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Laboratory Testing - Surgery Rounds

Transcript: Surgery Rounds December 11, 2018 Dr. Victor Leung, Dr. Janet Simons, Dr. Karen Dallas Too Much Information -- Choosing the Right Laboratory Services for your Patients Topic Too much information? Why it matters Physical harms Psychological consequences Treatment burden Social consequences Financial consequences Consequences of inappropriate testing Testing Cycle Analytic Pre analytic Post analytic Decision to perform test Test ordered Specimen collected and transported Specimen analyzed Result reported Data interpreted Clinical action Post-test probability Pre-test probability Diagnostic Stewardship Modifying the process of ordering, performing and reporting diagnostic tests to improve patient outcomes Topic Topic Subtopic One or more of the following: Dysuria New urgency New frequency New incontinence Suprapubic pain Costovertebral angle tenderness Checklist BEFORE Urine Culture Collection Cloudy or malodorous urine is insufficient to consider UTI Mental status change alone is insufficient to consider UTI Urine cultures at SPH Urine cultures at SPH Downstream effects: Unnecessary antibiotic use in > 30% of asymptomatic bacteriuria ~$10,000 wasted in laboratory costs Topic Daily Bloodwork 45 days of unnecessary bloodwork 45 pokes (no line, on apixaban) IV team had to draw near end of stay >8 hours of phlebotomy time 90 tubes >200 tests 300 mL of blood "CBC, lytes, Cr, BUN daily " Lauren “In the inpatient setting, don’t order repeated CBC and chemistry testing in the face of clinical and lab stability.” — Canadian Society of Internal Medicine, Choosing Wisely Canada recommendation #4 “Avoid standing orders for repeat CBC on inpatients who are clinically stable.” — Canadian Association of Pathologists, Choosing Wisely Canada Recommendation #4 “Don’t order repeat laboratory investigations on inpatients who are clinically stable.” — Resident Doctors of Canada, Choosing Wisely Canada Recommendation #2 What was the longest unbroken run of daily bloodwork? How much is too much? Inpatient data for St Paul’s Hospital, 2016-2018 202 days How many patients have had over 30 straight days of daily bloodwork? How much is too much? Inpatient data for St Paul’s Hospital, 2016-2018 270 patients Just surgical patients? 48 patients >30 days 327 patients 10-30 days Opportunity costs Happier patients More thoughtful ordering Less iatrogenic anemia Fewer morning collections Morning bloodwork done sooner Time and cost savings Better, more patient centred care Reducing ‘routine’ bloodwork could mean: Daily = x 3 days, then reassess Time limit on frequency (q4h, BID) orders – TBD Exceptions for ex. IV heparin Automatic Stop on ‘Daily’ Bloodwork Orders What you can do today Write orders for bloodwork 'in AM' or daily x2 or 3 days Review 'standing' bloodwork orders on your patients New Policy Proposal Topic Why give TWO when ONE will do? Don’t transfuse more than one red cell unit at a time when transfusion is required in stable, non-bleeding patients. Canadian Society for Transfusion Medicine Don’t transfuse patients based solely on an arbitrary hemoglobin threshold. Canadian Hematology Society Don’t transfuse red blood cells for arbitrary hemoglobin or hematocrit thresholds in the absence of symptoms, active coronary disease, heart failure or stroke. Canadian Society of Internal Medicine We are ready for change INR / PTT Hematology consult multiple tests hematopathology consult INR developed in 1930’s for Warfarin monitoring PTT developed in 1940’s for high-risk hemophilia screening & later validated for heparin monitoring INR & PTT Do these tests “predict” a patient’s propensity for bleeding? Emergency Department 81%  INR and PTT ordered together 18.2%  only INR 0.8%  only PTT In just one year @ SPH  ~20 patients each who had >10 days in a row normal INR or PTT What are we doing at PHC? REFLECT on your own practice - what could you question? COMMIT to one thing you will start doing differently or thinking about differently DISCUSS with your colleagues, trainees, supervisors, and patients Call to Action Topic providencelaboratory.comOnline Test Directory We're here to help! Contact Us Data Science for Doctors Free for PHC physicians course all day Feb 1/2 Come Visit Us!

Rounds Presentation

Transcript: Team - SLP, OT, TA 4-5 sessions/client Ax 2-3 Tx sessions with TA Follow up/Prescription Waitlist management 12 clients Phone History prior to Ax Plan: 3 Goals “The goal is to connect these children and youth to the services they need as early as possible and improve the service experience of families in three key areas: 1. Identifying kids earlier and getting them the right help sooner Trained providers ...will screen for potential risks to the child’s development as early as possible. 2. Coordinating service planning New service planning coordinators ... will connect families to the right services and supports. 3. Making supports and service delivery seamless Integrating the delivery of rehabilitation services...Services will be easier to access and seamless from birth through the school years.” ( Barriers and Reflections Barriers Identifying and Meeting Our Client Needs 1. Increasing awareness amongst first responder community.  2. Offering resources and training , e.g., CDAC for frontline workers, and possibly sharing information via catchment agencies’ web sites.  3. Review role of signifier/arm band (with or without CAN symbol). The client and family may make use of aid (if their preference) in order to help first responder. 1. Kingston ACS Screening Clinic Screening Assessment Existing Screening Measures 2. Early AAC Intervention. Triaging select clients on waitlist. Prospective clients may not benefit from high tech intervention. Offered recommendations and treatment. Placement on wait list removed or adjusted accordingly. Minimizing/mitigating service gaps, i.e., more seamless service.  9 clients seen across 3 clinics: Language Express (PSL Smiths Falls); Pathways for Children & Youth (IBI); and Early Expressions (PSL Kingston)  5/9 referrals, i.e., 4 potentially inappropriate referrals not received. *Community providers rated quality of service and benefit of recommendations 5/5. Satisfaction and meeting clients' needs 4/5. Liked specific activity examples and strategies most. Results Preliminary Planning Stage Tyler Levee, M.Cl.Sc, S-LP (C), Reg.CASLPO Problem 6/12 clients seen Purpose and rationale  Community partners promote use of high tech systems for face-to-face communication. Sometimes inappropriate suggestions for system and/or implementation made. Opportunity to offer recommendations, suggest system or resource. Occasionally inappropriate referrals received, e.g., a client has functional speech or he/she is preintentional or not a symbol user. Meeting needs across large catchment and narrows/shortens wait list. 3. Identification of Communication Needs to First Responders Jessica Whynot, RECE,CDA, Therapy Assistant Long waitlist Complex cases Not necessarily appropriate for high tech Proposed initiatives to meet these needs: Concerns, Barriers, and Benefits Clients not appropriate for high tech - sent with low tech goals to work on One-to-one Tx - clinic is consultative Integrated services with other teams (Special Needs Strategy)  Composite checklist of essential AAC skills, e.g., intentional communication attempts, recognition and discrimination of symbols  Obtain additional valuable information inc. ability to match item to category, access needs, etc. Serves as guideline  Communication and Symbolic Behaviour Scales – Developmental Profile (CSBS-DP)  Augmentative Communication Interaction Checklist (Church & Glennen, 1992)  Meaningful Use of Speech Scale (MUSS) (Robbins & Osberger, 1992)  Augmentative and Alternative Communication Information and Needs Assessment (Beukelman & Mirenda, 1992)  Communication Matrix (Rowland, 2004)  Interactive Checklist for Augmentative Communication (INCH) (Bolton & Dashiell, 1991) Greater sensitivity than specificity? I.e., based on items alone, it is not great at identifying those who meet criteria but would not be eligible for prescription (emerging speech, unintelligible speech, DAS).  Poor reliability? Recognition and discrimination for novel symbols. Some clients were able to demonstrate skills only after multiple teaching trials. Others were able to demonstrate skills with own device, symbols. Inconsistent intake (coordinator vs. community ACS clinician) and misunderstanding amongst community providers. Resource intensive. Assessment Overview Special Needs Strategy Scheduling/time of the year Referral information was outdated SLP only available one day per week  Avoid stigmatization. Are clients visibly labeled by wearing signal and/or arm band? Do specific goals outweigh this concern?  Client needs may/may not be visible. Benefit for first responders to seek out system/device, seek contact information, ask family or guardians about need for system.  Nil traction with regional EMS. A number of contacts made. Possible to collaborate at provincial level?  Soliciting honest feedback re. the proposal, contacts and coordination process. Please see

Surgery Presentation

Transcript: Surgery: ET's presentation to hopsital Renee Duvenage 25/06/2013 Past Medical History: * 4 months Post partum- vaginal birth * L Carpal tunnel release Family history: * Father: AMI (3rd decade) Medications: * nil * NKDA Social History: * Non Smoker * Non Drinker * Lives at home with husband and child Differentials Provisional Diagnosis: GORD Peptic Ulcer Differential Diagnosis: Pancreatitis Cholecystitis AAA Investigations Management Biliary Colic Acute Cholangitis Chronic Cholangitis Anatomy: Can you name all the structures Management: Categories: 1: Incidental : requires no managment 2: Biliary symptoms, Gallstones (U/S), no complications 3: Atypical Symptoms, Gallstones (U/S) 4: Biliary symptoms without Gallstones (U/S) Complications Outcome Definitions and Classification Examination Further History Findings Thank you Imaging U/S: multiple small mobile calculi, mildly distended, positive sonographraphic Murphy's sign. CBD was not dilated (4.6 mm). Fatty liver changes identified. Presentation FBC: Leukocytosis LFT: All mildly elevated Abdominal pain S: Epigastric O: 2/7 C: Crescendo-descrendo, Never fully remitting R: Radiating to back and up to jaw. A: Alleviated by vomiting, associated with nausea, anorexia, T: At night, after dinner E: Exacerbated by food S: ranging from 3-8/10 Observation: appears comfortable at rest, bandages over laprascopic incisions present, IV cannula in situ, and is obese. Palpation: demonstrated a tender RUQ, and Positive Murphy's sign, AA difficult to palpate Auscultation: Bowel sounds present, no respiratory findings, HSDNM Percussion: Liver 14cm, no acites Blood Work Vital Signs: * Heart Rate: 74 bpm * Blood Pressure: 131/88 mmHg * Respiratory Rate: 22 bpm * Temperature: 37.7 C PC

Surgery Grand Rounds

Transcript: CC: shortness of breath 9 Make a lateral skin incision overlying the rib that is below the desired intercostal level of entry Indications: - Denies: Nausea, vomiting, diarrhea, HA, sore throat, urinary symptoms -Admits to: fevers, weakness, fatigue, unintentional weight loss 50lb/6 months, shortness of breath, cough, congestion, pleuritic chest pain Opportunistic Infections in AIDS Specimen: left lung, fresh Persistent air leak Bleeding from pulmonary vessels Intercostal nerve damage due to insertion of instruments through ports Complications from single lung ventilation, including respiratory insufficiency or post-operative re-expansion pulmonary edema Tumor implantation following VATS C Per notes – based on presence of oral thrush, his presentation is consistent with HIV, likely his CD4 lymphocyte count is <200. Pathology Report CXR suspicious for Pneumocystis pneumonia. Treatment of choice is TMP-SMX for 3 weeks. Corticosteriods have been shown to improve the course of patients with moderate to severe PCP with oxygen saturation <90% or PaO2 <65mmHg Surgery Grand Rounds Absolute: need for emergent thoracotomy Relative: coagulopathy, pulmonary bullae, pulmonary, pleural or thoracic adhesions, loculated pleural effusion or empyema, skin infection over the chest tube insertion site What labs and imaging do you want to order? Literature Review: Continued 6 POD #0: VATS with pleurodesis & placement of L chest tube POD #1: CXR, suction on chest tube d/c’d POD #2: CXR shows worsening L pneumothorax likely 2/2 airleak, restart suctionPOD #3: CXR shows some improvement POD#4: CXR shows small increase in small L residual apical pneumothorax, +AFB from 2/14, started on RIPE tx for TB, 1-3 beta glucan fungal test positive, Pathology report returns POD #5: CXR shows trace pneumothorax POD #6: CXR stable, Mycobacterium TB complex PCR negative POD #7: CXR shows increased pneumothorax POD #8: CXR stable, must be cleared by the health department POD #9: CXR stable POD #10: CXR stable, no airleak noted POD #11: CXR shows decreasing pneumothorax POD #12: CXR stable, AFB grew M.avium complex x1 POD #13: CXR cleared by Epidemiology department for d/c home with Heimlich valve (one-way valve) Q: You are taking care of 40M with a history of HIV (diagnosed 2 years ago) and has been on therapy without disease progression. You order a PPD. What amount of induration would he be positive for TB? a) Any induration indicates a positive b) 3 mm c) 5 mm d) 10 mm e) 15 mm Heimlich Valve 1. Markedly unstable or shocked patient 2. Extensive adhesions obliterating the pleural space 3. Prior talc pleurodesis Deflated lung Contraindications: Anesthesia: General with selective single lung ventilation using a double-lumen endobronchial tube Positioning: lateral decubitus Steps: 1-4 incisions are used in thorascopic procedures, at least 5cm apart so instruments do not cross “baseball diamond” Endoscope along with instruments are used to manipulate the lung, staple lung biopsy retrieved with endocatch bag through trochar ports. Single stitch or few subcuticular stitches placed if needed. Chest tube placed in normal fashion THANKS, THAT'S IT!!!! Absolute Lymphocyte Count = WBC x Lymphocyte% x10 Vitals Signs: HR 110, RR 20, BP 132/77, T 100.6, O2 saturation 98% RA, wt 165lbs HEENT: NCAT, PERRL, EOMI b/l, no scleral icterus +mild to moderate oral thrush involving the roof of the mouth, no anterior cervical lymph node tenderness but +mildly enlarged lymph node palpated CV: regular rhythm, tachycardic, no murmurs Resp: Right lung – some rhonchi, Left lung – reduced breath sounds Abdomen: soft, ND, no TTP, bowel sounds normoactive x4, no HSM, no jaundice Ext: no edema, no clubbing, pulses strong Neuro: A&Ox4, neurologically intact OMM: b/l suboccipital hypertonicity, b/l hypertonicity with bogginess in b/l upper thoracics, L thoracic diaphragm restricted, L lower rib restriction (Ribs 7-12) Minkes (whale) & Deere 1 Treatments: Suboccipital release Thoracic diaphragm release Paraspinal inhibition MFR of thoracic paraspinal muscles Osteopathic Manipulative Medicine Objectives: To discuss the case presentation of surgical patient To describe the surgical management of the case To discuss the medical management of the patient subsequently To relate this patient to OP&P To provide board-study questions Look for respiration-related swing in the fluid level of the water seal device to confirm correct intrathoracic placement C Pneumothorax (open or closed) (simple or tension) Hemothorax Hemopneumothorax Hydrothorax Chylothorax Empyema Pleural effusion Patients with penetrating chest wall injuries (intentional/unintentional) "Sections show consolidated lung tissue containing alveolar spaces filled with pink foamy amorphous material and numerous macrophages..." "An AFB stain is negative for mycobacteria..." "A GMS stain on specimens A and B highlights numerous organisms consistent with Pneumocystis jiroveci." 7 Recurrent Pneumothorax Left Pneumothorax s/p chest

Surgery presentation

Transcript: Ductal Adenocarcinoma Surgical treatment? Both procedures provide adequate pain relief and quality of life after long-term follow-up with no differences regarding exocrine and endocrine function. However, short-term results favor the organ-sparing procedure.* Puestow procedure Duval US CT ERCP Pathological types Insulinoma Glucagonoma Gastrinoma Somatostatinoma VIPoma Prognosis Laparoscopic Treatment Open Abdominal pain Nausea, Vomiting Epigastric tenderness Tachycardia, Hypotension Fever Paralytic ileus Ecchymoses CT US Epidemiology teroids P A N C R E A S Distal pancreatectomy Whipple's procedure Subtotal pancreatectomy Total pancreatectomy Complications Pseudocyst Infected necrosis Abscess GI bleeding Thrombosis Analgesics Celiac plexus block Pancreatic enzyme supplements Fat-soluble vitamins Insulin may be needed Diet; No alcohol, low fat Clinical symptoms Surgical Management ge >55 Whipple's procedure Symptoms Puestow procedure Treatment G E T S M A S H E D <2% of all malignancies. Usually appears in elderly. Severe Pancreatitis Distal Pancreatectomy Pathophysiology Diagnosis RCP Causes Whipple's prcedure ugar, glucose >10 mmol/L Pseudocyst Pancreaticoenteric fistulas Diabetes Mellitus Malabsorption Pancreas carcinoma THANK YOU FOR YOUR ATTENTION yperlipidemia, hypercalcemia Minimally invasive - necrosectomy through small incision in skin or stomach Conventional - necrosectomy with simple drainage Closed - necrosectomy with closed continuous postoperative lavage Open - necrosectomy with planned staged reoperations utoimmune (PAN) Resectional rauma Nasogastic tube Nothing PO 60% pancreatic head 25% body 15% tail Surgery Presentation Diagnosis Distal pancreatectomy Cullen Sign rugs Surgical Thrombophlebitis migrans Hypercalcemia Portal hypertension Splenic vein thrombosis Hemorrhagic Treatment nzymes, LDH > 600 U/L, ASAT > 200 U/L Tumor < 3cm and no metastases No survival benefit in non-curative resections Post-op morbidity is high Symptoms Mild Alcohol eutrophilia, WBC > 15 Cholestatic jaundice CA 19-9 Diffuse scarring and strictures in the pancreatic duct Exocrine & endocrine insufficiency Drainage Resection with extended drainage Acute Complications Partial Fluids Blood tests corpion venom Pancreatitis Acute Pancreatitis Extended drainage Endoscopic or percutaneous stent insertion Bypass for duodenal obstructions Pain relief (opiates or radiotherapy) Celiac plexus infiltration Pain relief PPI H2 blocker * GET SMASHED! allstones Painless obstructive jaundice Courvoisier's sign Epigastric pain which radiates to the back and relieved by sitting forward Anorexia Diabetes mellitus Acute pancreatitis Surgical management of chronic pancreatitis: Imaging Risk factors Microvascular leakage Necrosis of fat by lipase SIRS Proteolytic destruction of parenchyma Destruction of blood vessels with hemorrhage Supportive of Severe Pancreatitis Pancreatic rest Shock with MODS ARDS Renal failure DIC Sepsis Hypocalcemia Pancreatic Tumors (Pancreatoduodenectomy) aO2 <8 kPa (<60 mmHg) thanol Symptomatic Rumpfs Diagnosis Late Secretin stimulation test Imaging (US, CT, XR, ERCP) Fecal elastase Amylase & lipase usually normal Complete Fluid resuscitation Respiratory care Cardiovascular care Pain relief Parenteral feeding Treatment of infection Chronic Frey's procedure Hans Beger's Pathology Partington-Rochelle procedure 12% Mortality Managed on surgical wards although surgery is not often involved Severe Blood tests PANCREAS! Early Symptoms of Mild Pancreatitis Surgical Mean survival 6 months 5-year survival <2% Imaging Medical Palliative Acute necrotizing Grey-Turner Sign Etiology Cystic fibrosis Hemochromatosis Hyperlipidemia Hyperparathyroidism by Eivind W. Aabel umps Clinical enal function, Urea > 16 mmol/L Others Smoking Alcohol Carcinogens Diabetes Chronic pancreatitis High fat diet Partington-Rochelle Bapat lbumin <32 g/L Location alcium <2 mmol/L Mid-epigastric pain Jaundice Weight loss Steatorrhea Tenderness Mass Diabetic symptoms Amylase & Lipase >3x Treatment

Surgery Presentation

Transcript: However, HIPEC itself carries morbidity and mortality -Reduce surgical trauma -Decrease recovery time -Increased intra-abdominal pressure during HIPEC improves penetration Median survival for Peritoneal sarcomatosis without treatment is about 6-15 months Laparoscopic Hyperthermic Intraperitoneal chemotherapy -Cao, et al. A Systematic Review and Meta-Analysis of Cytoreductive Surgery wtih Perioperative Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis of Colorectal Origin -Glehen, et al. Toward Curative Treatment of Peritoneal Carcinomatosis From nonovarian origin by cytoreductive Surgery Combined With Perioperative Intraperitoneal Chemotherapy -Facchiano, Laparoscopic Hyperthermic Intraperitoneal Chemotherapy: Indications, Aims, and Results: a Systematic review of the literature -Salti, et al. Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for the Treatment of Peritoneal Sarcomatosis -Perioperative morbidity was 33.6% -Mortality 4.1% (Glehen et al.) -Risk factors: -Extent of cytoreduction -Length of operative time -Number of intestinal anastamoses -Peritonectomy procedure (Facchiano et al.) THANK YOU Thus, laparoscopic HIPEC has been explored to reduce morbidity and mortality For the last two decades, cytoreductive surgery combined with peri- operative intraperitoneal chemotherapy has evolved to improve survival Of 183 patients, only 13 minor complications (7.1%). None required repeat operation. Nine of 13 were being treated to palliate malignant ascites. Leigh Casadaban Surgery 2012 -High concentration chemotherapy to peritoneal cavity -Locoregional treatment for malignancies of the peritoneum -Treats the microscopic disease that cytoreductive therapy may leave behind - Only plan that has produced curative results -Widely reported in last 2 decades Bibliography Malignancies of the peritoneum are often terminal Dr. Salti showed the mean disease free survival was 27 months, and overall survival was 35 months, for 9 patients that had achieved complete cytoreduction before HIPEC Advantages to Laparoscopic HIPEC Hyperthermic Intraperitoneal Chemotherapy (HIPEC):

Surgery Presentation

Transcript: Medical History Physiological history ABCDE: Allergies, Bleeding, Cortisone, Diabetes, Emboli Physical examination or CPX Educational evaluation Preoperative anesthesia evaluation: Resp,Cardio, Neuro Diet and Medication Nursing Diagnosis and Care plan Patient Consent Form Patient teaching Preopertative Assessment !!!!!!!!!!!! •PHOTOGRAPHS BY MAX AGUILERA-HELLWEG // WINTER 2007 Seroma Hematoma Evisceration Post operation Problems Post operative Fever Intra-operation Brief assessment Identify the patient Position the patient Safety Documentation PACU Post Operative Care Types of surgery Classified by: urgency: elective, semi-elective, and emergency Invasiveness: Minimal, Laparoscopic, and open surgery Instrumental usage: Laser, robotic, microsurgery SURGERY Additional Assessment: Wound Comlication: SURGERY TIME Protecting airways controlling hypoventilation Maintain Normal Blood Pressure Monitor return to consciousness Monitor resturn of sensation and motion Assess for normothermia Assess surgical site Electrolyte and fluid balance Manage drainage Promote comfort Complete the care plan Assess: respiratory, Cariac, Neuro. Monitor Wound, sutures, and staples Intravenouse Lines Drainage Tube, suctions, gravity base Comfort and Pain Nausea and vomitting Ambulation Surgery PACU or Post Anesthetic Care Unit Acute Pain Respiratory Depression Acute Infection Hemorrhage Hypotension Nausea and Vomiting Oliguria Dehydration Atelctasis wound complication Cheirourgik= Hand work Definition: The branch of medicine dealing with manual and operative procedures for correction of deformities and defects, repair of injuries, and diagnosis and cure of certain disease. (U-central)

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