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Difficulty: MediumPreoperative and Postoperative Care

A 62-year-old woman is evaluated on postoperative day 5 following a partial gastrectomy with Billroth II reconstruction for a refractory bleeding peptic ulcer. The nursing staff alerts the physician because the patient has become increasingly confused and lethargic over the past 4 hours. Her temperature is 39.2°C (102.6°F), blood pressure is 78/45 mmHg, heart rate is 132/min, and respiratory rate is 24/min. Oxygen saturation is 94% on room air. On physical examination, her abdomen is markedly distended and rigid, with diffuse rebound tenderness and involuntary guarding. Bowel sounds are absent. Urine output has been 10 mL over the past 2 hours. Which of the following are the most appropriate next steps in management? (Select exactly 2 options)

  1. Immediate intravenous crystalloid and broad-spectrum antibiotic administrationAnswer
  2. Urgent exploratory laparotomyAnswer
  3. C
    Computed tomography scan of the abdomen and pelvis
  4. D
    Placement of a nasogastric tube and continuous clinical observation
  5. E
    Bedside incentive spirometry and chest physiotherapy

Answer

The most appropriate next steps are immediate intravenous crystalloid and broad-spectrum antibiotic administration, followed by an urgent exploratory laparotomy.
This patient is experiencing septic shock due to generalized peritonitis, highly suggestive of an anastomotic leak on postoperative day 5 following a partial gastrectomy. The combination of hypotension, tachycardia, oliguria, altered mental status, and a rigid abdomen represents a surgical emergency. The fundamental principles of managing intra-abdominal sepsis involve immediate resuscitation (intravenous crystalloids), medical therapy to cover gastrointestinal flora (broad-spectrum intravenous antibiotics), and definitive source control. Because the patient is hemodynamically unstable with unequivocal peritonitis, urgent exploratory laparotomy is the required definitive step.

Step-by-Step Solution

1
Analyze the patient's postoperative timeline and vital signs.
The patient is on postoperative day 5 and is in distributive shock (hypotension, tachycardia, altered mental status, oliguria) along with a high fever.
Establishing the severity of the condition dictates the urgency of intervention.
2
Evaluate the physical examination findings.
The abdomen is rigid with diffuse rebound tenderness and absent bowel sounds.
These findings define an acute surgical abdomen (diffuse peritonitis), which, in the context of recent gastric surgery, strongly points to an anastomotic leak.
3
Determine the necessary medical and surgical interventions.
The patient requires immediate hemodynamic resuscitation with IV fluids, empiric broad-spectrum antibiotics, and prompt surgical source control (laparotomy).
In unstable patients with an acute surgical abdomen, delaying surgery for imaging or observation significantly increases mortality.

Key Concept

Hemodynamically unstable patients with signs of peritonitis following abdominal surgery require immediate fluid resuscitation, broad-spectrum antibiotics, and urgent surgical exploration (laparotomy) for source control.
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Topics

Preoperative and Postoperative Care

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