ILA 3: Post-operative sepsis

Question 1

You are the surgical F1 on call, and receive a bleep from the nursing staff on the colorectal ward to say one of the patients has a low blood pressure. You attend and review Mr Smith, a previously well 56 year old man who is 5 days post anterior resection for bowel cancer.
His blood pressure is 85/46mmHg.
How would you assess?
How would you manage?

Answer 1

Airway - talking?, if not - look, listen and feel. Manouvres and adjuncts as necessary
Breathing - assess RR and SpO2, oxygen as necessary
Circulation - HR, BP, CRT, peripheries, Urine output
Disability - GCS/AVPU, pupils, glucose
Exposure - temperature, expose surgical site, pressure sites, etc.

Fluid challenge

Question 2

NEWS-2 score:

a) Thresholds

Answer 2

a)

Question 3

Sepsis: specific investigations

Answer 3

• Culture anything you can! (blood, sputum, urine, wound, etc.)
• CXR
• ECG

Question 4

Hypotension: define

Answer 4

< 90/60 mmHg
Drop of SBP > 40 mmHg
MAP < 70mmHg

Question 5

Hypotension: fluid challenge

a) Fluid prescription
b) Monitoring
c) Max fluid given before calling critical care?

Answer 5

a) IV NaCl - 250mL STAT
b) Obs (BP, HR, urine output, CRT, etc.)
c) 2 Litres

Question 6

ABG interpretation: five steps

Answer 6

• Are they well?
• Oxygen (in context of how much oxygen they’re on?)
• pH (is it high, low or normal)
• Resp cause/compensation? (Look at CO2)
• Metabolic cause/compensation? (Look at HCO3)

Question 7

His repeat observations are:
A: Patent
B: Resp rate 18, sats 98% on 28%O2. Chest clear.
C: Peripherally warmer. CRT 2 secs. Pulse 95 bpm, blood pressure 105/50
mmHg (MAP 68)
D: Less drowsy
Still complaining of abdominal pain
85ml dark urine in bladder when catheterised

• What should you do next given that he has responded well to the fluid challenge?

Answer 7

Full history and examination, look at patient notes, look at all blood results, etc.

Impression and management plan.

Question 8

Sepsis:

a) define
b) identifying features
c) septic shock

Answer 8

a) Life-threatening organ dysfunction caused by dysregulated host response to infection
b) qSOFA (RR >22, SBP < 100, GCS < 14),
SIRS (T >38/<36C, HR >90, RR > 20, WBC > 12/ <4)
c) Sepsis + circulatory failure (hypotension unresponsive to fluids causing inadequate tissue perfusion and cellular hypoxia)

Question 9

Very unwell patient needs CT. What would you want to ensure prior to proceeding with this? What will
you take with you to the scanning room?

Answer 9

• Equipment: oxygen, monitoring, fluids, etc.
• Clinical need: contrast, safety risks, etc.
• Senior support: if airway risks, possibly need anaesthetic support

Question 10

There is a history of intra-abdominal infection. He is peripherally warm, well-perfused, hypotensive and not responding to fluid therapy. This makes vasodilatory shock secondary to sepsis the most likely diagnosis.
Oxygenation is not a major problem making large pulmonary embolism unlikely. There is no bleeding into the drains, the abdomen remains soft and the haemoglobin levels are stable. There is no history of chest pain and there are no signs of cardiac failure.

• What are the next steps in Mr. Smith’s management?

Answer 10

• Vasopressor therapy
• Escalate: call seniors and transfer to ITU
• Sedation and invasive ventilation as necessary

Question 11

Over the next 4 hours Mr Smith remains anuric. A diagnosis of acute renal failure is made.
How should you manage this?

Answer 11

• Check catheter - is it kinked, is it flushable?
• Check fluid balance (are they under/overloaded)
• Is there an obvious cause (e.g. very distended bladder secondary to BPH)
• Critical care: RRT

Question 12

You have to tell his wife that Mr Smith has been transferred to ITU. How would you break this to her?

Answer 12

S - Setting
P - Patient perception
I - Invitation to proceed
K - Knowledge and information to patient
E - Empathy to patient response
S - Summary and strategy