Subinternship Surgery · Year 4 · from Subinternship Surgery
Case 1: Septic Shock from Anastomotic Leak
Clinical Image
Source: Wikimedia Commons - Abdominal CT - CC BY-SA 4.0
Case Presentation
A 68-year-old man is post-operative day 5 from a low anterior resection for rectal cancer. He initially did well but now presents with fever to 39.2 degrees Celsius, heart rate 118 bpm, blood pressure 85/50 mmHg (previously 130/75 mmHg), and diffuse abdominal tenderness. Labs show WBC 18,000, lactate 4.8 mmol/L, and creatinine rising from 1.0 to 2.1 mg/dL. The sub-intern recognizes septic shock and initiates the sepsis bundle: blood cultures are obtained, broad-spectrum antibiotics (piperacillin-tazobactam and vancomycin) are administered within 30 minutes, and crystalloid resuscitation (30 mL/kg) is started. Despite 3 liters of fluid, blood pressure remains 80/45 mmHg. Norepinephrine is initiated through a peripheral IV while central access is obtained, rapidly titrated to achieve MAP greater than 65 mmHg. CT abdomen/pelvis with oral and IV contrast reveals free air, fluid collection at the anastomosis, and stranding consistent with anastomotic leak. The attending surgeon is notified for emergent source control. The patient is taken to the OR where a leaking anastomosis is taken down, an end colostomy is created, and the abdomen is copiously irrigated. Post-operatively, he requires 48 hours of vasopressor support and mechanical ventilation. Antibiotics are de-escalated to meropenem based on culture results (Escherichia coli and Bacteroides fragilis). He is extubated on POD 3 from re-exploration and discharged on POD 12.
Key Learning Points
- The one-hour sepsis bundle: measure lactate, obtain blood cultures, administer broad-spectrum antibiotics, give 30 mL/kg crystalloid for hypotension or lactate greater than 4, and start vasopressors if hypotension persists despite fluids
- Source control is critical in surgical sepsis; antibiotics alone cannot treat anastomotic leak, abscess, or necrotic tissue - the source must be addressed
- Anastomotic leak typically presents POD 3-7 with fever, tachycardia, abdominal pain, and signs of peritonitis; maintain high suspicion in post-colorectal surgery patients
- Norepinephrine is first-line vasopressor for septic shock, targeting MAP greater than 65 mmHg; peripheral vasopressors can be used temporarily while central access is obtained