Post-Operative Shortness of Breath

• I would immediately go to the patient, asking the nurses to take a set of observations and prepare the notes while I make my way
• I would assess using an A to E approach following CCrISP principles
• In a post-operative patient who is tachycardic and desaturating the main differential I am concerned about is pulmonary-embolism, as well as hospital-acquired pneumonia or basal atelectasis.

For A,

• Ensure the airway is patent and unobstructed, by assessing patient's ability to reply and talk when I greet them.

In B,

• Get an up-to-date respiratory rate and saturations
• Inspect and palpate the neck for neck vein distension and tracheal position
• Inspect, auscultate, palpate and percuss the chest to check for: symmetrical chest expansion, good air entry bilaterally, added sounds such as wheezing or crepitations
• Put her on 15L 100% oxygen through a non re-breather mask
• Request an arterial blood gas and get a chest X-Ray

In C,

• Get an up-to-date blood pressure and heart rate
• Examine the capillary refill time, radial pulses, for peripheral overload, and the temperature of her peripheries
• Insert x2 wide-bore cannulae and collect bloods including FBC, U&Es, Clotting, G&S, blood culture if septic; you'd have checked lactate in the ABG in (B)
• Request a 12 lead ECG as they're tachycardic
• Consider urinary catheterisation for strict input output monitoring
• If hypotensive and shocked, consider a Hartmann's fluid bolus
• If pyrexic, consider starting antibiotics
• If overloaded, consider furosemide

In D,

• Check AVPU score, blood glucose level, temperature, pupillary response

In E,

• Expose while preserving their dignity to complete physical assessment
• Palpate calves bilaterally ?DVT 
• Inspect wound site and observe for any signs of surrounding cellulitis, underlying collection or wound dehiscence ± send swabs 

After initial assessment:

• Keep re-assessing the patient to see their response to my interventions
• Escalate to my senior to make them aware
• Calculate a Well's score; consider CTPA or D-Dimer accordingly

To complete assessment:

• Chart review: Patient notes, drug chart / missed pLMWH doses, op note
• History using AMPLE structure
• Review prior results: Biochemistry, haematology, imaging

In the context of a post-op hemiarthroplasty patient with low saturations and tachycardia I would be particularly concerned about... pulmonary embolism

However, I would also consider other differentials including:

Cardiovascular

• Pulmonary embolism
• Fat embolism
• Myocardial infarction

Ventilatory

• Atelectasis
• Pulmonary oedema

Infective

• Community-acquired pneumonia
• Hospital-acquired pneumonia
• Aspiration pneumonia
• COVID
• Sepsis

Drug-related

• Ongoing action of neuromuscular blockers
• Anaphylactic reaction

Other

• Anxiety
• Pain

Bedside

• 12 lead ECG
• Wound swab sample for MC&S
• Urine dipstick and MC&S
• COVID-19 PCR swab

Haematological

• Arterial blood gas, rather than venous
• FBC, U&Es, Clotting
• Blood culture if pyrexial and starting antibiotics 

Radiological

• Chest X-ray: Consolidation, pneumothorax, pulmonary oedema
• CTPA: Pulmonary embolus
• Ultrasound scan of wound if clinically suspecting underlying collection

Use Well's criteria for pulmonary embolism.

Well's > 4 → Urgent CTPA < 4-6h; tLMWH if CTPA unavailable for > 6h

Well's < 4 → Consider D-Dimer and if D-Dimer is high → Get a CTPA

Note D-Dimer expected to be elevated in the post-operative period anyway so it's difficult to interpret.

Haemodynamically unstable

• Invasive management with thrombolysis
• Resuscitate using A to E approach
• Escalate to operating surgeon, critical care outreach team, haematology

Haemodynamically stable

• Anticoagulation based on local guidelines, contraindications and co-morbidities for a minimum of three months
• Re-assess the patient with an A to E approach
• Check bloods including clotting profile and U&Es
• Discuss preferred anticoagulation with surgen, pharmacist, patient
• Anticoagulation counselling so they are away of long-term management like INR checks and associated risks
• Book haematology follow-up

Similar sensitivitiy between V/Q and CTPA

CTPA more likely to detect clots in smaller vessels

CTPA more available out of hours

CTPA can help give more information on other differentials, showing infection, atelectasis and pulmonary oedema

V/Q doesn't need contrast

V/Q uses smaller radiation dose so can be used for pregnant women

Enhanced Recovery After Surgery

Programme of multidisciplinary pre-, intra- and post-operative interventions to improve post-operative surgical outcomes

Pre-operative interventions: Pre-admission counselling, patient education, nutritional support, medical optimisation

Intra-operative interventions: Minimally-invasive surgery, minimal use of drains

Post-operative interventions: Early tube and catheter removal, early mobilisation, analgesia optimisation, minimal opioid usage

Non-modifiable risk factors

• Age
• Pregnancy
• Previous VTE
• History of CODP
• Asthma
• OSA

Modifiable risk factors

• Smoking history
• Frailty: Rockwood Clinical Frailty Scale
• Malnourishment: Malnutrition Universal Screening Tool (MUST)