Case Studies

Case 10 - Management of a patient with bowel obstruction and a 3-day history of vomiting

A 72-year-old lady presents with a 3-day history of colicky abdominal pain, distension and vomiting. She is previously in good health, being treated for hypertension with bendrofluazide. She had a ruptured appendix treated 15 years ago, which required a laparotomy. On examination, she looks unwell and dehydrated. She has poor capillary return and is tachycardic 120 bpm. She has a distended abdomen. Her blood results show a haemoglobin of 160 g/L, K⁺ 2.4 mmol/L, urea 17 mmol/L, creatinine of 140 μmol/L. Her serum lactate is 6.2. There are multiple fluid levels on plain abdominal X ray.

• 1. What is the likely diagnosis?

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  Correct answer: Small bowel obstruction, possibly secondary to adhesions from previous surgery.

• 2. Why might she be hypokalaemic?

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  Correct answer: Due to vomiting. Also she is taking diuretics.

• 3. What evidence is there for haemoconcentration from the blood tests?

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  Correct answer: High haemoglobin, high urea.

• 4. The surgeons wish to take her to theatre immediately for a laparotomy. Is this wise?

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  Correct answer: No she requires resuscitation first.

• 5. Describe your initial management for resuscitation

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  Correct answer: Oxygen, i.v. fluids, NG tube (‘drip and suck’), urinary catheter, possibly a central line. She will require potassium supplementation too.

• 6. What are the signs of adequate resuscitation?

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  Correct answer: Normal blood pressure and heart rate; capillary return; urine output >0.5 mL/kg/h. CVP if measured greater than 5 mmHg. Normalization of biochemistry, especially lactate. Aiming for her potassium to be >3 and preferably >3.5 mmol/L.

• 7. Outline your anaesthetic management in theatre

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  Correct answer: She will require rapid sequence induction with cricoid pressure. She will require paralysis and IPPV. She may require extra monitoring, including arterial line and cardiac output. If she has perforated her bowel, then she will require antibiotics and in the event of a rapid cardiovascular deterioration, inotropes.

• 8. Describe your postoperative management

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  Correct answer: She will need oxygen and i.v. fluids for 48 hours or more. She will require careful postoperative monitoring for fluid balance and biochemical derangements. She will require thromboprophylaxis and possibly antibiotics. Pain control methods include epidural or PCA.