HDU admission checklist
- Level 1 (Step Up/Step Down Unit)
- Patients at risk of deterioration or those recently relocated from Level 2/3 care whose needs can be met on an acute ward with additional advice and support from specialist teams
- Level 2 (HDU)
- Patients requiring more detailed observation or intervention including support for a single failing organ system or postoperative care and those stepping down from Level 3 care or up from Level 1 / ward care
- Level 2 criteria examples
- A need for more than 50% inspired oxygen
- Non-invasive ventilation i.e. CPAP or BiPAP
- Invasive pressure monitoring
- Haemodynamic instability due to hypovolaemia, haemorrhage, sepsis or other cause
- Central nervous system depression that threatens to compromise airway and protective reflexes
- Impaired renal, electrolyte or metabolic function
- Patients requiring extended postoperative care (i.e. major elective surgery, intraoperative complications)
- Level 3 (ICU)
- Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems
- This level includes complex patients requiring support for multi-organ failure
- Level 3 criteria examples
- Respiratory failure from any cause that requires invasive ventilation support, increasing levels of non-invasive ventilation support or extracorporeal respiratory support
- Surgical high risk patients who, in the context of their medical history and co-morbidity factors, are likely to require advanced respiratory and monitoring/support of organ systems
- Continuous intravenous medications and supplementary oxygen / airway monitoring to control seizures
- Vasoactive drugs used to support arterial pressure or cardiac output or intra-aortic balloon pump support
- Patients resuscitated following cardiac arrest where intensive care is considered clinically appropriate
- Acute renal replacement therapy with other advanced levels of organ support
- Patients who have sustained an irreversible brain injury and for whom death is imminent, who meet the clinical criteria for a potential organ donor and/or the family has made an enquiry regarding organ donation during end of life discussions
Bowel cancer red flags
- Persistent rectal bleeding for 6 weeks without anal symptoms (>60 yrs)
- Change in bowel habit to looser stools/increased frequency for 6 weeks (>60 yrs)
- Change in bowel habit to looser stools/increased frequency and rectal bleeding (>40 yrs)
- Palpable right iliac fossa mass
- Palpable rectal mass (intraluminal)
- Unexplained iron deficiency anaemia (Hb<11g/dL men, <10g/dL non-menstruating women)
- Features indicating a low risk of colorectal cancer include:
- Rectal bleeding with anal symptoms
- Rectal bleeding with an external visible cause, such as:
- prolapsed piles
- rectal prolapse
- anal fissures
- Change in bowel habit (decreased frequency of defaecation and harder stools) for less than 6 weeks
- Abdominal pain without iron deficiency anaemia or palpable abdominal mass
- Abdominal pain without evidence of intestinal obstruction
Common cancer markers- Alpha fetoprotein (AFP)
- Germ cell tumor, hepatocellular carcinoma
- CA15-3
- CA27-29
- CA19-9
- Mainly pancreatic cancer
- Also colorectal cancer and other types of gastrointestinal cancer
- CA-125
- Mainly ovarian cancer
- May also be elevated in for example endometrial cancer, fallopian tube cancer, lung cancer, breast cancer and gastrointestinal cancer
- May also increase in endometriosis
- Carcinoembryonic antigen
- Gastrointestinal cancer, cervix cancer, lung cancer, ovarian cancer, breast cancer, urinary tract cancer
- Glial fibrillary acidic protein (GFAP)
- Glioma (astrocytoma, ependymoma)
- Prostate-specific antigen
- Thyroglobulin
- Thyroid cancer (but not in medullary thyroid cancer)
Common post-operative complications- Immediate
- Primary haemorrhage
- Basal atelectasis
- Shock
- Low urine output
- Early
- Acute confusion
- Nausea and vomiting
- Fever
- Secondary haemorrhage
- Pneumonia
- Wound or anastomosis dehiscence
- Deep vein thrombosis (DVT)
- Acute urinary retention
- Urinary tract infection
- Post-operative wound infection
- Bowel obstruction due to fibrinous adhesions
- Paralytic Ileus
- Late
- Bowel obstruction due to fibrous adhesions
- Incisional hernia
- Persistent sinus
- Recurrence of reason for surgery, eg malignancy
Post-operative fever - Days 0 to 2
- Mild fever (T <38 °C) (Common)
- Tissue damage and necrosis at operation site
- Haematoma
- Persistent fever (T >38 °C)
- Atelectasis: the collapsed lung may become secondarily infected
- Specific infections related to the surgery, eg biliary infection post biliary surgery, UTI post-urological surgery
- Blood transfusion or drug reaction
- Days 3-5
- Bronchopneumonia
- Sepsis
- Wound infection
- Drip site infection or phlebitis
- Abscess formation, eg subphrenic or pelvic, depending on the surgery involved
- DVT
- After 5 days
- Specific complications related to surgery, eg bowel anastomosis breakdown, fistula formation
- After the first week
- Wound infection
- Distant sites of infection, eg UTI
- DVT, pulmonary embolus (PE)
Surgical management of colorectal cancer
- Colon surgery
- Open colectomy
- Laparoscopic-assisted colectomy
- Polypectomy and local excision
- Rectal surgery
- Polypectomy and local excision
- Local transanal resection (full thickness resection)
- Transanal endoscopic microsurgery (TEM)
- Low anterior resection
- Proctectomy with colo-anal anastomosis
- Abdominoperineal (AP) resection
- Pelvic exenteration
- Colorectal cancer metastases
- Radiofrequency ablation
- Ethanol (alcohol) ablation
- Cryosurgery (cryotherapy)
- Hepatic artery embolisation
Quinine
- P. falciparum
- Inhibits hemozoin biocrystallization => aggregation of cytotoxic heme
- Free cytotoxic heme accumulates in the parasites, causing their deaths
- Muscle cramps
- Raises the threshold for acetylcholine at the motor end plate
Notes- Surgery => Pain on deep inspiration => Atelectasis
- Retroperitoneal organs tend to cause back pain
- Pain out of proportion to injury suggests cancer
- Adhesions from previous surgery => Obstruction
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