Anesthesia for Emergency Surgery

ANAESTHESIA FOR ANAESTHESIA FOR EMERGENCY SURGERYEMERGENCY SURGERY

Scope of TalkScope of Talk

DefinitionDefinition Problems related to emergency surgeryProblems related to emergency surgery Anaesthesia for trauma surgeryAnaesthesia for trauma surgery

Pre operative managementPre operative management Intra operative managementIntra operative management Post operative managementPost operative management

Scope of TalkScope of Talk

Anaesthesia for non trauma surgeryAnaesthesia for non trauma surgery Pre operative managementPre operative management Intra operative managementIntra operative management Post operative managementPost operative management

ConclusionConclusion

DEFINITIONSDEFINITIONS

Emergency surgeryEmergency surgery

is non-elective surgery performed when the is non-elective surgery performed when the patient's life or well-being is in direct jeopardy. patient's life or well-being is in direct jeopardy.

this surgery can be conducted for many reasons this surgery can be conducted for many reasons but occurs most often in urgent or critical cases in but occurs most often in urgent or critical cases in response to trauma, cardiac events, poison response to trauma, cardiac events, poison episodes, brain injuries, and pediatric medicine. episodes, brain injuries, and pediatric medicine.

DEFINITIONSDEFINITIONS

An elective surgery is a planned, non-An elective surgery is a planned, non-emergency surgical procedure. emergency surgical procedure.

It may be either medically required (e.g., It may be either medically required (e.g., cataract surgery), or optional (e.g., breast cataract surgery), or optional (e.g., breast augmentation or implant) surgery.augmentation or implant) surgery.

PROBLEMS RELATED WITH PROBLEMS RELATED WITH EMERGENCY ANAESTHESIAEMERGENCY ANAESTHESIA

Limited time to prepare the patient for surgery & Limited time to prepare the patient for surgery & anaesthesiaanaesthesia

Risk of aspirationRisk of aspiration Potential difficult airwayPotential difficult airway HypovolemiaHypovolemia Co existing diseaseCo existing disease Sedation & analgesiaSedation & analgesia CoagulapathyCoagulapathy

LIMITED TIME TO LIMITED TIME TO PREPAREPREPARE

Must deal quickly with the life-threatening Must deal quickly with the life-threatening situation. situation.

Often little time for extensive diagnosis Often little time for extensive diagnosis Minimal patient history. Minimal patient history. Decisions are made quickly about surgery, Decisions are made quickly about surgery,

often without adequate preoperative often without adequate preoperative assessment , preoperative laboratories & even assessment , preoperative laboratories & even in the presence of family membersin the presence of family members

RISK OF ASPIRATIONRISK OF ASPIRATION

Full stomach : Full stomach : inadequate fasting timeinadequate fasting timePregnancyPregnancy intestinal obstructionintestinal obstructionPainPainupload or intra abdominal massupload or intra abdominal massobesityobesity

RISK OF ASPIRATIONRISK OF ASPIRATION

Head & neck traumaHead & neck trauma Unable to protect airway [ head injury ,Unable to protect airway [ head injury ,

vocal cord injury ]vocal cord injury ]

Risk of aspirationRisk of aspiration

Complications of Complications of aspirationaspiration

Aspiration pneumonitisAspiration pneumonitis Aspiration pneumoniaAspiration pneumonia ARDS / ALIARDS / ALI SepsisSepsis Death Death

HYPOVOLEMIAHYPOVOLEMIA

Blood loss or/& fluid & electrolyte lossBlood loss or/& fluid & electrolyte loss Fluid / blood resuscitation prior & during Fluid / blood resuscitation prior & during

surgerysurgery crystalloid , colloid ,blood & blood product crystalloid , colloid ,blood & blood product

can be used to correct hypovolemiacan be used to correct hypovolemia

CLINICAL INDICES OF EXTENT OF CLINICAL INDICES OF EXTENT OF BLOOD LOSSBLOOD LOSS

GRADE OF GRADE OF HYPOVOLAEMIAHYPOVOLAEMIA

MILDMILD MODERATEMODERATE SEVERESEVERE

PERCENTAGE PERCENTAGE BLOOD LOSSBLOOD LOSS

2020 3030 >40>40

VOLUME LOST (ML)VOLUME LOST (ML) 10001000 15001500 >2000>2000

HEART RATE (BPM)HEART RATE (BPM) 100-120100-120 120-140120-140 >140>140

ARTERIAL ARTERIAL PRESSURE (MM HG)PRESSURE (MM HG)

ORTHOSTATIC ORTHOSTATIC HYPOTENSIONHYPOTENSION

SYSTOLIC <100SYSTOLIC <100 SYSTOLIC<80SYSTOLIC<80

URINE OUTPUT URINE OUTPUT (ML/H)(ML/H)

20-3020-30 10-2010-20 <10<10

SENSORIUMSENSORIUM NORMALNORMAL RESTLESSRESTLESS IMPAIRED IMPAIRED CONCIOUSNESSCONCIOUSNESS

STATE OF STATE OF PERIPHERAL PERIPHERAL CIRCULATIONCIRCULATION

COOL AND PALECOOL AND PALE COLD,PALE & SLOW COLD,PALE & SLOW CAPILLARY REFILLCAPILLARY REFILL

COLD & CLAMMY, COLD & CLAMMY, PERIPHERAL PERIPHERAL

CYANOSISCYANOSIS

Textbook of Anesthesiology by Alan R.Aitkenhead 3rd edition

Complications of Complications of hypovolemiahypovolemia

Difficult intravenous accessDifficult intravenous access Hypovolemic shockHypovolemic shock Hemorrhagic shockHemorrhagic shock Multi organ failureMulti organ failure HypothermiaHypothermia DeathDeath

COAGULOPATHYCOAGULOPATHY

Causes : Causes :

1.1. massive blood loss [ major trauma, massive blood loss [ major trauma, obstetric hemorrhage] obstetric hemorrhage]

2.2. patient on anticoagulant therapy patient on anticoagulant therapy require emergency surgery ,require emergency surgery ,

3.3. dilutional coagulopathydilutional coagulopathy

Complications of Complications of coagulopathycoagulopathy

Uncontrolled bleedingUncontrolled bleeding

Hemorrhagic shockHemorrhagic shock

deathdeath

POTENTIAL DIFFICULT POTENTIAL DIFFICULT AIRWAYAIRWAY

Risk factors :Risk factors :1.1. trauma involving upper part of the body trauma involving upper part of the body

[ faciomaxillary , spine ] [ faciomaxillary , spine ] 2.2. obstruction of upper airway [ epiglotitis , obstruction of upper airway [ epiglotitis ,

abscess , tumor , goitre ] abscess , tumor , goitre ] 3.3. congenital airway abnormalities patient congenital airway abnormalities patient

require emergency surgeryrequire emergency surgery4.4. obesityobesity5.5. pregnancypregnancy

Morbidly obeseMorbidly obese

Difficult airwayDifficult airway

Cervical spine immobilization Cervical spine immobilization in cervical spine injuryin cervical spine injury

Difficult airway :Difficult airway :faciomaxillary traumafaciomaxillary trauma

Complications of difficult Complications of difficult airwayairway

Aspiration Aspiration HypoxemiaHypoxemia Trauma to upper airwayTrauma to upper airway Potential spinal cord injury in cervical Potential spinal cord injury in cervical

injuryinjury BarotraumaBarotrauma

COEXISTING DISEASECOEXISTING DISEASE

Unknown medical condition in Unknown medical condition in unconscious patientunconscious patient

Not optimized medical condition such as Not optimized medical condition such as DM , HT , IHD , ASTHMADM , HT , IHD , ASTHMA

Limited time to optimize & elicit further Limited time to optimize & elicit further medical historymedical history

ANALGESIA AND ANALGESIA AND SEDATIONSEDATION

Preoperative sedation & analgesia have Preoperative sedation & analgesia have to be used with caution in hypovolemia, to be used with caution in hypovolemia, uncertain diagnosis , head & abdominal uncertain diagnosis , head & abdominal injury & difficult airwayinjury & difficult airway

Therefore pain relief is always Therefore pain relief is always inadequateinadequate

Intraoperative ProblemsIntraoperative Problems

Intraoperative awarenessIntraoperative awareness Intraoperative hypothermiaIntraoperative hypothermia

HYPOTHERMIAHYPOTHERMIA

Contributing factors :Contributing factors : hypovolemiahypovolemia general & regional anaesthesia general & regional anaesthesia cold surroundings , cold iv fluids, cold antiseptic cold surroundings , cold iv fluids, cold antiseptic

solutionsolution head injury head injury burn burn extreme age extreme age surgery exposes large area of skin & abdomen or surgery exposes large area of skin & abdomen or

thorax from which heat is lostthorax from which heat is lost

Problems with Problems with hypothermia :hypothermia :

Increased oxygen requirementIncreased oxygen requirement Myocardial depressionMyocardial depression Risk of ventricular fibrillation, T < 28 Risk of ventricular fibrillation, T < 28 °°CC Decreased conscious level T< 30Decreased conscious level T< 30°° C C Reduced drug metabolismReduced drug metabolism Prolonging effect of anaesthetic agentProlonging effect of anaesthetic agent Reduced urine outputReduced urine output

AWARENESSAWARENESS

Implies wakefulness with or without recall Implies wakefulness with or without recall of events during the period when the of events during the period when the patient is thought to be under patient is thought to be under anaesthesia.anaesthesia.

The sensations recalled can be auditory, The sensations recalled can be auditory, tactile, or pain.tactile, or pain.

It is an extremely traumatic experience It is an extremely traumatic experience for the patient.for the patient.

PATIENTS WHO ARE AT RISK OF PATIENTS WHO ARE AT RISK OF AWARENESSAWARENESS

Intra operative awareness can occur in Intra operative awareness can occur in high-risk surgeries such as trauma and high-risk surgeries such as trauma and cardiac surgery in which the patient’s cardiac surgery in which the patient’s condition may not allow for the usual condition may not allow for the usual dose of anaesthetic drug to be given.dose of anaesthetic drug to be given.

The same is true during a delivery by The same is true during a delivery by cesarean section, particularly if it is an cesarean section, particularly if it is an emergency delivery.emergency delivery.

PRE OPERATIVE PRE OPERATIVE MANAGEMENTMANAGEMENT

Pre operative managementPre operative management

Preoperative assessment Preoperative assessment

1.1. all injuries should be noted all injuries should be noted

2.2. neurological observations neurological observations

3.3. starvation timestarvation time

4.4. investigations as indicatedinvestigations as indicated

5.5. preoperative fluid therapypreoperative fluid therapy

6.6. pain relief as indicatedpain relief as indicated


Primary survey and resuscitationPrimary survey and resuscitation Airway with cervical spine controlAirway with cervical spine control

A clear airway and ability to maintain A clear airway and ability to maintain oxygenationoxygenation

Assume cervical injury in all patients with Assume cervical injury in all patients with head and maxillofacial injurieshead and maxillofacial injuries

Provide oxygen supplementationProvide oxygen supplementation Assess the need for intubationAssess the need for intubation


Primary survey and resuscitationPrimary survey and resuscitation BreathingBreathing

Look out for inadequate breathing effort and Look out for inadequate breathing effort and intervene earlyintervene early

Rule out serious life-threatening chest injuries Rule out serious life-threatening chest injuries such as tension pneumothorax, cardiac such as tension pneumothorax, cardiac tamponade.tamponade.


Primary survey and resuscitationPrimary survey and resuscitation Circulation and hemorrhage controlCirculation and hemorrhage control

Signs of shock such as cold clammy Signs of shock such as cold clammy peripheries, pallor, hypotension, small pulse peripheries, pallor, hypotension, small pulse volumevolume

Insert large bore intravenous cannula for Insert large bore intravenous cannula for rapid fluid infusionrapid fluid infusion

Blood for investigation and cross-matchBlood for investigation and cross-match Control major external hemorrhage with direct Control major external hemorrhage with direct

pressurepressure


Primary survey and resuscitationPrimary survey and resuscitation DisabilityDisability

A quick neurological assessment such as pupillary size A quick neurological assessment such as pupillary size and light reaction, Glasgow Coma Scale scoringand light reaction, Glasgow Coma Scale scoring

ExposureExposure Undress the patient for a thorough survey of other Undress the patient for a thorough survey of other

injuries and then cover the patient with blanket to injuries and then cover the patient with blanket to prevent hypothermia prevent hypothermia


Primary survey and resuscitationPrimary survey and resuscitation Conditions require urgent intubationConditions require urgent intubation

Lung contusion with hypoxaemia , chest injuriesLung contusion with hypoxaemia , chest injuries Upper airway obstructionUpper airway obstruction Severe head injury with GCS < 9Severe head injury with GCS < 9 Inability to protect airway such as active oral bleedingInability to protect airway such as active oral bleeding Shock requiring cardiopulmonary resuscitationShock requiring cardiopulmonary resuscitation

Intubation is done with care and in-line Intubation is done with care and in-line immobilization of the cervical spineimmobilization of the cervical spine

Secondary survey and Secondary survey and definitive caredefinitive care

Secondary survey and definitive careSecondary survey and definitive care It is done until the vital signs are relatively It is done until the vital signs are relatively

stablestable Re-evaluate the patient repeatedly so that Re-evaluate the patient repeatedly so that

ongoing bleeding is detected earlyongoing bleeding is detected early Patients with exsanguinating haemorrhage Patients with exsanguinating haemorrhage

may need a laparotomy as part of the may need a laparotomy as part of the resuscitation phase.resuscitation phase.

Goals for resuscitation of the trauma patient Goals for resuscitation of the trauma patient before haemorrhage has been controlledbefore haemorrhage has been controlled

PARAMETERPARAMETER GOALGOAL

Blood pressureBlood pressure Systolic 80 mmHg, mean Systolic 80 mmHg, mean 50-60mmHg50-60mmHg

Heart rateHeart rate < 120 bpm< 120 bpm

OxygenationOxygenation SaO2 > 95%SaO2 > 95%

Urine outputUrine output 0.5ml/kg/h0.5ml/kg/h

Mental statusMental status Following commandsFollowing commands

Lactate levelLactate level <1.6mmol/l<1.6mmol/l

Base deficitBase deficit > -5> -5

HaemoglobinHaemoglobin >8.0g/dl>8.0g/dlFrom Oxford Handbook of Anaesthesia 2nd edition

Measures to empty Measures to empty stomachstomach

Postpone operation if permissiblePostpone operation if permissible Adequate fasting timeAdequate fasting time Gastric suctionGastric suction Acid prophylaxisAcid prophylaxis

iv ranitidine 50 mg 15-30 before inductioniv ranitidine 50 mg 15-30 before induction

prokinetic agentprokinetic agent Iv metoclopromide 10 mgIv metoclopromide 10 mg

INTRA OPERATIVE INTRA OPERATIVE MANAGEMENTMANAGEMENT

Conduct of anaesthesiaConduct of anaesthesia

General anaesthesiaGeneral anaesthesia Regional anaesthesiaRegional anaesthesia

Eg for LSCSEg for LSCS

Combined anaesthesiaCombined anaesthesia Peripheral nerve blockPeripheral nerve block

Airway managementAirway management

Rapid sequence inductionRapid sequence induction Awake fibreoptic / video assisted Awake fibreoptic / video assisted

intubationintubation Inhalational inductionInhalational induction Emergency cricothyroidotomyEmergency cricothyroidotomy Tracheostomy under LA by ENTTracheostomy under LA by ENT

Rapid sequence induction (RSI)Rapid sequence induction (RSI)

Minimize risk of aspirationMinimize risk of aspiration breathes 100% oxygen for 3-5 minutes or takes 4 breathes 100% oxygen for 3-5 minutes or takes 4

vital breathsvital breaths predetermined rapid IV induction agentpredetermined rapid IV induction agent Followed by rapid acting muscle relaxant without Followed by rapid acting muscle relaxant without

waiting to assess the effect of induction agent.waiting to assess the effect of induction agent. Combined with cricoid pressure to reduce the risk of Combined with cricoid pressure to reduce the risk of

aspirationaspiration Manual in line stabilization intubation in cervical spine Manual in line stabilization intubation in cervical spine

injury injury

Rapid sequence inductionRapid sequence induction[ no evidence of airway [ no evidence of airway obstruction]obstruction]

IV induction agent used [ depends on IV induction agent used [ depends on hemodynamic status ]hemodynamic status ] IV thiopentone 2-4mg/kgIV thiopentone 2-4mg/kg IV etomidate 0.2-0.3mg/kgIV etomidate 0.2-0.3mg/kg IV ketamine 1-2mg/kg IV ketamine 1-2mg/kg

Use for hypotensive patientUse for hypotensive patient Contraindicated in head injured patient with Contraindicated in head injured patient with

potential high ICPpotential high ICP IV propofol 1-2mg/kgIV propofol 1-2mg/kg

Rapid sequence inductionRapid sequence induction

Muscle relaxantMuscle relaxant If no contraindication, IV If no contraindication, IV

suxamethonium 1.5mg/kg suxamethonium 1.5mg/kg IV rocuronium 0.9mg/kgIV rocuronium 0.9mg/kg

Rapid sequence inductionRapid sequence induction

Cricoid pressure (Sellick’s maneuver) Cricoid pressure (Sellick’s maneuver) A skilled assistant is positioned on the patient’s right A skilled assistant is positioned on the patient’s right

sideside the thumb and forefinger with middle finger of right the thumb and forefinger with middle finger of right

hand press the cricoid cartilage in the posterior hand press the cricoid cartilage in the posterior direction, compressing the oesophagus between the direction, compressing the oesophagus between the cricoid cartilage and the vertebrae column.cricoid cartilage and the vertebrae column.

It is applied as soon as the patient loses It is applied as soon as the patient loses consciousnessconsciousness

Released once ETT position is confirmedReleased once ETT position is confirmed

Cricoid pressureCricoid pressure

Sellick’s maneuver or Sellick’s maneuver or cricoid pressure cricoid pressure

Rapid sequence induction Rapid sequence induction (RSI)(RSI)

Disadvantages of RSIDisadvantages of RSI Hemodynamic instability in Hemodynamic instability in

hypovolaemic patienthypovolaemic patient Hypertensive and tachycardia if Hypertensive and tachycardia if

induction dose is not adequateinduction dose is not adequate

Monitoring during Monitoring during anesthesiaanesthesia

ECGECG NIBP, IABP (intra-arterial blood pressure) NIBP, IABP (intra-arterial blood pressure)

monitoring if indicatedmonitoring if indicated SpOSpO22 ETCO2ETCO2 TemperatureTemperature Urine outputUrine output CVPCVP

Maintenance of anesthesiaMaintenance of anesthesia

Be prepared to change the Be prepared to change the maintenance technique at any time maintenance technique at any time during the course of anesthesia as during the course of anesthesia as the patient’s condition and response the patient’s condition and response may changemay change

Fluid therapyFluid therapy

Volume status must be continuously Volume status must be continuously monitored and fluid therapy consistently monitored and fluid therapy consistently titrated in response to ongoing changestitrated in response to ongoing changes

RequirementRequirement Adequate intravascular accessAdequate intravascular access Intra osseous needle for difficult iv access in Intra osseous needle for difficult iv access in

paediatric patients paediatric patients Central venous access if possibleCentral venous access if possible


RequirementRequirement Warm all resuscitation fluidsWarm all resuscitation fluids Pressurized devices should be availablePressurized devices should be available A fluid-warming and infusion systemsA fluid-warming and infusion systems FluidsFluids

CrystalloidCrystalloid Ringer’s lactate, normal salineRinger’s lactate, normal saline

ColloidColloid Gelatin eg GelofusineGelatin eg Gelofusine Starch eg VoluvenStarch eg Voluven


After volume status stabilizeAfter volume status stabilize The second priority is the restoration of The second priority is the restoration of

blood oxygen-carrying capacityblood oxygen-carrying capacity Packed cell Packed cell Whole bloodWhole blood

The third priority is the normalization of The third priority is the normalization of coagulation statuscoagulation status FFPFFP PlateletPlatelet CryoprecipitateCryoprecipitate

Post Operative Post Operative ManagementManagement

Post Operative ManagementPost Operative Management

Decision for extubation depends on patient’s Decision for extubation depends on patient’s haemodynamic statushaemodynamic status

In stable patient, before extubationIn stable patient, before extubation Direct laryngoscopy is performed and secretion Direct laryngoscopy is performed and secretion

or debris are removed. If nasogastric tube is in or debris are removed. If nasogastric tube is in situ, it is aspirated.situ, it is aspirated.

Atropine and neostigmine are given and patient Atropine and neostigmine are given and patient will breathe in 100% oxygen.will breathe in 100% oxygen.

Because of the risk of aspiration, extubation is Because of the risk of aspiration, extubation is performed only when there is recovery of airway performed only when there is recovery of airway reflexes. reflexes.

Post Operative ManagementPost Operative Management

Some patients may require continuation Some patients may require continuation of ventilatory assistance postoperatively.of ventilatory assistance postoperatively.

They will be sent to ICU for further They will be sent to ICU for further resuscitation and ventilation.resuscitation and ventilation.

Indications for postoperative ICU Indications for postoperative ICU admissionsadmissions

Severe chest injury Severe chest injury Evidence of aspiration pneumoniaEvidence of aspiration pneumonia Unstable hemodynamic status Unstable hemodynamic status Severe head injury for cerebral protectionSevere head injury for cerebral protection Massive blood loss with massive blood Massive blood loss with massive blood

transfusion with DIVCtransfusion with DIVC polytraumapolytrauma

ANAESTHESIA FOR ANAESTHESIA FOR NON-TRAUMATIC NON-TRAUMATIC EMERGENGY SURGERYEMERGENGY SURGERY

Principle of emergency Principle of emergency anesthesiaanesthesia

To be prepared for all potential To be prepared for all potential complications complications vomiting and regurgitationvomiting and regurgitation hypovolaemia hypovolaemia HemorrhageHemorrhage abnormal reactions to drugs in the presence abnormal reactions to drugs in the presence

of electrolyte disturbances and renal of electrolyte disturbances and renal impairmentimpairment

PRE OPERATIVE PRE OPERATIVE MANAGEMENTMANAGEMENT


Objective is to permit correction of the Objective is to permit correction of the surgical pathology with the minimum of surgical pathology with the minimum of risk to the patient.risk to the patient.

Requires adequate and accurate Requires adequate and accurate preoperative evaluation of the patient’s preoperative evaluation of the patient’s general condition, with attention to general condition, with attention to specific problems which may influence specific problems which may influence anesthetic managementanesthetic management


To ascertain the likely surgical diagnosis, To ascertain the likely surgical diagnosis, the magnitude of the proposed surgery the magnitude of the proposed surgery and the urgency of the surgeryand the urgency of the surgery

To get as much as possible premorbid To get as much as possible premorbid medical problems, drugs, allergy and any medical problems, drugs, allergy and any past surgical and exposure to anesthesia past surgical and exposure to anesthesia history.history.


Physical examination may be selective to Physical examination may be selective to identify significant cardiopulmonary identify significant cardiopulmonary dysfunction or any abnormalities which dysfunction or any abnormalities which might lead to technical difficulties during might lead to technical difficulties during anesthesia.anesthesia.


Airway evaluation for rapid sequence inductionAirway evaluation for rapid sequence induction To anticipate potential of difficult intubationTo anticipate potential of difficult intubation Features of difficult airway including Features of difficult airway including

limitation mouth opening,limitation mouth opening, poor range of atlanto-occipital joint,poor range of atlanto-occipital joint, reduced distance between thyroid cartilage and the reduced distance between thyroid cartilage and the

mental symphysis mental symphysis a history of difficult intubationa history of difficult intubation


Assessment of volaemic statusAssessment of volaemic status Intravascular volume deficitIntravascular volume deficit Useful indices include Useful indices include

heart rateheart rate arterial pressurearterial pressure peripheral circulationperipheral circulation central venous pressurecentral venous pressure urine outputurine output

INDICES OF EXTENT OF LOSS OF INDICES OF EXTENT OF LOSS OF EXTRACELLULAR FLUIDEXTRACELLULAR FLUID

PERCENTAGE PERCENTAGE BODY WEIGHT BODY WEIGHT

LOST AS WATERLOST AS WATER

ML OF FLUID ML OF FLUID LOST PER LOST PER

70KG70KG

SIGNS & SYMPTOMSSIGNS & SYMPTOMS

>4%(mild)>4%(mild) >2500>2500 thirst, reduced skin elasticity, decreased intraocular thirst, reduced skin elasticity, decreased intraocular presurre, dry tongue, reduced sweatingpresurre, dry tongue, reduced sweating

>6% (mild)>6% (mild) >4200>4200 As above, plus orthostatic hypotension, reduced filling of As above, plus orthostatic hypotension, reduced filling of peripheral veins, oliguria, nausea, dry axillae & groin, low peripheral veins, oliguria, nausea, dry axillae & groin, low

CVP, apathy, haemoconcentrationCVP, apathy, haemoconcentration

> 8% (moderate)> 8% (moderate) >5500>5500 As above, plus hypotension, thready pulse with As above, plus hypotension, thready pulse with cool peripheriescool peripheries

10-15% (severe)10-15% (severe) 7000-105007000-10500 coma , shock followed by deathcoma , shock followed by death

Textbook of Anesthesiology by Alan R.Aitkenhead 3 rd edition


Extracellular volume deficitExtracellular volume deficit Assessment of extracellular fluid volume Assessment of extracellular fluid volume

deficit is difficultdeficit is difficult Guidance is obtained from Guidance is obtained from

the nature of the surgical condition the nature of the surgical condition the duration of impaired fluid intake the duration of impaired fluid intake the presence and severity of symptoms the presence and severity of symptoms

associated with abnormal losses ( vomiting).associated with abnormal losses ( vomiting).


Extracellular volume deficitExtracellular volume deficit Labarotory investigation may help to confirm Labarotory investigation may help to confirm

the extent of extracellular fluid volume the extent of extracellular fluid volume deficit.deficit.

Dehydration lead toDehydration lead to Hemoconcentration Hemoconcentration High blood ureaHigh blood urea High serum sodium / or abnormal electrolyteHigh serum sodium / or abnormal electrolyte


Extracellular volume deficitExtracellular volume deficit Under influences of ADH and aldosterone, Under influences of ADH and aldosterone,

conservation of sodium and water by kidney conservation of sodium and water by kidney result in excretion of urine of low sodium result in excretion of urine of low sodium content and high osmolalitycontent and high osmolality


The optimal time for surgical intervention The optimal time for surgical intervention is when all deficits have been corrected is when all deficits have been corrected but if there are urgent indications for but if there are urgent indications for surgery ( gangrenous bowel , active surgery ( gangrenous bowel , active bleeding) compromise is necessary.bleeding) compromise is necessary.


The full stomach with higher risk of vomiting The full stomach with higher risk of vomiting and regurgitation which may complicate with and regurgitation which may complicate with aspiration.aspiration.

In elective surgery, patients are starved of food In elective surgery, patients are starved of food and drink at least 4-6 hours.and drink at least 4-6 hours.

In emergency surgery, it may be necessary to In emergency surgery, it may be necessary to induce anesthesia urgently before an adequate induce anesthesia urgently before an adequate period of starvation occurs. period of starvation occurs.

Situation in which vomiting or Situation in which vomiting or regurgitation may occur regurgitation may occur

Peritonitis of any causePeritonitis of any cause Postoperative ileusPostoperative ileus Metabolic ileus: hypokalemia, uraemia, Metabolic ileus: hypokalemia, uraemia,

ketoacidosisketoacidosis Drug-induced ileus: anticholenergicsDrug-induced ileus: anticholenergics Small or large bowel obstructionSmall or large bowel obstruction Gastric carcinomaGastric carcinoma Pyloric stenosisPyloric stenosis Shock of any cause, trauma (high sympathetic Shock of any cause, trauma (high sympathetic

tone)tone)

Situation in which vomiting or Situation in which vomiting or regurgitation may occur regurgitation may occur

Fear, pain, anxiety (high sympathetic tone Fear, pain, anxiety (high sympathetic tone cause delayed gastric emptying)cause delayed gastric emptying)

PregnancyPregnancy OpiodsOpiods Recent solid or fluid intakeRecent solid or fluid intake Other causesOther causes

Hiatus herniaHiatus hernia Oesophageal stricture – benign or malignantOesophageal stricture – benign or malignant Pharyngeal pouchPharyngeal pouch


PreparationPreparation All patients undergone emergency operation must All patients undergone emergency operation must

well resuscitation with either intravenous fluid or well resuscitation with either intravenous fluid or blood product depends on nature of pathology.blood product depends on nature of pathology.

Adequate intravenous assessAdequate intravenous assess Group and cross-match blood whenever is indicatedGroup and cross-match blood whenever is indicated Obtain investigations if possible and time permittedObtain investigations if possible and time permitted Emergency drugs are prepared together with Emergency drugs are prepared together with

anesthetic drugsanesthetic drugs Appropriate monitoring devices are preparedAppropriate monitoring devices are prepared

INTRA OPERATIVE INTRA OPERATIVE MANAGEMENTMANAGEMENT

Techniques of anesthesiaTechniques of anesthesia

Rapid-sequence induction (RSI)Rapid-sequence induction (RSI) The decision is to balance the risks of losing The decision is to balance the risks of losing

control of the airway against the risk of control of the airway against the risk of aspirationaspiration

Other technique includeOther technique include Inhalational inductionInhalational induction Awake fibreoptic intubationAwake fibreoptic intubation Regional anesthesia Regional anesthesia

Maintenance of Maintenance of anesthesiaanesthesia

A balance technique of anesthesia A balance technique of anesthesia combiningcombining Anesthesia – oxygen with air or nitrous oxide Anesthesia – oxygen with air or nitrous oxide

and volatile agentand volatile agent Analgesia – opiods such as fentanyl or Analgesia – opiods such as fentanyl or

morphinemorphine Muscle relaxation - non-depolarizing muscle Muscle relaxation - non-depolarizing muscle

relaxant such as atracurium, vecuronium relaxant such as atracurium, vecuronium and rocuroniumand rocuronium

Fluid managementFluid management

During intra-abdominal surgery there may be During intra-abdominal surgery there may be large blood and fluid losses which exceed large blood and fluid losses which exceed maintenance fluid replacement.maintenance fluid replacement.

These include These include evaporation from exposed gutevaporation from exposed gut blood loss on to swab and into suction bottle blood loss on to swab and into suction bottle sequestration of fluid in inflamed and traumatized sequestration of fluid in inflamed and traumatized

tissue.tissue. An appropriate volume for replacement is An appropriate volume for replacement is

required depends on the degree of ongoing required depends on the degree of ongoing losses. It is range from 2 – 10 ml/kg/h.losses. It is range from 2 – 10 ml/kg/h.

Fluid managementFluid management

Hemorrhage in excess of 15% blood Hemorrhage in excess of 15% blood volume in adults or 10% in children is volume in adults or 10% in children is usually an indication for blood usually an indication for blood transfusion.transfusion.

Reversal and emergenceReversal and emergence

Decision for extubation depends on patient’s Decision for extubation depends on patient’s haemodynamic statushaemodynamic status

Prior to extubationPrior to extubation Direct pharyngoscopy is performed to remove the Direct pharyngoscopy is performed to remove the

secretion or debris. secretion or debris. nasogastric tube is aspiratednasogastric tube is aspirated Atropine and neostigmine are given once patient Atropine and neostigmine are given once patient

has spontaneous breathing.has spontaneous breathing. Extubation is performed only protective airway Extubation is performed only protective airway

reflexes intact. reflexes intact.

Indications for postoperative ICU Indications for postoperative ICU admissionsadmissions

Prolonged shock/hypotensive state of Prolonged shock/hypotensive state of any causeany cause

Severe sepsisSevere sepsis Severe ischaemic heart diseaseSevere ischaemic heart disease Overt gastric acid aspirationOvert gastric acid aspiration

CONCLUSIONCONCLUSION

Emergency patients have little Emergency patients have little cardiopulmonary reservecardiopulmonary reserve Anesthesia may induce further intolerable Anesthesia may induce further intolerable

stressstress

Acquire as much information as possible Acquire as much information as possible about the injuries, resuscitation status about the injuries, resuscitation status and co-existing disease of the patient so and co-existing disease of the patient so as to minimize anesthetic riskas to minimize anesthetic risk

CONCLUSIONCONCLUSION

The anesthetic plan must account for drugs The anesthetic plan must account for drugs and monitoring used throughout the surgeryand monitoring used throughout the surgery

Fluid management is challenging because Fluid management is challenging because changes in volume status can be rapid and changes in volume status can be rapid and unpredictable unpredictable

Possible complications must be anticipatedPossible complications must be anticipated Appropriate therapeutic options should be Appropriate therapeutic options should be

availableavailable

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Anesthesia for Emergency Surgery