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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
Breast cancer
CA27-29
Breast cancer
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
Prostate
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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