Day-2 Laparotomy with Falling Blood Pressure, Oliguria and a Falling Haemoglobin

Best explanation: hypovolaemic shock from combined third-space sequestration (bowel distension, ileus, nasogastric losses) with probable ongoing intra-abdominal bleeding.

Reasoning chain:

• Tachycardia, narrow pulse pressure, thirst, restlessness, cool peripheries and capillary refill of 4 s are the classic compensatory picture of reduced circulating volume.
• CVP of 4 cm H2O indicates low preload. A low CVP is not diagnostic on its own, but here it fits the whole picture rather than contradicting it.
• Urine output averaging 12 mL/h in an adult (well below 0.5 mL/kg/h) reflects renal hypoperfusion, not just a blocked catheter - the trend is falling, not fluctuating.
• The haemoglobin fall from 12.1 to 8.9 g/dL in 48 hours, with 180 mL of serosanguineous drain fluid and a distended tender abdomen, points to blood loss, either into the drain or into the peritoneal cavity/retroperitoneum.

Three findings that argue against sepsis as the primary cause:

1. The falling haemoglobin with a matching drain and abdominal findings - sepsis does not lower haemoglobin this way.
2. Temperature of 37.6 °C with no rigors or hypothermia, in a patient whose only invasive focus is a 2-day-old central line.
3. A low CVP with marked thirst and cool peripheries - septic shock in its warm phase usually shows vasodilatation and a normal-to-high CVP; when it becomes cold, the history is usually longer and there is an identifiable source.

These findings do not exclude sepsis. Lactate, white cell count and blood cultures from the line and a peripheral vein should still be taken, because both problems can coexist. The point of the discrimination is to prioritise volume replacement and surgical review without delaying cultures.

Nurse-initiated actions (cannot be delegated):

• Call the on-call surgical team and the anaesthetist now, and activate the rapid response/fast-bleep system. Waiting 90 minutes for the registrar is unsafe in a patient with hypotension, oliguria and a falling haemoglobin.
• Position supine with legs elevated, protect the airway, keep nil by mouth, and titrate oxygen to keep SpO2 at 94–98%.
• Reassess and document: full set of observations, urine output, drain volume and character, abdominal girth, level of consciousness, and check that the catheter is not blocked or kinked.
• Secure a second large-bore peripheral cannula, take blood for cross-match, full blood count, coagulation, urea, electrolytes and lactate, and send the drain fluid for analysis if the team requests it.
• Obtain an explicit medical order for a crystalloid bolus (for example 500 mL over 15 minutes) and blood products; administer and document. If no prescriber is reachable, escalate up the chain of command - do not simply wait.

Can be delegated to the nursing assistant:

• Physically carrying the cross-match forms and specimens to the laboratory and blood bank, and collecting the emergency trolley and blood warmer.
• Recording serial urine volumes and drain volumes once the RN has confirmed the catheter and drain are patent.
• Calling the theatre and blood bank to confirm receipt.

Should not be delegated: interpretation of observations, cannulation, blood administration, decisions about fluid rate, and assessment of deterioration. The assistant may record, but the RN must interpret and act on each set of observations.

This is not acceptable practice in the ordinary case.

• Nursing staff do not independently alter the rate of a prescribed intravenous infusion except under a formally approved nurse-initiated protocol or a documented standing order for a defined situation.
• The reasoning is not bureaucratic: a rapid unmonitored fluid load in a patient with possible intra-abdominal bleeding, an ileus and a low haemoglobin can worsen third-space loss, produce pulmonary oedema, dilute clotting factors and haemoglobin further, and delay the decision that actually matters - whether he needs blood and a return to theatre.
• There is also no observable endpoint written down. A fluid challenge is only safe when there is a defined volume, a defined time and defined reassessment criteria (blood pressure, heart rate, urine output, lung bases, CVP).

Correct course of action:

1. Escalate immediately - a falling urine output with hypotension is a trigger for medical review, not a unilateral prescription.
2. Obtain a clear verbal or written order, read it back to the prescriber, record the time and the name, and document it as a verbal order where hospital policy allows.
3. Where the hospital has an approved nurse-initiated fluid protocol, follow it exactly - including the maximum volume and the mandatory reassessment point.
4. Continue independent nursing measures: accurate intake–output, hourly urine measurement, patent catheter, observation frequency increase, positioning, oxygen.
5. Document the concern, the escalation and the response time - this protects both the patient and the nurse.