10 Hours Post-Op (4 Hours Later)

You are called to review the patient at midnight due to sudden respiratory distress and deteriorating hemodynamics.

Clinical update:

• Increasing restlessness, confused, GCS now E2V3M5
• HR: 128 bpm | BP: 86/44 mmHg | RR: 38/min
• SpO₂: 88% on non-rebreather mask (FiO₂ ~0.8)
• Temp: 38.6°C
• Urine output: 30 mL in last 4 hours
• Drain output: 220 mL/hr serosanguinous fluid continues

New findings:

• Bilateral coarse crepitations on auscultation, reduced air entry at bases
• Abdomen tense, tympanic, with increased ventilatory effort
• Peripheral pulses feeble, cap refill >3 seconds
• No neck vein distension

Questions

1. Interpret the ABG. What is the likely cause of this acid-base abnormality?
2. What are the likely causes for his current respiratory failure? (Name up to 3, in order of likelihood)
3. What does the bladder pressure suggest? How does it influence your management now?
4. Would you transfuse blood products at this stage? If yes, which ones and what targets will you aim for?
5. List 3 immediate interventions you would initiate right now to improve oxygenation and perfusion.