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The sick laparotomy

The sick laparotomy
Patients for emergency intra-abdominal surgery are at a much greater risk of perioperative complications than those presenting electively. The time available for preparation varies from only a few minutes to 12 h or more. The key is to strike the correct balance between the benefits of preoperative resuscitation and those of timely surgery. The principles described earlier regarding the care of the patient undergoing a laparotomy apply equally in the emergency situation.
Preoperative assessment
  • Discuss the probable diagnosis with the surgical team. The emergency laparotomy can be broadly divided into a bleeding problem (e.g. AAA, splenic laceration, avulsed vessel), intestinal perforation (e.g. perforated duodenal ulcer, intestinal ischaemia), or acute intestinal obstruction.
  • Bleeding problems present with hypovolaemic shock. Treat appropriately, but these cases need immediate treatment and resuscitation can occur during transfer to theatre and immediately prior to induction. Consider anaesthetizing the patient on the operating table with the surgeon scrubbed and the patient prepared for surgery.
  • Intestinal perforation/obstruction produces a greater metabolic derangement. Time spent on a detailed assessment and adequate resuscitation pays dividends perioperatively.
  • Careful examination of cardiorespiratory status is important and can reveal subtle clues regarding the severity of illness. Pulse oximetry is useful in those who are dyspnoeic.
  • Investigations should include FBC, electrolytes (include magnesium if possible), LFTs, clotting, ECG, chest radiograph, and cross-match.
  • ABGs are used to assess the degree of acidosis and oxygenation and may yield important information regarding the severity of illness, resuscitation, and the appropriate environment for perioperative care.
Preoperative preparation
  • A careful balance must be struck between preoperative optimization and surgical urgency. Patients presenting with an intra-abdominal catastrophe (acute obstruction/perforation) are often extremely unwell, with marked hypovolaemia, hypoperfusion, acidosis, severe renal impairment, and sepsis.
  • Optimize the patient’s cardiorespiratory status as far as possible in the time available. This may require admission to ICU/HDU, invasive monitoring of CVP and arterial pressure, aggressive rehydration, and possibly inotropic support. If ICU/HDU is not available, theatre recovery may be an option. Aggressive preoperative optimization in this group of patients is often beneficial in the perioperative period.
  • Oxygen should be administered to most emergency laparotomies in the preoperative period especially if hypotensive or with an oxygen saturation of less than 95% on pulse oximetry or arterial blood gas measurement.
  • Aggressive fluid management is essential. The first priority is to restore intravascular volume and perfusion. Initial resuscitation should be with

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    colloid or blood depending on the haemoglobin. Once an adequate circulating volume is achieved, prescribe crystalloid and/or colloid to maintain hydration and perfusion. Fluid resuscitation should be guided by CVP measurement, or at least hourly urine output.

  • Urinary catheter: start hourly measurement of urine output and use to guide fluid therapy.
  • A nasogastric tube should be inserted in patients presenting with intestinal obstruction to relieve gastric distension and reduce the risk of aspiration.
  • Electrolytes should be corrected as far as possible. Hypokalaemia and hypomagnesaemia provoke cardiac arrhythmias. Control diabetes with an insulin/dextrose infusion.
  • Metabolic acidosis should improve with aggressive fluid and cardiovascular manipulation. If the pH does not respond and remains low (<7.2) the patient is at high risk. Consider whether there may be an underlying metabolic problem (e.g. diabetic ketoacidosis) or pathology (e.g. bowel ischaemia). If surgery is indicated and the pH unresponsive, 100–200 ml of 8.4% sodium bicarbonate IV should be considered.
  • Problems with clotting should be addressed and treated appropriately.
  • Analgesia is not contraindicated in the acute abdomen. Use IV morphine. Avoid NSAIDs in the critically ill (renal damage, decreased platelet function, etc.).
  • Give antibiotics where appropriate.
Perioperative care
  • Aspirate the nasogastric tube prior to induction.
  • Pre-oxygenate.
  • Rapid sequence induction.
  • Have a large-bore IVI connected to pressurized fluids (gelofusine) and infusing rapidly.
  • Choice of induction agent depends on cardiovascular stability. A single dose of etomidate is unlikely to have major effects on the adrenocortical axis. Propofol or thiopental are more likely to cause hypotension in this group. Give any induction agent slowly allowing for the delay in onset.
  • Relaxants. Following suxamethonium use atracurium/cis-atracurium (metabolism not dependent on renal function). In the acidotic patient the duration of action of these drugs is prolonged.
  • Analgesia. Regional analgesia is often a poor choice in this group due to persisting hypotension and the risks of unmasking hypovolaemia. Fentanyl or morphine are good options. Give with induction and supplement as needed. TIVA using ketamine is sometimes useful.
  • Vasopressors and vagolytics should be drawn up before induction (atropine, glycopyrrolate, ephedrine, and metaraminol). If hypotension persists prepare an adrenaline or noradrenaline infusion and start preoperatively.
  • Monitoring. Invasive arterial and central venous pressure monitoring are extremely useful in this group and should be inserted preoperatively. Continue in recovery and postoperatively as required.
  • Patient warming should be as for any laparotomy.

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Postoperative
  • ICU/HDU care is often necessary for early and aggressive treatment of hypothermia, cardiorespiratory compromise, sepsis, coagulopathy, borderline urine output, etc. Consider postoperative ventilation for 24 h if the patient is particularly hypothermic or cardiovascularly unstable perioperatively.
  • Frequent review of postoperative fluids should be undertaken, guided preferably by CVP measurement.
  • Urine output should be measured hourly intra- and postoperatively. If <0.5 ml/kg/h urgent review is necessary.
  • Postoperative chest radiograph to check the position of the CVP line.
  • Oxygen should be administered for a minimum of 72 h postoperatively.
  • Pain—consider continuous morphine infusion. PCA is often not practical due to postoperative confusion.
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