In a patient with sickle cell anemia on postoperative day 10 after a lower segment caesarean section who has an intraperitoneal collection of approximately 600 mL with multiple septations, what is the appropriate management?

Management of Postoperative Intraperitoneal Collection in Sickle Cell Patient

This patient requires urgent surgical consultation for drainage of the septated intraperitoneal collection, combined with aggressive supportive care specific to sickle cell disease management.

Immediate Surgical Management

• Drainage is indicated for this 600 mL septated collection on POD 10, as septated fluid collections typically represent infected or organized hematomas/abscesses that will not resolve spontaneously and require intervention 1
• Obtain blood cultures immediately before initiating antibiotics, as fever or signs of sepsis mandate antibiotic therapy at temperature ≥38.0°C in sickle cell patients who are functionally asplenic 2
• Surgical options include CT-guided percutaneous drainage for accessible collections or laparoscopic/open drainage if septations are extensive or percutaneous approach fails 1

Critical Sickle Cell-Specific Supportive Care

Hydration Management

• Aggressive intravenous hydration is mandatory, as sickle cell patients have impaired urinary concentrating ability and dehydrate easily, which worsens sickling 1, 2
• Continue IV fluids until the patient tolerates adequate oral intake, with meticulous monitoring of fluid balance to avoid both dehydration and fluid overload 1
• Measure urine output carefully and consider central venous pressure monitoring if hemodynamic status is uncertain 1

Oxygenation

• Administer supplemental oxygen continuously to maintain SpO2 above baseline or 96% (whichever is higher) for at least 24 hours or until freely mobile 1
• Monitor oxygen saturation continuously until maintained at baseline on room air 1
• Oxygen therapy may be required for several nights following abdominal surgery 1

Temperature Control

• Maintain strict normothermia with active warming measures, as hypothermia leads to shivering and peripheral stasis, which increases sickling and hypoxia 1, 2
• Use warmed IV fluids and maintain ambient temperature appropriately 1

Pain Management

• Continue baseline long-acting opioid medications if the patient was already taking them 1
• Implement multimodal analgesia including patient-controlled analgesia (PCA), as sickle cell patients are often familiar with PCA from managing vaso-occlusive crises 1
• Use validated pain assessment scales and reassess regularly, encouraging the patient to report pain similar to usual sickle pain versus surgical wound pain 1
• Avoid undertreating pain—opioid dependency is rare in sickle cell patients; opioid sensitivity is more common 1

Infection Prevention and Monitoring

• Start empiric broad-spectrum antibiotics immediately if temperature reaches ≥38.0°C or any signs of sepsis are present, as functional hyposplenism makes these patients vulnerable to overwhelming sepsis within hours 2
• Do not delay antibiotics while waiting for culture results 2
• Obtain chest radiograph to evaluate for pneumonia or acute chest syndrome, which can be precipitated by infection and abdominal pathology 2

Respiratory Support

• Promote early mobilization when medically appropriate 1
• Implement incentive spirometry every 2 hours to prevent acute chest syndrome 1
• Consider continuous positive airway pressure or high-flow nasal oxygen if respiratory status deteriorates 1
• Bronchodilator therapy should be considered if history of small airways obstruction, asthma, or acute chest syndrome 1

Thromboprophylaxis

• Administer thromboprophylaxis as sickle cell patients have increased risk of deep vein thrombosis, particularly when immobilized postoperatively 3

Multidisciplinary Coordination

• Notify hematology team immediately for co-management 3
• Consider low threshold for high dependency or intensive care unit admission if patient develops fever, respiratory compromise, or hemodynamic instability 4
• Pain team consultation should be involved for complex pain management 1

Common Pitfalls to Avoid

• Do not assume simple pain crisis—investigate and treat the surgical complication aggressively while providing sickle cell-specific supportive care 1
• Do not allow prolonged starvation or inadequate hydration, which precipitates sickling 1
• Do not withhold adequate opioid analgesia due to unfounded concerns about addiction 1
• Do not overlook acute chest syndrome, which can present with abdominal symptoms and is the leading cause of acute death in sickle cell patients 2