Day-2 post-laparotomy failure with basal collapse, overnight FFP and an epidural — fork, reverse, relieve and rescue

Tasks

1. Examine her breathing, pain, fluid balance and transfusion record, then declare the leading fork with reasons — atelectasis, aspiration, TRALI, overload, ARDS or simple hypoxaemia.^[2][34]
2. State her ARISCAT-style risk and what it changes about monitoring and rescue planning.^[2]
3. Defend or criticise her intraoperative ventilation and reversal — quote the PEEP triad and SNaPP.^[5][17]
4. Judge the epidural: keep, stop, or replace — with MASTER numbers.^[23]
5. Prescribe pressure support now: prophylactic CPAP, HFNC, or curative NIV — with PRISM, OPERA and Jaber logic — and set the escalation rule.^[26][27][29]
6. Split any transfusion contribution from overload and state the aspiration precautions for her ongoing care.^[34][36]

Model management

Fork first: atelectasis with splinting until proven otherwise. Basal collapse with pain-limited inspiration on day 2 is the SNaPP phenotype — PPC-or-death 19.0 versus 21.5 percent by reversal choice, driven by atelectasis — so confirm reversal history, test the block, sit her up and treat pain before ordering scans.^[17] Keep aspiration (3.7 per 10,000 under liberal fasting — rare but examined through airway planning), TRALI (distress within 6 hours of plasma — check timing and product), overload (fluid-positive examination) and ARDS (low-stretch escalation pathway) explicitly open until each is excluded.^[36][34]

Risk and ventilation discipline. She carries five ARISCAT factors against a 5-percent derivation event rate with a forty-fold death gradient — high-observation care with a declared NIV and reintubation plan.^[2] Her operation should have run low tidal volumes with low PEEP and no routine recruitment — PROVHILO 40 versus 39 percent with hypotension cost on high PEEP — because driving pressure (OR 1.16 per unit, sole mediator) is the instrument, not PEEP itself.^[5]

Epidural stays; NIV starts; bundle replaces talisman. MASTER allows exactly one claim — respiratory failure 23 versus 30 percent with better pain — so keep the epidural for splinting relief, not survival.^[23] Established failure earns NIV now (Jaber: reintubation 33.1 versus 45.5 percent), never prophylactic CPAP (PRISM: 8.1 versus 8.2 percent) or preventive HFNC (OPERA null) — with escalation to reintubation the moment NIV fails.^[29][26][27] Physiotherapy and mobilisation as a bundle; no spirometry talisman; transfusion split by timing, product and examination.^[34]