Day 0, 6 Hours Post-Surgery

A 58-year-old male is admitted to your ICU 6 hours after undergoing an emergency laparotomy for perforated duodenal ulcer with generalized peritonitis.

Surgical note summary:

• Intra-op findings: 2 cm perforation in D1, pus in all quadrants.
• Procedure: Graham patch + peritoneal lavage + drain placement.
• Blood loss: ~1.2 L; received 2 units PRBC intra-op.
• Duration of surgery: 3.5 hours.
• Extubated post-op, shifted to ICU for monitoring.

Past medical history:

• Smoker (30 pack-years), moderate COPD (not on home O2)
• NSAID use for chronic back pain
• Controlled hypertension
• No known diabetes, CKD, or cardiac disease

Current status (6 hours post-op):

• Conscious but drowsy; GCS E3V4M6
• BP: 96/52 mmHg; HR: 118 bpm; SpO₂: 94% on 4 L O₂ nasal prongs
• RR: 30/min; Temp: 37.8°C
• Abdomen distended; moderate drain output of serosanguinous fluid (~200 mL/hr)
• Urine output: 20 mL in last 2 hours
• Fluid received: 1L Ringer lactate + 2 PRBCs intra-op; 500 mL NS in ICU

CXR (supine): Bilateral patchy infiltrates, right > left
Ultrasound (FAST): No free fluid
ECG: Sinus tachycardia
Bedside echo: Good biventricular function, IVC 2.3 cm, no collapse

1. Summarize the current clinical issues in this patient.
2. What are your top 2 immediate concerns and what are the next 2 steps you will take in the next 15 minutes?
3. Based on the data, what is your working diagnosis for his shock? Justify your answer using ABG and clinical findings.
4. Would you give fluids, vasopressors, or both right now? Explain the rationale, including any additional test (bedside or lab) you would perform to guide this.