CAPA (ABPANC): Hypotension and a Rigid Abdomen After Polypectomy

Differential, weighted by what the data show:

• Post-polypectomy bleeding (intraluminal). A 15 mm sessile lesion with cautery plus an anticoagulant held only two days makes this plausible; blood loss may be entirely internal, so absence of visible bleeding proves nothing.
• Perforation with pneumoperitoneum. Distension, guarding, and worsening pain after cautery are red flags; early perforation may present with hypotension and tachycardia before fever or rigidity.
• Hypovolemia from the bowel prep. A 4 L PEG prep with clear liquids only since noon the prior day is a substantial deficit, and sedation blunts compensatory response.
• Vasovagal response to colonic distension and residual sedation/diphenhydramine effect (anticholinergic, sedating, can contribute to tachycardia and confusion).

Note the numbers: HR 112 with BP 92/54 gives a shock index of roughly 1.2; a value above 1 in a recovery patient suggests significant volume loss or bleeding until disproven.

First five actions:

1. Airway/breathing/circulation check, position supine or head-down as tolerated, apply oxygen, continuous ECG/SpO2/BP cycling.
2. Large-bore IV access, isotonic crystalloid bolus, reassess response.
3. Focused abdominal exam (rigidity, rebound, tympany, distension) plus stool check if indicated; vitals every 5 minutes.
4. Notify the endoscopist and the covering physician immediately; escalate to the on-call surgeon or anesthesia if the endoscopist is unreachable - do not wait for a call-back to start looking for help.
5. Stat CBC, coagulation studies, type and screen, chemistry; keep NPO, hold apixaban, prepare for CT abdomen/pelvis and possible transfer to ED or OR.

No - and the reasoning matters more than the answer. Phase I to Phase II transfer requires stable vital signs near baseline, a patent airway with protective reflexes, oxygen saturation at baseline, controlled pain and nausea, and no evidence of an evolving complication. He fails on hemodynamics (BP 92/54 vs baseline 128/74, HR 112) and has an unexplained, worsening abdominal exam.

• Aldrete or a similar score is not a substitute for clinical judgment. He could score well on activity, respiration, and consciousness and still be bleeding or perforating.
• The bed pressure is an operational problem, not a clinical criterion. Say that explicitly when handing the decision back to the charge nurse, and offer the alternative: escalate level of care rather than transfer.
• Appropriate disposition: continued Phase I monitoring with increased frequency, physician at the bedside, and readiness for transfer to a higher-acuity setting.

What I would document: baseline vs. current vitals, the change over time, exam findings, the fact that a bed-availability request was declined and why, and who was notified.

SBAR handoff:

• Situation: 68-year-old, 25 minutes post colonoscopy with polypectomy, now hypotensive and tachycardic with a rigid, distended abdomen.
• Background: three polyps, 15 mm sessile removed with cautery; apixaban held two days; 4 L PEG prep with clear liquids only since noon yesterday; sedation totals midazolam 4 mg, fentanyl 100 mcg, diphenhydramine 25 mg; baseline BP 128/74, HR 68.
• Assessment: concerning for post-polypectomy bleeding, perforation, or prep-related hypovolemia; shock index ~1.2; airway currently patent but he is sedated.
• Recommendation: physician at bedside now, labs and type and screen sent, IV access and fluid bolus started, NPO, anticoagulant held, CT and higher level of care anticipated. Ask for explicit acceptance of the patient.

Documentation essentials: objective serial vitals with times, exam findings in your own words, every notification with time and response, interventions and the patient's response, the escalation path used if there was delay, the discharge/transfer decision and rationale, and the education given to the patient and family. Avoid retrospective charting; chart in real time.