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© Borgis - Nowa Medycyna 3/2020, s. 86-98 | DOI: 10.25121/NM.2020.27.3.86
*Jacek Wadełek
Anaesthetic considerations for emergency laparotomy
Opieka anestezjologiczna nad pacjentem zakwalifikowanym do laparotomii ze wskazań pilnych
Department of Anaesthesiology and Intensive Care, St. Anne’s Provincial Hospital of Trauma Surgery, Mazowieckie Rehabilitation Centre STOCER, LLC, Warsaw
Większość pacjentów wymagająca laparotomii wykonywanej w trybie nagłym jest obciążona innymi chorobami przewlekłymi. Zależnie od stopnia pilności zabiegu chirurgicznego, badanie przedoperacyjne i przygotowanie pacjenta mogą mieć charakter wybiórczy i ograniczyć się do wyrównania zaburzeń układu krążenia i oddechowego. Przygotowanie pacjenta do zabiegu operacyjnego nie powinno odwlekać leczenia operacyjnego zwłaszcza w sytuacji klinicznej hipowolemii i sepsy. Dlatego też wyrównywanie zaburzeń hemodynamicznych i metabolicznych może odbywać się równolegle z leczeniem chirurgicznym. Pacjenci poddawani laparotomii w trybie nagłym to grupa o wysokim ryzyku powikłań. Kluczowe dla poprawy wyników leczenia tej grupy pacjentów są: wczesne leczenie chirurgiczne z udziałem doświadczonego zespołu leczącego, stratyfikacja ryzyka, wczesna antybiotykoterapia, monitorowana resuscytacja płynowa. Resuscytacja płynowa pacjenta nie powinna opóźniać leczenia operacyjnego i należy ją prowadzić równolegle w okresie przed- i śródoperacyjnym. Ścisła współpraca interdyscyplinarna chirurgów z anestezjologami może poprawić wyniki leczenia tej trudnej grupy pacjentów.
The majority of patients undergoing emergency laparotomy have potentially life?threatening conditions that require prompt intervention. The reduced time?frames available due to surgical urgency necessitate prompt and senior decision?making to minimise delays. The time taken to correct any anomalies needs to be balanced against the need for prompt surgery, particularly in time?sensitive situations involving sepsis or hypovolaemia. Therefore, corrective measures may be performed in parallel with surgery. Patients undergoing emergency laparotomy are at a high risk of adverse outcomes. Key elements of care for these patients include repeated risk assessment, early antibiotic therapy, as well as fluid resuscitation and appropriate timely interventions provided by clinicians with the right level of experience.

Emergency laparotomy is a common surgical intervention, with 30,000-50,000 such procedures performed annually in the UK. The procedure is associated with high risk of complications and high mortality. Emergency laparotomies are a diverse group of surgical procedures, where advanced age of patients, their baseline ASA physical status, the urgency of the need for surgery, as well as the need for postoperative management in an anaesthesiology and intensive care unit have an impact on perioperative mortality (1, 2). Improvement of treatment outcomes in this group of patients may be achieved by better identification of high-risk patients and improved intra- and postoperative anaesthetic care, increased postoperative supervision in anaesthesiology and intensive care setting in particular. The initiative of improving the quality of surgical treatment in patients after emergency laparotomy led to the formation of groups of experts on emergency laparotomy, who publish their reports every few years (Emergency Laparotomy Network, National Emergency Laparotomy Audit – NELA, and the Emergency Laparotomy Collaborative – ELC) (3).
Preoperative management
Indications for emergency laparotomy
The indications for emergency laparotomy are broad. Advances in diagnostic imaging and minimally invasive surgical techniques reduced the need for exploratory laparotomy, with diagnosis and prediction of surgical extent possible already before the surgery in most cases. The most common indications for laparotomy are presented in table 1.
Tab. 1. Indications for emergency laparotomy. Data collected by the NELA (2015) (6)
Indication for surgeryNumber of patientsFrequency (%)
Bowel obstruction9,81149
Bowel perforation4,74424
Bowel ischaemia1,7209
Abdominal abscess1,4747
Anastomotic leak6183
Intestinal fistula3262
Abdominal wound dehiscence1160.6
Abdominal compartment syndrome550.3
Planned relook510.3
Patients with GI perforation, peritonitis and GI obstruction are the most common group requiring emergency laparotomy. Expectant conservative treatment and patient monitoring are appropriate in some cases, such as adhesion-related obstruction with no symptoms of bowel ischaemia, limited abscess that can be punctured and drained under imaging guidance (e.g. ultrasonography), or malignant bowel obstruction in the absence of peritonitis or perforation, when treatment using stents may be implemented. Colon perforation extending from the ileocaecal valve to the border of the intraperitoneal rectum causes symptoms of bacterial peritonitis, which is often referred to as faecal peritonitis. The symptoms are violent in the case of full-thickness bowel rupture and spillage of faecal contents into the peritoneal cavity (7). Large amount of bacteria released from the colon cause septic shock. Mandatory antibiotic therapy involves both empirical and targeted treatment after obtaining bacterial culture findings (8). Empirical treatment should be implemented in the initial stage of acute abdominal symptoms due to perforation. The choice of treatment strategy depends on whether the infection is community- or hospital-acquired, as well as on the type of pathogen resistance to treatment in a given hospital ward (9, 10). The 2016 Guidelines of the Surviving Sepsis Campaign have been updated to include a bundle of interventions in the first hour from sepsis recognition. According to the authors of the bundle, the following interventions should be undertaken within 1 hour of sepsis diagnosis: measurement of blood lactate levels, collecting blood for culture, initial broad-spectrum antibiotic therapy, fluid therapy: administration of 30 mL/kg crystalloid or, for hypotension or blood lactates ≥ 4 mmol/L, vasopressors in the case of hypotension not responding to the initial fluid therapy to maintain MAP ≥ 65 mm Hg (11). The 2016 sepsis and septic shock care bundles proposed by the experts on sepsis and septic shock are summarised in table 2. See table 3 for the updated guidelines.
Tab. 2. 2016 International Guidelines for Management of Sepsis and Septic Shock (12)
The 3-hour bundle:
– measure blood lactate levels
– collect blood for culture before antibiotic therapy
– use empirical broad-spectrum antibiotic therapy
– administer 30 mL/kg crystalloid for hypotension or blood lactates ≥ 4 mmol/L (36 mg/dL)
The 6-hour bundle:
– administer vasopressors for hypotension not responding to initial intensive fluid therapy to maintain MAP ≥ 65 mm Hg
– in the event of persistent hypotension despite fluid resuscitation (MAP < 65 mm Hg) or initial lactate ≥ 4 mmol/L (36 mg/dL), reassess fluid level and tissue perfusion using one of the following methods: assessment of vital functions and physical examination of the cardiovascular and respiratory systems, including capillary refill, pulse and skin; two of the following tests: CVP, ScvO2, point-of-care cardiovascular ultrasound, dynamic assessment of fluid response using passive lower limb elevation or trial fluid administration
– remeasure lactate if initial lactate level was elevated
CVP – central venous pressure, SvcO2 – superior vena cava oxygen saturation
Tab. 3. Sepsis, the hour-1 bundle (13)
Measure blood lactate levels
– Collect blood for microbiology before antibiotic therapy
– Include empirical broad-spectrum antibiotic therapy
– Initiate rapid IV infusion of a balanced crystalloid solution at 30 mL/kg body weight for hypotension or lactate levels ≥ 4 mmol/L
– Apply vasopressor for hypotension not responding to initial intensive fluid therapy to maintain MAP ≥ 65 mm Hg
Anaesthetic management begins with risk assessment involving medical history, physical examination and complementary tests. Routinely performed tests include laboratory blood testing (including pregnancy test in a selected group of patients), arterial or venous blood gas, lactate levels, chest radiography, electrocardiography and, usually, abdominal CT. Patients after surgery due to GI obstruction, presenting with sepsis due to bowel perforation or ischaemia develop deep hypovolaemia, which may in turn lead to secondary organ pathologies, such as acute renal damage and atelectasis. Recent (2016) guidelines of the Working Group on Sepsis-Related Problems recommend early antibiotic therapy in the first hour of treatment to reduce mortality due to septic shock (12, 14). A similar recommendation to administer antibiotic within first hour of sepsis recognition is suggested by the NELA working group. Preoperative fluid resuscitation with 30 mL/kg body weight of intravenous fluids to achieve MAP > 65 mm Hg is another recommendation of the Working Group on Sepsis-Related Problems. Fluid resuscitation requires remeasurements to achieve its goals. It should be emphasised that in most cases of emergency laparotomy fluid resuscitation should not delay surgical treatment, but should be run in parallel in the pre- and intraoperative period. Sepsis, which is common in this group of patients, is a condition involving the following pathophysiological processes: venous and arterial vasoplegia, tissue oedema due to redistribution of fluid from vessels to tissues as a consequence of damage to the vascular endothelium and impaired myocardial contractility (15). The multifactorial relationships of fluid balance, as well as significant fluid shifts between fluid spaces and fluid loss emphasise the importance of early fluid therapy, as well as monitoring and assessment of fluid balance. Assessment of fluid balance in this group of patients poses difficulty, and fluid overload may worsen the general condition of the patient. Therefore, great importance is attached to the monitoring of cardiac output and early administration of vasopressors.
Anaesthesia for emergency laparotomy
Anaesthetic management focuses on rapid and reliable securing of airways to minimise the risk of aspiration of gastric contents into the lower respiratory tract, stabilisation of cardiovascular function during rapid induction of anaesthesia and perioperatively, optimisation of the amount and type of intravenous fluid therapy, protective intraoperative mechanical ventilation, as well as postoperative analgesia and other postoperative care.
Securing lower respiratory tract and rapid induction of general anaesthesia

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otrzymano: 2020-07-13
zaakceptowano do druku: 2020-08-03

Adres do korespondencji:
*Jacek Wadełek
Oddział Anestezjologii i Intensywnej Terapii Szpital Chirurgii Urazowej św. Anny w Warszawie Mazowieckie Centrum Rehabilitacji „STOCER” Sp. z o.o.
ul. Barska 16/20, 02-315 Warszawa
tel.: +48 (22) 579-52-58

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