What are the next steps for a post-operative adult patient with a recent Graham patch repair for a perforated peptic ulcer, presenting with leukocytosis (elevated white blood cell count) and normal levels of neutrophils, basophils, and monocytes?

Post-Operative Leukocytosis After Graham Patch Repair

Your patient's leukocytosis of 17,000 with normal neutrophils and elevated monocytes/basophils at 8% each represents an atypical post-operative response that warrants immediate evaluation for complications, particularly intra-abdominal abscess or ongoing sepsis, while simultaneously ensuring adequate source control was achieved during surgery. 1

Immediate Assessment Required

Evaluate for Post-Operative Complications

• Rule out intra-abdominal abscess or leak: The atypical leukocyte differential (elevated monocytes/basophils without neutrophilia) may indicate evolving infection or inadequate source control. 1

• Assess for signs of sepsis/septic shock: Check for hypotension (MAP <65 mmHg), tachycardia, altered mental status, decreased urine output (<0.5 mL/kg/h), and measure lactate levels immediately. 1, 2

• Obtain CT scan with IV contrast: This is essential to identify intra-abdominal collections, assess the repair site for breakdown, and evaluate for ongoing contamination. 1

Critical Laboratory Monitoring

• Serial lactate measurements: Lactate normalization is a critical resuscitation target; persistent or rising lactate indicates ongoing tissue hypoperfusion and potential sepsis. 1, 3, 2

• Complete metabolic panel: Evaluate creatinine (renal dysfunction), liver function tests, and assess for coagulation abnormalities. 1

• Blood and peritoneal fluid cultures: If not already obtained during surgery, these should be collected now to guide antibiotic therapy adjustment. 1

Antibiotic Management

Current Antibiotic Regimen Assessment

• Ensure broad-spectrum coverage: You should have initiated empiric antibiotics covering gram-positive, gram-negative, and anaerobic bacteria immediately post-operatively. 1

• Recommended regimen: Piperacillin/tazobactam 4.5g every 6 hours is first-line for post-operative perforated peptic ulcer. 1

• Duration: Plan for 3-5 days total or until inflammatory markers normalize, not longer unless complications develop. 1

De-escalation Strategy

• Adjust based on cultures: Once peritoneal fluid culture results return, narrow antibiotics to target specific organisms identified. 1

• Monitor inflammatory markers: If leukocytosis persists beyond 3-5 days or worsens, suspect complications requiring intervention rather than extending antibiotics blindly. 1

Hemodynamic Monitoring

Resuscitation Targets (If Unstable)

• Mean arterial pressure ≥65 mmHg: Use fluid resuscitation first, then vasopressors if needed. 1, 2

• Urine output ≥0.5 mL/kg/h: Indicates adequate renal perfusion. 1, 2

• Lactate normalization: This is non-negotiable; persistent hyperlactatemia indicates inadequate resuscitation or ongoing sepsis. 1, 3, 2

Surgical Re-evaluation

Indications for Re-exploration

• Clinical deterioration despite resuscitation: Worsening peritonitis, persistent fever, or hemodynamic instability suggests repair breakdown or inadequate source control. 1

• Radiological evidence of leak or collection: CT findings of free fluid, abscess, or contrast extravasation mandate intervention (percutaneous drainage or reoperation). 1

• Persistent leukocytosis with clinical sepsis: If the patient meets sepsis criteria and imaging shows complications, do not delay surgical consultation. 1

Damage Control Considerations

• If severe sepsis/septic shock present: Consider damage control approach with abbreviated procedure, focusing on contamination control rather than definitive repair if the patient is physiologically deranged. 1

Common Pitfalls to Avoid

• Do not attribute leukocytosis solely to "normal post-operative response": The atypical differential (monocytosis/basophilia without neutrophilia) is unusual and warrants investigation. 1

• Do not delay imaging: Waiting for "clinical improvement" while missing an intra-abdominal abscess increases mortality. 1

• Do not extend antibiotics beyond 5 days without identifying a specific complication: Prolonged empiric antibiotics without source control breeds resistance and does not improve outcomes. 1

• Do not ignore persistent hyperlactatemia: This indicates ongoing tissue hypoperfusion or sepsis and requires aggressive intervention, not just observation. 1, 3, 2

Antifungal Therapy Consideration

• Not routinely indicated: Reserve antifungal therapy for high-risk patients (immunocompromised, advanced age, prolonged ICU stay, or positive fungal cultures). 1

• If indicated, use fluconazole: Loading dose 12 mg/kg (max 800mg), then 6 mg/kg/day for community-acquired Candida peritonitis without prior azole exposure. 1