The stem
A 68-year-old man is on day 3 after a bowel resection with an anastomosis. These are his observations over the day.
Observation chart
| Observation | 08:00 | 14:00 | 20:00 |
|---|---|---|---|
| Respiratory rate /min | 18 | 22 | 24 |
| SpO2 % (air) | 96 | 95 | 94 |
| Systolic BP mmHg | 128 | 112 | 98 |
| Pulse /min | 88 | 104 | 118 |
| Consciousness | Alert | Alert | Confused |
| Temperature °C | 37.6 | 38.1 | 38.6 |
Cell colours follow the NEWS2 chart bands: none, low, medium and high scoring.
NEWS2 scoring, Royal College of Physicians, 2017.
The examiner’s questions
Question 1Calculate his NEWS2 score at each time.Show the model answer
08:00: 0. 14:00: 5 (respiratory rate 2, saturation 1, pulse 1, temperature 1). 20:00: 11 (respiratory rate 2, saturation 1, systolic pressure 2, pulse 2, new confusion 3, temperature 1).
Question 2What response does each score require?Show the model answer
A score of 5 to 6, or 3 in any single parameter, needs urgent review by a clinician. A score of 7 or more needs an emergency response from a team with critical care skills. The 14:00 score of 5 should already have triggered a review.
Question 3What is the most likely cause?Show the model answer
Sepsis from an anastomotic leak, which typically shows on days 3 to 5. Other causes to consider are pneumonia, urinary infection and a line infection.
Question 4What are your immediate actions?Show the model answer
Within the first hour: oxygen to target saturation, blood cultures, intravenous antibiotics, intravenous fluids, lactate and full blood count, and hourly urine output. Urgent senior surgical review, CT with contrast, and return to theatre if a leak is confirmed.
After you answerThe teaching pointShow
The trend matters more than any single set of observations. A rising pulse and new confusion after bowel surgery are a leak until proved otherwise.
The patients are written for teaching and are not real.