Post-operative haemorrhagic shock on a surgical ward at night
A 58-year-old man is 18 hours after emergency laparotomy for a perforated duodenal ulcer. Over the last 4 hours his left abdominal drain has collected 400 mL of blood-stained fluid, the nasogastric tube 150 mL of dark fluid, and the urinary catheter only 30 mL of urine. He is drowsy but rousable. Supine pulse is 126/min and thready, blood pressure 92/58 mmHg, respiratory rate 26/min, SpO2 96% on 4 L/min nasal prongs, temperature 36.4 °C. Capillary refill is 4 seconds and the extremities are cold and clammy. Central venous pressure is 3 cmH2O and haemoglobin has fallen from 11.2 g/dL pre-operatively to 7.8 g/dL. He is receiving noradrenaline 0.08 microgram/kg/min through a 22G peripheral cannula in the hand. The only other cannula is 20G. The surgical registrar is scrubbed in theatre and one staff nurse is covering the other 22 patients on the ward.
1. Classify this patient's circulatory state and justify your classification using at least four specific findings. Why is continuing haemorrhage a better explanation than dehydration or sepsis?
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Classification: decompensated hypovolaemic (haemorrhagic) shock, approximately Class III–IV.
Supporting findings
- Measured losses: 400 mL of blood-stained drain fluid in 4 hours plus falling haemoglobin (11.2 → 7.8 g/dL) indicates whole blood loss, not third-space loss.
- Haemodynamics: pulse 126/min, systolic 92 mmHg with a pulse pressure of only 34 mmHg - a narrowing pulse pressure is an early and sensitive sign of reduced stroke volume.
- Filling and perfusion: CVP 3 cmH2O, capillary refill 4 seconds, cold clammy peripheries, urine output only 30 mL in 4 hours (well below 0.5 mL/kg/h).
- Cerebral and respiratory compensation: drowsiness, tachypnoea of 26/min and a thready pulse.
Why not dehydration or sepsis? Dehydration after surgery would not produce fresh blood in the drain or such a steep haemoglobin fall. Sepsis would usually give fever or hypothermia with warm, vasodilated peripheries, and here the temperature is normal with cold, shut-down skin. Note also that the noradrenaline is artificially supporting the blood pressure - the patient's true haemodynamic state is likely worse than the cuff reading suggests, and the drug must not be used as a substitute for restoring circulating volume.
2. List, in order, your first six actions over the next 15 minutes, giving the reasoning behind each.
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- Call for help first - activate the rapid response/obstetric-style emergency call, ask the ward clerk or a relative to phone theatre for the registrar, and request a second nurse. A single nurse cannot resuscitate and monitor 22 other patients.
- Position and oxygen - lay him flat with legs elevated, keep him warm (warm blankets, warm fluids) and give oxygen titrated to SpO2 94–98%. Cold, coagulopathic patients bleed more.
- Secure large-bore access - insert at least one 16G or larger cannula; the existing 20G and 22G are inadequate for rapid volume or blood. Take blood simultaneously: full blood count, coagulation screen, urea and electrolytes, crossmatch 4 units, arterial blood gas with lactate.
- Restore volume cautiously - give a 500 mL bolus of balanced crystalloid while blood is being organised, then reassess pulse, blood pressure and capillary refill. Do not run litres of crystalloid in a bleeding patient; it dilutes clotting factors and worsens hypothermia.
- Activate the massive haemorrhage protocol and alert theatre - request emergency O-negative blood if crossmatched blood is not immediately available, and ask the surgeon to review at the bedside now, not after the list.
- Move the noradrenaline to a large vein or central line and document - peripheral extravasation through a 22G cannula risks tissue necrosis; dilute and site it properly, and record hourly urine output, drain volume and observations every 15 minutes.
3. Which three parameters would you use to judge whether resuscitation is working, and at what values would you escalate immediately?
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1. Urine output - the single best bedside marker of organ perfusion. Target at least 0.5 mL/kg/h (about 30–35 mL/h for a 70 kg man). Less than 0.3 mL/kg/h for two consecutive hours despite fluid means the resuscitation is failing.
2. Haemodynamics - pulse, blood pressure and pulse pressure - a falling pulse towards 100/min and a widening pulse pressure with warm peripheries indicate response. Escalate if, after 1 litre of crystalloid and the first units of blood, the systolic remains below 90 mmHg, the pulse stays above 120/min, or the noradrenaline requirement rises rather than falls.
3. Drain output, haemoglobin and lactate - continuing drain losses above 100 mL/h, a haemoglobin that does not rise after transfusion, or a lactate that fails to fall by at least 10–20% over 2 hours all indicate ongoing bleeding and the need for surgical control rather than more transfusion.
Add CVP trend (target 8–12 cmH2O), capillary refill under 2 seconds and level of consciousness as supporting checks. Any deterioration in conscious level or a new need for airway support is an immediate escalation to critical care.