Postoperative Tachycardia After Emergency Laparotomy

Frame the problem as undifferentiated postoperative deterioration with distributive and possibly hypovolemic or septic physiology. Use a structured ABCDE reassessment with the bedside team rather than a single intervention. Priorities: secure airway and reassess GCS trend; confirm adequate oxygen delivery and consider escalation of respiratory support; establish reliable large-bore access; send cultures before antibiotics if this does not delay them; check lactate, blood gas, glucose, and coagulation; catheter and hourly urine output; review fluid balance and blood loss from drains and wound; examine abdomen for distension, tenderness, and wound dehiscence; check for missed sources such as anastomotic leak, intra-abdominal collection, aspiration, line infection, or urinary source. Start broad-spectrum antibiotics covering gut flora after cultures. Give a balanced crystalloid challenge of 250-500 mL with reassessment, but avoid blind repeated boluses in a patient with CKD and possible capillary leak; consider dynamic assessment. Escalate noradrenaline if MAP remains below 65 after initial resuscitation. Simultaneously involve the on-call consultant surgeon and ICU, and start the process for CT abdomen/pelvis with contrast if the patient is stable enough to transfer. The key judgement is not choosing between fluid, antibiotics, and theatre but recognising that all three may be needed and sequencing diagnostic uncertainty safely.

This is a suspected stump leak or pelvic abscess with systemic sepsis and rising lactate despite resuscitation. The decision is source control: return to theatre for washout and drainage, with a low threshold for completing a defunctioning or end colostomy if the stump is unsalvageable. Percutaneous drainage may be considered in a stable patient with a well-defined collection and no generalized peritonitis, but physiological derangement, rising lactate, and free gas make operative source control safer here. Justify to the family by explaining that the original operation controlled the perforation, but a new infection has developed at the join in the pelvis; antibiotics alone cannot drain pus, and delay increases the risk of organ failure and death. Explain the plan, the possibility of a stoma, the possibility of ICU stay, and the uncertainty. Document the discussion, involve the consultant, and ensure consent is taken by an appropriately experienced clinician. Postoperatively, plan for ICU, repeat lactate, antimicrobial review, and nutrition.

Reconsider if fever persists despite adequate source control; if lactate fails to fall; if vasopressor requirement escalates; if urine output remains low after resuscitation; if platelets fall further or coagulation deranges, suggesting disseminated intravascular coagulation; if respiratory requirement rises, suggesting aspiration or ARDS; if abdominal pain localises elsewhere; if there is wound erythema, crepitus, or disproportionate pain suggesting necrotising infection; if there is line-site inflammation or new murmur; or if glucose control deteriorates unexpectedly. Also reconsider non-infective causes: myocardial infarction, pulmonary embolism, adrenal insufficiency in a chronically unwell patient, drug reaction, or alcohol withdrawal. Each would change management, and the discipline is to reassess rather than anchor on the initial label.