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Home | Articles | Admission | Acute Surgical Admissions

Acute Surgical Admissions

Last updated 14th May 2021

If patient is unstable/ acutely unwell please follow A-E assessment and call for senior help early.

Clerk In

  1. Ensure thorough clerk in is done including past medical/ surgical history, family history, smoking status, alcohol intake/ recreational drug use, home situation – carers, mobility
  2. Examination – observations, listen to heart & lung sounds, abdominal examination including PR exam
  3. DNACPR/ TEP – if DNACPR present in community, print this out – a new form would however need to be filled in

IV Access + Bloods

  1. Routine – FBC, U&E, LFT (AST & Gamma GT needs to be added on), CRP
  2. Others
    • On warfarin – INR
    • Pancreatitis – amylase, LDH, Calcium
    • High risk of refeeding syndrome – Mg & Phosphate
  3. Venous blood gas – lactate (especially for acutely unwell patient, normal lactate is usually reassuring)
  4. Blood cultures – if septic/ has temperature

Investigations

  1. Erect CXR – to rule out pneumoperitoneum/ chest pathology
  2. AXR – bowel obstruction
  3. ECG – if indicated
  4. Urine dip
  5. Urine pregnancy test/ serum HCG – for every female of reproductive age
  6. US Liver/ gallbladder – suspicious of acute cholecystitis/ cholangitis/ pancreatitis
  7. US Abdo/pelvis – suspicious of acute appendicitis/ ovarian pathology

HEPMA

  1. Print out ECS and perform med rec
  2. Stop nephrotoxics – ACEi, NSAIDs
  3. Discuss with senior if pt is on anticoagulant or antiplatelet
    •   Please refer to Haematology & Thrombosis -> Antithrombotics & Surgery
  4. Prescribe TEDs stockings (unless contraindicated, eg PAD) and Dalteparin (based on patient’s weight) at 1600 (unless if pt is already on anticoagulant)

Antibiotics

  1. Discuss with senior prior to starting IV antibiotics unless clearly indicated
  2. See local antibiotics guideline for antibiotics
  3. If starting on gentamicin, pls request bloods for gentamicin level 6-14 hours post dose (ensure correct patient location)

IV Fluids

  1. Hartmann’s preferred for resuscitation as 0.9% NaCl may cause hyperchloremic acidosis
  2. Maintenance fluids – 0.18%Nacl/ 4% Dextrose if Na >132 or 0.9% if Na<132
  3. Prescribe based on guidance of fluid charts

Others (Based on Clinical Situation)

  1. Catheter insertion
  2. NG wide bore tube insertion

Analgesia

  1. WHO pain ladder, take into account patients weight, renal function
  2. Prescribe paracetamol regularly 1g QDS (if <50kg or severely deranged LFT 500mg QDS)
  3. NSAIDs – avoid if AKI/CKD, background of gastritis, UGI bleed, severe asthma
  4. Codeine – can be prescribed separately as codeine or as co-codamol (ensure paracetamol not prescribed concurrently)
  5. Morphine – prescribe 10mg oral 4hourly unless opioid naive/ elderly/ low weight
  6. Some patients may require IV Morphine – titrate this based on symptoms
    • Often the FY1 would need to administer IV Morphine
    • 1-2mg per 1-2 minutes, administer until patient starts seeing improvement in symptoms (max 10mg at one time)

Laxatives

  1. If prescribing opioids, ensure laxatives are prescribed PRN
  2. See Laxatives section for further info

NBM

  1. Discuss with surgical reg if patient need to be NBM (patient is needing surgery, patient has bowel obstruction)
  2. Ensure critical medications are still prescribed and patient is getting these – Parkinson’s meds, anti-epileptics, oral steroids, etc (discuss with pharmacists if unsure)