Anesthesia for Emergency GI

Surgeries

Presenter:
Dr. Abinash Sapkota
20th batch

Moderators:
Assoc. Prof. Dr. Anuj Jung Karki
Dr. Gaurav Ratna Bajracharya
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Objectives

Anesthetic concerns
Risk Assessment
Patient Assessment
Preparation
Anesthetic technique (RSI)
Intra and Postoperative management
Emergency Laparatomy Pathway Quality Improvement Care Bundle
(ELPQuiC)

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Introduction

Emergency Surgery can be defined as surgery that is required to deal

with an acute threat to life, organ, limb or tissue caused by external
trauma, acute disease process, acute exacerbation of a chronic disease
process, or a complication of a surgical or other interventional
procedure.

European Union of Medical Specialists

Section of surgery and European Board of Surgery

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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.

Ass/w significantly higher risk than elective surgery (upto 8 fold)

Mortality 3 times higher in low resource setting .

Saunders DI, Murray D, Pichel AC, Varley S, Peden CJ and members of the UK Emergency Laparotomy Network. Variations in
mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network. Br J Anaesth 2012; 109: 368–
75.

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Categorization

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Common emergency GI surgeries
Appendectomy
Hollow viscous Perforation
Peritonitis
Small or large bowel obstructions
Strangulated hernia

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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.

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Anesthetic Concerns

Needs urgent intervention.

Uncertain diagnosis.
Elderly with coexisting diseases and poorly controlled chronic medical disease.
Difficult airway.
Full stomach with risk of aspiration.

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Patho-physiology

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Risk Assessment

Recommended in routine practice.

Helps to determine:
Degree of urgency.
Mobilize appropriate resources timely.
Involve experienced senior staffs.
Plan post-op care ( eg: ICU/HDU).
Importantly, understanding among families(Counselling).

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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

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Generic care pathway for emergency laparotomy

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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

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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.

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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

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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

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Risk factors for Aspiration

Full stomach Delayed gastric emptying

Emergency surgery Systemic diseases including DM and
Inadequate fasting time CKD
Gastrointestinal obstruction Opioids use
Recent trauma
Previous GI surgery
Pregnancy
Obesity

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Risk factors for Aspiration

Incompetent lower oesophageal Anesthetic factors

spinchter Light anesthesia
Hiatus hernia Supraglottic airways
Recurrent regurgitation Inadequate cricoid pressure
Dyspepsia Length of surgery more than 2 hrs
Pregnancy Difficult airway

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Strategies to reduce aspiration risk

Reducing gastric PH and Preoperative fasting

gastric volume NG aspiration
Avoidance of GA Regional anesthesia
Airway protection Tracheal intubation
2nd gen supraglottic airway
Position( lateral, head down or
upright)

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Circulating Volume Assessment

Clinical evaluation is must:

Heart rate
Arterial pressure (pulse pressure variation)
Central venous pressure
Urine output
Sensorium
CRT

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Circulating Volume Assessment

Assessment further guided by:

Nature of the surgical condition.
Duration of impaired fluid intake.
Presence and severity of symptoms associated with abnormal losses (eg:
vomiting).
Clinical signs with lab investigations is helpful.

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Fluid Resuscitation

Guided by urine output, hemodynamic parameters and mentation.

Choice of fluid replacement depends on nature of loss, hemodynamic status and
comorbidities in patient.

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Patient Assessment

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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.

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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 .

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Fluid Resuscitation

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Fluid Resuscitation

Correction of electrolyte imbalance:

Hyponatremia.
Hypokalemia.
Correction of acid base imbalance.

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Fluid Resuscitation

Abdominal sepsis/ peritonitis

In severe deficit, the initial rate may be as high as 1000 ml per hour reducing the
rate as condition improves.
Precaution in elderly patients and patients with cardiac disease
Aim- Hourly urine output of at least 30 to 50 ml.
Fluid challenge is given of 20 ml/kg rapidly or 500 to 1000 ml of crystalloids or
300 to 500 ml of colloids over 30 min.
Overzealous fluid administration should be avoided.

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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.

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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

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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.

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Abdominal Compartment Syndrome

Normal intra-abdominal pressure: 0-6 mmHg

Critically ill patient: 5-7 mmHg
IAH: Greater than 12 mmHg
IAP greater than 20 mmHg with dysfunction of at least one thoraco -abdominal
organ or Peak airway pressure more than 20 cm H20 or urine output less than
0.5ml/kg/hr
Abdominal Compartment Syndrome

Characterized by:
Tense and distended abdomen.
Hypotension and hypoventilation.
High airway pressures.
Hypercapnia and oliguria.

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Emergency Laparotomy Pathway Quality
Improvement Care Bundle (ELPQUIC)

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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.

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Immediate preoperative period

OT preparation
Preparation of all equipments and drugs.
Tippling table.
IV fluids (warm).
Monitoring.
Warm room temperature.

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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.

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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.

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Limitations of Regional Anesthesia Technique

Epidural in normal cougulation profile.

Epidural anesthesia combined with general anesthesia in a partially rehydrated state
and elderly are prone to hypotension.
Spinal or epidural analgesia only is not advisable in case of intestinal obstruction or
abdominal sepsis.

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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.

European Union of Medical Specialists 44

Patient preparation

Formulation of anesthetic plan

Confirmation of patients identity and procedure
Counselling
Consent
Availability of blood and blood products
Availability of HDU/ICU

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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.

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Patient Preparation Antibiotic Prophylaxis

To reduce intraoperative bacterial load to a degree than can be controlled by

patient’s innate immunity.
To prevent SSI.
Within one hour of recognition of sepsis.
There is an increase in mortality of around 8% for every 1 hour delay in antibiotic
administration.

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.

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Patient Assessment with Full stomach

Aspiration of gastric contents.

Occurs with depressed airway reflexes( during anesthesia, sedation, decreased
level of consciousness).
Outcome depends on type, pH and volume of gastric fluid.
pH less than 2.5
Volume of aspirate greater than 0.3ml/kg body weight ( 20-25ml in adults).

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Risk Factors for Aspiration
Full stomach
Emergency surgery.
Inadequate fasting time.
Gastrointestinal obstruction.

Delayed gastric emptying

Systemic diseases including DM and CKD.
Opioid use.
Recent trauma.
Previous GI surgery.
Pregnancy.
Obesity

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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

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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)
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Patient preparation
NG tube insertion and suction.
Pain management.
Catheterization.
Premedication.
-Prokinetics- Metoclopramide, erythromycin.
-Antacids- sodium citrate.
-H2 blockers.
-Proton pump inhibitors.

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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)

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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.

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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

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Intraoperative fluid requirements
Correction of the preoperative deficit.
Maintenance fluids.
Blood loss.
Third space loss.
Vomiting, urine output, NG aspirate.

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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.

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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.

RELIEF Trial ( Restrictive vs liberal fluid management)

Restrictrive vs Liberal Fluid Therapy for Major Abdominal Surgery, The New England Journal of Medicine,
june 14,2018 59
Intraoperative fluid requirements

So RELIEF trial suggests: moderate fluid management strategy maybe more

prudent.
Modestly liberal administration of isotonic balanced crystalloid solution.
Aiming for overall slightly positive balance (1-2 L) at the end of surgery.
Use goal directed fluid therapy for high risk pts and in high risk surgical cases.

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 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

Ongoing or anticipated hypotension

Presence of end organ damage
CVS or respiratory compromise.
Major blood loss.
Sepsis.

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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.

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Benefits of opioid sparing analgesic strategies:

Improved intestinal blood flow.

Short duration ileus.

Improved post operative pulmonary function.

Early mobilization and resumption of diet.

Less inflammatory mediators production.

No side effects of opioids.

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 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.

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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.

European Union of Medical Specialists 66

 Indications for Post-op Continuation of Ventilator
Assistance
• Severe sepsis.
• Uncontrolled co-morbid conditions, e.g. recent MI,hypertension, uncontrolled diabetes.
• Unstable hemodynamic condition.
• Intra-abdominal hypertension with insufficient ventilation.
• Risk of pulmonary aspiration of gastric contents.
• Obesity—hypoventilation.
• Prolonged shock/hypoperfusion state of any cause.
• Severe ischemic heart disease.
• Overt gastric acid aspiration.
• Previously severe pulmonary disease.

European Union of Medical Specialists

Postoperative care:
One has to take care of:
Hemodynamic support
NPO order Renal replacement therapy
Analgesia Postoperative ventilator support
PONV prophylaxis Maintaining blood glucose level < 150 mg/dl
Monitor fluid balance ( ongoing loss, Deep vein thrombosis prophylaxis
abdominal drains, ileostomy, NG Stress ulcer prophylaxis
aspirate)
Assessment of need for further blood
replacement
Postoperative feeding ( early except
paralytic ileus, intestinal
obstruction, anastomotic leakage,
shock, intestinal ischemia)

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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

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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.

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References

Smith and Aitkenhead’s Textbook of Anaesthesia, 7th edition.

Ian Desham, The emergency laparotomy- principles and perioperative
management, update in anesthesia, May,2016.
Enhanced recovery after surgery for gastrointestinal surgery(ERAS).
Huddart S et al. Use of a pathway quality improvement care bundle to
reduce mortality after emergency laparotomy. Br J Surg 2015; 102: 57–
66.
Restrictrive vs Liberal Fluid Therapy for Major Abdominal Surgery, The
New England Journal of Medicine, June 14,2018.
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THANK YOU

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