ANAESTHESIA FOR EMERGENCY SURGERY

Scope of Talk
Definition Problems related to emergency surgery Anaesthesia for trauma surgery
Pre operative management Intra operative management Post operative management

Scope of Talk
Anaesthesia for non trauma surgery
Pre operative management Intra operative management Post operative management

Conclusion

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

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

DEFINITIONS
An elective surgery is a planned, nonemergency surgical procedure. It may be either medically required (e.g., cataract surgery), or optional (e.g., breast augmentation or implant) surgery.

PROBLEMS RELATED WITH EMERGENCY ANAESTHESIA

Limited time to prepare the patient for surgery & anaesthesia Risk of aspiration Potential difficult airway Hypovolemia Co existing disease Sedation & analgesia Coagulapathy

LIMITED TIME TO PREPARE

Must deal quickly with the life-threatening situation. Often little time for extensive diagnosis Minimal patient history. Decisions are made quickly about surgery, often without adequate preoperative assessment , preoperative laboratories & even in the presence of family members

RISK OF ASPIRATION
Full stomach : inadequate fasting time Pregnancy intestinal obstruction Pain upload or intra abdominal mass obesity

RISK OF ASPIRATION
Head & neck trauma Unable to protect airway [ head injury , vocal cord injury ]

Risk of aspiration

Complications of aspiration
Aspiration pneumonitis Aspiration pneumonia ARDS / ALI Sepsis Death

HYPOVOLEMIA
Blood loss or/& fluid & electrolyte loss Fluid / blood resuscitation prior & during surgery crystalloid , colloid ,blood & blood product can be used to correct hypovolemia

CLINICAL INDICES OF EXTENT OF BLOOD LOSS

GRADE OF HYPOVOLAEMIA PERCENTAGE BLOOD LOSS VOLUME LOST (ML) HEART RATE (BPM)
MILD

MODERATE 30 1500 120-140

SEVERE >40 >2000 >140

20 1000 100-120

ARTERIAL PRESSURE (MM HG)

URINE OUTPUT (ML/H) SENSORIUM STATE OF PERIPHERAL CIRCULATION

ORTHOSTATIC HYPOTENSION
20-30 NORMAL COOL AND PALE

SYSTOLIC <100
10-20 RESTLESS COLD,PALE & SLOW CAPILLARY REFILL

SYSTOLIC<80
<10 IMPAIRED CONCIOUSNESS COLD & CLAMMY, PERIPHERAL CYANOSIS

Textbook of Anesthesiology by Alan R.Aitkenhead 3rd edition

Complications of hypovolemia
Difficult intravenous access Hypovolemic shock Hemorrhagic shock Multi organ failure Hypothermia Death

COAGULOPATHY
Causes : 1. massive blood loss [ major trauma, obstetric hemorrhage] 2. patient on anticoagulant therapy require emergency surgery , 3. dilutional coagulopathy

Complications of coagulopathy
Uncontrolled bleeding

Hemorrhagic shock death

POTENTIAL DIFFICULT AIRWAY

Risk factors : 1. trauma involving upper part of the body [ faciomaxillary , spine ] 2. obstruction of upper airway [ epiglotitis , abscess , tumor , goitre ] 3. congenital airway abnormalities patient require emergency surgery 4. obesity 5. pregnancy

Morbidly obese

Difficult airway

Cervical spine immobilization in cervical spine injury

Difficult airway : faciomaxillary trauma

Complications of difficult airway

Aspiration Hypoxemia Trauma to upper airway Potential spinal cord injury in cervical injury Barotrauma

COEXISTING DISEASE
Unknown medical condition in unconscious patient Not optimized medical condition such as DM , HT , IHD , ASTHMA Limited time to optimize & elicit further medical history

ANALGESIA AND SEDATION

Preoperative sedation & analgesia have to be used with caution in hypovolemia, uncertain diagnosis , head & abdominal injury & difficult airway Therefore pain relief is always inadequate

Intraoperative Problems
Intraoperative awareness Intraoperative hypothermia

HYPOTHERMIA
Contributing factors :
hypovolemia general & regional anaesthesia cold surroundings , cold iv fluids, cold antiseptic solution head injury burn extreme age surgery exposes large area of skin & abdomen or thorax from which heat is lost

Problems with hypothermia :

Increased oxygen requirement Myocardial depression Risk of ventricular fibrillation, T < 28 C Decreased conscious level T< 30 C Reduced drug metabolism Prolonging effect of anaesthetic agent Reduced urine output

AWARENESS
Implies wakefulness with or without recall of events during the period when the patient is thought to be under anaesthesia. The sensations recalled can be auditory, tactile, or pain. It is an extremely traumatic experience for the patient.

PATIENTS WHO ARE AT RISK OF AWARENESS Intra operative awareness can occur in high-risk surgeries such as trauma and cardiac surgery in which the patients condition may not allow for the usual dose of anaesthetic drug to be given. The same is true during a delivery by cesarean section, particularly if it is an emergency delivery.

PRE OPERATIVE MANAGEMENT

Pre operative management

Preoperative assessment 1. all injuries should be noted 2. neurological observations 3. starvation time 4. investigations as indicated 5. preoperative fluid therapy 6. pain relief as indicated

Pre operative management

Primary survey and resuscitation
Airway with cervical spine control
A clear airway and ability to maintain oxygenation Assume cervical injury in all patients with head and maxillofacial injuries Provide oxygen supplementation Assess the need for intubation

Pre operative management

Primary survey and resuscitation

Breathing
Look out for inadequate breathing effort and intervene early Rule out serious life-threatening chest injuries such as tension pneumothorax, cardiac tamponade.

Pre operative management

Primary survey and resuscitation
Circulation and hemorrhage control
Signs of shock such as cold clammy peripheries, pallor, hypotension, small pulse volume Insert large bore intravenous cannula for rapid fluid infusion Blood for investigation and cross-match Control major external hemorrhage with direct pressure

Pre operative management

Primary survey and resuscitation
Disability
A quick neurological assessment such as pupillary size and light reaction, Glasgow Coma Scale scoring

Exposure
Undress the patient for a thorough survey of other injuries and then cover the patient with blanket to prevent hypothermia

Pre operative management

Primary survey and resuscitation
Conditions require urgent intubation
Lung contusion with hypoxaemia , chest injuries Upper airway obstruction Severe head injury with GCS < 9 Inability to protect airway such as active oral bleeding Shock requiring cardiopulmonary resuscitation

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

Secondary survey and definitive care

Secondary survey and definitive care
It is done until the vital signs are relatively stable Re-evaluate the patient repeatedly so that ongoing bleeding is detected early Patients with exsanguinating haemorrhage may need a laparotomy as part of the resuscitation phase.

Goals for resuscitation of the trauma patient before haemorrhage has been controlled PARAMETER Blood pressure
Heart rate

Oxygenation Urine output Mental status Lactate level Base deficit Haemoglobin

GOAL Systolic 80 mmHg, mean 50-60mmHg < 120 bpm SaO2 > 95% 0.5ml/kg/h Following commands <1.6mmol/l > -5 >8.0g/dl
From Oxford Handbook of Anaesthesia 2nd edition

Measures to empty stomach

Postpone operation if permissible Adequate fasting time Gastric suction Acid prophylaxis
iv ranitidine 50 mg 15-30 before induction

prokinetic agent
Iv metoclopromide 10 mg

INTRA OPERATIVE MANAGEMENT

Conduct of anaesthesia
General anaesthesia Regional anaesthesia
Eg for LSCS

Combined anaesthesia Peripheral nerve block

Airway management
Rapid sequence induction Awake fibreoptic / video assisted intubation Inhalational induction Emergency cricothyroidotomy Tracheostomy under LA by ENT

Rapid sequence induction (RSI)

Minimize risk of aspiration
breathes 100% oxygen for 3-5 minutes or takes 4 vital breaths predetermined rapid IV induction agent Followed by rapid acting muscle relaxant without waiting to assess the effect of induction agent. Combined with cricoid pressure to reduce the risk of aspiration Manual in line stabilization intubation in cervical spine injury

Rapid sequence induction [ no evidence of airway obstruction]

IV induction agent used [ depends on hemodynamic status ]
IV thiopentone 2-4mg/kg IV etomidate 0.2-0.3mg/kg IV ketamine 1-2mg/kg Use for hypotensive patient Contraindicated in head injured patient with potential high ICP IV propofol 1-2mg/kg

Rapid sequence induction

Muscle relaxant If no contraindication, IV suxamethonium 1.5mg/kg IV rocuronium 0.9mg/kg

Rapid sequence induction

Cricoid pressure (Sellicks maneuver) A skilled assistant is positioned on the patients right side the thumb and forefinger with middle finger of right hand press the cricoid cartilage in the posterior direction, compressing the oesophagus between the cricoid cartilage and the vertebrae column. It is applied as soon as the patient loses consciousness Released once ETT position is confirmed

Cricoid pressure

Sellicks maneuver or cricoid pressure

Rapid sequence induction (RSI)

Disadvantages of RSI Hemodynamic instability in hypovolaemic patient Hypertensive and tachycardia if induction dose is not adequate

Monitoring during anesthesia

ECG NIBP, IABP (intra-arterial blood pressure) monitoring if indicated SpO2 ETCO2 Temperature Urine output CVP

Maintenance of anesthesia
Be prepared to change the maintenance technique at any time during the course of anesthesia as the patients condition and response may change

Fluid therapy
Volume status must be continuously monitored and fluid therapy consistently titrated in response to ongoing changes Requirement
Adequate intravascular access Intra osseous needle for difficult iv access in paediatric patients Central venous access if possible

Fluid therapy
Requirement Warm all resuscitation fluids Pressurized devices should be available A fluid-warming and infusion systems Fluids Crystalloid
Ringers lactate, normal saline

Colloid
Gelatin eg Gelofusine Starch eg Voluven

Fluid therapy
After volume status stabilize
The second priority is the restoration of blood oxygen-carrying capacity
Packed cell Whole blood

The third priority is the normalization of coagulation status

FFP Platelet Cryoprecipitate

Post Operative Management

Post Operative Management

Decision for extubation depends on patients haemodynamic status In stable patient, before extubation Direct laryngoscopy is performed and secretion or debris are removed. If nasogastric tube is in situ, it is aspirated. Atropine and neostigmine are given and patient will breathe in 100% oxygen. Because of the risk of aspiration, extubation is performed only when there is recovery of airway reflexes.

Post Operative Management

Some patients may require continuation of ventilatory assistance postoperatively. They will be sent to ICU for further resuscitation and ventilation.

Indications for postoperative ICU admissions Severe chest injury Evidence of aspiration pneumonia Unstable hemodynamic status Severe head injury for cerebral protection Massive blood loss with massive blood transfusion with DIVC polytrauma

ANAESTHESIA FOR NON-TRAUMATIC EMERGENGY SURGERY

Principle of emergency anesthesia

To be prepared for all potential complications
vomiting and regurgitation hypovolaemia Hemorrhage abnormal reactions to drugs in the presence of electrolyte disturbances and renal impairment

PRE OPERATIVE MANAGEMENT

Pre operative management

Objective is to permit correction of the surgical pathology with the minimum of risk to the patient. Requires adequate and accurate preoperative evaluation of the patients general condition, with attention to specific problems which may influence anesthetic management

Pre operative management

To ascertain the likely surgical diagnosis, the magnitude of the proposed surgery and the urgency of the surgery To get as much as possible premorbid medical problems, drugs, allergy and any past surgical and exposure to anesthesia history.

Pre operative management

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

Pre operative management

Airway evaluation for rapid sequence induction To anticipate potential of difficult intubation Features of difficult airway including
limitation mouth opening, poor range of atlanto-occipital joint, reduced distance between thyroid cartilage and the mental symphysis a history of difficult intubation

Pre operative management

Assessment of volaemic status
Intravascular volume deficit Useful indices include
heart rate arterial pressure peripheral circulation central venous pressure urine output

INDICES OF EXTENT OF LOSS OF EXTRACELLULAR FLUID

PERCENTAGE BODY WEIGHT LOST AS WATER >4%(mild) ML OF FLUID LOST PER 70KG >2500 SIGNS & SYMPTOMS

thirst, reduced skin elasticity, decreased intraocular presurre, dry tongue, reduced sweating
As above, plus orthostatic hypotension, reduced filling of peripheral veins, oliguria, nausea, dry axillae & groin, low CVP, apathy, haemoconcentration

>6% (mild)

>4200

> 8% (moderate)

>5500

As above, plus hypotension, thready pulse with cool peripheries coma , shock followed by death

10-15% (severe)

7000-10500

Textbook of Anesthesiology by Alan R.Aitkenhead 3rd edition

Pre operative management

Extracellular volume deficit
Assessment of extracellular fluid volume deficit is difficult Guidance is obtained from
the nature of the surgical condition the duration of impaired fluid intake the presence and severity of symptoms associated with abnormal losses ( vomiting).

Pre operative management

Extracellular volume deficit
Labarotory investigation may help to confirm the extent of extracellular fluid volume deficit. Dehydration lead to
Hemoconcentration High blood urea High serum sodium / or abnormal electrolyte

Pre operative management

Extracellular volume deficit
Under influences of ADH and aldosterone, conservation of sodium and water by kidney result in excretion of urine of low sodium content and high osmolality

Pre operative management

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

Pre operative management

The full stomach with higher risk of vomiting and regurgitation which may complicate with aspiration. In elective surgery, patients are starved of food and drink at least 4-6 hours. In emergency surgery, it may be necessary to induce anesthesia urgently before an adequate period of starvation occurs.

Situation in which vomiting or regurgitation may occur

Peritonitis of any cause Postoperative ileus Metabolic ileus: hypokalemia, uraemia, ketoacidosis Drug-induced ileus: anticholenergics Small or large bowel obstruction Gastric carcinoma Pyloric stenosis Shock of any cause, trauma (high sympathetic tone)

Situation in which vomiting or regurgitation may occur

Fear, pain, anxiety (high sympathetic tone cause delayed gastric emptying) Pregnancy Opiods Recent solid or fluid intake Other causes
Hiatus hernia Oesophageal stricture benign or malignant Pharyngeal pouch

Pre operative management

Preparation
All patients undergone emergency operation must well resuscitation with either intravenous fluid or blood product depends on nature of pathology. Adequate intravenous assess Group and cross-match blood whenever is indicated Obtain investigations if possible and time permitted Emergency drugs are prepared together with anesthetic drugs Appropriate monitoring devices are prepared

INTRA OPERATIVE MANAGEMENT

Techniques of anesthesia
Rapid-sequence induction (RSI)
The decision is to balance the risks of losing control of the airway against the risk of aspiration Other technique include
Inhalational induction Awake fibreoptic intubation Regional anesthesia

Maintenance of anesthesia
A balance technique of anesthesia combining
Anesthesia oxygen with air or nitrous oxide and volatile agent Analgesia opiods such as fentanyl or morphine Muscle relaxation - non-depolarizing muscle relaxant such as atracurium, vecuronium and rocuronium

Fluid management
During intra-abdominal surgery there may be large blood and fluid losses which exceed maintenance fluid replacement. These include
evaporation from exposed gut blood loss on to swab and into suction bottle sequestration of fluid in inflamed and traumatized tissue.

An appropriate volume for replacement is required depends on the degree of ongoing losses. It is range from 2 10 ml/kg/h.

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

Reversal and emergence

Decision for extubation depends on patients haemodynamic status Prior to extubation Direct pharyngoscopy is performed to remove the secretion or debris. nasogastric tube is aspirated Atropine and neostigmine are given once patient has spontaneous breathing. Extubation is performed only protective airway reflexes intact.

Indications for postoperative ICU admissions Prolonged shock/hypotensive state of any cause Severe sepsis Severe ischaemic heart disease Overt gastric acid aspiration

CONCLUSION
Emergency patients have little cardiopulmonary reserve
Anesthesia may induce further intolerable stress

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

CONCLUSION
The anesthetic plan must account for drugs and monitoring used throughout the surgery Fluid management is challenging because changes in volume status can be rapid and unpredictable Possible complications must be anticipated Appropriate therapeutic options should be available