Day-1 after laparotomy: is this bleeding or sepsis?
Mr. R, 58 years, 82 kg, is 14 hours after emergency laparotomy with omental patch repair of a perforated duodenal ulcer. He has a nasogastric tube on free drainage, a Foley catheter, a closed suction drain and a right internal jugular triple-lumen catheter. The 07:00 handover reads: heart rate 124/min, BP 92/56 mmHg, respiratory rate 28/min, SpO2 95% on 4 L/min nasal prongs, temperature 38.4 °C, 40 mL of dark urine in the bag over 3 hours, drain 300 mL of blood-stained fluid since 05:00, abdomen distended with guarding, capillary refill 4 seconds, drowsy but rousable. The night resident has written: 'Ringer lactate 500 mL over 6 hours; inj. ketorolac 30 mg IV 8-hourly; inj. tramadol 100 mg IM 8-hourly if pain; encourage 200 mL oral fluids hourly; repeat haemoglobin at 6 pm.' Last night's haemoglobin was 8.4 g/dL against a preoperative 12.1 g/dL. There are no blood products in the ward refrigerator, the blood bank closes at 20:00, and the night nurse-to-patient ratio is 1:6.
1. What are the two most likely explanations for this deterioration, and which bedside findings would you use to separate them? State your first three nursing actions in the next 15 minutes.
Read the worked answer
Two competing explanations
- Ongoing intra-abdominal bleeding (slipped ligature, eroded vessel at the patch site): falling haemoglobin, large blood-stained drain output, tachycardia with narrow pulse pressure, cold peripheries, oliguria.
- Sepsis with third-space loss after perforation peritonitis: fever, guarding, rising respiratory rate, but drain output should be serosanguineous and modest.
Discriminating data - measure and record hourly, not once: drain volume and character (fresh blood >100 mL/hour is surgical), haemoglobin trend, capillary refill and core–peripheral temperature gap, urine output and specific gravity, lactate if available, response of BP and heart rate to a fluid bolus. Temperature alone cannot separate them; both cause tachycardia.
First three actions
- Call the surgical resident and the rapid response team now - do not wait for the 6 pm haemoglobin.
- Secure a second 14–16 G cannula, send blood for cross-match (2 units), CBC, coagulation, lactate, electrolytes, and start a 500 mL crystalloid bolus over 15 minutes with reassessment.
- Hourly drain measurement, strict input–output chart, vital signs every 15 minutes, oxygen to keep SpO2 ≥94%, keep the patient nil by mouth, and withhold the ketorolac dose pending review.
2. Which of the night resident's written orders would you question, and what would you propose instead? Give the reason for each.
Read the worked answer
- Inj. ketorolac 30 mg IV 8-hourly - question and withhold. NSAIDs are contraindicated after peptic ulcer perforation: they impair platelet aggregation and renal perfusion in a hypovolaemic patient and delay mucosal healing. Propose IV paracetamol plus titrated opioid (morphine 2–3 mg IV increments) with sedation scoring.
- Inj. tramadol 100 mg IM - question the route. In a patient with cold peripheries and poor muscle perfusion, IM absorption is erratic. Propose the IV route, and note that tramadol lowers the seizure threshold.
- Encourage 200 mL oral fluids hourly - unsafe. After laparotomy with a distended, guarded abdomen there is ileus and aspiration risk. Keep nil by mouth, keep the nasogastric tube on free drainage, and replace losses intravenously.
- Ringer lactate 500 mL over 6 hours - far too slow for a tachycardic, hypotensive patient with oliguria. Propose 500 mL bolus over 15 minutes, then reassess and repeat if no improvement in BP, heart rate or urine output.
- Repeat haemoglobin at 6 pm - too late; send it now and again after resuscitation, remembering that haemoglobin lags behind acute loss.
Document each query, the time, and the response in the nursing notes.
3. At 09:30 the drain has added 500 mL and BP falls to 78/44 mmHg with a pulse of 138/min. The intensivist is in theatre. Write the SBAR you would give the surgeon and state three decisions you need from him.
Read the worked answer
SBAR (spoken in under 45 seconds)
- Situation: Mr. R, day-1 laparotomy, is now 78/44 with a pulse of 138 and drowsy, probably in haemorrhagic shock.
- Background: Perforated duodenal ulcer repair; haemoglobin fell 12.1 to 8.4 g/dL; drain 300 mL at 07:00 rising by 500 mL in two and a half hours; urine 40 mL in 3 hours; no blood products on ward, blood bank shuts at 20:00.
- Assessment: Active intra-abdominal bleeding, not sepsis alone; responding poorly to crystalloid.
- Recommendation: Review now; authorise blood and a return to theatre if needed.
Three decisions required
- Resuscitation target and whether to activate the massive transfusion protocol, plus how many units to requisition before 20:00.
- Whether to return to theatre for re-exploration, and if so, pre-operative preparation and consent.
- Whether to transfer to HDU and whether to start a vasopressor or tranexamic acid while awaiting blood.
Record the time of the call, the surgeon's replies, and escalate to the duty administrator if no review occurs within 15 minutes.