During your surgical ward round, a nurse calls you to review a 34-year-old woman who is 3 days post laparoscopic cholecystectomy. She has a past medical history of type 1 diabetes mellitus and obesity. The patient complains of pain at the site of a peripheral venous cannula and has developed a fever. The nurse tells you she has become increasingly drowsy and responds to voice. You start to assess the patient using the ABCDE approach.

Airway is patent. Assessing breathing, respiratory rate is 35 breaths/min, oxygen saturations 96% on air and bilateral equal air entry with no added sounds. Her temperature is 38.5oC

What could be causing her elevated respiratory rate?

There are numerous causes of an increased respiratory rate. A full respiratory examination is necessary to rule out respiratory causes of tachypnoea (e.g. pneumonia, asthma, pneumothorax, pleural effusion etc.). Tachypnoea is also importantly a sign of sepsis. Another cause for tachypnoea would be a metabolic acidosis (compensatory mechanism).

What are the red flag parameters of sepsis?

Redflag parameters of sepsis are

You proceed to assess circulation. The patient is sweaty to the touch with a capillary refill time of 4 seconds and is difficult to rouse. Her heart rate is 140 beats/min and regular. Her blood pressure is 85/40 mmHg. She has a decreased urine output (less than 60 mls in the last 4 hours).

What do you think is going on?

She is tachycardic, hypotensive with signs of poor end organ perfusion (drowsy and poor urine output). The patient is shocked and at risk of developing acute kidney injury.

What factors do you think might contribute to the post-operative patient developing this condition?

Hypovolaemia is common in post operative patients and may be due to dehydration, increased fluid loss or bleeding. Sepsis can also occur in post operative patients, from sources such as wound infections, pneumonia or cannulas. Cardiogenic shock could occur if the patient has a perioperative myocardial infarction.

How might you differentiate between hypovolaemic and septic shock?

There are a lot of common clinical features within the different shock aetiologies. Septic shock will typically occur in the presence of pyrexia, increased white cell count, and an identifiable source of infection. The patient may feel warm and sweaty rather than cool and peripherally shut down as in hypovolaemia.

When assessing and treating shock as a junior doctor, is it always necessary to make an immediate definitive diagnosis ?

No. Identifying the patient is shocked with evidence of reduced end organ perfusion should prompt you to call for help first. Supportive treatment such as oxygen therapy and fluid resuscitation can be commenced. However it is essential to make a definitive diagnosis if the patient is to recover.

Having established the patient is shocked, you insert a new cannula and take bloods for Full Blood Count (FBC) and Urea and Electrolytes (U&E), clotting and blood cultures. A fluid bolus (500 mls of 0.9% sodium chloride) is administered. In this case avoid fluids containing potassium as the patient is developing oliguria and may be at risk of developing hyperkalaemia. You progress to assessing the D and E components of ABCDE. The patient scores V on the ACVPU scale, and has a blood sugar of 8.4 mmol/L. Exposing the patient reveals a cellulitis at the old peripheral cannula site, the abdomen is soft and wounds are clean. The patient's temperature is 38.5 °C.

What 6 things should be done within an hour of diagnosing sepsis?

  1. B - Blood (and other cultures) should be drawn prior to antibiotic
  2. U - U&Es (kidney function), monitor hourly urine output
  3. F - Fluids for hypotension / clinical shock
  4. A - Antibiotics (Trust Guidelines) within 1 hour if possible
  5. L - Lactate (and haemoglobin) - marker of perfusion
  6. O - Oxygen - High flow

Could the patient’s deterioration have been detected earlier and if so how?

The patients NEWS2 is 13. This is unlikely to have happened suddenly as most patients show a period of deterioration prior to decompensation. Regular monitoring of NEWS2 may have detected the deterioration earlier.

The patient has received intravenous fluids and commenced antibiotics (after blood cultures have been taken). The patient should be referred to the critical care outreach team and moved to the HDU for further care.