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EMERGENCY LAPAROTOMY
In many hospitals, emergency laparotomy for peritonitis, bowel
obstruction or abdominal trauma is second in frequency only
to caesarean section as a major intervention. Without surgery,
death is certain. Good anaesthetic management determines the
outcome in equal measure to good surgery.
After initial resuscitation, the overall aims are to intubate,
ventilate and maintain the blood pressure. The following actions
to achieve this are
important.
| 1 |
Put
a large bore cannula (16 gauge) in place and have a
stock of IV fluids (normal saline or Ringer’s
lactate) available. Run the drip fast, but watch for
overfilling of the internal jugular vein. |
| 2 |
Check
blood pressure every few minutes and oxygen saturation,
if you have an oximeter. |
| 3 |
Insert
a nasogastric tube and suck on the tube or use gravity
to empty the stomach as much as possible just before
induction. Be sure the tube is not blocked. |
| 4 |
Have
the sucker switched on and a large Yankauer sucker
ready under the pillow. |
| 5 |
Preoxygenate
and use cricoid pressure: regurgitation is common. |
| 6 |
Check
the airway and the position of the head to make sure
intubation will not be difficult. |
| 7 |
Give
a cardiostable induction. If in doubt about the circulating
volume, use ketamine 1–2 mg/kg. Otherwise, thiopental
is quite acceptable; give a reduced dose (2 mg/kg) if
the patient is in poor condition or the blood
pressure is low. |
| 8 |
Give
suxamethonium 100 mg as soon as possible after the
induction agent. Run the drip fast during the injection. |
| 9 |
Intubate
as quickly as possible and inflate the cuff. |
| 10 |
Ventilate
and check the position of the tube. |
| 11 |
Check
blood pressure and oxygenation again before starting
ether or halothane. If the blood pressure is still
low, you may wish to continue with ketamine and oxygen
alone. |
Ventilation with or without a relaxant may be needed, although
many patients will have adequate spontaneous respiration. If
the abdomen is distended, assist ventilation by hand.
Use a non-depolarising muscle relaxant such as vecuronium only
if there is a mechanical ventilator in the operating room and
if postoperative ventilatory support is available.
Intensive care management is advised, where available,
with particular attention to intravenous fluids and urine
output. Continuing hypovolaemia, sepsis and hypotension are
the main causes of death in the first 24 hours postoperatively.
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