Postoperative sepsis — from ward fever to ICU rescue: scoring, timing wars, and the urgent-versus-crash call

Examiner probes

1. Score him overnight and this morning — qSOFA, SOFA, and why the score changes with location.^[1][5]
2. He now meets shock physiology. Argue the antibiotic hour for and against, with numbers, and tell me what you actually do.^{[39][40][41][42]}
3. Resuscitate him: fluids, pressor choice, pressure target and perfusion endpoints.^[1][57]
4. No stoma, likely leak, resuscitated by hour 3 — crash theatre now or urgent booking? Defend with the paradox.^[44]

Model responses

1. Overnight qSOFA 2, morning septic shock — and the score follows the bed. Overnight: respiratory rate 24 scores 1 point while systolic 102 misses the 100 threshold and mentation is intact — so qSOFA 1, already a ward prompt for cultures, lactate and senior review, since first fever after day 2 carries sixfold odds of infectious complication.^[1][15] Morning: drowsy, systolic 88, tachypnoeic — qSOFA 3 with lactate 3.4 on fluids, vasopressor-imminent: Sepsis-3 shock physiology with mortality above 40%.^[1][3] Use qSOFA here because he is on the ward — in surgical cohorts it predicts mortality best on the intermediate unit (AUC 0.82) while SOFA takes over once ICU care is involved.^[5]

2. For the hour: gradients in thousands; against: one honest null — and shock decides. For: mortality rises steadily after 1 hour across 17,990 patients; each hour costs odds 1.07 pooled across 106,845 patients; and the shock-stratified cohort gives within-1-hour odds 0.66 in shock versus 0.85 non-significant without it.^[39][41][40] Against: a 482-patient Sepsis-3 cohort at 115-minute median found no timing association at 7, 14 or 28 days.^[42] Action: antibiotics now, inside the hour, with cultures first but never delayed — he is in shock, where the benefit is proven, and the CT happens in parallel.^[40][39]

3. Fluids, then norepinephrine first to 65 — then stop chasing pressure. Crystalloid bolus with reassessment, then norepinephrine to mean arterial pressure 65 mmHg or more: mortality relative risk 0.89 over dopamine with number needed to treat 9 and fewer arrhythmias.^[57][1] Endpoints are perfusion — mentation, urine output, lactate kinetics in context, capillary refill — not a higher number, because persistent lactate without hypoperfusion misleads.^[1]

4. Urgent at 2 to 6 hours, not crash — resuscitated urgency beats unprepared speed. Against emergency control inside 2 hours, urgent 2-to-6-hour control carried half the mortality odds (0.50) in 1,077 secondary-peritonitis patients at 29.7% mortality — while failed control multiplied death 5.71-fold.^[44] So: resuscitate, contrast CT for leak versus collection, book urgently, operate without a stoma by resection or repair with washout — and if physiology collapses despite resuscitation, the indication becomes emergency regardless of the clock.^[44]