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
Pre operative managementPre operative management
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
Pre operative managementPre operative management
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.
Pre operative managementPre operative management
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
Pre operative managementPre operative management
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
Pre operative managementPre operative management
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
Fluid therapyFluid therapy
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
Fluid therapyFluid therapy
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
Pre operative managementPre operative management
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
Pre operative managementPre operative 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.
Pre operative managementPre operative management
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.
Pre operative managementPre operative management
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
Pre operative managementPre operative management
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
Pre operative managementPre operative management
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).
Pre operative managementPre operative management
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
Pre operative managementPre operative management
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
Pre operative managementPre operative management
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.
Pre operative managementPre operative management
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
Pre operative managementPre operative management
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