Post-operative Day 5 Tachycardia After Emergency Laparotomy
A 57-year-old man is day 5 after an emergency laparotomy and small bowel resection for adhesional obstruction with ischaemic bowel. He has a midline wound closed with clips, a nasogastric tube, a urinary catheter and a rectus sheath catheter infusing local anaesthetic. He is normally fit and well, on no regular medications. Overnight nursing notes record HR rising from 88 to 116, temperature 38.2 C, and 40 mL of urine in the last 4 hours. On review he is drowsy but rousable, BP 104/62, RR 24, SpO2 94% on 2 L, abdomen distended and tender with reduced bowel sounds. WCC 18.9, CRP 240, lactate 3.1, creatinine 168 (day 1 value 92). The ward doctor has prescribed paracetamol and written 'likely atelectasis, continue physiotherapy'.
1. Identify the likely diagnosis and explain the reasoning that makes the current plan inadequate.
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The likely diagnosis is an intra-abdominal complication, most probably an anastomotic leak with secondary peritonitis and sepsis, or a collection/abscess. Alternatives include aspiration pneumonia, urinary infection, line sepsis or a rectus sheath catheter complication, but the combination of abdominal tenderness, distension, rising CRP and creatinine, oliguria and lactate of 3.1 points strongly to an intra-abdominal source.
The current plan is inadequate because:
- Tachycardia and fever on day 5 are not explained by atelectasis alone; atelectasis rarely causes a CRP of 240 or a lactate of 3.1.
- Oliguria with creatinine rising from 92 to 168 indicates acute kidney injury from hypovolaemia and sepsis, not a benign finding.
- Lactate 3.1 suggests tissue hypoperfusion and mandates urgent action.
- Drowsiness may reflect sepsis or opioid accumulation; the rectus sheath catheter should be reviewed.
This meets sepsis criteria. The appropriate response is to escalate to a senior surgeon immediately, take blood and urine cultures, start broad-spectrum antibiotics within an hour, give a fluid bolus with careful reassessment, and arrange an urgent CT abdomen and pelvis with contrast. Do not simply continue physiotherapy and paracetamol.
2. CT shows a 6 cm fluid collection adjacent to the anastomosis with no free gas and no generalised peritonitis. Describe your management, including how you would monitor for failure.
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Initial management:
- Resuscitate: oxygen to keep saturations above 94%, cautious fluid boluses guided by urine output and lactate clearance, and urinary catheter monitoring.
- Broad-spectrum antibiotics covering gram-negative and anaerobic organisms.
- Image-guided percutaneous drainage of the 6 cm collection, with fluid sent for culture and microscopy.
- Keep nil by mouth, continue nasogastric decompression, and consider total parenteral nutrition if prolonged ileus is anticipated.
- Involve critical care; if hypotension persists despite fluids, vasopressors and organ support may be needed.
- Review the rectus sheath catheter: if there is any concern about the catheter site or systemic local anaesthetic toxicity, stop the infusion.
Monitoring for failure:
- Reassess at least every 4-6 hours: HR, BP, respiratory rate, urine output, GCS and abdominal examination.
- Repeat lactate, FBC, CRP and creatinine at 12-24 hours; a falling lactate and CRP and improving urine output suggest success.
- If there is persistent tachycardia, rising lactate, worsening renal function, new free gas or generalised peritonitis, proceed to laparotomy and take down the anastomosis, forming an end ileostomy or stoma.
- A repeat CT may be needed if the drain output is poor or the collection recurs.
Judgement point: percutaneous drainage is a bridge, not a cure, and is only appropriate if the patient is stable and there is no generalised peritonitis or free gas. The threshold for surgery must be low and reviewed frequently.