PAINE #PANCE Pearl – Surgery


When looking an abdominal radiograph, what are the bowel diameter measurements that are generally NOT normally exceeded and would be concerning for potential obstruction?


The normal diameter of the intestines on an abdominal radiograph generally do not exceed:

  • 3 cm for small bowel
  • 6 cm for the colon
  • 9 cm for the cecum

This is often referred to as the 3/6/9 rule.


  1. Radiopaedia.
  2. Geeky Medis.


Pouch of Douglas

Other Known Aliasesrecto-uterine pouch

Definitionspace in the peritoneal cavity between the rectum and the posterior wall of the uterus

Clinical SignificanceAs this is the most posterior and inferior recess in the peritoneal cavity, it is a potential space for fluid and blood to accumulate. This area should always be investigated in trauma as part of the FAST examination.

HistoryNamed after James Douglas (1675-1742), who was a Scottish physician, anatomist, and physician extraordinaire to Queen Caroline. He received his medical doctorate from University of Reims and went on to have a prolific career as an obstetrician and anatomist. He also befriended an early career William Hunter and made him an assistant prior to his own fame as an anatomist. Due to his anatomic research in female pelvic anatomy, there are many eponymonic structures that bear his name including the Douglas fold, Douglas line, and Douglas septum.


  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved
  4. Whonamedit – dictionary of medical eponyms.
  5. Up To Date.
  6. Brock H. James Douglas of the Pouch. Medical history. 1974; 18(2):162-72. [pubmed]
  7. Rectouterine Pouch. Radiopaedia.

PAINE #PANCE Pearl – Surgery



What is the main difference between these two instruments?


Image result for allis clampImage result for allis clamp




Image result for babcock clampImage result for babcock clamp



The first instrument is an Allis clamp, which has sharp teeth and can crush tissue.  It is used for grasping fascia or tissue that needs to be removed or manipulated during procedures.


The second instrument is a Babcock forceps,  which is non-toothed and has a wider grasping surface.  These forceps do not damage tissue and are considered non-crushing and can be used to grasp delicate tissue.  The head of the forceps is open and helps for rapid identification.


Debakey Forceps


Other Known Aliases – atraumatic vascular forceps

Definitionlarge, coursely ribbed tissue forceps


Clinical Significanceused for delicate vascular surgery as these forceps do not crush or damage tissue


History – Named after Michael Ellis DeBakey (1908-2008), an American cardiac surgeon who received his medical degree from Tulane University School of Medicine in 1932.  He spent the majority of his career with Baylor in Texas and was prolific medical trailblazer and pioneered, among many others,:

  • The roller pump for the heart-lung machine and made open-heart surgery possible
  • Postulating the link between smoking and lung cancer
  • One of the first surgeons to perform coronary artery bypass
  • Performed the first successful carotid endarterectomy
  • Using synthetic grafts for blood vessel repair
  • Video live surgery for medical purposes

In 2005, at the age of 95, he suffered an aortic dissection (for which there is the DeBakey classfication for) and became the oldest person to survive the operation.  He died 2 months before his 100th birthday.  Dr. DeBakey received so many awards and recognition that they are too numerous to count and is arguable one of the main reasons modern cardiac surgery has advanced to where it is today.



  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved
  4. Whonamedit – dictionary of medical eponyms.
  5. Up To Date.
  6. U.S. National Library of Medicine
  7. The Michael E. BeBakey papers
  8. NY Times
  9. Academy of Achievement

#42 – Postoperative Fever



My JAAPA article from October 2016 (JAAPA. 2016;29(10):23-28)



Postoperative fever an elevation of body temperature to ≥ 38.3oC (100.4oF) following major surgical procedures.  The vast majority of postoperative fevers occur within the first 5 days of surgery, which is why the timing of the fever is so important in differentiating the potential causes.


Physiologic Response to Surgery

Surgery cause a massive inflammatory cascade due to the physiologic and cellular damage injury.  This is a completely normal homeostatic response, but the release of IL-1, IL-6, and TNF-alpha (to name a few) are all pyrogenic cytokines that can contribute to a febrile response.

These cytokines act on the preoptic area of the hypothalamus to increase prostaglandin E2 secretion and raises the thermostatic endpoint of the body.  This cascade usually peaks at 48 hours and care should be given to prevent costly and unnecessary infectious work-ups.


The Seven W’s of Postop Fever



Atelectasis usually occurs within the first 48 hours due to splinting and incomplete lung expansion secondary to pain following surgery.  It has long been considered the leading cause of postop fever, but has been debunked in the literature for decades now with increased knowledge of the cellular inflammatory cascade.  Decreased breath sounds , SOB, crackles, tachypnea can be indicators for atelectasis and CXR may show dependent, L>R infiltrates.  Treatment should be incentive spirometry and early mobilization to promote expansion.



Urinary tract infections (UTI) are the most common postoperative nosocomial infection secondary to the placement of a urinary catheter for surgery.  Risk factors for postoperative UTI are length of catheterization need, female gender, older age, history of diabetes, and previous history of UTIs.  Signs and symptoms can reveal suprapubic pain, CVA tenderness, flank pain, and malodorous, cloudy urine.  Clean catch sample is ideal, but a clean aspirate from an indwelling catheter may be used.  Urinalysis can provide a quick idea if it is infectious are not, specifically looking for positive nitrites and/or leukocyte esterase, or sending for a urine culture and finding > 105 cfu of the offending organism.  Treatment should be removing the catheter (if possible) and tailoring antibiotic therapy to the organism in question.



Surgical site infections (SSI) generally begin to manifest 3-10 after surgery and risk factors for developing are ASA score of 3-5, contaminated or dirty procedure, or an extended length of surgery.  Signs and symptoms of an SSI are increased pain, redness, and swelling at or near the incision.  These can be superficial skin, deep skin, or deep space and ultrasound can help differentiate between cellulitis and focal infection.  Treatment is either antibiotics (for cellulitis) or drainage (for abscess).



Deep venous thrombosis (DVT) can be common in surgical patient (up to 20%) secondary to immobilization and resistance to move due to pain.  To make matters worse, many can be asymptomatic with the exception of the fever.  The incidence is highest 3-5 days after surgery and you should have a low threshold to order a bilateral lower extremity ultrasound.  Treatment for a DVT following surgery can be tricky due to bleeding risk.


Wonder Drugs

Medications are the most common, noninfectious cause of fever in patients following surgery.  Timing is variable from immediately after administration to hours, or even days, later.  Most cases are due to antibiotics or heparin and result in only a mild, transient febrile response.  There are 3 life-threatening cause of medication induced fevers that you at least need to think of and rule-out:

  • Serotonin syndrome
  • Malignant hyperthermia
  • Neuroleptic malignant syndrome



Up to 50% of adults over the age of 18 admit to regular alcohol consumption and up to 50% of these patients report withdrawal symptoms when abstinent.  Signs and symptoms of acute withdrawal can begin to manifest 6-72 hours after the last ingestion and range in severity from mild, vague symptoms to florid delirium tremens.  Treatment is aggressive benzodiazepine regimens to abate the symptoms, with a gradual taper while in the hospital.


“Wonky” Glands

Though rare, two endocrinologic conditions can cause fever in the postoperative period.  Adrenal insufficiency and thyrotoxicosis can both occur due to disruption of the hypothalamic-pituitary-adrenal/thyroid axis by the inflammatory mediated response of surgery.  Coupled with a patient being NPO prior to surgery, a patient may not be able to take their medications to keep these conditions at bay.  Careful preoperative history will identify these patients prior to surgery and recommendations can be made on which medications can be taken the morning of surgery, or what medications can be given in perioperatively.

Cottage Physician Treatment for Fever