SESSION 1: PERIOPERATIVE CARE

I) POSTOPERATIVE CARE
Apply findings from Hx, PE, investigations to ​Dx ​& propose initial m
​ gmt​ plan for post-op complications
Pneumonia Hx​:
● Fever, chills, cough, SOB, pleuritic chest pain
● PMHx: immunosuppression, smoking, CF, aspiration risk
PE​:
●
Cough, tachypnea, tachycardia, fever
●
Consolidation - dullness to percussion, bronchial breath
sounds, crackles, decreased air entry
Investigations​:
● Pulse ox
● CBC + diff, sputum and blood gram stain / C&S,
● CXR (± CT)
Management​: ABC, O2, IV fluids, salbutamol, antibiotics (resp FQ)

Pulmonary embolism
Hx​: pleuritic chest pain, dyspnea, hemoptysis, RF for VTE
(immobility, hypercoagulation, recent surgery, cancer)
PE​: tachycardia, dyspnea, hypoxemia, evidence of DVT
Investigations​: pulse ox, ECG, CXR, CT pulmonary angiogram, leg
Doppler
Management​: ABCs, O2, airway management, ​anticoagulation
(LMWH/UFH min 5 days + heparin ​OR ​DOAC monoTx)​, catheter
directed thrombolysis or surgical thrombectomy

DVT Hx​:
PE​:
Investigations​:
Management​:

Atelectasis Hx​: low grade fever POD 1; RF = smoking, COPD, obesity, elderly,
upper abdo/thoracic surgery
PE​: tachycardia, tachypnea, crackles, decreased breath sounds,
bronchial breathing
Investigations​: SpO2
Management​: deep breathing exercise, chest PT, positive-pressure
breathing, early ambulation, appropriate pain control

Hypoventilation Hx​:
PE​:
Investigations​:
Management​:

Urinary retention Hx​: abdominal discomfort, overflow incont

PE​: palpable bladder
Investigations​: PVR >100ml
Management​: Foley catheter → trial of voiding

UTI Hx​: FUND

Investigations​: UA, urine culture
Management​: antibiotics

Oliguria Hx​:
 PE​:
Investigations​: Cr, eGFR, BUN, Na, UO <0.5cc/kg/h
Management​: fluid deficit replacement, treat underlying cause

Compartment syndrome Hx​:

PE​:
Investigations​:
Management​:

Surgical site infection Hx​: POD 3-7

PE​:
Investigations​:
Management​:

Increased enteric losses Hx​:

PE​:
Investigations​:
Management​:

Ileus Hx​:
PE​: abdominal distension
Investigations​: abdominal XR (r/o impaction)
Management​: bowel rest

Hypovolemia Hx​:
PE​:
Investigations​:
Management​:

Delirium Hx​:
PE​:
Investigations​:
Management​:

Describe approach to assessment & mgmt of post-op fever

Common post-op complications - including fevers
Waves MI, PE, VTE

Wind Pneumonia, PE, atelectasis, pulmonary edema

Water UTI, AKI, retention

Wound (often day 5-7) SSI, superficial or deep infections

Widgets Infected implantables -- e.g. pacemakers, platelets

Wonder drugs Drug fevers, withdrawal, side effect

Describe approach to assessment & mgmt of wound complications -- infection, dehiscence

Dressings can be removed POD #2, skin sutures/staples removed POD 7-10
Examine wound if wet dressing or signs of infection (erythema, pain, oozing, warmth, fever, tachy)
 ● Tx of wound infection: swab for C&S and gram stain; reopen affected part of incision to
drain, pack & heal by 2ary intention; debride necrotic & nonviable tissue for deeper
infection; antibiotics & demarcation of erythema only if cellulitis or immunodef
Wound dehiscence frequently from serosang drainage, possible evisceration
● Transfer to OR for re-closure

II) RADIATION ONCOLOGY

Basic terminology
● Tumor/neoplasm: abnormal mass of tissue resulting from when cells divide more than they
should or not die when they should - may be benign (not cancer) or malignant (cancer)
● Cancer: dz where abN cells divide w/o control & able to invade other tissues
○ Hallmarks:
■ Inappropriate cell proliferation - ↑ cell production, ↓ cell death
■ Neoangiogenesis
■ Invasion & metastasis
■ Genomic instability

Describe how cancer spreads & relevance of this to the TNM staging system, Hx, P/E & mgmt of cancer
pts
Mechanisms of spread:
1. Direct invasion
2. Lymphatics
3. Hematogenous (blood stream)
4. Transcoelomic: pleural, pericardial, peritoneal
● Understanding spread can help conduct proper Hx (potential local/lymph/hematogenous
Sx of spread), proper physical, order correct staging investigations

Stage​ = based on tumor extent, nodal status & spread VS ​grade​ = how ab/normal cells look
Staging cancer:
T​umor Size/extent of 1ary tumor, correlates with direct invasion

N​odes Spread to nearby LN, correlates w/ lymphatic spread

M​etastasis Spread to other parts of body, correlates w/ hematogenous spread

Clinical staging: P/E, imaging, lab reports
Pathological staging: pathology & surgery reports

Differentiate goals of cancer Tx

Radical Curative intent; complete ablation

Adjuvant Curative intent; addresses microscopic dz & reduce recurrence risk

Palliative Reduce/prevent Sx

Describe and provide examples of patient factors, tumor factors, treatment factors that influence Tx
decisions of cancer patients
Patient factors Performance status (comorbidities)
Patient preference

Tumor factors Type of cancer (histology, natural history)

Extend of cancer (TNM)
Symptoms

Treatment factors Availability & effectiveness of Tx

Potential toxicity

Treatment options
Surgery Mainstay for radical therapy for most ​solid​ cancers
● Allows pathologic examination of tumor ± LN

Systemic Tx Mainstay for radical therapy for most ​hematologic​ cancers

 Radiation Tx Used as radical therapy for some solid cancers ± chemo

Principles of radiation therapy

Radiation: high energy ionizing photons (= strong XR) that causes damage to cellular DNA
● Cancer cells have difficulty repairing cell damage
● Tx usually delivered in series of small daily Tx (“fractions”)
○ Small doses allow time for normal tissues to heal
○ Total dose = # fractions x daily dose
● Accurate treatment is important -- require imaging for planning (CT, MRI, PET),
immobilization devices (masks, shells), routinely check set-up during Tx

Types of Radiation Therapy

External Beam Radiation Radiation given from a source outside of the body
Therapy (EBRT) *​most ● Radiation beam must go through normal tissue before
reaching target -- SE dictated by area the beams transverse

Brachytherapy Direct application of a radioactive source into/adjacent to the tumor

● Used in cervix, prostate, lung, esophagus

Isotope therapy IV or PO ingestion of radioactive isotopes that concentrate in

malignant tissue
● I​131​ for thyroid cancer

List common acute & late SE of radiation Tx

Acute​ (w/i 6mo of Tx) From acute inflammatory reaction
● Ex: moist skin desquamation after chest wall radiation
 Late ​(>6mo of Tx) From connective tissue fibrosis & obliteration of small blood vessels
● Ex: changes in skin pigmentation, fibrosis, telangiectasia

Describe clinical presentation, investigations & immediate mgmt of common oncologic emergencies
Radiation oncology emergency: medical condition arising from reversible threat to organ function
requiring radiation Tx w/i few hours of Dx
Spinal cord Compression of dural sac & its contents (spinal cord or cauda equina)
compression by extradural tumor mass
40% cancer pts have ● Min radiologic evidence: indentation of thecal sac @ level of
spinal metastasis → 20% clinical features
will develop Sx’atic spinal ● Spinal cords ends ~L1/L2
cord compression ○ Above = spinal cord compression
● C: 10% ○ Below = cauda equina syndrome
● T: 60%
● L/S: 30% Pathophys:
● Growth & expansion of vertebral bone metastasis into
epidural space
● Neural foramina extension by paraspinal mass
● Destruction of vertebra → collapse & displacement of bony
fragments into epidural space
*Results in ​vascular damage
● ↑ arteriole pressure, venous plexus compression, reduced
capillary blood flow → spinal cord edema
○ = White matter ischemia & infarction
○ Permanent cord damage

Sx:
● Back pain​ - first Sx in 90%, hallmark of early SCC
○ Localized, radicular pain is most common, often
precedes other neuro deficits by months
○ Most severe over involved vertebra
■ Tight/gripping sensation
○ Can have numbness/paresthesia (usually later)
● Weakness​ - most common Sx leading to medical attn

● Sphincter dysfn​ (bowel/bladder) - rarely in isolation

○ Foley catheter, rectal exam

Investigations:
● Plan XR, CT
● Myelography ​(not routine, historically used when MRI unavail)
● MRI -- test of choice if high suspicion
● Involve rad onc or neurosurgery if worried!
 Ambulatory status pre-Tx related to post-treatment outcomes
Earlier Tx = better
Treatment:
Steroids First step: ​dexamethasone
Help retain motor function
No evidence for dose >16mg/day ​(same E, more SE)
Short term SE: antiemetic, anti-inflam, insomnia, incr glc

Surgery For: vertebral body instability, tissue/Dx, prior to

radiation Tx -- improves outcomes in subsets of
pts

Vs radiotherapy:
● Intuitively Sx advantage of providing
immediate functional & physiologic
stability
● But rehab & wound healing post-op not
suitable for all pts

Radiotherapy For: all pts who aren’t candidates for

decompressive Sx upfront, given to surgical
candidates after surgery

5-10 fractions directed at involved site

Goals: improve pain, improve/maintain
ambulation

Chemo May be useful in select cases of highly

chemo-sensitive tumors
 Generally not first line Tx

Take home:
● Decision for Tx considers medical status, ambulatory status,
structural factors, anticipated outcomes, Tx goals
● Tx goals = improve/maintain QoL w/ pain relief & restoring
function
● Early referrals = best results

SVC obstruction Pathophys:

2-4% of lung cancer pts
More common small cell >
non-small cell -- rapid
growth of chest dz
Sx:
● SVC obstruction by invasion, external compression or internal
blockage
● Can be due to:
○ Benign - thrombus, goitre, sarcoid, aneurysm
○ Malignant - ​lung cancer​ (75%), germ cell cancer,
thyroid cancer, metastatic dz
● D​yspnea
● D​istension
○ Edema of face (with erythema/plethora)
○ Edema of arms
● D​ilated chest wall vessels

Investigations:
● CXR
● Chest CT w/ contrast -- to see SVC

Treatment:
ABC’s

Steroids Dexamethasone

Radiotherapy Best for non-small cell lung cancer

● Unless pt is very unwell, wait for tissue
confirmation before Tx
● Takes days/weeks to work -- not really
emergency, more of an urgency
● E: relief of Sx in most cases

Chemotherapy Best for small cell lung cancer, lymphoma

Surgery Endovascular stent for rapid relief

Malignant hemorrhage Bleeding from disruption of friable vasculature associated w/ tumor

● Most common: gyne/cervix, lung, H&N

Treatment:
ABC’s
 Physical Packing (pressure)
measures Cautery
Surgery
Vascular embolization

Radiation therapy Goal: Sx improvement

● Takes days/weeks -- not really
emergency, more of an urgency

Brain metastases Causes increased ICP

Sx: variable
● Asymptomatic
● Symptomatic: H, cognitive impairment, hemiparesis, seizures

Treatment:
ABC’s

Medical Steroids (dexamethasone)

± anti-epileptics

Surgical Reduce mass effect, Dx, can improve outcome

Radiation therapy Goal: Sx improvement

● Takes time (worsens edema initially)
-- not really emergency, more of an
urgency

Describe importance of interprofessional team care based in oncology

**​Radiation Oncology Basics​ lecture has a case to go through**

III) SURGERY BASICS WORKSHOP

Describe the uses of basic surgical instrumentation
Basic steps to surgery: open, expose/retract, remove/repair, close
● Requires management of homeostasis
Cutting Scalpels - handle & detachable blade vs disposable
Scissors

Retracting & exposing Skin/dura hooks

Rakes/double ended
Weitlaner self retaining retractor

Grasping, dissecting, clamping, Forceps

occluding instruments Simple clamps, fascia/organ clamps

Homeostatic instruments Cautery: monopolar vs bipolar

● Have cut (con’d voltage) & coagulate (bolts of
 voltage) settings
● Monopolar: requires grounding pad to prevent burns
● Bipolar: current goes btw tips, no need for grounding
pad, safer in defib/pacemakers

Wound closing instruments & Surgical adhesives ​e.g. cyanoacrylate

materials Self-adhesive strips ​e.g. Steri-strip
Staples
Sutures, needle (point & circle), needle driver
● Needle point: conventional △, reverse cutting ▽,
taperpoint ൦

Describe the chara & uses of surgical sutures

Anything with “glyc” in its name Nylon (polyamide), polypropylene

*Absorbable = breakdown @ 2mo
Ideal Suture
● Not electrolytic, allergenic, carcinogenic
● Non-ferromagnetic
● Easy to handle
● Minimally reactive in tissue & not predisposed to bacterial growth
● Capable of holding tissue layers throughout wound healing
● Resistant to shrinking in tissues
● Sterile

Outline stages of soft tissue healing & factors altering healing process - From Video
Wound: any interruption in normal structure and fn in the skin layer and underlying tissue
Primary wound healing: wound edges approximated w/ sutures or other measures of closure
Secondary wound healing: wound left open to heal
Tertiary healing: intentionally left open and later closed

3 Phases of Wound Healing

Inflammation w/i seconds → ​hemostasis​: clotting cascade, platelet aggregation → fibrin clot,
Seconds vasoconstriction = reduce active bleeding
5-10min later → vasodilation & more permeable = allow fluid exudate to pass
thru vessel walls & into injured area
● Neutrophil & monocyte recruitment → phagocytosis of bacteria &
wound debris
● Macrophages release cytokines & present antigens for healing

Proliferation Angiogenesis (O2 and nutrients for high levels of cellular activity)
Fibroblast recruitment and form matrix of type III collagen
● Some forms myofibroblasts for wound contracture
Granulation tissue: made of new blood vessels, fibroblasts, inflam cells, ECM

Keratinocyte migration → epithelialization

● Grow until contact inhibition
● Release proteins to form new BM
● Divide & differentiation of basal cells

Remodeling Type III collagen → type I collagen

3 wks - 1 yr ● Rearranged and cross linked, aligned along tension lines to increase
tensile strength of wound
● Tensile strength 50% @ 3mo, max 80% @ 1yr

Decreased proliferation = decrease O2 demand = apoptosis of unnecessary

blood vessels = lighter scar

Wound Modulators
 Local Systemic

Infection Age
Foreign body in wound Cancer
Radiation injury Nutrition
Surgical technique Uremia
Suture type & tension Sepsis
Drugs (e.g. steroids)

Bone bowel & nerves undergo special healing processes

Describe basic wound care for 1ary closed & open wounds
Wound Healing and Wound Care – Lecture
Assessing the patient Surgical/trauma history
Age
General medical state: DM, cardiopulmonary, nutritional, peripheral
circulation, edema, cancer, smoking
Medications
Activity level & type of activity
Assessing the wound Type of wound: open vs closed
Classify wound
● Surgical wound classification
Clean E.g. hernia repair SSI risk 5%
Clean E.g. elective GI/GU/resp Sx SSI risk 10%
contaminated w/o spillage
Contaminated E.g. breech sterility, gross GI SSI risk 50%
spillage, encounter acute
non-purulent inflam
Dirty E.g. perforated viscus, pus SSI risk
encountered >>50%
Closing techniques: stitches, steri-strips, staples, glue, nothing

Ask for help: nurses, specialized wound care nurses, enterostomal therapists (ETs), technology
representatives (e.g. VACs), wound care clinics, dermatologists, plastic surgeons
Wound care basics
Manage the bioburden Factors adversely affecting wound healing:
● Excess bacteria or bacteria of wrong type
● Devitalized tissue, foreign material
Management:
● Cleansing: mechanical, chemical, enzymatic
● Debridement: surgical (safest), mechanical, enzymatic, biologic
● Prevention: washing, dressing
Help the circulation Address factors impairing circulation:
● Prevent/treat edema
● Systemic optimization

Vacuum Assisted Closure (VAC) can help manage bioburden & improve
circulation

Moisture balance Wounds heal better in moist environment

● Don’t let a wound ​dry​ out: use hydrogels (e.g. Intrasite to add
moisture), less freq dressing changes, primary closure
● Manage excess ​moisture​ (e.g. exudate)
o Dressings that absorb or wick away moisture
▪ Packing to reduce dead space
o More frequent dressing changes
o Drains
o VACs

Define: beneficence, non-maleficence, autonomy, justice

What is right? – moral, ethical, practical, legal

4 Key Ethical Elements

Autonomy Patient’s right to make free decisions about his/her own health care ​and others
● Has aspect of respect, responsibility, rationality, and ability to make own
choices
Beneficence Anything done by physician is done based on expectation that pt will likely
benefit from it
Non-maleficence Physician will refrain from any Tx that will likely result in harm to patient
Justice Burdens & benefits shared throughout society
● Fair distribution of scarce resources
● But need to consider competing needs, rights, obligations
Other Research – is surgical research ever possible?
considerations Confidentiality – when can you discuss a pt’s condition/care
Surgical training & associated risks
 ● Overview of surgical ethics: be self-conscious, wonder, discuss, try to do good

Demonstrate ability to obtain informed consent for a minor procedure (e.g. colonoscopy)
Surgical Informed Consent
● Telling vs informing; understanding vs signing form; piece of paper vs process
● Valid consent requires sufficient information, lack of coercion, competence
● Challenges: temporary incompetence, deemed incompetence, immaturity, explicit vs
implicit

Outline roles of OR staff

Anesthesiologist
Chief surgeon
Assistant surgeon
Circulating nurse - help with paperwork, obtaining new materials
Scrub nurse - sterile, passes instruments