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Perioperative management

of Gastrointestinal
Emergencies
Dr sandya Somaweera
Gastro Intestinal Emergencies (Acute Abdomen)
Sudden severe abdominal pain of unclear aetiology

Usually acute onset ( less than 24 hours)

May be medical or surgical

May require emergency laparotomy

Can be associated with high morbidity and mortality

Why?

Generally elderly population with multiple co morbidities and poor reserves

No time for proper optimisation

Risk of aspiration of gastric contents due to full stomach

Sepsis
Aetiology
Inflammatory bowel conditions acute appendicitis

Gastric /Intestinal obstruction

Bowel perforation

Bowel ischaemic conditions

Volvulus

Acute pancreatitis

Acute cholecystitis

Acute pyelonephritis

Diabetic ketoacidosis
Problems

Fluid balance

Electrolyte balance (sodium, potassium)

Metabolic derangement (acidosis, alkalosis)

Abdominal distension causing


respiratory embarrassment ,renal impairment

Gangrene , perforation , peritonitis , sepsis

Full stomach and risk of aspiration

Optimisation of other medical co morbidities


Overview
Pre op assessment and optimisation
Premedication
Induction of anaesthesia rapid sequence induction

Intra operative management


Post operative management
Post op complications
Common conditions
Pre operative assessment

Dehydration
Why?
Fasting
Nausea and vomiting
Fluid secreted into the GIT is not reabsorbed
(about 9L of gastrointestinal juice is secreted into the gut but only
100 ml is ultimately excreted in faeces)
Large volumes are reabsorbed mainly in large intestine
Gastric and colonic losses hypotonic dehydration as more water
than electrolytes lost
Small intestinal losses isotonic dehydration
Assessment of dehydration

History

Duration, amount lost, thirst, urine output

Examination

Tongue, buccal mucosa, skin turgor, capillary refill

Pulse, BP, JVP, respiration, level of consciousness

SPO2
Assessment of dehydration
Calculated in litres as % of body water in Kg

Mild 4%
Moderate 6%
Severe 8%
60 kg patient with severe dehydration needs approximately 4.8 L of fluid

There are 3 body compartments


Interstitial
Intracellular
Intravascular
When fluid is lost in dehydration initially it happens from
interstitial compartment
Secondly from intracellular compartment.
Finally intravascular compartment
Hypotension is a late sign of severe dehydration

But during resuscitation, fluid is administered first to intravascular


compartment.
From there redistributed to interstitial and intracellular
compartments.
Needs time to replenish those compartments
How much to give , how fast , and what fluid ?
No fixed regime
Tissue perfusion should be adequate avoiding overload.

Goal directed fluid therapy


Pulse rate
Blood pressure
Capillary refill
Urine output
CVP
Correction of acidosis in ABG

Watch for
Overload
Lung bases for fine crepts
Investigations

Full blood count Hb,PCV,platelets,WBC


Serum electrolytes
Blood urea and serum creatinine
Fasting/random blood sugar
Electrolytes
Arterial blood gas
Metabolic acidosis in small intestinal losses (contains more HCO3)
Metabolic alkalosis in gastric losses (more H loss)
Base deficit
Lactate (>4 mmol indicates severity of tissue hypoxia)

Other relevant investigations


ECG
INR
Liver function tests
USS
Type of fluid
Crystalloid or colloid
Makes no difference

aim is to maintain tissue perfusion and oxygenation

Crystalloids- 0.9% saline, ringers lactate, plasmalite


Readily available,low cost, but need to give in large volumes
Saline causes hyperchloraemic metabolic acidosis

Colloids (less volume, may be beneficial to avoid overload) but


Gelatin - anaphylactic reactions (not available)
Hetastarch - may precipitate renal failure in high risk patients , risk
of coagulopathy
Dextran - intereferes with cross matching

Human albumin (cost)


Mild to moderate dehydration
Only ISF and ICF is depleted
Crystalloid will replace ISF
5% dextrose will replace both ISF and ICF
Severe dehydration
All 3 compartments depleted
If cardiovascular instability is seen replete intravascular
compartment first

How?
Crystalloid boluses 20ml/kg over 20 minutes or even a rapid
bolus of 500 ml
Repeat until goals are achieved (pulse rate <100/min), SBP
(>90mmhg), urine output (>0.5ml/kg/hr))
Careful with boluses in elderly and cardiac patients (100 200
ml)
Once B P is stable replace with 5% dextrose to replenish ISF and
ICF
Further monitoring
Passive
CVP guided fluid therapy for fine tuning
leg raising test
IVC
Gocollapsibility
for the CVP trend but not for an absolute reading
Trans
Normal 6-8 cmdoppler
oesophageal H2O
Electrolyte replacement
Mainly sodium and potassium

Potassium manly intracellular (90%)


Normal (3.5-5.5meq/l)
Distribution between ICF and ECF governed by many factors
Metabolic acidosis with hyperkalaemia
Metabolic alkalosis with hypokalaemia
Gastric losses contains- more sodium and HCl with water -
hypochloraemic metabolic alkalosis - replace with 0.9% Saline

Intestinal losses contain more bicarbonate ,potassium


hyponatraemic,hypokalaemic metabolic acidosis - replace with
hartmanns
Hypokalaemia (less than 3.5 meq/l)
ECG- u waves, T inversion, ST depression
Important- to ensure normal urine output before replacement

Calculate the deficit in mmol


(Normal measured) B wt (kg) 0.4
20 mmol= 1.5g
Complete correction may take even days

How to infuse KCL?


Irritant need a large vein,central vein
Maximum rate 20 40 mmol/hr (with ECG monitoring for T
wave)
10 mmol/hr via peripheral vein
Dilute in 5% dextrose 100 ml
Measure serum levels 2 hrly
Hyperkalaemia (>5.5 meq/l)
Mainly intracellular
High levels may be due to shift from ICF to ECF
May be in renal failure or rhabdomyplysis

ECG- tall peaked T waves with a narrow base, ST depression, short QT, long
PR,wide QRS , cardiac arrest

Management
IV calcium to stabilise the myocardium
IV insulin Dextrose
Severe metabolic acidosis should be corrected with Sodium
Bicarbonate
Nebulise with inhaled beta blockers
If not responding renal replacement therapy (dialysis)
Premedication

H2 receptor blockers (Ranitidine)

Prokinetics (metoclorpramide)

Analgesics (do not use NSAIDS for emergency laparotomy, specially


bowel surgery)

Antibiotics

May need to start insulin if blood sugar control is poor infusion (0.1
u/kg/hr)
NG tube and aspirate the stomach contents
Epidural analgesia
Intra op

Rapid sequence induction


Titrate drugs
Avoid N2O ,use air
Warm IV fluids , patient warming device
IPPV
DVT prophylaxis (mechanical)
Post op
HDU or ICU care
Do not extubate if haemodynamically unstable
Warming
Oxygen
Analgesia
Monitoring
IV Fluids
Early feeding (preferably enteral)
Continue DVT prophylaxis (mechanical,LMWH)
Antibiotics step down after culture and ABST
Post op complications
Difficult in weaning from ventilator
Hypoventilation atelectasis pneumonia
Ventilator associated pneumonia
Intra abdominal hypertension
Nosocomial infections
Confusion and delirium

Renal impairment or failure


May be acute on chronic in the elderly patient
Reasons
Pre renal dehydration, hypotension
Renal sepsis, drugs (NSAIDS), contrast
abdominal compartment syndrome
Abdominal sepsis

Intestinal obstruction
Bowel gangrene
Perforation
Faecal peritonitis

Patient may present with features of sepsis,severe


sepsis,septic shock with multi organ dysfunction

Septic shock
SBP< 90 or MAP < 65 mmhg despite adequate fluid
resuscitation

Most important is to eradicate the source of infection by early


intervention once the patient is optimised
Goals of optimisation

Septic bundles(3 and 6 hrs)


Target MAP >65 mm hg or SBP > 90 mmhg , UOP > 0.5 ml/kg/hr
Initial fluid resuscitation
If target is not achieved vasoconstrictors
(noradrenaline,adrenaline,vasopressin)
Inotropes (Dobutamine ) with measurement of cardiac output

Early empirical broad spectrum antibiotics after taking blood for


culture

Glycaemic control (<180 mg%)

Monitor
CVP
Lactate <4
Abdominal trauma
Blunt or penetrating injury
Patient may present in haemorrhagic shock
Hypotensive resuscitation (only upto a SBP of 80 mmhg)
Early blood and blood products
Do not use excessive crystalloids or colloids
Resuscitation and surgery goes hand in hand in ongoing
bleeding
Questions?
A 85 year old patient is undergoing a laparotomy.
List the factors you would consider when prescribing post op
analgesia ,giving reasons.

Options
Simple PCM,NSAIDS
Opioids mild, strong (Side effects,routes of administration)
Local anesthestics (epidural,TAP)

1.Age and related problems including other co morbidities


(RS,COPD,CVS,HT,IHD,Diabetes,renal
impairment,GORD,arthritis)
2.Nature of the surgical problem-bowel perf,sepsis
3.Nature of pre op optimisation
4.When to start oral
write the post op instructions for the 1st 48 hours in an adult
patient who underwent major abdominal surgery under GA

Monitorng clinical,equipment
Oxygen
Analgesia
IV fluids
Feeding
Antacid prophylaxis
DVT prophylaxis
A 60 year old previously healthy female patient is
admitted to surgical casualty ward with features of
intestinal obstruction
On examination her pulse rate is 124/min,low volume
BP- 80/40
RR- 40/min
Surgeons want to do emergency lap after resuscitation
1.What are the problems you may find in her
2.How would you resuscitate
3.What are your goals of resuscitation
Thank You