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Case Report
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Adv Hum Biol. 2015;5(3):106-108.
AHB Advances in
Human Biology
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Anesthetic Management in Emergency Exploratory Laparotomy

of Perforation Peritonitis in 92 Years Old patient: A Case Report
Rutu Shah1* BJ Shah2 Anisha Choksi3 Sonal Patel4

1Resident, Department of Anaesthesiology, BJ Medical College, Ahmedabad, Gujarat, India.

2Dean and Professor, Department of Anaesthesiology, BJ Medical College, Ahmedabad, Gujarat, India.
3Associate Professor, Department of Anaesthesiology, BJ Medical College, Ahmedabad, Gujarat, India.
4Tutor, Department of Anaesthesiology, BJ Medical College, Ahmedabad, Gujarat, India.

ABSTRACT

Background: Perforation peritonitis is a common surgical emergency. Geriatric patient presenting with
perforation peritonitis is a challenge for an anaesthetist. Risk and outcome in such patients depend upon age, the
patient’s physiological status, co-existing disease and whether the surgery is elective or emergency and type of
procedure. Preoperative optimization, hemodynamic stability can reduce intraoperative and postoperative
morbidity and mortality. Considering decreased physiological reserve of all body organs and systems intensive
care in critical care setting is essential.

Keywords: Anaesthesia, Laparotomy, Perforation.

INTRODUCTION

Exploratory laparotomy is a method of microbial therapy and intensive care, management

abdominal exploration, a diagnostic tool that allows of peritonitis continues to be highly demanding,
physicians to examine the abdominal organs. The difficult and complex.
procedure may be recommended for a patient who
has abdominal pain of unknown origin or who has Peritonitis usually presents as an acute
sustained an injury to the abdomen. Injuries may abdomen pain. Local findings include abdominal
occur as a result of blunt trauma (e.g., road traffic tenderness, guarding or rigidity, distension,
accident) or penetrating trauma (e.g., stab or diminished bowel sounds. Systemic findings include
gunshot wound). Because of the nature of the fever, chills or rigor, tachycardia, sweating,
abdominal organs, there is a high risk of infection if tachypnea, restlessness, dehydration, oliguria,
organs rupture or are perforated. In addition, disorientation and ultimately shock.
bleeding into the abdominal cavity is considered a
In Geriatric patient, the mortality and morbidity
medical emergency. Exploratory laparotomy is used
after emergency laparotomy is closely related to
to determine the source of pain or the extent of
presence or absence of diabetes mellitus,
injury and perform repairs if needed.
hypertension, chronic renal impairment,
Perforation peritonitis cardiovascular disease (angina), asthma, liver
is one of the commonest disease, chronic obstructive pulmonary disease and
surgical emergencies in India. metastatic disease1.
Despite advancements in
surgical techniques,
anaesthetic techniques, anti–
_______________________________________________________________________________________
Received: July. 11, 2015: Accepted: Oct. 16, 2015
*Correspondence Dr. Rutu Shah.
Department of Anaesthesiology, BJ Medical College, Ahmedabad, Gujarat, India.
Email: ritaparasshah@gmail.com

Copyright ©2015 Association of Clinicians pISSN 2321-8568

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CASE REPORT
A 92 year old female patient reported at
civil hospital, Ahmedabad complaining of abdominal
pain, vomiting since 3 days. There was a decrease in
urine output since 1 day. Patient was hypertensive
and under medication on Tab.Carvidilol:30mg O.D,
Tab.Telmisartan 40mg O.D, Tab.Torsamide since 15
yrs. Patient was having diabetes mellitus since 10
years and was on medication Tab.Metformin 500mg
B.D. Patient had a history of facial palsy before 10
years.
General Examination
Patient was conscious, co-operative,
oriented and afebrile. Pulse rate was 110/min and
regular. Blood pressure of patient was 136/84 mm
of Hg in right upper arm in supine position.
Airway Examination
 Mouth Opening - Adequate
 Modified MPG Grade 1
 Neck Movement- Normal
Systemic Examination
While examination of respiratory system-
air entry was equal on both sides. There were no
added sounds heard. Heart sounds were normal and
there were no murmurs while examination of
cardiovascular system.
Investigation
Patient's haemoglobin and platelet count
was in normal limit. Total leukocyte count was
increased which was 13700. Patient's renal function
test was altered. Serum urea and serum creatinine
both were high respectively 147 and 3. Liver
function test was in normal limit. Random Blood
Sugar of the patient was very high (217). Serum
electrolytes were normal. No abnormality was
detected in chest x-ray. ECG showed Right Bundle
Branch Block. Q wave was seen in lead 2,3 and aVf.
1st degree heart block was present.
Echocardiography was done for ECG changes.
Ejection Fraction was 60% & RVSP was 28mmhg.
Arterial Blood Gas Analysis was also done which
was within normal limit.
Anesthetic Management
It was advisable to avoid Nephrotoxic drugs
and I/O chart was maintained. Ca gluconate 10% in
10 ml i.v was given slowly.
Pre-operative preparation
Anesthesia trolley was prepared taking all
precaution for geriatric patient. 18 gauge
intravenous line was secured in left hand. Arterial
line was secured in right radial artery with 20 G
cannula. Central line was inserted in right IJV under
USG guidance. Patient was premedicated with Inj.
Glycopyrrolate 0.2 mg i.v, Inj. Ondansetron 4 mg i.v,
Inj. Fentanyl 50 mcg i.v.
Induction
Epidural catheter was inserted
preoperatively. Patient was pre-oxygenated with
100% oxygen for 3 minutes. Inj. Thiopentone
Sodium was given as an induction agent. Inj.
Atracurium was given as a muscle relaxant. 3
minutes of IPPV with 100% oxygen was given.
Patient was intubated using 7.5 no. cuffed
endotrachal tube. Cuff was inflated and tube was
fixed after checking bilateral air entry.
Maintenance
Patient was maintained with oxygen and
sevoflurane. Intravenous fluid was given according
to central venous pressure. Target CVP was 8-10 cm
of H2O. Input was 2100 ml and output was 600 ml.
Patient was hemodynamically stable throughout the
surgery.
DISCUSSION
Managing appropriate intravascular
volume is essential by avoiding over & under fluid
administration. Because of the increased after load
due to stiffened vascular system1, decreased
inotropic and chronotropic responses, the elderly
depend on adequate preload. Elderly are also prone
to dehydration because of illness, use of diuretics,
preoperative fasting & lack of thirst response.
Post-operative Management
This patient was managed in postoperative
critical care unit for better outcome. Epidural
analgesia with injection Bupivacaine & Fentanyl
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would be better2. Age related changes in respiratory CONFLICT OF INTEREST
mechanics and control of respiration accentuated
by pain, anaesthetics induced effects, fluid shift and No potential conflict of interest relevant to this
atelectasis made this patient more prone to article was reported.
respiratory complications3-4.
REFERENCES
Acute pain management is very important
1. Jin F, Chung F. Minimizing perioperative
in elderly surgical patients as the postoperative
adverse events in the elderly. Br J Anaesth.
pain can produce most harmful effects. Inadequate
2001;87(4):608-24.
pain control can increase morbidity & mortality in
the elderly because of the associated comorbidities 2. Rooke GA. Autonomic and cardiovascular
like ischemic heart disease, decreased ventilator function in the geriatric patient. Anesthesiol
reserve, altered drug metabolism, effects & Clin North America. 2000;18(1):31-46, V-VI.
excretion. Postoperative delirium & POCD affects 5-
50% of elderly patients. The onset of delirium 3. Lakatta E. Aging Effects on the Vasculature in
typically presents after 24-72 hours postoperatively Health: Risk Factors for Cardiovascular
& persists for about a week, prolonging hospital Disease. Am J Geriatr Cardiol. 1994;3(6):11-17.
stay & reducing the functional reserve further5.
Cognitive dysfunctions have also been observed 4. Baker AB: Phyisology and pharmacology of
very frequently with transient or prolong memory ageing. IARS. Review lectures. 1995;106-9.
impairment. No single cause has been found to be
5. Zaugg M, Lucchinetti E: Respiratory functions
responsible for triggering delirium or POCD as
in the Elderly. Geriatric Anaesthesia. Anesth Cl.
narcotics, sedatives, anticholinergic, infection,
N Am 2000: 18(1): 47-57.
general or regional anaesthetic techniques all have
been blamed. Hospitalization, pain, sleep 6. Vaughan MS, Vaughan RW, Cork RC.
deprivation & unfamiliar environment may be the Postoperative hypothermia in adults:
contributing factors6. Therefore a broad based relationship of age, anaesthesia and shivering
multidisciplinary approach to plan perioperative to warming. Anesth Analg. 1981;60(10):746-
management in the elderly surgical patients shall be 51.
most helpful. This can serve as a foundation for
organizing comprehensive evidence based geriatric How to cite this article:
perioperative care & might be beneficial in
Shah R, Shah BJ, Choksi A, Patel S. Emergency
preventing postoperative complications especially
Exploratory Laparotomy of a Case of Perforation Peritonotis
cardiac, pulmonary or delirium/cognitive
in 92 Years Old patient: A Case Report. Adv Hum Biol.
dysfunction significantly.
2015;5(3):106-108.

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