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Your patient (male, 73 years old) has been admitted  following an emergency laparotomy secondary to a small bowel obstruction. He has a medical history of T2DM, obesity and hypertension. He takes metformin, lingaliptin and ramipril.
He is a retired bus driver.

There are ECG changes (see snapshot below) which could indicate a myocardial event has occurred recently.

The patient is intubated and mechanically ventilated.

HR 120 in ST, Temp 35.9
His blood pressure is 70/40, MAP of 50

Urine output 10 ml/hr x 3 hours.

Cool peripheries, CRT 4-5 secs.

Recent ABG: pH 7.32, PaCO2 4.3, HCO3 18, BD -5, PaO2 11.1 on 0.5 FiO2, Hb 98, SaO2 96%, lactate of 3.1, K+ 3.0, Glucose 12.8.

Abdomen closed, soft and mildly distended

Sedated via Propofol and a Fentanyl infusion.

Assess his haemodynamics using Problem, Objectives, Plan....

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filter if poor renal function/diuretics if appropriate (FB dependent)

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filter if poor renal function/diuretics if appropriate (FB dependent)

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T wave inversion in the lateral leads potentially due to acute ischaemia. In this ECG T wave inversion occurs in contiguous leads 1, AVL, V5 and V6

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T wave inversion in the lateral leads potentially due to acute ischaemia. In this ECG T wave inversion occurs in contiguous leads 1, AVL, V5 and V6

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prevent further ischaemia and reperfuse heart 

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prevent further ischaemia and reperfuse heart 

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review for ? PCI or conservative management 

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review for ? PCI or conservative management 

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low blood pressure, leading to reduced prefusion of the organs, causing potential AKI

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low blood pressure, leading to reduced prefusion of the organs, causing potential AKI

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control glucose levels, insulin infusion

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control glucose levels, insulin infusion

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Formal blood result to determine renal function

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Formal blood result to determine renal function

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Give blankets or potentially warming blanket to help peripheral and core temperature

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Give blankets or potentially warming blanket to help peripheral and core temperature

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Anticoagulation review if safe to use after surgery

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might need CRRT

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Abdo mildly distended with lactate of 3.1 - to monitor this closely

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Abdo mildly distended with lactate of 3.1 - to monitor this closely

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Fluid resuscitation - inc K+ top up +/- Mg top up if required.

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Fluid resuscitation - inc K+ top up +/- Mg top up if required.

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Imaging such as CT Chest and Abdo Pelvis 

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Imaging such as CT Chest and Abdo Pelvis 