General Surgery · Year 3 · from General Surgery

Case 1: Septic Shock from Intra-abdominal Source

Patient Demographics

  • Age: 65 years
  • Sex: Female
  • Occupation: Retired school teacher

Chief Complaint

"She's confused and has a fever - we think something is wrong with her belly."

History of Present Illness

The patient's daughter brought her to the emergency department with a 2-day history of progressive confusion, fever, and malaise. The patient has been complaining of abdominal pain for the past week, initially mild but worsening. She had a laparoscopic cholecystectomy 10 days ago for acute cholecystitis. She was discharged on POD 1 and initially doing well. Over the past 48 hours, she has become increasingly confused, febrile, and has had rigors. She is unable to provide a clear history.

Past Medical History

  • Recent laparoscopic cholecystectomy (10 days ago)
  • Type 2 diabetes
  • Hypertension
  • Hypothyroidism

Medications

  • Metformin 1000 mg BID
  • Lisinopril 10 mg daily
  • Levothyroxine 75 mcg daily

Physical Examination

  • Vitals: BP 78/42 mmHg, HR 124 bpm, RR 26/min, Temp 39.2°C, SpO2 92% on room air
  • General: Acutely ill-appearing, confused, diaphoretic
  • Cardiovascular: Tachycardic, regular
  • Pulmonary: Tachypneic, clear to auscultation
  • Abdomen: Distended, diffuse tenderness, RUQ guarding, decreased bowel sounds
  • Skin: Mottled extremities, delayed capillary refill (>4 seconds)
  • Mental status: Confused, GCS 13 (E3V4M6)

Initial Assessment

  • SIRS criteria met: Temperature, heart rate, respiratory rate, WBC (pending)
  • Suspected sepsis with organ dysfunction (septic shock)
  • Source: Likely intra-abdominal (recent surgery, abdominal findings)

Resuscitation (Hour-1 Bundle)

  1. Lactate: Ordered immediately
  2. Blood cultures: x2 sets drawn before antibiotics
  3. Broad-spectrum antibiotics: Piperacillin-tazobactam IV (within 1 hour)
  4. Fluid resuscitation: 30 mL/kg crystalloid bolus initiated
  5. Vasopressors: If hypotension persists after fluid resuscitation

Initial Laboratory Results

  • WBC: 22,400/μL (left shift, 15% bands)
  • Hemoglobin: 10.8 g/dL
  • Platelets: 98,000/μL (decreasing - DIC concern)
  • Creatinine: 2.4 mg/dL (baseline 0.9 - AKI)
  • Lactate: 5.8 mmol/L (elevated)
  • Total bilirubin: 3.2 mg/dL
  • ALT: 128 U/L
  • AST: 142 U/L
  • Procalcitonin: 28 ng/mL (markedly elevated)
  • ABG: pH 7.28, pCO2 28, HCO3 14, PaO2 68 on 4L NC (metabolic acidosis, hypoxia)

SOFA Score Assessment

  • Respiratory: PaO2/FiO2 <300 (+2)
  • Coagulation: Platelets <100k (+2)
  • Liver: Bilirubin 3.2 (+1)
  • Cardiovascular: Requiring vasopressors (+3)
  • CNS: Confused (+2)
  • Renal: Creatinine 2.4 (+2)
  • Total SOFA: 12 (severe organ dysfunction)

Imaging

CT Abdomen/Pelvis with IV contrast:

  • 6 cm rim-enhancing fluid collection in the gallbladder fossa
  • Surrounding inflammation
  • Small amount of free fluid
  • Possible bile leak with secondary infection (biloma/abscess)
  • Surgical clips in place

Diagnosis

  • Septic shock secondary to infected biloma/intra-abdominal abscess
  • Likely complication of recent cholecystectomy (bile leak)

Management

Resuscitation continued:

  • After 30 mL/kg fluid bolus, MAP remained <65 mmHg
  • Norepinephrine infusion started, titrated to MAP ≥65

Source control:

  • IR-guided percutaneous drainage of abscess
  • Drain placed: 150 mL of purulent, bilious fluid
  • Culture sent

ICU Management

  • Mechanical ventilation: Intubated for respiratory failure and airway protection
  • Vasopressors: Norepinephrine, added vasopressin when NE dose high
  • Renal: Oliguric despite fluids, started CRRT for AKI and acidosis
  • Stress-dose steroids: Hydrocortisone 50 mg q6h (vasopressor-refractory shock)
  • Glucose control: Insulin infusion targeting 140-180 mg/dL
  • DVT prophylaxis: SCDs initially, then LMWH when platelets stable

Clinical Course

  • Day 1-2: Remained critically ill, high vasopressor requirements
  • Day 3: Drain output decreased, cultures: E. coli and Enterococcus
  • Day 4: Vasopressors weaned
  • Day 5: Extubated successfully
  • Day 7: Off CRRT, renal function recovering
  • Day 10: Drain removed, transferred to floor

Discharge

  • Day 14
  • Oral antibiotics to complete course
  • Follow-up with surgery and infectious disease

Teaching Points

  1. Sepsis-3 definition: Infection + organ dysfunction (SOFA ≥2)
  2. Hour-1 bundle: Lactate, cultures, antibiotics, fluids, vasopressors if needed
  3. Source control is essential - drainage, debridement, or surgery
  4. MAP ≥65 mmHg target with vasopressors
  5. Norepinephrine is first-line vasopressor
  6. Consider steroids for vasopressor-refractory shock
  7. Postoperative complications can present delayed and severe

Clinical Image

Image Description: Chest X-ray of a patient with septic shock and acute respiratory distress syndrome (ARDS) demonstrating bilateral diffuse opacities consistent with pulmonary edema and acute lung injury. The endotracheal tube and central venous catheter are in appropriate position.

Attribution: Image from Wikimedia Commons, Category:X-rays of the chest. Source: https://commons.wikimedia.org/wiki/Category:X-rays_of_the_chest

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