VivaCast 5 – Clinical Station – Onco-Laparotomy

A Framework to answering a clinical primary orca viva question is found below:

1. Summarise and describe chief concerns
2. Pre operative – Hx/exam/bloods/obs/consent/problems/post op plans
3. Intra operative – Induction maintenance +/- wakeup
4. Post operative – HDU/ITU, risk mitigation (post op CPAP) pain management, return to theatre plan?

Summarise and describe chief concerns

As it says on the tin + demonstrate that you have grasped the key factors that should be addressed from the history. Go on to say ‘my structured approach to assessing this patient begins with….’

Pre op

Information gathering from surgical team booking patient:

• History / Allergies / CT Findings
• Clarification if surgical consultant has been spoken with
• Current physiological state and admission state
• How long the patient has been unwell (sudden or drawn out deterioration at home)
• Confirmation that critical investigations have been arranged inc bloods/ECG/catheters/cultures etc.
• What their NELA score is.

Attend the patient

• I will attend the bed-space of the patient, If they appear critically unwell conduct a Primary survey / ABCDE and ensure adequate resuscitation is commenced (examiner might say, talk me through your ABCDE approach, or suggest they do look unwell what will you do, or let you keep talking)
• I will review their clerking, and subsequent clinical notes to understand their background and their clinical course in hospital.
• I will review recent investigations and imaging reports.
  • Clarifying if a recent Venous/Arterial blood gas has been sent (context dependent) and confirming that appropriate group and save is with the lab team.
• I will attend the patients bedside and conduct an anaesthetic History focussing on:
  • Previous Anaesthetic history
  • Clarify previous operative interventions
  • Medical history – including a system review approach to ensure nil missed
  • Current medications
  • Allergy status
  • Smoking and alcohol history
  • Performance Status / Frailty / Exercise tolerance (see METS / PS tables below)
  • Identify last meal, Nausea, Vomiting and also in this case diet over preceding week
  • Dental state and airway examination.
• I will then conduct a focussed clinical examination to identify respiratory state, volume state, presence absence shock /// I will clinically examine using an ABCDE approach… blah blah.
• I will then discuss with the patient:
  • Anaesthetic approach including possibility of (including possible complications)
    • CVC / A line
    • Epidural / Spinal / LA infusions / PCAs
    • NG tube
    • Cricoid pressure
    • Critical care requirements afterwards level 2/3
  • What their wishes are, from a life at any cost vs quality of life perspective, any family they would like me to talk with in order to advocate for them if needed.
  • I will also explain the potential side effects and complications of anaesthesia including (depending on frailty,) the impact a critical care stay may potentially have, aspiration, PPCs, stroke/MI/Death
• I will liaise with the critical care, surgical and anaesthetic teams in order to plan this patients clinical course.
• Attend theatre and Brief for the case with the team.

Getting called up to talk through the A-E

• A
• B – RR / SPO2 / Character of Resps / Rest Exam
• C – HR – BP – CRT – Volume Status
• D – BM – GCS – pupils…
• E – Abdo / Temp / Other injuries/issues
• F – Fluids and electrolyte state.

Give the examiner a bit of a chance to give you information (There may be no info to give)

Intra Operative – How will you anaesthetise this patient?

1. I would like to (transfer to theatre to resuscitate / resus on ward / go to crit care first
2. Ensuring they are appropriately resuscitated prior to induction.
3. RSI yes no ( suction ready / tipping theatre trolley / cricoid plan)
4. Conduct appropriate checks into theatre.
5. People – Ensure trained ODP present, and consultant anaesthetist present (sick laparotomy)
6. Prep – Suction NGT, Free flowing drip running, Pre oxygenate (peep/hiflow/apnoeic o2)
7. Monitoring Present including Co2 +/- Awake art line.
8. Equipment – VL / Warming + Temp probes / Blood giving sets if potential issue / TEDs/Flotrons
9. Equipment – COETT/ ITU Tube, size up and down, Bougie, HME
10. Drugs – Appropriate induction agents (tell the examiner what YOU will do) – Emergency drugs +/- dilute adrenaline
11. Brief anaesthetic team on Airway plan prior to induction
12. Consideration for critical intra op steps, ie septic shower / ischaemic reperfusion if twist in bowels etc

Post operative

1. Complete relevant documentation
2. Where will the patient go
3. What monitoring do they require
4. What their pain control plan is
5. Decision making for level 2/3 if for critical care.
6. Are they for a return to theatre

When approaching clinical questions in the FRCA Clinical Viva it is important to listen to the question they ask! Instead of going to your comfort zone of ‘how are you going to anaesthetise this patient’ whilst they may well ask you this, don’t start answering the question you want to hear.

Appendix

METS – Metabolic Equivalents of activity

A MET relates to the amount of oxygen consumption required to achieve an activity

• Patients often over estimate
• There are validated questionnaires that do a better job of this.
• ‘if you cant get up the stairs (note – how slowly….? doesn’t feature) then the odds of post op complications increases

MET	Activity
1 (Vo2 at rest) (approx 3.5ml o2/kg/min)	Reading . Watching TV
	Eating / Getting dressed
2-3	Walking on the flat
	‘light’ Housework
4+	Climbing stairs
	Brisk walk
	short run
	‘heavy chores
>10 (35 ml o2 /kg/min +)	Tennis /football…

Performance Status

PS 0 = Fully Active, Disease state causing no compromise

PS 1 = Restricted in physically strenuous activity, but can potter about

PS 2 = Can self care, but cant work, active for >50% waking hours

PS 3 = Limited self care – confined to bed / chair >50% waking hours

PS 4 = Completely disabled, nil self care, confined to bed/chair

REF

Nature Scientific Reports: Association between self-reported METs and other perioperative cardiorespiratory fitness assessment tools in abdominal surgery—a prospective cross-sectional correlation study

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Transcript

# Gas Gas Gas Podcast – Episode 005: Clinical Oncology Laparotomy

Introduction

00:00-00:34 Welcome to Gas Gas Gas, your one-stop podcast for the FRCA primary exam. This podcast will fill your brain with information – listen to it, think about it, and check out the show notes on the website. There you’ll find the core diagrams you need to be able to draw and describe for the exam. This podcast can squeeze into your day – listen whilst driving to work, cooking dinner, when on call, or in the gym. Eventually, revision will end, but for now, expect facts, concepts, model answers, and the odd tangent.

Clinical Viva: Oncology Patient for Laparotomy

00:34-01:18 This episode features Tom answering questions on approaching a laparotomy in an oncology patient. It’s important to have structure when answering these questions so it doesn’t look like you’re jumping between ideas during your fifteen minutes. We’ll let Tom answer this question and then debrief afterwards, exploring how to improve structure. The show notes contain a framework for approaching these questions systematically.

The Clinical Scenario

01:19-01:53 You’ve been asked to see a patient on the oncology ward who has unfortunately developed bowel perforation with bowel obstruction. The surgeons have listed them for laparotomy. Their urine output has been 15ml/hour since catheterisation six hours ago before their scan. Heart rate is 124 bpm, blood pressure is 103/40 mmHg, and the surgeons plan to give fluid.

Initial Assessment and Concerns

01:53-02:39 Tom’s Summary: Patient with known bowel obstruction and perforation, showing signs of hypovolaemia and possible shock onset – either sepsis-driven or due to massive third-space fluid loss. This is a sick patient requiring urgent surgery.

Examiner: What is your approach?

Tom’s Response: We have a sick patient with poor urine output, low blood pressure, bowel perforation, and known obstruction on an oncology ward – potentially comorbid with chronic, possibly incurable illness. My initial approach will be A-to-E assessment, as this is clearly an unwell patient. I need to systematically check nothing is being missed that’s making them more unwell.

A-to-E Assessment Details

02:59-05:32 Focus Areas:

1 Patient optimisation for surgery – including fluid resuscitation

2 Comprehensive investigations – VBG for lactate and electrolytes, lab bloods for FBC to assess bleeding or chemotherapy-related anaemia

3 Suitability assessment – determining if surgery is appropriate based on clinical background and functional status

⠀Specific A-to-E Components:

• Airway/Breathing: End-of-bed assessment, respiratory pattern indicating acidaemia, oxygen requirements (patient on 2L nasal specs, RR 25-30), chest auscultation for concurrent pneumonia or pneumothorax, chest X-ray if requiring oxygen
• Circulation: Peripheral temperature, mucous membrane assessment, urine output analysis
• Disability: Consciousness level – drowsy or alert
• Exposure: Review of imaging for bowel fluid volumes

⠀Clinical Findings Provided:

• Cool peripherally, central capillary refill 4 seconds, pale
• Conscious to voice but dozes mid-conversation
• Normal blood sugar, dry mucous membranes

⠀Investigation Strategy

06:43-07:41 Required Tests:

• FBC: Assess anaemia, iron deficiency, transfusion requirements
• U&Es: Evaluate electrolyte derangement and renal function in bowel obstruction
• VBG: Acid-base status, lactate levels (may suggest ischaemic bowel)
• ECG: Baseline and current comparison given major surgery requirements
• Cross-match: Blood products preparation

⠀Cardiac Management

07:44-08:51 Clinical Finding: Atrial fibrillation with heart rate 130 bpm

Management Approach:

• Initial fluid resuscitation appropriate to medical history and weight
• May stabilise blood pressure and heart rate for induction
• Electrolyte correction – potassium >4 mmol/L if time permits
• Consider slow magnesium administration (avoiding hypotension)
• Assess anticoagulation status and potential reversal requirements
• Review rate control medications and absorption status

⠀Risk Stratification

08:54-09:32 NELA Score (National Emergency Laparotomy Audit): Multi-parameter assessment including blood pressure, blood results, proposed procedure and pathology. Provides 30-day mortality risk – >5% considered high risk. Informs perioperative planning and patient/family discussions about proceeding.

Anaesthetic Approach

09:37-11:01 Key Principles:

• Consultant presence mandatory for sick patient undergoing major procedure
• Monitoring: Consider arterial line for induction based on resuscitation response; definitely post-induction
• Central venous access if deteriorating despite resuscitation (pre-induction for vasopressor support)
• Induction agents: Consider ketamine over propofol to maintain blood pressure (adjust based on cardiac history – high-dose opiates/low-dose propofol for severe IHD)
• RSI required due to bowel obstruction
• Gastric decompression via NG tube suction pre-theatre to prevent vomiting in anaesthetic room

⠀Multidisciplinary Planning

11:01-12:08 Critical Care Requirements:

• High-risk patient likely needs HDU bed minimum post-operatively
• May require level 3 ICU if significant intraoperative vasopressor support needed
• ICU discussion for post-operative destination

⠀Patient and Family Communication:

• High mortality risk discussion essential
• Resuscitation status decisions for intraoperative vs. ICU/post-operative scenarios
• Clear communication about procedure risks before operation

⠀Post-Viva Debrief

12:10-17:24 Tom’s Reflection: Familiar scenario but launched too quickly without proper structure. A-to-E approach was adequate, but subsequent discussion became “higgledy-piggledy” in order.

Examiner Feedback:

• Structure is crucial – examiners want succinct, systematic responses
• Framework suggestion: Pre/intra/post-operative structure
  • Pre: Information gathering from surgeon, structured A-to-E with specific details, history/examination, investigations, appropriate discussions
• Anaesthetic considerations: Must mention consultant presence, competent ODP, resuscitation location (ward vs. theatre), RSI requirements (suction, tilting trolley, pre-oxygenation)
• AF Management: Correctly identified the challenge of not using negatively chronotropic/inotropic drugs in sick patients
• NELA scoring: Excellent use of risk stratification tool
• MDT Discussion: Surgeon, ICU consultant, anaesthetic consultant involvement; patient/family values assessment crucial for decision-making

⠀Key Teaching Point: In bowel obstruction cases, operative intervention is rarely avoided due to patient distress, making MDT assessment even more critical.