CCrISP Examination

I would follow the Care of the Critically Ill Surgical Patient, CCrISP, structure: immediate management, full patient assessment, decision and plan, then definitive care. Immediate management is an Airway, Breathing, Circulation, Disability and Exposure, ABCDE, assessment with simultaneous resuscitation.

Before you start

• Introduce yourself, wash your hands and gain consent
• Ask for the observation chart, the fluid chart, the drug chart and the notes
• Call for senior help early if the patient is unwell

A: Airway

• Can you tell me your name? A clear reply confirms a patent airway
• If there is no reply, use the look, listen and feel approach
• Give oxygen at 15 L/min through a reservoir bag
• Open the airway with a chin lift or jaw thrust, and suction secretions
• Insert a Guedel airway, or a nasopharyngeal airway, if the airway is not maintained
• Use a jaw thrust with in-line immobilisation, not a head tilt, if cervical spine injury is possible
• Avoid a nasopharyngeal airway if a base of skull fracture is possible
• Call an anaesthetist early if you cannot maintain the airway

B: Breathing

• Count the respiratory rate
• Check the oxygen saturation and aim for 94 to 98%
• Target 88 to 92% where there is a risk of hypercapnic respiratory failure
• Remember that pulse oximetry does not detect hypercarbia, so a normal saturation does not mean ventilation is adequate
• Look at the exposed chest for cyanosis, accessory muscle use, symmetry and depth of breathing, sweating, a raised jugular venous pressure, chest drain patency and paradoxical abdominal movement
• Feel for equal chest expansion, tracheal position and any surgical emphysema
• Percuss the chest
• Auscultate the breath sounds, and check the patient can talk in full sentences
• Find and treat at once anything that threatens life, such as a tension pneumothorax
• Request a chest X-ray, and consider capnography to confirm ventilation

C: Circulation

• Assess the capillary refill time, and the peripheral and central pulses for rate, quality and regularity
• Check the blood pressure
• Insert two large-bore 16G cannulae, and send blood for cross-match, routine tests and a blood gas
• Give a warmed crystalloid fluid challenge, then reassess. In suspected sepsis, give a 250 mL bolus over 10–15 minutes. Reassess after each bolus and repeat up to 1,000 mL in total
• Outside sepsis, a fluid challenge is 500 mL of a crystalloid containing sodium 130 to 154 mmol/L over less than 15 minutes
• Do not use tetrastarch for resuscitation
• Reassess with ABCDE, then respiratory rate, pulse, blood pressure, perfusion and lactate. A falling lactate is the objective evidence that the challenge worked
• Two boluses without response means the problem is not hypovolaemia. Escalate rather than give a third
• Check the temperature. If sepsis is likely, start the Sepsis Six: ensure a senior clinician attends, give oxygen, take bloods including cultures and lactate, give intravenous antibiotics and fluids, and monitor, including urine output
• Insert a urinary catheter and urometer for hourly fluid balance
• Find and control any external bleeding, and check the drains for fresh blood
• Raise both legs from flat to test fluid responsiveness, looking for a rise in blood pressure. Passive leg raising tests responsiveness without committing fluid
• Request an electrocardiogram, ECG

D: Disability

• Assess consciousness with AVPU: Alert, responds to Voice, responds to Pain, Unresponsive
• Examine the pupils for size and reaction
• Check the blood glucose
• Review the drug chart for opiates and sedatives as a cause of drowsiness

E: Exposure

• Expose the patient fully to complete the assessment, while preserving dignity and keeping them warm
• Look for drains, catheters, infusions and any bleeding
• Inspect the wound, any stoma and both calves

Complete the immediate management

• Confirm the patient is on oxygen and intravenous fluids, and attach continuous monitoring
• Reassess from A after every intervention
• Escalate early if the patient is not improving, to the anaesthetist, the surgical registrar on call or the intensive care team
• Document your findings and hand over clearly

👩‍⚕️ Do not withhold 15 L/min oxygen from a patient with chronic obstructive pulmonary disease while you resuscitate them. Hypoxia kills long before hypercapnia does.

I would gather all the information and move towards a diagnosis and a plan. Full assessment is the chart, the case notes, the patient and the results, in that order.

• Review the observation charts, including the National Early Warning Score, NEWS2, trend, and the fluid balance charts
• Read the case notes and the operation note, for what was done and what was expected afterwards
• Take an AMPLE history: Allergies, Medications, Past medical history, Last meal, Events leading up to the deterioration
• Examine the patient fully, starting at the hands and including the neck, chest, abdomen and limbs, plus any wounds, drains and stomas
• Review all available results, including blood gases, glucose, blood count, clotting, cross-match, cultures, imaging and the ECG
• Check the drug chart for new, missed or no longer needed drugs, including thromboprophylaxis and antibiotics
• Form a problem list, decide on the definitive plan, and agree it with a senior

👩‍⚕️ Early atelectasis is far more likely to be found clinically than on a film, so do not skip the chest examination.

Tachycardia and tachypnoea come first. Hypotension is a late sign.

• A rising early warning score with a falling urine output is the classic pattern
• Oliguria is under 0.5 mL/kg/hour, roughly under 35 mL/hour in a 70 kg adult
• C-reactive protein peaks at about 48 hours after uncomplicated surgery and then falls
• A C-reactive protein still climbing after day 3 has lost its surgical explanation. Think leak, collection, abscess or pneumonia at that point

My main diagnosis is generalised peritonitis from an anastomotic leak, with sepsis.

Day 6 is the classic timing, and the combination of abdominal pain, shoulder-tip pain and breathlessness fits a leak until proven otherwise.

Beyond an anastomotic leak, I would consider collections, ileus, bleeding and ischaemia. The differential is:

• Anastomotic leak
• Intra-abdominal or subphrenic collection
• Postoperative ileus, or mechanical obstruction from adhesions
• Intra-abdominal bleeding or a haematoma
• Wound infection or wound dehiscence
• Mesenteric or anastomotic ischaemia
• Clostridioides difficile colitis after perioperative antibiotics
• Acute pancreatitis
• Perforated peptic ulcer, particularly on steroids or non-steroidal drugs
• Referred pain from a lower lobe pneumonia or a myocardial infarction
• Volvulus, uncommon this early after surgery

A collection of pus or bowel content under the diaphragm is irritating the diaphragmatic peritoneum.

Sensation from the central diaphragm travels in the phrenic nerve, which arises from C3, C4 and C5. The same roots supply the skin over the shoulder tip through the supraclavicular nerves. The brain cannot separate the two, so diaphragmatic irritation is felt at the shoulder.

I would start at the bedside, send bloods, then image. A patient with peritonitis and sepsis goes to theatre, so do not let a scan delay the operation.

Bedside

• Observations with a NEWS2 score, and continuous monitoring
• Arterial blood gas, for hypoxia, metabolic acidosis and the lactate
• ECG, to exclude ischaemia or an arrhythmia as the cause of the pain and breathlessness
• Hourly urine output through a catheter
• Swab the wound, and send any drain fluid that looks enteric

Blood tests

• Full blood count, urea and electrolytes, liver function and C-reactive protein
• Clotting, and group and save with cross-match since theatre is likely
• Blood cultures before antibiotics, provided they do not delay them
• Amylase, to exclude pancreatitis
• In sepsis, the bloods are cultures, lactate, glucose, full blood count, renal function, C-reactive protein, liver tests and clotting

Imaging

• Erect chest X-ray, for free gas under the diaphragm and to exclude a respiratory cause
• Computed tomography, CT, of the abdomen and pelvis with contrast, which is the test that confirms an anastomotic leak
• CT pulmonary angiogram, CTPA, if pulmonary embolism is still likely after the initial assessment
• Ultrasound of the abdomen, useful for a collection but poor at excluding a leak

Special tests

• Water-soluble contrast enema, in selected cases where the CT is equivocal
• Interventional radiology, to drain a localised collection
• Diagnostic laparoscopy or laparotomy, which is both the investigation and the treatment once the abdomen is peritonitic

This is a surgical emergency. I would urgently perform a rapid yet thorough assessment of the airway, breathing and circulation in an A to E manner, following the CCrISP protocol. I would run resuscitation and source control in parallel while calling for senior help.

Resuscitate

• Assess along ABCDE lines with 15 L/min oxygen and two large-bore cannulae
• Warmed crystalloid guided by response, with a urinary catheter for hourly urine output. The UK Sepsis Trust gives up to 20 mL/kg in divided boluses. The National Institute for Health and Care Excellence, NICE, gives 250 mL boluses, up to 1,000 mL, then asks for senior advice
• Start the Sepsis Six within one hour, per the UK Sepsis Trust, taking blood cultures and lactate before the first dose of antibiotics
• Continuous monitoring, and early referral to critical care for a central line and organ support

Conservative

• Nil by mouth with bowel rest, and a nasogastric tube to decompress the stomach
• Adequate analgesia, and correction of electrolytes and any coagulopathy
• Consent the patient for a laparotomy and possible stoma, and ask the stoma nurse to site it if there is time
• Hold thromboprophylaxis before theatre and restart it afterwards

Medical

• Broad-spectrum intravenous antibiotics to local policy, covering Gram-negative and anaerobic organisms
• Source control belongs with the antibiotic step
• Vasopressor support in critical care if the blood pressure does not respond to fluid

Antibiotic timing

• NICE gives antibiotics within 1 hour when NEWS2 is 7 or more. At 5 or 6, antibiotics can wait up to 3 hours. At 1 to 4, they can wait up to 6 hours
• The blanket one hour rule for all suspected sepsis is the superseded answer

I would take this patient to theatre for source control, because they have generalised peritonitis. A small contained leak in a stable patient can be managed with antibiotics and radiological drainage.

I would take down the failed anastomosis, resect it, bring out an end colostomy and close off the distal end. I would not trust a fresh anastomosis in a contaminated septic field. I would then wash out the peritoneal cavity and leave drains. That operation is a Hartmann's-type procedure.

I would involve the consultant early, and critical care before the patient is in extremis.

• Decide whether the patient needs theatre, imaging, or a higher level of care
• Document the assessment, the working diagnosis, the plan and the review interval
• Ceilings of treatment and resuscitation status are part of the plan, not an afterthought
• Never leave the deteriorating patient without a plan and a named review time