Introduction
An emergency condition means when there is a danger to the patient’s life. It occurs in conditions such as ruptured ectopic pregnancy, stabbed heart, and ruptured abdominal aortic aneurysm. In such situations, surgery is performed within one hour. Patients undergoing emergency surgery have more associated risks than those who have planned surgeries. Emergency anesthesia ensures minimum risk to the patient. Risk in emergency anesthesia can also be reduced by taking proper patient history, clinical findings, and special investigations. Emergency anesthesia allows adequate correction for surgical pathology with fewer risks. Anesthesiologists should be prepared for all the potential risks and complications associated with the surgery, such as hypotension (decrease in blood pressure), dysrhythmias (a problem in the rhythm of the heart), and adverse drug reactions.
What Are the Preoperative Risks Associated With Anesthesia for Emergency Surgery?
The preoperative risks associated with anesthesia for emergency surgery include:
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Less time to diagnose and check the patient.
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Risks related to aspiration.
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Coexisting comorbidities.
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Inexperienced staff or need for proper knowledge.
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Poorly controlled medical conditions.
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Derangement in body fluids and electrolytes.
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Blood disorders.
How Is Preoperative Evaluation Done in Patients With Anesthesia for Emergency Surgery?
The preoperative evaluation includes:
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History Taking: The first step involves detailed history taking, which includes medical, drug, and surgical history. More emphasis should be given to cardio-respiratory symptoms such as angina, orthopnoea (breathlessness relieved by sitting or standing), dyspnea (difficulty breathing), coughing, wheezing, and also ask about vomiting, and diarrhea because that affects the status of fluid loss. Preoperative assessment of emergency surgical patients is pivotal for successful treatment. The objective includes an assessment of the risk of anesthesia, preoperative preparation of the patient, and the choice of anesthetic technique.
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Airway Assessment: The airway should be assessed before giving anesthesia to the patient. All vital signs, such as blood pressure, heart rate, respiratory rate, and temperature, should be checked.
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Basic Investigations: Some basic investigations should be carried out, such as hemoglobin, serum creatinine, urea, lactate, glucose, and blood gas analysis. This will help determine the extracellular fluid reduction and give a better prognosis or outcome of the treatment plan.
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Special Investigations: Special investigations should be carried out, such as pulmonary function tests, liver function tests, blood profiles, coagulation tests, and computed tomography scans.
How to Conduct Anesthesia for Emergency Surgery Patients?
Few patients immediately require emergency surgery when there are life-threatening conditions. General anesthesia is most employed during surgeries, but sometimes regional anesthesia is used. Before giving general anesthesia, hemodynamic and pharmacological implications such as decreased blood volume, sepsis, uremia, and hypokalemia need to be considered.
1. Anesthetic Agents: Anesthetic agents play the most important role. Propofol is not given as it can cause hemodynamic changes. The most commonly used anesthetic agents are Thiopentone, Etomidate, and Ketamine. If a patient is in shock, all the doses of drugs should be reduced. If the patient is extremely unstable, then high dose short-acting opiates such as Fentanyl should be used. These patients require ICU (intensive care unit) for further postoperative ventilation. Regional anesthesia can also be a preferred option. It inhibits stress better than opioids. It also has advantages that include fewer side effects as compared to opioids and reduced risk of laryngospasm. It is a choice of anesthesia when the management of airways is complex. But the use of regional anesthesia is limited because of the very short time for conducting emergency procedures, and the use of anticoagulant agents makes it a significant limiting factor. All the contraindications need to be considered before giving regional anesthesia.
2. Rapid Sequence Induction: It is a safe and successful method. The anesthetist should prepare a contingency plan for managing patients with aspiration risk. The disadvantage of rapid sequence induction is hemodynamic instability, which causes hypertension, tachycardia, and dysrhythmia. Identify the cricoid cartilage before induction of anesthesia. A predetermined sleep dose of an induction agent is given to the patient. After that, pressure is applied to the cricoid cartilage. Intubation is done with the help of a paralyzing dose of Succinylcholine. Once the relaxation of the jaws begins, a laryngoscopy is done, and the trachea is intubated. By this procedure, cricoid pressure is maintained until the cuff of the tracheal tube is inflated. Releasing the cricoid pressure is only done when the trachea is intubated, the cuff is inflated, or when the correct position of the tube is confirmed. During the rapid sequence induction procedure, the lungs are not ventilated because it decreases the barrier pressure and increases the risk of aspiration in such patients.
3. Intraoperative Management: It is essential to be vigilant during the procedure. There is a need to closely monitor the patient and check the patient's hemoglobin, acid-base status, urine output, and hemodynamic status with arterial blood gases. It is also essential to look for fluid and blood loss. Intravenous fluid, either a synthetic colloid or blood product, can be given. Fluid loss is seen in patients who have vomited or have intestinal obstruction—in such patients, rechecking of hemoglobin after fluid resuscitation is done.
4. Postoperative Management: Postoperative Management is done in patients requiring ongoing anesthesia, fluids, and other blood products. It depends on the patient's preoperative, intraoperative, and other conditions to keep the patient. Patients who require postoperative management include prolonged shock, sepsis, extreme obesity, severe pulmonary disease, renal failure, respiratory failure, hypothermia, and requiring inotropes.
Conclusion
Once the general anesthesia has started, the emergency surgery will start. A thorough sterilization is maintained before the procedure. The nature of the surgery will determine the domain subject expert and how long the process will take. If required, a blood transfusion may be undertaken to stabilize the patient. IV (intravenous) fluids during the surgery are also given if there is any blood loss or fluid loss. Once the surgery is done, the patient is shifted to the post-anesthesia care unit. During the recovery phase, patient vitals must be closely monitored, and a prescription must be given accordingly. Recovery time can vary depending on the patient. The patients who are admitted to ICU will remain there till the time they can breathe without assistance. Management of emergency surgical patients involves a multidisciplinary approach to dealing with such cases.
