Emergency resection and stoma principles

A 78-year-old with severe chronic renal impairment presents with a perforated obstructing sigmoid tumour.

1. He has blood pressure 86/52, respiratory rate 28, confusion and lactate 4.6 mmol/L. Baseline creatinine clearance is documented as 18 mL/min and current assessment remains in that severe range. The team treats high-risk adult sepsis: cultures are obtained without delay and intravenous antibiotics start within an hour. A balanced crystalloid is unavailable, so 250 mL of 0.9% sodium chloride is given intravenously over 15 minutes. Reassessment finds blood pressure 92/56 with slightly improved alertness, persistent poor peripheral perfusion and no new crackles or oxygen requirement. Senior and critical-care support is requested immediately while surgical source control proceeds. Further 250 mL boluses are considered only if needed and tolerated, with reassessment after each and an initial cumulative ceiling of 1,000 mL including any earlier fluids; insufficient improvement by that point requires senior advice. This is not a target to reach in severe renal impairment: overload or inadequate response prompts earlier senior/critical-care decisions, including vasopressor assessment, rather than waiting for a litre to be delivered.
2. The colorectal surgeon and anaesthetist organise urgent surgery while resuscitation continues. A trained clinician marks a feasible colostomy site without delaying theatre. Consent covers oncological resection where possible, an end stoma, the possibility of staged treatment and uncertainty about future reversal.
3. At laparotomy the sigmoid tumour is perforated with faecal contamination. The proximal bowel is viable, but ongoing circulatory instability and contamination make an immediate colorectal anastomosis unsafe. The surgeon performs a Hartmann resection, closes the viable rectal stump and forms a well-perfused end colostomy without tension.
4. The selected renal-context antimicrobial regimen is piperacillin/tazobactam 4 g/0.5 g IV every 12 hours, infused over 30 minutes, under the cited NHS Dumfries and Galloway intra-abdominal sepsis pathway and infection-team review. This is the CrCl below 20 mL/min option, not a default schedule for normal renal function.
5. In critical care, perfusion and mentation improve after source control. Daily renal and antimicrobial review confirms that the severe renal category persists; operative cultures support the chosen coverage, and treatment is stopped after the planned five-day total course once clinical review finds adequate source control and no ongoing infection.
6. The stoma remains viable and functions, oral intake recovers and specialist teaching allows supported discharge. Pathology and completion staging are reviewed by the colorectal team. At follow-up, reversal is discussed as a future possibility requiring recovery and reassessment, rather than promised on a fixed timetable.