Postoperative circulatory collapse

Causes of postoperative circulatory collapse:

• Haemorrhage
• Severe sepsis, including septicaemia
• Myocardial infarction
• Pulmonary embolus
• Hypersensitivity reaction

Haemorrhage:

Major postoperative haemorrhage can be recognised by:

• Evidence of overt bleeding including heavily bloodstained fluid from a drain
• Cold and wet (clammy) peripheries
• Distension after abdominal procedures

Usually, the diagnosis is self-evident but occasionally it may not be apparent that major bleeding has occurred, particularly if the patient is obese or if the drain malfunctions because of obstruction by clot. In such circumstances the diagnosis may need to be confirmed by urgent, repeated Hb estimation and by US examination

Management:

• The loss is stopped by control of the source of bleeding or by correction or coagulopathy
• Either at the same time or immediately subsequently, transfusion corrects the deficit
• Re-operation may be required to control a bleeding point

Severe sepsis and septicaemia:

Septic circulatory failure is associated with:

• Surgical procedures carried out in the presence of sepsis
• Technical failure (e.g. anastomotic dihescence) with intraperitoneal or intrathoracic leakage of GI contents
• General spread from a focus
• Bloodstream contamination from a device (most commonly a central line)

A direct effect of circulating cytokines, and other inflammatory mediators, is to cause arteriolar dilatation so that, in contrast to other forms of circulatory failure, the peripheries may be warm. In addition, there is loss of circulating blood volume as a result of capillary leakage.

Clinical features:

• High pyrexia
• Hypotension
• Tachycardia
• Warm periphery

Management:

• Resuscitation is with IV fluids and IV antibiotics
• Re-exploration may be indicated to deal with a septic focus or a technical failure

Hypersensitivity reactions:

• This may develop as an immune response to a blood infusion or to drug administration (e.g. IV antibiotic)
• There is usually pyrexia and the circulatory collapse may also be accompanied by respiratory distress and urticaria

Management:

• Discontinue the drug/infusion
• IV corticosteroids
• Circulatory support