Acute Abdomen — Preoperative Resuscitation in Perforated Viscus
A 62-year-old man has a 12-hour history of sudden severe epigastric pain that is now generalised. His abdomen is rigid, and an erect chest radiograph shows free air under the diaphragm. He is alert and talking, with blood pressure 88/55 mm Hg, heart rate 124 beats/min and oxygen saturation 96% on room air. Theatre is being prepared for laparotomy. What is the most appropriate immediate action?
- A.Rapid intubation and start of a vasopressor infusion
- B.Intravenous colloid given through a newly inserted central line
- C.Proceed directly to theatre without delaying for fluids
- D.Warmed crystalloid bolus through two large-bore peripheral cannulaeCorrect
Explanation
A perforated viscus causes peritonitis with large fluid losses into the peritoneal cavity and gut wall, so hypotension here is mainly hypovolaemic and septic, and the first treatment is volume. Two short, wide peripheral cannulae of 14 to 16 gauge deliver fluid faster than a long central catheter and can be placed in seconds. Balanced crystalloid, about 30 mL/kg in the first three hours with frequent reassessment, is the recommended starting fluid; albumin is reserved for patients who need very large volumes, and synthetic colloids are avoided because they increase kidney injury. Antibiotics and analgesia go in at the same time, and surgery follows promptly once resuscitation is under way. Intubating a patient who is protecting his airway and well oxygenated, before restoring volume, invites cardiovascular collapse when induction agents and positive pressure ventilation abolish sympathetic tone and reduce venous return. Vasopressors are added only when hypotension persists despite adequate fluid. The point most often missed is that resuscitation and source control run together: fluids should not postpone the laparotomy for hours, but taking an unresuscitated patient straight to induction is dangerous.
Why each option
- A.
- Induction and positive pressure ventilation in an under-filled patient with an intact airway risks collapse; vasopressors follow inadequate response to fluid.
- B.
- Central line insertion delays resuscitation, a long catheter flows slower than wide peripheral cannulae, and colloid offers no outcome advantage.
- C.
- Anaesthetic induction in an unresuscitated hypotensive patient is dangerous; resuscitation should begin immediately and run alongside preparation for surgery.
- D.
- Correct. Hypotension from peritonitis is volume loss, and warmed crystalloid through wide peripheral cannulae is the fastest effective first treatment.
Reference: Surviving Sepsis Campaign International Guidelines 2021; WSES guidelines for management of perforated peptic ulcer 2020; ATLS 10th edition, 2018
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