take a long time before surgery which is not recommended in case of malignancy. This pt can be categorised as high risk for thrombosis and 2 hr pre op low molecular wt heparin (prophylactic dose) is recomended followed by prophylactic dose from 6 hrs post operatively. Intraoperative pneumatic compression may be helpful in case of prolonged surgery.Post operative good hydration and early mobilsation is recomended.
b) pre op tretment of infection if present, stop smoking, shower, cutting or clipping of hairs can be better then shaving in the immediate pre op period.Good strelization and disinfection of theater instruments and staff should be ensured.Antibiotic prophylaxis at induction of anaesthesia using penicillin/augmentin/cefuroxime, and metronidazole is useful in preventing infection. continued 5 days post op.Meticulous haemostasis, isertion of drains in order to avoid intra-abdominal collections, quick and expert surgery, use of appropriate suture material like vicryl to minimise tissue reaction and intrrupted skin suturing to allow drainage of collections. Removal of catheter within 24 hr can reduce the risk of UTI. Chest physiotherapy, good wound hygiene advice, all play a role in preventing post op infection.
c) The provisional diagnosis that should be made is of pulmonary embolism untill proved otherwise. Imediately call for help, from senior midwife , nurse, gynaecologist, anaesthetist and physician. meanwhile maintain airway, check oxygen saturation. give high flow o therapy. maintain 2 IV lines with wide bore canulae preferably a CVP line should be maintained. If pt is in cardiac arrest to start CPR on the spot.send blood CBC, clottig profile and arterial blood gas analysis imeditely and save blood for further investigations.Commence iv heparin therapeutic dose according to the unit protocol. After initiall resucsitation arrange the pt to be shifted to HDU for continues monitorong of vital signs and oxygen saturation. ECG, VQ, scan and spiral CT should be done to confirm the diagnosis. Cardiology consultation should be done to rule ot any cardiac disease.Streptokinase can be used in case of any contraindication to heparin or if pt not responding to heparin.
Posted by H H.
A-Risk assesment is vital in minimising risk of venous thromboembolism (VTE). In this woman who is obese , 57 y old and listed for total abd hysterectomy and BSO for endometria carcinoma the risk of VTE is high.Prophylactic anticoagulation with low molecular weight heparin (LMWH) should be started before surgery by 12 hours and continued 8 hourly till discharge and fully mobile.She should stop smoking if smoker.Avoid immobility and dehydration in pre operative and post operative period.Thrombo embolic elastic stockings should be worn before surgery and continued post operatively.Post operative exercises are of value.

B-This woman is obese and is at high risk of post operative infection due to more dissection in fatty tissue and bleeding.She is also at high risk of wound dehiscence.Prophylactic antibiotics started 2 hours pre operatively will reduce both(infection and dehiscence).The surgery should be done at strict antiseptic conditions in a center where infection control is done according to proper guidline and protocols.The staff should understand the principles of infetion contol and antisepsis Sterilization of operative field is vital.Hair clipping at operation site should be done just prior to surgery.Proper anaesthetic examination to exclude any chest problems that may increase chest infection and also during the anaesthesis to avoid collapse of zones in the lung.
Proper positioning in the post operative period and chest excersises.Proper hemostasis during surgery .Drains may be needed in wounds to avoid hematoma formation.

C-This should be considered as pulmonary embolism till proven otherwise.Initial assessment should include call for assistance and resuscitation if needed (airway, breathing, circulation). Examination of chest should include air entery in both lungs and exclusion of pneumothorax in which case emergency application of chest tube and underwater seal is life saving.If in doubt of VTE anticoagulation with LMWH should be started while further tests are done.ECG , blood gases and cardiac enzymes are performed.The possibility of cardiac ischemia and infarction should be excludrd.Chest x ray can show pneumothorax and early features of pulmonary embolism. A ventilation perfusion scan or CTPA can dignose pulmonary embolism.Patient is put in intensive carewith proper monitoring.

Posted by Priti T.
Various risk factors which increase the risk of VTE in this 57 years old lady is-age more than 35 years,obesity BMI-48,listed for major sugery for malignancy which will last for more than 30 minutes.Personal history of smofing should be elicited as quitting decreases the risk fot VTE.Past history of Thrombophilias and previous episode of VTE,Varicose veins ,high parity in obstetric history increases the risk further.
She should be examined clinically for anaemia,varicose veins,calf tenderness,pelvic tenderness,chest auscultation for pleuritic rub.This patient is a high risk and should be started on thromboprophylaxis preferrably LMW Heparin Enoxaprin 40mg BD Pre operatively ,to be continued post operatively.Alternative is UH [Unfractionated Heparin]5000 8hourly.This requires monitoring with Xa levels.As opelvic surgery for malignancy can\'t be delayed she can not be advised weight reduction.She should use graduated compression stockings[TEDS] Pre,intr and post operatively.Post surgery she should be hydrated well and mobilised early.

b]Senior OB-GYN Consultant in consultation with Onchologist should manage the patient.There shouls be minimum interval between the hospital admission and the surgery to minimise the bacterial colonisation of the Hospital flora.Shaving of the abdomen done may be done at the time of operation.Bladder should be cathetarised aseptically and prophylactic antibiotics are given at the time of anasthesia.Combination of Amoxyclav/Cefuroxime with Metronidazole takes care of the mixed aerobes and anaeobic bacterial flora.
During pelvic surgery tissue handling should be gentle.Adequate haemostasis is achieved to avoid infection.Excessive cauterisation should be avoided and wound drain may be placed to placed to be removed with in 24 hours.For the skin suturing metalic staples are avoided.


c]Shortness of breathing and pleuritic chest pain suggest pulmonary embolism or may be mycardial infarction in very obese patient.Patient should be resuscitated immediately with emergency call for help.This includes cardiologist,consultant Gynaecologist,Senior Staff and patient should be shifted to HDU.
Airway,breathing assessed immediately and high flow oxygen is started.2 large intravenous cannulas are inserted for fluids and the investigations like FBC,U&E ,Blood gas analysis.X ray chest,ECG Is undertaken initially to be followed up later by V/Q Perfusion scan or CTPA.Patient is started immediately on anticoagulation therapy LMWH OR steptokinase ,which will be discontiued only when pulmonary embolism definitively ruled out by CTPA/CUSG.
Posted by Manoj M.
A. This patient is listed for major pelvic surgery which carries a risk of 40-80% for deep vein thrombosis and a 1-10% risk of fatal pulmonary embolism, in addition to this because of her age group , obesity, malignancy and possible complexity of her pelvic surgery she is classified as a high risk for venous thromboembolism.

Thromboprophylaxis for this patient includes unfractionated heparin 5000 IU ( subcutaneous t.d.s) or low molecular weight heparin like enoxaparin 40mg daily to begin 12hours prior to surgery and continue for 5 days postoperative or full mobilised.
In addition to this graduated elastic compression stocking, pneumatic compression perioperatively, adequate hydration and minimising immobility.

Multidisiplinary team invlovment especially with Haematologist, Gynaecologist and Oncologist with regards to duration of thromboprophylaxis should be considered.

B. Post operative wound infection is a major concern for increased morbidity for patient and also cost invloved in healthcare.
Adherence to infection control standards, good surgical technique with scrupulous sterile technique in theatre and on wards prevents post operative infection.
Antibiotics should be used at induction preferrably broad spectrum antibiotics with anaerobic cover depending on the duration of surgery, if the procedure is prolonger for more than one hour 2 further post operative doses should be considered, if significantly prolonged or complex surgery furher intraoperative and post operative antibiotic prophlyaxis should be considered.

Continous free drainage of urine post operative to prevent urinary tract infection and explanation regarding wound hygiene care especially with regards to obesity will reduce post operative infection.

As this patient has no other medical history no further respiratory or cardiac prophylaxis required. If she is a smoker she should be strongly advised to stop smoking well prior to surgery.

C. Initial management of chest pain and shortness of breath involves taking a quick history of presenting complaint and working towards a diagnosis.
Check pulse, blood pressure, saturation, respiratory rate, temperature, respiratory and cardiovascular examination, any signs and symptoms of deep vein thrombosis.
Electrocardiograph, chest X-ray, cardiac enzymes and arterial blood gas analysis.

Depending on working diagnosis it can be myocardial infarction, pulmonary embolism, chest infection which are of main concerns.
If it is myocardial infarction needs Cardiology input and care of patient in intensive cardiac unit.
If a pulmonary embolism is the likely diagnosis, treatment should be started straight away with heparin and organise V/Q scans and Doppler\'s of both legs. Involve physicians in the care of patient and may need further investigation for diagnosis depending on clinical situation like CTPA/ Spiral CT/Pulmonary angiogram. Thrombolysis is contraindicated as she is 3 days post operative. She may require long term anticoagulation involving multidisciplinary team with Oncologist and Haematologist.

If chest infection is the working diagnosis treatment with antibiotics involving respiratory physicians and physciotherapist maybe needed

It is imperative to stabilise this patient and also to give adequate pain relief as part of initial management also inform and involve Gynaecology consultants oncall for better care and continuity of care.
Posted by SK K.
1) this lady is at a increased risk of VTE in view of her age, malignancy, BMI=48 and major surgery.
while counseling her regarding the nature of surgery AND complications, I will specially emphasis on the high possibility of VTE in view of the above factors I would also enquire for h/o smoking, concurrent infection, past or family h/o thrombophilias.
Ideally it would be reasonable to decrease BMI before undertaking surgery but waiting is not possible in this case due to diagnosis of endometrial carcinoma.
A thorough Pre anesthetic check with relevant investigations will be undertaken to categorize the surgical & anesthetic risk.
Senior consultant , anesthetist & hematologist will be involved to optimize the outcome in this high risk case.
I would aim to correct any degree of anemia, infection, hypertension (all of which would increase risk of VTE) along with other parameters like her blood glucose levels. If she is a smoker, she would be persuaded to stop.
She will be given thromboprophylactic dose of LMWH or UH starting 12 hours before surgery.
Intraoperatively it is important to maintain good hydration, provide intermittent pneumatic compression or TED stockings, keep blood loss to minimum, minimize the time of surgery.
Prophylactic antibiotics need to be prescribed to decrease the risk of postoperative infection.
Postoperatively, a strict watch will be maintained for signs of DVT & VTE.
Early mobilization& good hydration will be encouraged thromboprophylaxisis will be continued for a complete of 5 days along with use of TED stocking.
Before discharging the patient, I would explain to her in a non frightening manner the warning signs of DVT & Vte and ask her to report at the earliest.

2)Minimizing the risk of postoperative infection would entail preoperative correction of anemia, any concurrent infection, prophylactic iv antibiotics before surgery, shaving of the operative field early on the day of surgery, ensuring that the patient has had a clean bath on the day of surgery. Practice of cleaning the operative area with betadine before taking to OT & vaginal douching with betadine may improve outcome .
Intraoperatively minimizing the duration of surgery, aseptic technique, good surgical skills, minimum number of drains, good surgical closure, using nonabsorbable intermittent sutures for skin will all aid in reducing infection.
Postoperative prophylactic antibiotics according to local protocol, practice of open dressing from day 2 of surgery, education regarding good hygiene & wound care will also help in minimizing infection. If there has been massive blood loss during surgery, correction of anemia with blood transfusion will help in wound healing and improving resistance to infections.

3) As she presents with sudden onset chest pain & shortness of breath, the most likely diagnosis in her case would be pulmonary embolism.
To start with I would quickly record her pulse, bp, oxygen saturation, auscultate chest for sign of pleural rub decreased air entry. Look for signs of DVT in lower limbs.
I would alert the senior consultant , ICU, hematologist & radiologist and call for help.
At the suspect of pulmonary embolism, I would start therapeutic dose of UFheparin /LMWH without delay. Therapeutic dose of UH = 80 u/kg followed by continuos iv infusion of 18 units/kg . measure APTT – 4-6 minutes after loading dose and maintain at 1.5 – 2.5 times control.
Collect relevant blood investigation urea , electrolyte, LFT, FBC, coagulation assays, D dimmer assay, FDP.
Arrange for chest x ray, duplex compression scan of lower limbs, V/Q scan of lungs or CT pulmonary angiogram, portable echocardiogram, ECG
Patient will be shifted to ICU for further monitoring & care.
At the earliest opportunity the patient and her relatives will be briefed of the complication.
After this initial management patient would be further subjected to thrombolytic therapy, thoractotomy or surgical embolectomy.
Posted by Sabahat S.
a)She is undergoing surgery for malignant disease therefore she is at high risk of VTE .Moreover her age and high BMI add to her risk. Liaison with haemotoglist and anaestheist should be done regarding her thromboprophylaxis assessment and management. She should be given heparin prophylaxis 12 hours pre operatively and then eight hourly post operatively until fully mobilized or discharged. Thromboprophylaxis is associated with 50% reduction in risk of VTE but may cause 2 fold increase in risk of haemorrhage requiring transfusion and increase risk of wound haematoma .LMWH are associated with lower risk of haemorrhage.Intraoperatively,pressure on calf muscles should be reduced by pneumatic or electric compression devices or TED stocking. In post operative period, good hydration and early mobilization along with heparin and TED stocking are of paramount importance to reduce risk of VTE.
b)Considering her high BMI,she is at high risk of getting respiratory problems like breathing difficulty,atetectasis, chest infection, wound infection,DVT as well as UTI.Pre operative assessment by anaesthetist in this regard is helpful to decide for the type of anaesthesia,pain relief and immediate post op- care of breathing.G.A is more likely to cause chest infection. Her stay in hospital from admission to surgery to be minimized to reduce risk of getting hospital acquired infection. Shaving a day before surgery should be avoided. Clipping just before surgery is recommended.introperatively anaesthetist should take care to prevent hypothermia as it increases risk of post operative sepsis. Measures should be taken to avoid hypovolumaeia, hypoxaemia.A septic measures should be taken during catheterization of bladder to reduce risk of UTI.Prophylactic antibiotics should be given after induction of anaesthesia to reduce post operative infection. Surgical measures include disinfection prior to surgery, techniques to redues blood loss and tissue trauma and prevention of haematoma .Single use disposable instruments should ideally be used.post operatively, early mobilization, adequate pain relief and physiotherapy (breathing & leg exercises )should be encouraged.
c) These symptoms are suggestive of pulmonary embolism.Clinilcal history and examination cannot reliably exclude PE, therapeutic anticoagulation should be started until diagnosis is excluded by objective testing. An enquiry is made about the acuteness of symptoms, haemoptysis, fainting, calf swelling or pain. Examination includes pulse, BP, temp, O2 saturation, chest auscultation. Exam of legs will be done to look for signs of DVT.Invstigations will include FBC, Clotting profile, ABG analysis, D.dimer, Xray chest. As she was already on heparin, it can be switched to therapeutic doses or UH may be chosen either intravenously or subcutaneously. Local hospital protocols should be followed in this regard. Transfer to ITU may be considered in this situation to have appropriate management by the consultant physician. Provision of adequate analgesia and TED stocking should be continued. Facial oxygen should be given if there is evidence of hypoxaemia.Further investigations like spiral CT or computed pul.angiograhpy should be performed to diagnose PE.
Posted by H P.

(a)According to the history given, this patient has a high risk for venous thrombo-embolism (VTE). Preoperatively she should be assessed for other risk factors like smoking, family history of VTE or presence of varicose veins. She should be counseled to stop smoking. After adequate counseling and taking into account her wishes, she should be offered VTE prophylaxis. She should be given above-knee graduated elastic compression stockings (GECS) preoperatively and to be continued postoperatively till complete mobilization. Other mechanical devices like intermittent pneumatic compression devices or mechanical foot pumps can also be used. Baseline investigations for blood count, platelet count and coagulation screen should be sent She should be started preoperatively on subcutaneous low molecular weight heparin (LMWH) 0.4-1 mg once a day or subcutaneous unfractionated heparin(UH) 5000IU 8-hourly twenty-four hours prior to surgery according to the hospital protocol. This should be continued at least 5 days postoperatively or until complete mobilization. To decrease the chance of wound hematoma, the injection site should be away from the operative site. The anaesthetist should be informed and last dose of LMWH should be atleast 10 hours and uh atleast 4 hours prior to regional block. Infection increases the risk of VTE, so all necessary precautions should be taken. Postoperative lower limb physiotherapy should be encouraged. Early post operative mobilization and adequate hydration should be ensured.


(b)Postoperative infection could be in the form of abdominal wound infection, urinary tract infection, vault infection or chest infection. Preoperatively, correction of anaemia/ cessation of smoking and improving general condition help prevent infection.
Vaginal swabs should be taken and treatment given if necessary. Operative site skin should be examined and treated for superficial infections. Hair at the operative site should be clipped rather than shaved.
Proper antisepsis in the theatre and ward including periodic check ups of the staff for occult infections should be done. Strict adherence to aseptic technique, minimal tissue handling, usage of proper suture material and meticulous hemostasis will minimize infection. Skin should be prepared with antiseptic solution to decrease the bacterial load. Indwelling catheter (IDC) should be inserted with proper aseptic and antiseptic precautions. Prophylactic intravenous broad-spectrum antibiotics should be given at the time of induction of anaesthesia. If the surgery is prolonged (> 4 hours), post operative antibiotics should be given for 24 hours. Proper catheter care should be given postoperatively and the IDC should be kept for minimum period required. Chest physiotherapy decreases risk of chest infection and atelectasis. Post operative anemia should be corrected. Oral diet should be started as soon as possible to minimize infection from the site of intravenous canula.

(c) Her complaints on third post-op day are suggestive of pulmonary embolism (PE) unless proved other wise. Immediate help should be summoned and senior gynecologist, physician, anaesthetist and hematologist involved in the management. She should be given cardiopulmonary resuscitation. Her pulse, blood pressure, oxygen saturation and chest examined. While decreasing her anxiety, oxygen through mask should be given and two large-bore iv canula secured. Blood samples should be collected for coagulation screen and platelet count in citrated bulb and for D-Dimer essay, baseline liver and renal function tests. She should be given IV bolus heparin in therapeutic dose followed by intravenous drip unless her cardiorespiratory reserve is severely impaired. Urgent diagnostic imaging in the form of echocardiography, spiral CT, pulmonary angiography or ventilation perfusion scan should be arranged. Bedside chest x-ray showing lobar collapse and pulmonary edema and electrocardiogram suggestive of right sided strain pattern may be helpful till definitive imaging is arranged. She should be transferred to high dependency unit for further management.
Posted by Shabana M.
Presence of multiple risk factor (morbid obesity ,age and malignancy) put this woman at increased risk of venous thromboembolism so careful planning and team work is required to minimize the risk of thromboembolism .General measures like smoking cessation or reduction (if she is smoker)will be required .If she is anemic then it will be corrected. Weight reduction will not be advised as it will delay the surgery which is not appropriate in case of malignancy .HRT need not to be stopped before surgery.
Close collaboration with hematologist and anesthetist will be needed for appropriate dose and timing of thromboprophylaxis. Surgery will be performed by an experienced surgeon to avoid prolongation as it encourages immobility which is a risk factor for thromboembolism .if she is in early stage of endometrial carcinoma then vaginal route may be an option as it is less morbid and encourages early mobilization
Thromboprophylaxis will be initiated 12 hours before surgery and will be continued 8 hourly till she is fully mobile or discharged. She will be warned of potential adverse effect of heparin(bleeding ,and wound haematoma). TED stockings or pneumatic boots of appropriate size will be encouraged along with good hydration. and Early mobilization will be advised. She will be warned of signs and symptoms of thromboembolism like chest pain tachypnea and calf pain and tenderness and will be given appropriate information regarding whom to contact .Appropriate dietry advise,involvement in weight reduction programme andlife style modification will be advised after surgery
B)Appropriate skin preparation of patient before entering in the theater, prophylactic antibiotic iv along with metronidazole before starting surgery ( will reduce the postoperative infection in approximately in 50percent of cases),correction of anemia, and aseptic bladder catheterization are important to minimize post operative infection
An experienced gynecological oncologist, anesthetist should perform surgery to minimize the chances of prolong surgery .Adequate haemostasis ; aseptic technique and minimal handling of tissue intraoperatively are the other means of minimizing post operative infection .Careful closure of wound with non absorbable suture to minimize chance of wound infection. Addition of regional analgesia along with general anesthesia will provide excellent postoperative pain releif without compromising respiratory function and will avoid chest infection . Post operative care in high dependency unit will allow maintainence of good hygiene and will avoid overcrowding of attendents and other patients and close observation of patient and so does the care of wound and catheter. physiotherapist involvement will minimize chance of post operative chest infection .Pneumatic beds will be helpful to avoid bed sores if prolong immobilization is the concern as this can lead to infection
c)These features are highly suggestive of pulmonary embolism which is a major cause of mortality .prompt action must be taken for early diagnosis and appropriate management. History and clinical features cannot reliably diagnose pulmonary embolism so thromboprophylaxis with heparin will be stated without awaiting for the result of confirmatory objective testing unless diagnosis is excluded or heparin is contraindicated. Senior gynecologist, anesthetist hematologist and ITU physician will be involved in her care
History will be explored regarding faintness, breathlessness and haemoptysis. Leg pain ,calf pain and swelling will also be asked, personal and family history of THE and history of prolong immobility will also be enquired. Compliance with anticoagulant and dose will a be checked Examination will include temp ,pulse BP and SO2, auscultation for chest sign(tachypneae, tachycardia, raised JVP and right ventricular heave )and examination of legs for varicosities, for swelling in the calf and tenderness and induration will be done .Investigation required include full blood count,Urea and Electrolyte, coagulation profile and liver function test as these are base line before anticoagulation therapy. Arterial blood gases ,ECG,and chest x-ray will be needed although they may not diagnose pulmonary embolism but will exclude other causes of chest pain
Ventilation and perfusion scan will be advised for diagnosis and if result is equivocal then pulmonary angiography will be advised to confirm the diagnosis
Treatment will include continuation of heparin and monitoring for the level will be done by measuring anti Xa level
Adequate analgesia will be provided, facial oxygen if evidence of hypoxemia and TED stockings
Posted by Iffat ara M.
a):In view of age and weight (BMI 48)& going to have major surgery + risk of 1% PE for major surgery. So she is labeled as height risk for VTE. So she should receive LMW heparin s/c12 H before opr & should continue 8 hrly for 5 days post.op or until she is completely mobilized.
She should be counseled properly regarding risk of VTE & how we can prevent It. She should be advised TED stocking, avoid intra operative press on calf by using pneumatic or electrical calf compression devices. Proper hydration.
b):to decrease post op infection we should adopt all aseptic measure starting in preoperation period i.e. giving bath to pt, wearing sterilized gown, starting antibiotic(augmantin/flagyl)on day of surgery, minimal handling during operation, proper homeostasis, using rectus drain to avoid haematoma, infection. Avoid peritoneal drain. Use interrupted sutures. Continue post op antibiotic,proper aseptic dressing, early mobilization, as she is more prone to get respiratory problems like breathing difficulty, atelectasis, chest infection, so anesthetist should be consult before surgery, for proper assessment to decide the type of anaesthesia,as GA increase risk of chest infection & breathing difficulty in obese pt so epidural/spinal anaesthesia will be preferred. After operation physiotherapy for chest & legs will be advised.
c): Provisimal diagnose of this pt seems pulmonary embolism initial management include assessment of pt properly by taking vital sign(B.P, pulse, temp)see the legs for S/S of DVT. Maintain iv line, in the meantime send blood for FBC ,LFTs ,ABG ,coagulation profile ,request ECG ,CRP ,portable X ray chest .if needed request for ventitilation perfusion scan of lungs/CTPA after consulting gynecological consultant and radiologist. switch prophylactic dose of heparin to therapeutic dose according to unit protocol.& give oxygen if S/S of hypoxemia.
Posted by Vaishali Sriniv J.
a. Morbid obesity and increasing age are high risk factors for venous thromboembolisim (VTE). The other risk factors include planned major surgery for malignancy. So the patient belongs to high risk group for VTE. She should be counseled about that and started on thromboprophylaxis with LMWH or unfractionated heparin 12 hours before the surgery. Patient is to be advised to wear TED stockings. During surgery and post operatively dehydration should be avoided. Early ambulation is to be encouraged. Thromboprophylaxis should be continued till patient is completely mobile. She should be advised to loose weight after discharge.
b. Morbid obesity also increases the risk of infection. Meticulous asepsis should be followed. Patient is to be started on broad spectrum antibiotic prophyloxis. First dose is to be given two hours before surgery and continued postoperatively for minimum of three doses. Catherisation of the bladder should be carried out using aseptic technique. Before surgery abdomen should be cleaned using betadine solution. During surgery meticulous haemostatis is to be achieved and minimum tissue handeling is advised. Drains should be kept to facilitate drainage. Mass closure of incision can be considered. Catheter care and care of operation site is to be given. Post operatively patient should be observed for development of infection. Monitoring of vitals and abdominal examination for evidence of distention and tenderness is necessary. Consultant should be informed early if in doubt.
c. The provisional diagnosis will be pulmnory embolism in this case. The initial management includes call for help and to inform consultant gynecologist, consultant anesthetist, nursing staff and medical staff. Respiratory passage is to be assessed for patency and respiration should be maintained.. Nasal oxygen should be given. Oxygen saturation can be determined using pulsoximeter. Wide bore I/V canula can be put to maintain circulation . Blood should be sent for CBC, coagulation profile and fibrin degradation products (FDP). Negative predictive value of FDP to rule out thromboembolism is high. ECG should be done to rule out Myocardial infarction. X ray chest is to be done but in about 50% patients with pulmonary embolism there may not be any changes. Unless proved otherwise patient should be treated for pulmonary embolism. Therapeutic dose of LMWH should be started as per weight based regime. As per local availability V/Q scan or computed tomography pulmonary angiography can be carried out for confirmation of diagnosis.
Posted by hoping ..
this patient is at high risk of venous thromboembolism and therefore measures should be taken to reduce her risk. Unfortunately weightloss preoperatively needs time and thus not reasonable in view of malignancy. optimising her nutrional status and correcting anaemia reduce this risk. general advice regarding avoiding dehydration and mobilisation also reduce the risk. smoking cessation if she is a smoker is important. prophylactic antibiotics and prompt treatment of infection should be priority. haematologist input should be requested and perioperatively anticoagulation with heparin given which should be continued until she is full mobile. she should be provided with compression stockings which should be of appropriate size for her. special antithrombosis mattress should be provided.

postoperative infection can be avoided by use of prophylactic antibiotics to cover surgery and be continued for 5 days postoperatively as she is at high risk of infection. meticulous aseptic techniques should be used for all invasive procedures including venous punctures. physiotherapist input to avoid chest infection should be requested. mobilisation reduces respiratory and urinary infections. appropriate mattress and frequent change of position to avoid pressure sores . catheter and drains should be removed when appropriate at earliest as these are sites for infection. hand hygeine measures reduce cross infection between patients. wound and drain sites should be reviewed daily to pick up subclinical infection and prompt treatment.
her symptoms are highly suspicious of pulmonary embolism. her pulse , blood pressure and oxygen saturations should be checked. If patient is clinically unstable - resusitation measures instituted which include critical care team, oxygen , iv heparin infusion and thrombolyis.she should be examined for signs of DVT and cardiorespiratory assesment for lung fields, JVP and heartsounds. ECG , arterial blood gases and chest Xray should be done as matter of urgency. Her bloods should be sent for full blood count, urea,electrolytes , d dimers , coagulation and liverfunction. VQ scan or CTPA is most sensitive diagnostic test and should be requested. While these investigations are being arranged therapeutic anticoagulation with low molecular heparin calculated as enoxaparin 1.5 mg/kg body weight should be commenced.haematologist advice should be sought.
Posted by NARGIS  K.
a) This pt is at very increased risk of venous thromboembolism .To minimze the risk of VTE she should reccived some prophylactic measure .Prophylactic heparin should be given to the pt pre operatively,should continue postoperatively until pt is fully mobilize. Intermittent pneumatic cuff compression or graduated stocking should be given to the pt during operation .Adequate hydration and early mobilization is very much important to minimize risk of vte.

b) Correction of anemea preoeratively is an important step to minimize the risk of infection. Any pre existing infection should be properly eradicated preoperatively. Prophylactic antibiotic must be used to minimize the risk of infection .Pt should take shower in the morning on the day of operation. Proper sterilization of all the surgical instrument,operation theatre is to be done. Minimal tissuehandaling ,proper haemostasis ,minimum use of cautery is an another step. Non closure of the peritoneum is to be done. Adequate hydration and proper nutrition including protein,zinc, vit-C should be given.Early ambulation isan important step.She should counselled regarding her personal hygene.

c) Pt seems to be devoloping pulmonary embolism .Urgent call for help to involve nurse , midwife or any other available personnel. oxygen is to be started. Heparin is to be started from prophylactic dose to therapeutic dose.Vital sign is to be recorded. Multi disciplinary team should involved in the care of this Pt including gynaecologist, anaesthetist, haematologist, radiologist, intensive care unit physician. Venous channel is to be started with two wideboard cannula and blood sample is to be sent for urea, electrolyte, coagualtion profile, LFT, ABG. Chest x ray and ECG is to be done
Posted by N K.
(a) How would you minimise the risk of venous thrombo-embolism? [5 marks]
She is at high risk for VTE because of age, BMI and CA. Risks reduction can be achieved perioperatively. Preoperative assessment about family or personal history of VTE/thrombophilia and managing appropriately (involvement of haematologist). Stop HRT if on any because long term immobilisation is anticipated.
Correctly fitted graduated compression stocking and adequate hydration should be maintained during and after surgery.
Intraoperatively, intermittent pneumatic compression of the calves is helpful for major surgeries and long immobilisation.
Thromboprophylaxis with unfractionised heparin or low molecular weight heparin(tinzeparin, enoxeparin) adjusted to body weight and preferable first dose on the evening before the surgery and, continued postoperatively until full mobilisation.
Early mobilisation and physiotherapy if appropriate, is also essential strategies in minimising risk.

(b) How will you minimise the risk of post-operative infection? [8 marks]
Post operative infections could be urine, chest, wound, pelvic, vaginal and cannula or drain site infections. Risk reduction before the operation begins with proper control of pre-existing diseases such as anaemia, diabetes and other systemic illnesses. Preoperative bathing and clipping of pelvic hair are also prooven to be beneficial.
During the surgery strict adherence to aseptic technique, good skill, careful tissue handling and avoiding injury to organs, use of appropriate suture materials are essential. Prophylactic antibiotics could be given intraoperatively if indicated (contamination, injuries, prolonged surgery). Consideration should be given to prophylactic drainage tube if necessary.
Post operatively, personal hygiene, strict adherence to ward infection control protocols (hand washing, gloves, appropriate disposal, isolating ) is vital. Early mobilisation, early removal of catheter and drains if possible will avoid relevant infections. Maintenance of wound, cannula and drain site dry and clean will prevent infections in those areas. Chest physiotherapy will help preventing chest infection. Watching out for infective complications and treating them with broad spectrum antibiotics initially, followed by specific antibiotic after culture and sensitivity -this will prevent colonisation of c.difficille or MRSA like organisms.

(c) She complains of sudden onset of pleuritic chest pain and shortness of breadth 3 days post-op. Justify your initial management [7 marks].
A quick general, cardiovascular and respiratory assessment (BP, PR, RR, pO2, Heart sounds, air entry, and temperature) for diagnostic clues will be followed by IV access to take bloods and administer medication and fluids. Propping up and Oxygen via mask may be beneficial if saturation drops and breathing is difficult. Bloods will be sent for FBC, U+E, LFT and clotting to check for baseline levels and cardiac enzymes to exclude MI and D.Dimers for PE. If MI or tension pneumothorax is suspected, she should be managed appropriately.
In case of suspected PE, she should be started on therapeutic dose of low molecular weight heparin ( daltoparin, enoxeparin) adjusted to body weight and continued until proven otherwise by objective testing such as CT-PA or VQ scan. If PE is confirmed, she could be continued on the LMW heparin or converted to warfarin (Dose adjusted to INR) in liaison with the haematologist. Follow up will be arranged at haematological clinic.
Posted by Farkhanda A.
This woman is at high risk of developing venous thrombo embolism (VTE) due to her advanced age, high body mass index (BMI), indication and nature of surgery. Her risk of VTE can be minimised by wearing deterrent stockings, by keeping her well mobilised , good hydration and giving her anticoagulant. For prophylactic dose low molecular weight heparin such as enoxaprin 40 mg once a day or unfractionated heparin subcutaneous 5000 international units twice a day. Risk with LMW heparin are less and so most units use this.Heparin should be given away from the operation area to avoid haematoma.
Post operation infection can be minimised by treating any pre operation infection. She should be given prophylactic ant acid to prevent aspiration pneumonia and mandleson syndrome. There should be physiotherapy of the chest. Intra operative prophylactic shot of antibiotics is valuable to prevent post operative infection.
Oral rout fluids and solid food should start after bowel movements by auscultating bowel sounds to prevent para iliac problem and distensions of the abdomen.
There should be good irrigation of the kidneys by giving enough parentral fluids. There must be input, output balance chart to observe renal function on one side and to prevent pulmonary oedema on other side. If there is any urinary symptom, send mid stream urine sample for culture and sensitivity for suitable antibiotics. There should be good care of abdominal wound as there is a risk of burst abdomen due to high BMI and also secondry infection.
Check her haemoglobin and if anemic give iron supplements either orally or blood transfusion.
Sudden pleuritic chest pain and shortness of breath warrant prompt investigations. This should be due to pulmonary embolism, angina pain or chest pain due to pneumonia or musculoskeletal pain. Send her full blood count for white cell count which may be increased in infection, she may be sever anemic. Arterial blood gases for hypoxia and respiratory acidosis, chest portable (xray) , echocardiography (ECG) . Check her Oxygen saturation. Treat her immediately by giving oxygen by mask, start therapeutic dose of LMW heparin according to her weight.
Posted by S D.
a) I would undertake risk assessment for VTE and as she has 3 or more moderate risk factors (Age>40 yrs, BMI 48, Major surgery, cancer), she comes under high risk category for VTE. I would involve anaesthetist pre-op in her care. Pre-op heparin (12 hrs pre-op) should be given and continued till the patient mobilises. Good hydration, compression stockings should be given. Pt should be advised to start mobilising as soon as possible after the surgery. She should be advised about the signs and symptoms of VTE and prompt treatment instituted instituted if any symptoms develop.
Posted by Anna L.
Anna O\'Brien wrote:
a) A pre-operative reduction of weight would be optimal but can not be achieved in safe time frame of needed cancer treatment. However, healthy diet, smoking cessation and mobility should be encouraged pre-operatively. A thorough pre operative assessment should include early referral to anaesthetist and screening for undiagnosed, obesity associated diseases like Hypertension/Cardiac disease (ECG, CXR) and DM (fasting plasma glucose). Pre op admission, good hydration and pre op thromboembolic Prophylaxis reduces her risk. Low molecular weight heparin (Clexane, Tinzaparine) is the drug of choice with only minimally raised risk of intra operative bleeding. Intraoperative sequential calf compression effectively reduces VTE. Her Risk is highest Post op and she shoud receive weight adjusted thromboprophylaxis, Teds and good analgesia to allow early mobilisation and effective physiotherapy.

b) Morbidly obese patients have a high risk of impaired wound healing and infection. Pre operatively she should be screened for MRSA. This patient would benefit from broad spectrum iv antibiotics at induction (Augmentin or Cefuroxime & Metronidazole). Maintenance of intraoperative asepsis is mandatory (effective hand washing of surgeons, sterile gloves and equipment). Post operatively the wound/dressing should be checked regurlarly and changed with aseptic technique. The wound should be allowed to air dry - deep skin folds provoke extra heat / moisture and a base for bacterial proliferation. Drying the wound with a blow dryer or fan may be helpful. Early and aggressive antibiotic treatment schoul be initiated at suspicion of superficial or deep wound infection. This should be managed in multidiscipilnary team with a tissue viability nurse.

c) Initially I will asses the patient\'s general status to avoid a delay in needed resusitation adressing airway, breathing and circulation. I will connect a monitor and check her HR, BP, Saturation on air, Respiratory rate and temperature. I will auscultate her chest, assessing her for PE, Pneumothorax, Pneumonia. Followed by an examination of her abdomen for signs of peritonitis and her legs for signs of peripheral DVT as source of PE. I will check her peripheral perfusion and urine output to asses for general compromise. I will insert an iv access and send blood urgently for FBC, G&S, Clotting, U+Es, LFTs and possibly Thrombophilia screen (to exclude underlying cause). She should have an ECG to check for electric signs of PE or other cardiac causes. And an ABG is a useful investigation to check for respiratory alkalosis with PE. Since the risk for PE and the associated mortality is high I will initiate therapeutic dose of Clexane according to weight prior objective confirmation of diagnosis. With severe compromise iv Heparin infusion, thrombolysis or surgical thrombolectomy needs to be considered in liaison with hamatologists, anesthetists and surgeons. Objective diagnosis must be seeked with duplex compression US of both legs and The gold standard to diagnose PE is a CTPA with high specifity and sensitivity or a VQ scan, according to local equipment and radiological protocols. After confirmation of PE therapeutic Clexane for at least 3 days can be followed by Warfarin anticoagulation with aim for INR beween 2-3. The treatment needs to be accompanied by regurlar checks in the coagulation clinic. With the background of endometrial cancer and high risk of recurrence the insertion of a IVC filter should be considered.
Posted by Sabahat S.
I went through your valuable essay answers on reducing risk of VTE in gynae surgery before answering,you have clearly mentioned,thromboprophylaxis for high risk, heparin 12hours preop then 8 hourly,for moderate risk 2hours preop then 12 hourly,this point discussed in two essays. Although I could not get this difference of 2hour vs 12 hours in preop adminstration of heparin.Please clarify this point.nothing was mentioned about type of heparin.
secondly you mentioned involement of haematologist in high risk patients, like this patient
having surgery for malignant disease with additional factors of age and BMI .You objected his involement.Patient has been already listed for surgery means we can take opinion of haematologist and anaesthetist.
Thirdly,institutional measures for prevention of infection seems to be applied in general topic ,here we are discussing a clinical approach and measures, I ignored these not to make it general.So I should mention these measures as well.Thanks
Posted by S G.
(a) How would you minimise the risk of venous thrombo-embolism? [5 marks]
I will ask her about smoking habit. She needs to cut down on smoking as it is a risk factor for thrombo embolism. During operation, she need to have flow tron boots(for intermittent pneumatic compression). After the operation , she should be on prophylactic dose of low molecular weight heparin and should have thrombo embolic deterrent stockings to prevent venous stasis. I will advise her early mobilization and to keep her well hydrated.
(b) How will you minimise the risk of post-operative infection? [8 marks]
She should have a broad spectrum antibiotic coverage for at least 24 hours after the operation. Urinary catheter removal next post operative day in case of uncomplicated operation will prevent post operative infection. Catheter specimen of urine for culture and sensitivity should be for testing to detect the infection at the earliest. Frequent hand washing and the use of alcohol rub during ward rounds prevents infection. Use of sterile instruments and dressings for removal of staples or stitches will help in minimizing the risk of post operative infections.
(c) She complains of sudden onset of pleuritic chest pain and shortness of breadth 3 days post-op. Justify your initial management [7 marks].
Her symptoms during post operative period are suggestive of pulmonary embolism. How ever, it may be due to chest infection or any cardiac cause like myocardial infarction. She may be pyrexial and tachycardiac in case of chest infection. She may be hypotensive with low oxygen saturation in case of pulmonary embolism or myocardial infarction. I will auscultate her chest for any signs suggestive of infection. I will arrange a full blood count, c reactive protein(CRP) though white cell count and CRP might be raised in post operative period. She needs to have arterial blood gases to look for hypoxia, chest x ray to rule out any infection, ECG to look for cardiac cause of pain. I needs to be in semi recumbent position and will give her oxygen. I will give her therapeutic dose 1.5 mgs/kilo body weight once a day of enoxaparin. Meanwhile I will arrange a ventilation/perfusion scan for confirmation of pulmonary embolism. This dose of enoxaparin can lead to bleeding from the wound so she should be observed for that and full blood count needs to repeated accordingly. Haematology team should be involved in the management of the patient. She should wear thromboembolic deterrant stocking during her stay in the hospital. In case ECG is suggestive of cardiac cause, cardiology team should be involved in her management. Chest infection should be covered with antibiotic.
Posted by SHAGUFTA T.
Dear Dr paul
I posted my answer of Q. on Perioperative care twice, once on 8th, then again on 9th but still its not appearing in answer section of forum, could you please sort out where is the problem, as I want to send the next answer on GDM now
Regards
ST
Posted by SHAGUFTA T.
a). How would you minimize risk of VTE(5).

Answer :- This patient is at high risk of developing VTE in context of her age,(>30)BMI of 48 (>30), diagnosed carcinoma & major surgery(Hysterectomy). All of them are independent risk factors to develop VTE. Brief history taken from her to detect other associated risk factor like H/O smoking- if positive should be advised to stop smoking before surgery. Base line investigations done before thromboprophylaxis FCB, coagulation profile ,Platelet count, APTT if UH to be given. Examination & investigation for anemia, to correct before surgery. Multidisciplinary team approach is to be opted involving senior gynecologist ,oncologist, senior anesthetist and thorough pre anesthetic checkup to be done by consultant anesthetist to minimize the risk and to take proper action at proper time. Thrombo-prophylaxis to be started 12 hrs prior to surgery in high risk cases (and 2 hrs in low risk)with either prophylactic dose of low molecular weight heparin (LMWH)like enoxaparin 40 mg. twice a day X S/C or unfractionated heparin in dose of 5000 U/Day, if there is risk of haemorrhage U.H. to be given, as short half life, easy to reverse by protamine sulphate. Late admission to reduce pre-op prolong immobilization, per-op measures to reduce risk of hemorrhage, reduce time of surgery, proper analgesia ,post-op early mobilization, proper hydration, TED stockings & thrombo-prophylaxis to be continued till 5 day or till patient becomes completely mobile .Every hospital should have agreed local protocol for diagnosis investigation and management of VTE.

B). How you will minimize the risk of post-op infection.

Ans. :- All hospitals should have protocol for strict infection control in-place. I would like to educate and inform the patient about possible risk of getting post-op infection before surgery and what measures could be opted to minimize risk. I will admit pt. maximum 1 day before surgery to avoid colonization of bacteria present in the hospital environment ( to avoid nosocomial infection). Proper part preparation before surgery, clipping of hairs / shaving of field of surgery not to be done very early and to be done with proper aseptic precautions, properly cleaned and draped at time of surgery. Pt. advised to take shower at the day of surgery before going to OT to reduce bacterial load. Theater, linen & equipments to be properly sterilized. If any risk factor like anemia present , to be controlled before surgery to reduce risk f post-op infection. Indwelling catheter to be inserted with aseptic precautions.

Intra/ perop antibiotic prophylaxis given with broad spectrum AB like ampiclox + metronidazole to cover aerobic & anaerobic, gram positive & negative bacteria. Per-op –minimal handling of tissue will reduce the risk of infection. Less use of cauterization to avoid adhesion & infection. Less use of extra suture material & clip, choice of proper suture material will also help, interrupted sutures to allow drainage of collected pus/ fluid, mass closure in morbidly obese will reduce the risk . Avoid excessive pre-op bleeding, if risk of haematoma, drain inserted. Post-op – continue intravenous AB till allowed orally then to continue with oral AB. Remove dressing early and allow the wound to get dry . early mobilization , encourage to pass urine to avoid stasis of urine & UTI after removal of catheter. Chest physiotherapy to avoid pulmonary edema & infection. heparin inj. away from wound. Close monitoring post-op look/ identify signs of infection like pyrexia, tachycardia.

c). She c/o sudden onset pleuritic chest pain & shortness of breath 3 days post operatively . Justify your initial clinical management.

Ans. :- The clinical picture is highly suspicious of PTE. which should be dealt immediately. I will inform senior consultant gynecologist, anesthetist, radiologist & hematologist . Same time will take H/O onset of symptoms and severity, examin the lady for vital signs Pulse, BP, Temp. SPO2, chest, limbs for swelling, numbness. Ask for continuous monitoring by pulse oxymeter & automated BP apparatus/. In case she goes in shock --- Resuscitation started, maintain airway, breathing, circulation, insert 2 large bore IV cannula -- blood taken for FBC, ABG,Platelet count, U&E & LFT ,urgent ECG, chest Xray + Doppler arranged to see signs of PTE & to exclude other cardiac or lung pathologies like MI or lung infection. As the woman with age 57 &BMI48 is at increased risk of getting MI after stress of surgery. If acute MI – cardiologist to be involved in management. If lung pathology – respiratory physician t be called. But therapeutic dose of heparin to be started immediately with consultant gynecologist & physician’s advise till PTE is excluded or heparin strongly contra indicated. Patient to be transferred to & managed in HDU with close monitoring if need arises. If condition not confirmed or not improving V/Q scan or CTPA might be needed with senio\'s advise
Posted by Sandra  L.
(a)The risk of venous thromboembolism can be minimised preoperatively by first advising patient to lose weight. A Bmi of 35 and below should be aimed for before surgical treatment is commenced. (Balen et al 2006).

As HRT increases the risk of thromboembolic events I would discuss alternative therapy to HRT prior to surgery.

Thromboprophylaxis shoulld be given in the form of ted stockings and low molecular weight heparin. Rehydration should be encouraged as weel as early mobilisation.

(b) Obesity, anaemia, poor surgical etiquette in the way of contamination/poor sterile techniques lends itself to post operative infections. Again, I would encourage weight loss and refer to dietitian. In pre operative assessments Haemoglobin counts should be optimised. Preoperative should screen for any obstructive airway disease that might lead to chest infections post op.

Intraoperative I would ensure sterile procedure for urinary catheterisation to reduce the risk of urinary tract infections. I would endeavour to keep blood loss at a minimum and transfuse if deemed necessary. Intra operative antibiotics should also be administered as this also reduces the risk of post operative infection.

Post operatively, deep breathing exercises and or physiotherapy should be exercised. I would ensure that the wound site is clean. There should be guidelines on the ward with regards to reduction of nosocomial infections (eg Clostridium welchi) and ensure that hidh standards of practice are upheld.

(c) Sudden onset of pleuritic pain 3 days post op may be due to a pulmonary embolus. Initial management therefore would be to implement the ABC\'s of resuscitaion. I would check her O2 saturation and commence oxygen therapy via a face mask. Pulse and Blood pressure should be checked for a tachycardia and hypotensive episode which can occur with a PE. A raised temperature can also occur as well and this should be checked.

An electrocardiogram, and arterial blood gas should be done as it may show features in keeping with a PE. A chest xray and vq scan should be requested and the anaesthetist and medical physician should be informed with a view to seeing this patient promptly. I would document my management in the casenotes.
Posted by Farkhanda A.
Dear paul
Please can you check my answer on peri-operative care.

Thank you very much
Posted by Hethere D.
a-
The patient is at high risk of developing VTE in view of her age and morbid obesity, also because she has malignancy and planned for major pelvic surgery.
Pre-operatively, we can advice for weight loss; however, her operation should not be delayed in view of her malignancy. Also we advice to avoid immobility and stop any hormonal therapy if she take any.
Intra-operative time should be minimized as much as possible and the operation should be carried by most experienced surgeon to avoid excessive manipulation or damaging of pelvic veins. In addition intermittent pneumatic stocking can be used intraoperatively.
We encourage early mobilization post-operatively with adequate hydration. Prophylactic dose of LMWH is introduced 2-hours before operation and continued postoperatively until the patient is fully mobile.

b-

Good homeostasis is mandatory to avoid heamatoma formation which predispose to secondary infection. As far as the patient is undercover of heparin therapy, two drains are inserted, one intraperitoneal and the other one put over the rectus muscle to facilitate drainage of any accumulated blood. Transverse incision is associated with less formation of heamatoma and subsequently less incidence of infection, however, visualization of upper abdominal cavity may not be feasible and the operation may be more difficult with such incision in view of her weight. In addition, totally aseptic technique should be followed.
Antibiotic cover should prescribe and the dressing should be kept clean and dry.

We encourage chest physiotherapy to minimize chest infection, also advice for early removal of folly\'s catheter to avoid urinary tract infection.

c-

We do rapid assessment of the general condition of the patient; check if the patient is cyanosed, we measure vital signs to assess haemodynamic stability. Pleuretic chest pain goes with pulmonary embolism particularly the patient is at high risk of VTE, however, we should exclude other causes of chest pain like Ischeamic heart disease and pericarditis, we exam the chest, pleuretic rub goes with pericarditis while finding Gallop rhythm goes with heart failure.
We call for help of Multidisplinary team including physician, cardiologist and haematologist. Resuscitation is done and patient kept under liberal oxygen with maintenance of circulation.
We do ECG, blood gas analysis and chest X-ray. The heparin is changed to therapeutic dose of unfractionated heparin as it acts more rapidly than LMWH, streptokinase can be prescribed according to physician advice.
If the patient is haemodynamicaly unstable, percutanous pulmonary angiography is advisable to fragment the thrombus if facilities are available. The patient will need close monitoring in ICU as it can be a fatal condition.
Posted by San S.
a) A pre-op assessment is important to assess her risks of thromboembolism and other significant medical problems e.g. cardiovascular disease, immobility and chronic respiratory disorders. She is at high risk due to age, raised BMI, undergoing major abdominal surgery and underlying malignancy. It is important that she is on adequate prophylactic anticoagulant with low molecular weight heparin for her weight and TED stocking to prevent thromboembolism. She should be advise on keeping well hydrated pre and post operation and encouragemen of early mobilisation. She should stop taking any hormonal medication e.g. HRT or smoking.
b)Prophylactic intraoperative antibiotics has shown to decrease risk of infection. Aseptic techniques and hand washing od medical and nursing staffs prior to operation is vital to prevent infection. Post-operatively, it is important to emphasise hygiene and hand washing by medical and nursing staffs on the ward when handling with the wound. Iv access and catheter should be removed when appropriate as these may increase her risk of pheblitis and urinary tract infection. Physiotherapy should be considered especially in her case to prevent chest infection.
c)The initial assessment would be based on basic resuscitation if appropriate. I would make sure that her airways are patent, commence her on oxygen and gain iv access. Her initial observations e.g. temperature, pulse, BP, respiratory rate and oxygen saturation would be useful as she may be tachycardic, with low oxygen saturation and should cardiovascular compromise with low BP. Analgesia should be given to help relieve of her pleuritic chest pain while awaiting for other investigations. An ECG is useful as it may show right heart strain and S1Q3T3 pattern in pulmonary embolism. An arterial blood gas may show hypoxia and hypercapnia if she is hyperventilating. A CXR may be useful to rule out other causes e.g. pnemonia, atelactasisa, collapse.
She should be put on therapeutic LMWH due to her symptoms and increased risk for thromboembolism. I would also liase with the radiologist to arrange a v/Q scan or CTPA depending on availability. The gynaecology consultant or team should be informed of the event. Should she become cardiovascular compromised or unstable, the gynae consultant, anaesthetist, physician or ITU team should be involved in the management.