Post-operative day one: rising NEWS2 on the surgical ward
You are the foundation doctor covering a 42-bed surgical ward at 02:15. A nurse phones about Mr Derek Okafor, 68, day 1 after emergency laparotomy for perforated sigmoid diverticulitis. He has a background of hypertension and stage 3 CKD (baseline eGFR 41). Observations over the last hour: BP 92/54 mmHg, HR 118 sinus tachycardia, RR 26, SpO2 93% on 2 L nasal cannulae, temperature 38.6°C, NEWS2 11. He is drowsy but rousable, abdomen distended and tender, PCA morphine in use, urine output 12 mL/hr for 3 hours via catheter. Bloods from 20:00: Hb 78 g/L (pre-op 121), WCC 19.8, lactate 4.1 mmol/L, creatinine 168 µmol/L (baseline 132). He is on enoxaparin 40 mg daily. The nurse asks whether to give paracetamol and repeat observations in an hour or call the surgical registrar. The registrar is in theatre for another 90 minutes; the consultant is off site.
1. The nurse asks whether to give paracetamol and repeat observations in an hour or call the surgical registrar. What should you advise, and why? Include the immediate actions you would authorise while awaiting review.
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Do not give paracetamol and repeat observations in an hour. The combination of NEWS2 11, hypotension (92/54), tachycardia (118), tachypnoea (26), fever (38.6°C), oliguria (12 mL/hr) and lactate 4.1 suggests sepsis, and the fall in Hb from 121 to 78 g/L raises post-operative bleeding. Drowsiness and abdominal tenderness make a surgical cause likely. The first action is to call the surgical registrar now, using SBAR. If the registrar cannot attend within about 15–20 minutes, escalate to the on-call consultant and critical care outreach/rapid response; do not let the theatre commitment delay senior review.
While awaiting review, authorise: oxygen titrated to 94–98%; IV access; blood cultures, repeat lactate, FBC, coagulation and crossmatch 4 units; a 500 mL crystalloid bolus with reassessment; hourly urine output; and antibiotics according to the sepsis protocol after cultures. Paracetamol can be given as an adjunct but must not replace escalation. Review the PCA if he is drowsy. The reasoning is that this is time-critical deterioration, not routine post-operative pain.
2. The registrar is scrubbed and asks you to 'just give 1 litre of fluid and call me in an hour'. How should you respond, and what communication and documentation points matter?
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I would not accept '1 litre and call me in an hour' as a complete plan. A fluid bolus is reasonable, but in a 68-year-old with CKD and possible bleeding, 500 mL aliquots with reassessment are safer than a fixed 1 L, and the patient still needs a physical review. I would say: 'I'll start 500 mL now and reassess, but I'm not comfortable waiting an hour without senior review. Please nominate a covering surgeon or I will escalate to the consultant and outreach.'
Communication points: use closed-loop communication - repeat the order back, state the dose, rate and time; document the registrar's name and advice; record NEWS2 before and after fluids; document that the registrar was unavailable and who was escalated to. Ask the registrar to confirm who is covering theatre. This protects the patient and makes the escalation trail clear if there is later deterioration.
3. Write the SBAR you would give the registrar in no more than 120 words.
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S: Mr Derek Okafor, 68, day 1 after emergency laparotomy, NEWS2 11. B: perforated sigmoid diverticulitis; hypertension; stage 3 CKD (baseline eGFR 41); enoxaparin. A: BP 92/54, HR 118, RR 26, SpO2 93% on 2 L, temp 38.6°C, urine 12 mL/hr, drowsy, tender distended abdomen. Hb 78 g/L (pre-op 121), lactate 4.1, creatinine 168. Impression: sepsis plus possible post-operative bleeding. R: I need immediate senior review. I have started oxygen, cultures, crossmatch and 500 mL crystalloid. If you cannot attend within 15 minutes I will escalate to the consultant and critical care outreach.