Post-operative desaturation after emergency laparotomy
Mrs Latu, 58, is day 1 after an emergency laparotomy for perforated diverticulitis. She has a midline wound, an epidural, BMI 34, and a 40-pack-year smoking history. The nurse calls you because Mrs Latu's SpO2 is 90% on 2 L/min nasal prongs, respiratory rate 24, heart rate 112, blood pressure 105/60 mmHg, temperature 38.1°C, and pain 7/10 at the wound. She is drowsy but rousable, has not coughed since surgery, and has diminished breath sounds at both bases. The surgical registrar is in theatre and the house surgeon is covering three wards. The physiotherapy department has a policy of not doing 'routine chest physio' without a documented indication. You have 20 minutes before your next patient. The ward is short-staffed and the nurse asks you to 'just do the chest physio'.
1. What is your immediate assessment and escalation plan, and why?
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ABC first: she is drowsy but rousable, so I would assess airway patency, breathing (rate, depth, effort, auscultation, SpO2), circulation (HR, BP, capillary refill, urine output), and disability (GCS, pain). RR 24, SpO2 90% on 2 L, HR 112, BP 105/60, temperature 38.1°C and pain 7/10 suggest deterioration, not simply sputum retention. I would calculate a NEWS2 or early warning score and escalate urgently to the surgical team; if the house surgeon is unavailable, I would use the hospital's escalation policy and call the rapid response or duty medical officer. I would not wait for the registrar. I would check her epidural level, wound, abdomen and fluid balance, and ask about chest pain, calf swelling and urine output. Possible causes include atelectasis, pneumonia, sepsis, pulmonary embolism, anastomotic leak and epidural-related hypotension. My role is to recognise deterioration and escalate, not to diagnose alone. I would start oxygen titration per target, position her upright if tolerated, and do a brief chest assessment. Documentation and a clear SBAR call are part of the treatment.
2. Which treatment options are appropriate and which are contraindicated or lower priority?
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Appropriate options include positioning, supported coughing or huffing, coordination of pain relief, incentive spirometry or deep breathing, early mobilisation when safe, and suction only if indicated. If she has atelectasis, directed breathing exercises and secretion clearance may help. I would coordinate analgesia before coughing. Lower priority: routine 'chest physio' without indication, percussion or vibration in a postoperative patient with recent abdominal surgery, and aggressive suctioning. Contraindicated or cautionary: vigorous manual techniques over the abdomen, prone positioning without team agreement, and mobilising before medical review if she is hypotensive and febrile. I would avoid interrupting essential medical assessment. The key reasoning is that physiotherapy is an adjunct, not a substitute for sepsis management. I would reassess after medical review and document response. If she deteriorates, I would stop treatment and call for help.
3. What infection prevention and control measures apply, and how do you document and communicate risk?
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Standard precautions apply: hand hygiene before and after, gloves and apron for contact with secretions, and correct PPE if infection is suspected. If she has a productive cough or diarrhoea, I would check whether transmission-based precautions are needed; for suspected respiratory infection, a surgical mask on the patient and PPE for staff according to policy. I would clean the spirometer and any equipment. I would document vital signs, assessment findings, treatment, response and escalation in the clinical record, using SBAR to communicate. I would inform the nurse in charge and the medical team of the deterioration and the infection risk. I would not take equipment between patients without cleaning. If I have a cold or symptoms, I would not provide direct care. I would also consider antibiotic stewardship - not my prescribing role, but I can flag concerns.