Postoperative Day 1: Tachycardia After Abdominal Surgery
A 58-year-old man is on postoperative day 1 after an open laparotomy for a perforated appendix. His baseline vitals on admission were HR 78, BP 128/76, RR 16, T 37.0 °C. At 06:00 he reports feeling 'a bit off.' Current vitals: HR 118, BP 102/64, RR 22, T 38.4 °C, SpO2 94% on room air. Urine output over the last 6 hours is 90 mL. He has a midline incision with a dry dressing, an IV of 0.9% sodium chloride running at 75 mL/hr, and is receiving IV paracetamol and morphine PRN. He is drowsy but rousable and answers questions slowly. The night nurse documented a similar set of vitals at 02:00 and gave 4 mg IV morphine for 'restlessness.'
1. What is your priority interpretation of these findings, and what is the first action you take?
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Interpretation: This is not isolated pain or restlessness. The combination of rising heart rate, falling blood pressure, tachypnea, low-grade fever, oliguria (90 mL/6 hr ≈ 15 mL/hr, well below the 0.5 mL/kg/hr threshold), and new drowsiness points to evolving hypovolemia/sepsis - most likely from third-spacing, inadequate resuscitation, or an intra-abdominal source. The 02:00 'restlessness' treated with morphine was probably an early warning sign that was masked rather than assessed.
First action: Do not give more morphine. Perform an ABCDE assessment, confirm the vitals manually (recheck BP and HR yourself), and escalate immediately - call the surgical team and initiate the sepsis pathway. Start a bolus of isotonic crystalloid as ordered, obtain blood cultures and lactate before antibiotics, and increase monitoring frequency to at least hourly. Document the trend from 02:00 to 06:00 so the receiving clinician sees the trajectory, not a single snapshot.
2. The surgical resident orders 1 L of 0.9% sodium chloride over 1 hour and says 'reassess after.' Outline how you will reassess and what findings would tell you the patient is responding versus deteriorating.
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Reassessment plan (structured, timed):
- Vital signs every 15 minutes during the bolus, then hourly.
- Strict intake/output with hourly urine measurement and a bladder scan if output does not improve.
- Mental status (AVPU/GCS) each check - compare to the drowsy-but-rousable baseline.
- Capillary refill, skin temperature, and mucus membranes.
- Repeat lactate per protocol; track the trend, not just the number.
Responding: HR trending down toward baseline, BP rising toward 128/76, urine output rising above 0.5 mL/kg/hr (≈ 40 mL/hr for this patient), improving alertness, warm peripheries, falling lactate.
Deteriorating: HR stays >110 or climbs, BP continues to fall or becomes narrow (rising diastolic with falling systolic), urine stays <30 mL/hr despite a full liter, worsening drowsiness, mottling, or new fever. Any of these means the resident needs to be called back immediately - do not wait for the hour to finish if the picture is worsening.