Professional Documents
Culture Documents
Abinash em Gi Sur
Abinash em Gi Sur
Surgeries
Presenter:
Dr. Abinash Sapkota
20th batch
Moderators:
Assoc. Prof. Dr. Anuj Jung Karki
Dr. Gaurav Ratna Bajracharya
1
Objectives
Anesthetic concerns
Risk Assessment
Patient Assessment
Preparation
Anesthetic technique (RSI)
Intra and Postoperative management
Emergency Laparatomy Pathway Quality Improvement Care Bundle
(ELPQuiC)
2
Introduction
3
Introduction
Emergency GI surgery, especially laparotomy is the most common surgical
procedure with high rates of mortality and morbidity especially when
associated with peritonitis
30 day inpatient mortality rate following emergency laparotomy was 14.9% for
all patients and 24.4 % in patients of age 80 yrs or more.
4
Categorization
5
Common emergency GI surgeries
Appendectomy
Hollow viscous Perforation
Peritonitis
Small or large bowel obstructions
Strangulated hernia
6
Anesthetic Concerns
Pathophysiological changes resulting from their surgical
pathology:
Pain.
Dehydration.
Hemorrhage.
Hemodynamic instability.
Electrolytes and acid base disorders.
Anemia and coagulation abnormalities.
Altered sensorium.
Respiratory distress.
7
Anesthetic Concerns
8
Patho-physiology
9
Risk Assessment
10
National Early Warning Score (NEWS)
National Early Warning Score (NEWS) – Standardizing the assessment of acute-illness severity in the NHS. The Royal College of Physicians (2015).
NEWS
POSSUM score: Physiological and Operative Severity
Score for the enumeration of Mortality and Morbidity
Generic care pathway for emergency laparotomy
14
Generic care pathway for emergency laparotomy
15
Preoperative assessment and optimization
History
Last meal intake
Signs and symptoms of present illness
Past medical and surgical history
H/O Anesthesia exposure
Personal history
Family history
Drug and allergy
Bleeding disorder
Burn
Cardiovascular reserve
16
Preoperative assessment and optimization
Examination
A swift but thorough airway assessment and spine examination.
Physical examinations including PILCCOD.
Evaluation of the volume status.
Peripheral venous access.
Assessment of respiratory distress: increased respiratory rate, use of accessory
muscles of respiration, breathing patterns.
Assessment of cardiac system: heart rate, capillary refill time, blood pressure,
murmurs.
-Rapid, low volume pulse, raised JVP, basal crepitations indicate that the
patient is in cardiac failure and may need perioperative cardiac support.
17
Preoperative assessment and optimization
Preoperative investigations
CBC
RBS USG abdomen
RFT X- ray chest
LFT CT scan
Coagulation profile UPT ( Female patients)
ECG
ABG
Blood grouping and cross matching
18
Preoperative assessment and optimization
Risk of Aspiration
Always considered full stomach
High risk due to depressed airway reflexes
Risk depends on PH and Volume of gastric Secretions
19
Risk factors for Aspiration
20
Risk factors for Aspiration
21
Strategies to reduce aspiration risk
22
Circulating Volume Assessment
23
Circulating Volume Assessment
24
Fluid Resuscitation
25
Patient Assessment
26
Fluid Resuscitation
Intestinal Obstruction
Volume of sequestration can be as large as 4 to 6 L/24 hrs.
The volume of fluid lost could be as much as:
In early bowel obstruction – 1500 ml
In well established obstruction – 3000 ml
Hypotension and tachycardia with circulatory insufficiency – 6000 ml
Important to know the site of the obstruction.
27
Fluid Resuscitation
Fluid deficit—5 percent dehydration is 50 ml/kg, 7.5 percent dehydrated then the
deficit is 75 ml/kg and 100 ml/kg deficit with 10 percent dehydration.
Maintenance fluid—2000-3000 ml/day.
Ongoing losses—initially difficult to quantify but Includes NG loss and loss into
bowel. A conservative estimate would be 2000 ml/day.
May require 10litres/day .
28
Fluid Resuscitation
29
Fluid Resuscitation
30
Fluid Resuscitation
31
Fluid Resuscitation
Any increase in cardiac filling pressure will push the patient in cardiac failure.
Vasopressors may be started to augment the cardiac output. Patients with perforation
of long duration or pancreatitis require massive volumes for resuscitation.
32
Fluid Resuscitation
Signs of Adequete Resuscitation
Heart rate below 120/minute
Systolic blood pressure 80-100 mm Hg
Hematocrit at 25-30%
Core temperature higher than 35°C
Urine output > 0.5-1 ml/kg
Normalization of PT and PTT
Platelet count > 50,000 / mm3
SpO2 > 95%
pH > 7.3
33
Fluid Resuscitation
Abdominal trauma
ATLS mentions RL as the choice of fluid.
Blood transfusion if loss of blood > 30%
Blood transfusion if Hb < 7 gm%.
Target hemoglobin should be between 7 to 9 gm%
Use of vasopressors to maintain MAP > 65 mmHg.
34
Abdominal Compartment Syndrome
Characterized by:
Tense and distended abdomen.
Hypotension and hypoventilation.
High airway pressures.
Hypercapnia and oliguria.
36
Emergency Laparotomy Pathway Quality
Improvement Care Bundle (ELPQUIC)
37
Immediate preoperative period
Patient preparation
Preoperative antibiotics.
Anticholinergics and anti emetics.
Oxygen by mask or by nasal prongs.
NG tube insertion and anti-aspiration prophylaxis.
Pain management.
39
Immediate preoperative period
OT preparation
Preparation of all equipments and drugs.
Tippling table.
IV fluids (warm).
Monitoring.
Warm room temperature.
40
Anesthesia Technique
General anesthesia is always considered as the first choice in case of intestinal
obstruction and abdominal sepsis particularly with perforative peritonitis. The
reasons being:
Unstable hemodynamics with subarachnoid block.
High level of block required.
Preoperative respiratory embarrassment because of abdominal distention.
Possibility of precipitous hypotension.
Associated with coagulation abnormalities and insertion of epidural catheter is not
advisable.
Infectious complications in the epidural space.
41
Regional Techniques
Use of epidural anesthesia along with General Anesthesia
Excellent analgesia.
Reduces stress response to surgery.
Increases gastrointestinal blood flow.
Improved tissue oxygenation.
Reduced incidence of myocardial infarction.
Reduced recovery time from surgery.
42
Limitations of Regional Anesthesia Technique
43
Intraoperative Monitoring
Pulse
Blood pressure
Urine output
Oxygen saturation
EtCO2
Blood loss
Temperature
Biochemical tests such as blood glucose, serum electrolytes,
PT/INR, ABG can be sent during surgery.
Invasive- Central Venous catheter/ Arterial line.
45
Patient preparation fluid management
Adequate tissue perfusion and oxygenation
Iv access- wide bore cannulas
Blood loss-replaced by balanced crystalloids or suitable colloids until blood
available
Extracellular fluid deficit should be corrected by
-Crystalloid solution containing appropriate potassium- hartmanns solution
often used volume for volume.
Meticulous intake output monitoring.
46
Patient Preparation Antibiotic Prophylaxis
Dellinger RP, Levy MM, Rhodes A et al. and the Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup.
Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock. Intens Care Med
2013; 39: 165–228.
47
Patient Assessment with Full stomach
48
Risk Factors for Aspiration
Full stomach
Emergency surgery.
Inadequate fasting time.
Gastrointestinal obstruction.
49
Risk factors for aspiration
Incompetent lower oesophageal spinchter
Hiatus hernia
Recurrent regurgitation
Dyspepsia
Pregnancy
Anesthetic factors
Light anesthesia
Supraglottic airways
Inadequate cricoid pressure
Length of surgery more than 2 hrs
Difficult airway
50
Strategies for reducing aspiration risk
Preoperative fasting
Reducing gastric volume
NG aspiration
Avoidance of GA
Prokinetic premedication
Reducing pH of gastric
contents Regional anesthesia
Airway protection Antacids and H2 histamine antagonist
Prevent regurgitation PPI
Extubation Tracheal intubation
2nd gen supraglottic airway
Cricoid pressure
Rapid sequence induction
Awake after return of airway reflexes
Position( lateral, head down or upright)
51
Patient preparation
NG tube insertion and suction.
Pain management.
Catheterization.
Premedication.
-Prokinetics- Metoclopramide, erythromycin.
-Antacids- sodium citrate.
-H2 blockers.
-Proton pump inhibitors.
52
Induction
Preoxygenation
Choice of the induction agent will depend on general condition of
the patient, hemodynamic stability and specific risk factors. It
can be thiopentone sodium, propofol or ketamine intravenously.
Muscle relaxant of choice- Suxamethonium or rocuronium.
Position for intubation: Head low position promotes passive
regurgitation.
Cricoids pressure (Sellick’s maneuver)( RSI or Modified RSI)
53
Classical RSI
Emptying of the stomach via a gastric tube which is then removed.
Pre-oxygenation.
Positioning the patient supine with a head-down tilt.
Induction of anaesthesia with a barbiturate (e.g. thiopentone) or volatile and a rapid-
acting muscle relaxant (e.g. suxamethonium).
Application of cricoid pressure.
Laryngoscopy and intubation of the trachea with a cuffed tube immediately
following fasciculations.
54
55
Maintainance of anesthesia :
oxygen,inhalational agents, intermittent short acting narcotics
or inhalational agents and NMBAs.
The choice of the latter should depend on patient’s renal,
cardiac and hepatic functions.
Intraoperative hypothermia prevention:
Forced air warming devices
Warming Mattress
Warm iv fluids
56
Intraoperative fluid requirements
Correction of the preoperative deficit.
Maintenance fluids.
Blood loss.
Third space loss.
Vomiting, urine output, NG aspirate.
57
Intraoperative fluid requirements
The therapeutic goal is:
CVP > 8 mm Hg. In mechanically ventilated patients, in patients with increased
intra-abdominal pressure and patients with pre-existing decreased ventricular
compliance, the CVP should be around 12 to 15 mm Hg.
MAP > 65 mm Hg.
Urine output > 0.5 ml/kg/hr.
SvO2 > 70 percent or mixed venous saturation > 65
percent.
Repeated lactate levels to < 2 mmol/l.
58
Intraoperative fluid requirements
Restrictive: net zero balance during surgery and 24 hours postop (≤5ml/kg preop
bolus, 5ml/kg/h intraop, 0.8ml/kg/hour 24 h postop).
Liberal : 10ml/kg bolus preop, 8-10ml/kg/h intraop, 1.5ml/kg/hour 24h postop.
Primary outcome: disability free survival at one year was similar in both groups
(81.9% vs 82.3%).
Secondary outcome: incidence of AKI, RRT, SSI was relatively higher is restricted
group.
60
Indications to insert a central venous line include:
Large fluid shifts.
Major blood loss.
Prolonged surgery.
To guide fluid therapy especially in the elderly and those with impaired cardiac
function.
To give inotropes if necessary.
To aspirate mixed venous blood and determine its oxygen saturation.
Indications for Arterial line
62
Intraoperative Pain management
Aim:
Optimal pain control
Early mobilisation
Opioids – commonly used perioperatively
Opoid sparing analgesic strategies:
Epidural analgesia.
TAP block.
Rectus sheath block.
NSAIDS.
Paracetamol.
Local anesthetics infiltration at incision site.
63
Benefits of opioid sparing analgesic strategies:
64
Emergence
Whether to reverse and extubate the patient at the end of surgery would depend
upon:
Pre- and intraoperative hemodynamic instability/ use of ionotropic support.
Involvement of lungs and kidneys due to sepsis.
Co morbid conditions such as diabetes, IHD, etc.
Nature and extensiveness of the surgery.
Intra-abdominal pressure, bowel edema, tension while closing the abdomen.
Blood loss.
65
Emergence
Awake extubation.
Full protective airway reflexes.
Responds to commands.
Patient is turned to lateral position if possible.
Deep inspiration and gentle positive pressure.
At peak of inspiration:
-cuff is deflated.
- tube removed as patient exhales.
100% oxygen until regular respiratory rhythm is re-established.
68
Postoperative Considerations
Infection prevention
Extended lung expansion exercises
Early removal of tubes, catheters and drains
Early mobilisation and prevention of venous thromboembolism
Early detection of complications and management
69
Summary
Immediate surgical intervention is the only way to solve the problem in surgical
emergencies.
Rapid assessment is necessary because patient’s condition may deteriorate rapidly.
Early preoperative assessment of the patient and stabilization of the patient is the
crucial part of anesthetic management.
Proper intraoperative and postoperative anesthetic plan before surgery helps in early
recovery of the patient and shorter hospital stay.
Coordination between anesthesiologists, surgeons and various other disciplines of
medicines is always required to accomplish the task.
70
References
72