Vascular Surgery Induction

Vascular Surgery induction booklet was contributed by the following;

written by physician associate Richard Tullett
reviewed by Mr A Rehman
updated by Dr Yiiwen Wee

Select the booklet titles below to view the information. 

Introduction

Vascular Surgery Introduction

On this rotation you will be working in the Vascular Hub for the Black Country, the unit specialises in major index arterial procedures, aortic surgery, lower limb bypass, carotid surgery and major lower limb amputation.

On this rotation you will be working in the Vascular Hub for the Black Country, the unit specialises in major index arterial procedures, aortic surgery, lower limb bypass, carotid surgery and major lower limb amputation.

Vascular ward B3 is split into two areas;

  • 3 stations with 12 beds per station
  • There may also be outliers (on ITU and HDU mainly)
  • The nursing ratio for these areas is 1:6 ideally (two nurses per station).


VASCU – vascular specialist care unit

  • A vascular HDU with 4 beds, based on B3 station 3
  • Used for immediate post-operative vascular and critically ill patients
  • The nursing ratio for this area is 1:2
The Team

Vascular Surgery Ward Team

Consultants and Nurse Specialists 

Consultant Secretary Extension Hospital

Mr Pathak -
Vascular and General Surgeon
Maxine Winmill
2245
Russells Hall Hospital

Mr Rehman - Vascular and Endovascular Surgeon
Lara Golding
2176
Russells Hall Hospital

Mr Garnham -
Vascular and Endocrine Surgeon
RHH - Sharondeep Gandham
NXH - Kash Rahal
2681
New Cross Hospital

Mr Khan - General, Vascular & Paediatric Surgeon
RHH - Lara Golding
WMH - Lisa Maxwell
2176
Walsall Manor Hospital

Mr Newman - Vascular and Endovascular Surgeon
RHH - Alison slater
NXH - Gagan Grewal
2243
Russells Hall Hospital

Mr Hobbs - Clinical Service Lead
Vascular and Endovascular Surgeon
RHH - Maxine Windmill
NXH - Jacqui Stacey
2245
New Cross Hospital

Mr Wall - Vascular and Endovascular Surgeon
RHH - Alison Slater
WMH - Lisa Maxwell
2243
Russells Hall Hospital

Mr Shalan - Vascular and Endovascular Surgeon
RHH - Sharondeep Gandham
NXH - Gagan Grewal
2681
Russells Hall Hospital

Mr Popplewell - Vascular and Endovascular Surgeon, Senior Lecturer at UofB
RHH - Sharondeep Gandham
NXH - Gagan Grewal
2681
Russells Hall Hospital
Clinical Nurse Specialists Hospital
Sharron Trouth
Russells Hall Hospital
Vicky Baker
Russells Hall Hospital

Leanne Barker
Russells Hall Hospital
Physician Associate Hospital
Richard Tullett
Russells Hall Hospital
Ward Rounds

Vascular Surgery Ward Rounds

Ward round starts at 8:00am at station 3 (VASCU) on B3 by on-call consultant of the week

  • Arrive at 7:45 to give you time to update the patient list and start preparing the notes (all ward rounds are now documented on Sunrise)
  • Some consultants will want to go to ITU first
  • Juniors are expected to have an up-to-date patient list by 8:00am. The list is found in in the Vascular section of the SUV team on Microsoft Teams
  • Update the previous day’s list with any new patients or changes in bed. Remember to save the new copy with today’s date.
  •  The overnight Vascular SpR should also handover any new patients that they have seen before 8am
  • Richard will help you with the list at first until you are more confident with updating it

Please Note: the ward round on Vascular Surgery is very fast. You will therefore need to prepare the notes as much as possible in advance usually in the morning before the round.

In Ward Rounds you need to document;

  • Current issues
  • Background
  •  Assessment
    • Observations and BMs – write numbers/figures (not “normal” or “stable”)
    • Bowel movements, catheter ‘upkeep’, input and output
    • Recent bloods
    • Wound reviews – drawings may be difficult due to computerised ward round notes but try to be descriptive as much as possible
    • Review drug charts (i.e., reg meds, antibiotics, anti-coag, infusions)
    • Plan
    • Always remember to clearly document if a patient has been made MFFD
    • To make sure patients are on Best Medical Therapy (BMT) – that includes antiplatelet therapy (aspirin or clopidogrel, sometimes both), appropriate statin, antihypertensive and diabetic medications.
    • Clarify follow-up plans and follow-up ultrasound/CT surveillance

 

  •  
Vascular Admissions

Vascular Surgery Admissions

surgeon

Elective and Emergency

Abdominal aortic aneurysm – elective and with ruptured AAA, to be considered for open and endovascular

Popliteal aneurysm – for elective surgery or as an emergency

Pseudoaneurysm

Acute limb ischaemia – 6 P’s (Pain, Pallor, Pulseless, Perishing cold, Paralysis, Paraesthesia)

Critical limb ischaemia (rest pain, ABPI’s < 5, tissue loss – gangrene, painful ulcer – on pressure areas)

Septic diabetic foot, a real emergency. Get an urgent foot x-ray to make sure there is no gas in tissue, antibiotics, theatre prep and senior involvement

AV fistula repair/ligation (for dialysis), admission with bleeding or occluded fistula

Post CVA/TIA – normally to be admitted under vascular surgeon for carotid endarterectomy

Varicose vein ablation VNUS Closure (elective or rarely with bleeding following surgery)

Common ordered scans

MRA (magnetic resonance angiogram)

CTA (computer tomography angiogram)

DSA digital subtraction angiogram – normally for angioplasty, sometimes diagnostics

Duplex ultrasound (leg arteries and veins, for aorta, and carotid arteries)

Regional ultrasound (esp. groins mainly for any pseudo–aneurysm, any occlusive arterial disease)

Simple x-ray – mainly foot x-rays for diabetic foot

Graft scan – discuss with vascular lab – 2329, sometimes used to make sure a graft is patent also on discharge g. graft surveillance

If a scan is requested, it must then be discussed for it to happen in a timely fashion (apart from plain x-rays)

  • This will require discussion/negotiation with radiologists, mainly interventional radiologists. Most mornings the first job after the Ward Round will be a trip down to radiology to discuss Again, Rich will usually accompany you, sometimes the consultant or SpR will also go.
  • Doppler ultrasound scans (esp. legs) will be done at the VascLab + will need discussing – phone 2329

To get into the Vascular Lab, patients must be able to mobilise in a chair (i.e. no beds).

pharmacy

Different and common drugs on ward B3

  • Post-operative analgesia – please talk/refer to acute pain team (bleep 7851/Sunrise), patients could be on epidural infusion, nerve catheter after open abdominal surgery

  • Best Medical Therapy – make sure all vascular patients are on antiplatelets therapy (aspirin or clopidogrel or sometimes dual – check with seniors) and appropriate statin

  • Make sure to check with seniors whether to add antiplatelets or not if patients are on anticoagulation

  • Antibiotic, osteomyelitis therapy – (with / without diabetes)
    • Antibiotic guidance is available through MicroGuide which is on the hub
    • MicroGuide also has an app for phones which can be very useful
    • Clarify duration of antibiotics – to be documented on notes, ward rounds and prescription
    • Make sure to chase bone cultures post-op as this will also determine length of antibiotics treatment (if bone involvement, will require 6 weeks course)
  • Gabapentin / Pregabalin
    • As per BNF or pain team advice with titration
    • Be cautious when initiating in patients with a history of opioid dependency, seek advice from pain team first

  • Methadone initiation or continuation
    • Always check with DALT on current dose or initiation protocol is on the hub

  • Palliative care EOL anticipatory infusions (note renal adjustments)
    • Protocol is available on the hub
    • Palliative care EOL anticipatory medications (note renal adjustments)

  • Potassium permanganate soaks
    • Ask vascular CNS on specifics

  • Flaminal forte dressings
    • Ask vascular CNS on specifics

  • IV heparin infusion
    • Protocol is available printed on the ward or electronically on the hub. Requires regular PTTK monitoring until in range (usually handled by the nursing staff but you may be asked to advise)
Vascular Operations

Vascular Surgery Operations

surgeon

Elective and Emergency

All patients need consenting and booking for theatre. This is to be done by the operating
surgeon – you should not be asked to consent any patients as an FY1.

Heparin infusions may need to be stopped before surgery (+/- clotting screen) – always check with surgeon – but it is usually at least two hours before operation.

Open Repair of Abdominal Aortic Aneurysm

This usually occurs after MDT decision & CPET testing, admitted on the day of operation.

  • ITU post-op – usually 1 – 2 days then are transferred to VASCU
  • Need to be closely monitored and any immediate issue check with on-call vascular consultant, operating consultant and ITU
  • Monitor closely pain relief, renal function and normal post-operative care
  • 4-6 units of blood cross-matched usually at pre-op check
  • Monitor feet closely – temp, colour, pulses, pain (+ doppler)
  • Monitor bowels movements

Endovascular aneurysm repair (EVAR)

  • VASCU post-op
  • 4-6 units of blood cross-matched usually done during pre-op
  • Monitor feet closely – temp, colour, pulses, pain (+ doppler)
  • Monitor renal function
  • All patients need US surveillance scan at their follow-up hospital at 4/52 (except New Cross Hospital where CT surveillance is required by SH and AG).

Bypass Operation

  • Aorto-bifemoral bypass – for occlusive aorto-iliac disease
  • Axilla-bifemoral again for arto-iliac occlusive disease – unfit patients
  • Ilio-femoral & femoral – femoral cross over bypass
  • Femoral-popliteal AK bypass, usually called fem-pop AK bypass
  • Femoral-popliteal BK bypass, usually called fem-pop BK bypass
  • Femoral-distal (AT, TPT, PT, peroneal) bypass, usually called fem-distal bypass
  • Popliteal-distal (AT, TPT, PT, peroneal), usually called pop-distal bypass

For these interventions...

  • Patients will have an A-line + require at least VASCU post-op
  • Sometimes patients will be on a metaraminol infusion
  • Monitor foot/feet closely – temp, colour, pulses, pain (+ doppler)
  • Wound r/v at day 3 (unless stated otherwise)

Embolectomy / thrombectomy

Femoral, Popliteal or Brachial embolectomy

  • Patients may be on IV heparin pre-op and this will need managing, PTTK ratio checked and usually stopped 2 hours before
  • Monitor leg, foot or hand closely – temp, colour, pulse, pain, loss of sensation or movements (may require doppler)
  • Always be sure on anti-coagulation plan post-op, usually heparin infusion then warfarin or NOAC
  • Has a source of embolus been found? – e. ECG, ECHO (transthoracic or TOE), CTA (thorax and abdomen CT) and blood film (seek a cardiologist or haematologist opinion)

Endarterectomy

Common Femoral Endarterectomy

  • Patients may have an A-line + require VASCU post-op
  • Monitor leg & foot closely – temp, colour, pulses, pain, sensation and movements (+Doppler & ABPI)
  • Wound r/v at day 3 (unless stated otherwise)

Carotid

  • Patients have an A-line + require VASCU post-op – sometimes on metaraminol infusion
  • Monitor any neck swelling, swallowing and voice character and any other focal neurology
  • Closely monitor BP + note post-carotid surgery BP guidelines – available on Hub and VASCU
  • Usually STAT dose of aspirin + clopidogrel pre-op + continued for 6/52 post-op – check with operating consultants – different preferences

Major amputations (AKA, TKA, BKA)

  • All patients need a pre-op physio and pain team review
  • Many of these patients have DM and would benefit from Diabetic outreach team (DOT referral/assessment)
  • All patients will have an AMBIT pump post-op
  • Wound r/v at day 3 and 6 (unless stated otherwise)

Minor amputations (digital, multi-digital, forefoot)

  • Chase theatre cultures – tissue and bone – to guide antibiotic therapy
  • Wound review when stated

Debridement

  • Chase theatre cultures – tissue and bone – to guide antibiotic therapy
  • Wound review when stated

Angioplasty

  • This needs to be requested on sunrise
  • Multiple vessels
  • Usually under LA
  • Monitor incision site for swelling and bleeding
  • If under sedation/GA patients need to be NBM
  • Patients require bed rest (usually lying flat) post-op for usually 4 hours
  • If stent is deployed – dual antiplatelet for 6 months (unless anti-coagulated)
  • Follow-up is usually 6/52 with the vascular consultant who requested

Pseudo Aneurysm repair

  • Main theatre or in radiology theatre (US-guided thrombin injection or compression)
  • Wound review as directed

Groin collection / abscess I+D

  • Only under vascular if involving vessels (confirmed on scan – US or CT)
  • Ensure antibiotic therapy as per guidelines
Ward Work

Vascular Surgery Ward Work

Select the titles in red below to find out further information. 

Discharge Letters

  • Presenting complaint and consultant who is in charge of overall care
  • Diagnosis (1st, 2nd, 3rd)
  • Intervention
    • (Operation/procedure) including detail, date + any complications
    • Post-op complications and what management was taken
  • Medications
    • Detail any new medications and why they were started, and also explain if and why any were stopped
  • GP instructions if required
  • Follow-up
    • Where, who with, and when
    • Mainly which consultant and which hospital – this is very important. Try to confirm this during the ward round as soon as the patient is deemed fit for discharge, as it may be more difficult to contact the consultant at a later date
  • What surveillance (USS/ CT) and is it booked/organised

Pre-op Checklist

  • All patients need 2 group + saves on the system to be valid
    • Policy on this change frequently, but most patients will need a G&S before their procedure. If no previous G&S on the system that is still valid, you will need to take 2 pre-procedure
    • Ring blood bank (ext. 2488) to confirm if unsure – I usually call them every time I send a G&S off just to clarify whether I need another one or not
  • All patients will need an up-to-date INR
  • All patients will need a recent ECG
  • Do they need NBM – fluids, clear fluids, AM medications
  • Do they need Lung function / ECHO / CPET
  • Do they need pre-hydration regime

Clerking

Emergency patients are clerked in ESH (B5) with all the ENT, urology and general surgical patients. They will usually then be transferred to B3 if requiring admission.

Urgent patients are reviewed in the Vascular Hot Clinic (B3). You are expected to clerk these patients and get an urgent senior review. They may then require admission. 

The following will need to be included in addition as part of a vascular history and assessment

  • Always palpate pulses (+++/++/+)
  • Doppler signals if needed (mono/bi/triphasic)
  • ABPI – do it yourself or request help from the team or CNS
  • Describe wounds + draw pictures
  • Give impression / diagnosis
  • Bloods + investigations – mention if done or requested
  • Any recent discharge letters
  • Any recent scans

Remember to

  • Prescribe regular medications (many vascular patients have diabetes, clarify insulin dose)
  • Some patients may not be local, consider obtaining SCR (ward clerks and pharmacists are very helpful)
  • Consider if warfarin/NOACs need to be paused for pre-op, and prescribe prophylactic enoxaparin
  • AES may not be appropriate in many vascular patients
  • Pre-op work up, if appropriate – new set of bloods (including INR, G&S), ECG +/- ECHO +/- spirometry

Try to keep the patient list updated constantly throughout the day

  • Update any operations/scans/notable blood results as they happen
  • Add any new patients who have been admitted over the course of the day
  • Remove anyone who has been If they have been moved to a different ward but still require vascular input, move them to the bottom of the list to the outliers section
  • At the end of the day, go over the list once more to ensure everything is up-to-date

Follow up / Outpatients Appointments

Russells Hall Hospital is the vascular hub, so has vascular patients from Dudley, Walsall and Wolverhampton – the follow-up will be at 1 of the 3 hospitals.

For most major operations a 6/52 follow-up appointment is given (unless stated), or 8/52 for Mr Garnham at New Cross Hospital

For most limb bypass and EVAR operations an US/CT surveillance scan is needed before or at the first follow-up appointment (usually at 4/52, but check before booking)

  • If the follow-up is at Russells Hall then book the scan on sunrise
  • If the follow-up is at New Cross or Walsall Manor email the secretaries
Vascular on Call (weekend cover)

Vascular Surgery on calls (weekend cover)

Typical Day

Before arriving, pick up a NerveCentre from Capacity Hub. You are only covering vascular patients, and so shouldn’t be getting jobs for general surgical patients. Let the nurses know you are the vascular on-call doctor, and this will limit the amount of nerve jobs created as they will approach you first.

Arrive onto B3 at 08:00, you do not need to go to the surgical handover based on B5. Start by preparing the notes until the consultant arrives.

Access the vascular list through:

Computer > Microsoft Teams > SUV Team > Vascular > Files > Year > Month > Date

(it should already be up-to-date, as of end of the previous day)

 Update this by checking the boards on each station and Sunrise Tracking board to see if there are any new patients or location changes.

Ward Rounds

The vascular ward round starts on VASCU (B3, Station 3) and is very quick, hence why you need to prep beforehand. Pre-prep the ward rounds by using the ward round tab on Sunrise (use the prior days ward round for reference and be sure to annotate ‘PREP’ or ‘DRAFT’ in the plan section, and the use the ‘modify document’ link to complete the document during the ward round).

 

After the ward round with the consultant, start the jobs! If you have any queries check with the registrar or consultant on-call who will be available through switch. Medical questions which require senior input can be directed to the general surgery or medical on-call team for support. Please note, the vascular registrar is a ‘non-resident post’ and they are on call for 48 hours straight. They are there for emergency vascular issues, rather than day-to-day cover.

MRI Scans

For MRA scans, vascular have 1 slot reserved every day for MRA, so discuss with the vascular consultant as to which is the most urgent, and then go to MRI in the radiology department and write this in the book. They may need the vascular IR consultant to approve this, the vascular SPR or consultant will contact IR.

Bloods

At the end of the day, check bloods results, action any abnormal bloods and request for the following day if required. REQUESTING NECESSARY BLOODS FOR THE FOLLOWING DAY IS A ROUTINE JOB FOR ANY WARD COVER JUNIOR DOCTOR (including vascular).



Pre-theatre Checklist

If any patients are to be taken to theatre over the weekend or early in the week, it can be helpful to go through the pre-theatre checklist with the on-call SPR;

For vascular patients going to theatre they all need the following:

  • Recent bloods including INR
  • ECG
  • Drug Chart
  • VTE assessment
  • Pacemaker/ICD check within last 12 month if applicable
  • ?do they need G+S – certain operations do – so check with the on-call SPR. To have a ‘valid’ G+S, patients need 2 samples, first can be historic but at least one needs to be within that last 7 days (or 3 days if patient has received blood products in the last 3 months).

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