13.

EMERGENCY SURGERY

Patients for emergency surgery are at a very high risk of perioperative morbidity and
mortality. They represent a heterogenous group from relatively well patients requiring
urgent surgery to complex critically ill patients with imminent life and limb threatening
disease. Optimal management of emergency surgical patients requires a multidisciplinary
response with well-established and tested local protocols. It is imperative that further
deterioration of the patient must not occur because of unnecessary anaesthesia/surgical
delays. Equally it is imperative that maximal resuscitation, assessment and optimisation are
achieved within the available time. The team managing emergency surgical patients must
ensure early identification of emergency patients, rapid and complete resuscitation,
prioritisation of definitive treatment and anticipation of potential complications with
appropriate critical care provision.

For extreme emergencies, resuscitation and anaesthesia may occur simultaneously. The
history may be very limited or non-existent. Examination should focus on ABCD. Airway:
ensure patency and assess potential for difficult intubation. Breathing: ensure adequacy,
assess oxygen saturation, administer supplemental oxygen, assess for
pnuemo/haemothorax, and flail segment and respiratory failure. Circulation: correct
hypovolaemia/shock and control haemorrhage. Disability: assess Alert, Voice, Pain,
Unresponsive (AVPU) score or Glasgow Coma Score and temperature. Investigations, as part
of an initial urgent screen, may include immediate trauma X-rays, full blood count,
coagulation profile, electrolytes, blood glucose, lactate and if appropriate, blood group and
screening or cross-match. 

For the majority of emergency surgical patients, though management must be expedited,
there is time for detailed assessment and optimisation/stabilisation of medical problems. If
time permits, critically ill patients should be transferred to a critical care location for invasive
monitoring and intensive circulatory/respiratory support. The anaesthesia provider should
focus on the presenting problem and on other medical conditions that are undiagnosed or
poorly managed and could influence anaesthesia and postoperative recovery. These medical
conditions include cardiac failure, ischaemic heart disease and arrhythmias. Exacerbations
of asthma/COPD and intercurrent respiratory infections should be excluded or treated.
Patients may also have other conditions that will influence anaesthesia management like
diabetes or other endocrine disorders, renal impairment and neurological disease. Patients
with signs and symptoms consistent with sepsis should receive antibiotics as a matter of
urgency after the diagnosis is suspected, irrespective of the timing of surgery.

Optimal management of emergency surgical patients include early and continued

involvement of senior surgical/anaesthesia providers, availability of intraoperative point of
care testing (Hb, blood gases, lactate, glucose and coagulation), provision of warming
devices, rapid infusers and potentially cell salvage. The anaesthesia provider must prevent
worsening of the ‘lethal triad’ of hypothermia, acidosis and coagulopathy. Postoperatively,
patients may require admission to high acuity clinical care areas. Triggers for disposition to
high acuity care include prolonged surgery, massive transfusion, hypothermia, sepsis, renal
failure, respiratory failure and ongoing inotropic support.
Perioperative risk

The anaesthesia provider must be aware of problems related to inadequate preparation of

the patient. The clinical condition of emergency surgical patients is not static and will
change with time. Significant deterioration can occur suddenly, and all emergency surgical
patients should be re-assessed frequently. An early warning score (EWS) system should be
used to monitor improvement or deterioration in all patients. The EWS has been developed
as an objective bedside tool to help clinicians identify patients at risk of adverse events.
They are evaluations of a patient’s basic physiology, changes of which are the first indicators
of clinical decline and prompt a predetermined patient assessment/intervention. The
Modified Early Warning Score (MEWS) and the Rapid Emergency Medical Score (REMS) are
valid scoring systems for in-hospital mortality prediction and they have the advantage of
being solely clinical, not requiring sophisticated laboratory investigations. 

Emergency surgical patients should be considered as being unfasted, regardless of the

duration of fasting. In acutely unwell patients, gastric emptying is delayed by pain, drugs
(opioids), physiological stress or mechanical obstruction. Aspiration prevention is essential.
Patients should remain fasted, have neutralisation of gastric acid and have a rapid sequence
induction or an awake intubation.

Choice of Anaesthesia

The choice of anaesthesia will depend on the type of surgery, the experience of the
anaesthetist, the equipment available, the time available and the condition of the patient.
Hypovolaemia and a full stomach are two common but deadly problems in emergency
anaesthesia that the anaesthesia provider must be aware of when they plan the type of
anaesthesia. If appropriate to the surgery required, regional anaesthesia of a limb or local
anaesthesia may be the safest choice of anaesthesia. Spinal/epidural anaesthesia will
reduce the risk of aspiration; however, hypovolaemia must always be corrected before
spinal/epidural anaesthesia. General anaesthesia may be safer for patients with untreated
hypovolaemia, but they should receive reduced doses of almost all anaesthetic drugs except
muscle relaxants. Induction agents especially need to be given very carefully as these may
cause cardiovascular collapse from vasodilatation in the hypovolaemic patient 

Intraoperatively the anaesthesia provider must maintain normothermia, haemodynamic

stability, ensuring adequate fluid replacement and frequently monitor Hb and acid/bases
status. Burns patients will need at least 4 ml/kg times the percentage of body burnt in the
first 24 hours to replace fluid loss. For example, a 70 kg man with 30 percent burns will need
at least (70 x 4 x 30) 8.4 litres in the first 24 hours. Usually half of the calculated fluid loss is
given over the first 8 hours and the remainder over the next 16 hours. The patient will also
need their daily maintenance fluid.