NEWS 10 on Post-operative Day 3
Mr B, 62, is day 3 after emergency laparotomy for perforated sigmoid diverticulitis with faecal peritonitis. He has a midline wound with a closed suction drain and an indwelling urinary catheter. At 07:00 he is drowsy but rousable; at 08:00 his wife says he 'isn't himself'. Observations: temperature 38.9 °C, HR 124 in sinus rhythm, BP 92/54 (baseline 140/85), RR 26, SpO2 93% on 2 L/min nasal cannula, GCS 14 (E4 V4 M6), urine 45 mL in the last 3 hours, capillary refill 4 seconds, cool peripheries, mottled knees. The ward early warning score totals 10. Lactate 3.6 mmol/L, WBC 19.4 × 10⁹/L, creatinine risen from 78 to 132 µmol/L. Blood cultures have been ordered. The surgical registrar is in theatre and the on-call cover is a foundation doctor 20 minutes away. Antibiotics are prescribed but not yet given.
1. Interpret the findings and set out your priority actions in the first 30–60 minutes.
Read the worked answer
This is sepsis with hypoperfusion until proven otherwise: post-operative day 3, new confusion, fever, tachycardia, hypotension relative to baseline, tachypnoea, oliguria, delayed capillary refill, mottling and lactate 3.6 mmol/L.
First 30–60 minutes, run in parallel:
- Call for help now. Activate the rapid response/MET and contact the surgical team. A registrar in theatre and a foundation doctor 20 minutes away is not an adequate response to a score of 10 - ask for the on-call consultant or the MET, whichever can attend first.
- Breathing: sit him up, titrate oxygen to SpO2 94–98%, continuous SpO2 and cardiac monitoring, respiratory rate and, if available, capnography.
- Circulation and samples: two large-bore cannulae; send lactate, FBC, U&E, LFTs, coagulation, group and save, and blood cultures.
- Antibiotics within one hour. Do not delay them for cultures - take cultures first only if this costs minutes; the cultures are already ordered, so give the prescribed dose now.
- Fluids: begin weight-based crystalloid resuscitation (typically 30 mL/kg for sepsis-induced hypoperfusion - approximately 1.8 L for a 62 kg man, given in aliquots with reassessment).
- Find the source: wound, drain (has it stopped draining or is it now purulent?), abdomen for new pain, guarding or rigidity suggesting anastomotic leak, lines, chest, urine.
- Document, and repeat observations every 15 minutes with a repeat lactate at 2 hours.
2. Specify your fluid resuscitation and monitoring plan, including the signs that would make you stop and escalate.
Read the worked answer
Fluid resuscitation is a monitored intervention, not a single order.
- Use balanced crystalloid (Hartmann's/Ringer's) rather than large volumes of 0.9% saline where available, to limit hyperchloraemic acidosis.
- Give in aliquots - for example 500 mL over 15 minutes - and reassess after each: heart rate, blood pressure (target MAP ≥65 mmHg), capillary refill, mentation, urine output ≥0.5 mL/kg/h (about 30 mL/h), lung sounds and work of breathing.
- Watch for fluid intolerance: this patient is post-laparotomy, may have an ileus or leak, and is at risk of pulmonary oedema. Rising JVP, new crackles, falling SpO2, or a lactate that does not fall despite fluid should prompt senior review for vasopressors and critical care rather than more blind boluses.
- Monitoring to establish: continuous ECG and SpO2, blood pressure at least every 15 minutes initially, hourly urine output via urometer, strict fluid balance, GCS, capillary refill and mottling score.
- Reassess and record the response to each bolus - a fluid challenge without documented reassessment is not resuscitation.
Escalate to critical care early if he remains hypotensive after the initial resuscitation, needs vasopressors, or has a rising lactate and worsening mentation - these are discussions to start, not to defer until the ward round.
3. Write the SBAR you would use to escalate, and explain why waiting for the registrar or for culture results is the wrong call.
Read the worked answer
S - Situation: 'Mr B, 62, day 3 after laparotomy for perforated diverticulitis with faecal peritonitis. I am calling because he is septic and hypotensive and I need senior review now.'
B - Background: baseline BP 140/85, baseline creatinine 78; current antibiotics and time of last dose; drain output; last urine output; allergies.
A - Assessment: 'NEWS 10. Temperature 38.9, HR 124, BP 92/54, RR 26, SpO2 93% on 2 L, new confusion, urine 45 mL in 3 hours, mottled knees, capillary refill 4 seconds, lactate 3.6, WCC 19.4, creatinine 132.'
R - Recommendation: 'I need senior surgical review for a possible intra-abdominal source, confirmation of antibiotic choice and dose, a fluid plan and a vasopressor decision, and critical care review. What do you want me to do in the next 15 minutes?'
Why not wait: mortality in septic shock rises with each hour that antibiotics and source control are delayed. The blood cultures have already been taken, so there is nothing to wait for on that front. The registrar being in theatre is a staffing problem, not a clinical justification - escalate to the consultant, MET or site coordinator, and document who you called, when, and what they said. If the response remains inadequate, escalate again; that documented chain is what protects the patient and demonstrates appropriate professional judgement.