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Post-operative day 2 after laparotomy: sepsis, hypovolaemia, or both?

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Post-operative day 2 after laparotomy: sepsis, hypovolaemia, or both?

Mr R, 46 years old, is on post-operative day 2 after an emergency laparotomy for a perforated appendix in a district hospital. At 06:00 the chart reads: temperature 38.9 °C, pulse 118/min and thready, BP 96/58 mmHg, respirations 24/min, SpO2 94% on room air, urine 15 mL/hour for the last four hours, nasogastric aspirate 300 mL over 8 hours, drain output 200 mL of bile-stained fluid over 8 hours. The abdomen is distended and tender, and he has passed no flatus since surgery. The 24-hour intake-output sheet shows 3000 mL of intravenous fluid in and 900 mL out. Reports: Hb 10.8 g/dL, WBC 19,400/µL, sodium 132 mmol/L, potassium 3.2 mmol/L, creatinine 1.9 mg/dL (pre-operative 0.9), lactate 3.4 mmol/L. He is drowsy but rousable and does not know where he is. The surgical unit is in theatre and the ward has one staff nurse for 28 patients.

1. Interpret the clinical picture. Which findings point to hypovolaemia, which to sepsis, and what does the combined picture mean for your immediate priorities?

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Both processes are present, and the nurse should treat them together rather than choosing one.

Evidence for hypovolaemia

  • Ongoing losses that are not matched: 3000 mL in versus 900 mL out, with 500 mL of that output being nasogastric and drain fluid rather than urine. Much of the deficit is third-space and insensible, which the intake-output sheet cannot show.
  • Tachycardia 118/min, thready pulse, hypotension 96/58 mmHg, oliguria 15 mL/hour, potassium 3.2 mmol/L from upper gastrointestinal loss.

Evidence for sepsis

  • Fever 38.9 °C, WBC 19,400/µL, lactate 3.4 mmol/L, abdominal tenderness and distension with no flatus (possible persisting intra-abdominal source or anastomotic leak).
  • qSOFA: respiratory rate ≥22 (24) = 1, systolic BP ≤100 (96) = 1, altered mentation = 1, giving 3 of 3 - high risk, the patient needs senior review now, not at the next round.

Renal

  • Creatinine has doubled from 0.9 to 1.9 mg/dL, which is AKI stage 1 (1.5–1.9 times baseline); the oliguria is therefore not simply an empty bladder.

Priority Resuscitate and screen for sepsis in parallel: oxygen, fluid boluses, cultures then early antibiotics, hourly urine measurement, and urgent escalation to the surgeon or medical officer rather than waiting for theatre to finish.

2. List your actions in the first 30 minutes in priority order, and name three interventions you should avoid, with reasons.

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First 30 minutes

  1. Call for help first. Inform the medical officer or surgeon and the on-call anaesthetist; ask for a second nurse. Alone with 28 patients, this determines whether anything else is achievable.
  2. Airway and oxygen. Sit him up, keep the airway clear, give oxygen to keep SpO2 at least 94%; recheck respiratory rate and depth.
  3. Two large-bore intravenous cannulae (16–18 G) and blood sampling for cultures (two sets from different sites), lactate, electrolytes, creatinine, complete blood count and coagulation, before antibiotics if it does not delay them.
  4. Fluid resuscitation. Balanced crystalloid boluses of 500 mL with reassessment of pulse, BP, lung bases and urine output after each; a septic adult typically needs around 30 mL/kg. Do not chase a single number - reassess.
  5. Antibiotics within one hour of recognising sepsis, according to hospital policy, usually a third-generation cephalosporin plus metronidazole for a colorectal source.
  6. Catheterise for accurate hourly urine measurement; strict hourly intake-output charting.
  7. Potassium replacement for 3.2 mmol/L by slow diluted infusion, with cardiac monitoring if available.
  8. Keep nil by mouth, keep the nasogastric tube draining, and document the time of every action.

Avoid

  • Frusemide for the oliguria: the problem is a depleted circulation, not overload; a diuretic worsens the AKI.
  • NSAIDs and aminoglycosides: nephrotoxic in a patient whose creatinine has already doubled.
  • Rapid undiluted potassium bolus: fatal arrhythmia risk; must be diluted and rate-controlled.
  • Withholding antibiotics while waiting for cultures, or delaying them for a theatre review.

3. What will you monitor and chart over the next four hours, and what specific findings would make you escalate immediately?

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Routine monitoring, at least hourly

  • Pulse rate and volume, blood pressure, respiratory rate, SpO2, temperature and level of consciousness (use a simple scale such as AVPU or GCS so that change is detectable).
  • Hourly urine output with a urometer; target at least 0.5 mL/kg/hour, roughly 35 mL/hour for a 70 kg man, and report two consecutive hours below that.
  • Nasogastric and drain volumes and character - a change to faeculent or suddenly bloody drainage is a surgical emergency.
  • Cumulative fluid balance calculated from zero at the start of the shift, not just the 24-hour total, and daily weight if possible.
  • Capillary refill, skin temperature and peripheral colour; repeat lactate and electrolytes as ordered.
  • Abdominal girth or inspection for increasing distension, and the wound for dehiscence or discharge.

Escalate immediately if

  • Systolic BP remains below 90 mmHg after two fluid boluses, or the pulse rises above 130/min.
  • Urine output stays below 0.5 mL/kg/hour despite adequate filling, or anuria develops.
  • Respiratory rate climbs above 28/min or SpO2 falls below 92% despite oxygen - think of worsening sepsis or acute respiratory distress.
  • New confusion, agitation or unresponsiveness.
  • Drainage becomes faeculent, the abdomen becomes rigid, or there is new guarding - possible anastomotic leak requiring theatre.

Handover should be structured (situation, background, assessment, recommendation) and recorded with the time the doctor was informed and the response.