Update in Anaesthesia 43

ANAESTHESIA FOR THE PATIENT REQUIRING EMERGENCY ABDOMINAL SURGERY

Professor Garry Phillips, Dr. Harry Aigeeleng, Dr. Gertrude Didei, Dept of Anesthesiology, University of
Papua New Guinea, Port Moresby, PNG.

Introduction ● Fresh gas supply - is it air, or oxygen. If it is oxygen, is it

supplied by an oxygen concentrator, a cylinder, or from a wall
The principles of anaesthesia for the patient requiring emergency
outlet? What reserves are there in theatre or in the bulk supply?
abdominal surgery are common to adults and children, and to
the patient and their anaesthetist wherever they are, and whatever ● Gas delivery system - is it draw-over, demand flow, or
resources are available. Within this framework, the article will continuous flow?
address the importance of attention to:
● Anaesthetic delivery - will nitrous oxide be used? Is the
● Airway
main agent ether, halothane, enflurane, isoflurane, sevoflurane?
● Breathing
Is the vaporiser full, and does it work? Is it draw-over or plenum?
● Circulation
Is there extra agent available?
● Drugs
● Equipment ● Breathing circuit - does it have carbon dioxide absorption
● Fluids and electrolytes or not? If so, is it fresh? Is the circuit intact, and does it work?
The major part of the article is about general anaesthesia, with ● Airway equipment (Figure 1, Table 2) - Are there airways
some comments on regional anaesthesia, which may be the only of various types and sizes - oropharyngeal, nasopharyngeal,
option on some occasions. endotracheal tubes, laryngeal masks? Are an endo-tracheal tube
introducer and a bougie immediately available? Are there a
The Anaesthetist and the Environment
syringe, clamp, tape, Magill’s forceps, catheter mount available?
The anaesthetist has to bear in mind a number of things when Is there a way to insufflate the trachea with oxygen if the patient
preparing to anaesthetise a patient for emergency abdominal cannot be ventilated or intubated? Can an emergency
surgery. This not only includes the patient’s condition, and the cricothyroidotomy be performed? Is there effective suction with
nature of the surgery, but also the anaesthetist’s own knowledge handpieces and catheters?
and experience, the anaesthetic equipment, and the consumables
● Breathing equipment - Are there face masks of various
and drugs which are available.
types and sizes? What is the main ventilating system? Is there a
The anaesthetist must take into account issues such as the self-inflating bag in reserve? Is the equipment for emergency
knowledge and experience of the surgeon, the availability of an decompression of a tension pneumothorax available? Is there a
anaesthetic assistant, and the reliability of services such as oxygen, ventilator for long cases?
suction and power. For emergencies, particularly, there is often
● Circulatory equipment - What intravenous equipment is
no second chance should a crisis occur, and if fall-back plans
there? - syringes, needles, catheters, fluids, ability to infuse under
have not been made before starting the anaesthetic.
pressure, ability to warm intravenous fluids.
Pre-Anaesthetic Check
● Other equipment - What equipment is available to warm
The operating theatre needs to be always ready for an emergency or cool the patient? What monitoring equipment is there that
procedure, so the anaesthetist does not have to waste time cleaning works and has been checked. Complete monitoring can be listed
up and finding things used in the previous case. A systematic as follows, bearing in mind that some hospitals will have all of
approach is necessary. An example is to check the following it, and some will have very little.
(Table 1).
● Clinical monitoring by the anaesthetist, of the patient, the
Table 1 Pre-Anaesthetic Checklist surgery and the equipment.
● Fresh Gas Supply ● Pulse, colour, blood pressure, perfusion, skin feel.
● Gas Delivery System
● Chest movement, breath sounds.
● Anaesthetic Gases
● Anaesthetic Agents ● Pupil size, lacrimation
● Breathing Circuit ● Temperature, urine output.
● CO2 Absorber
● Airway Equipment ● Pulse oximetry (the most useful electrical monitor)
● Breathing Equipment ● Capnography (the second most useful electrical monitor)
● Circulatory Equipment
● Monitors ● ECG(the third most useful electrical monitor)
● Resuscitation Drugs ● Airway pressure, tidal and minute volumes
● Resuscitation Equipment
44 Update in Anaesthesia

● Blood sugar, haemoglobin level, blood gases Table 3 Intravenous Agents

● CVP monitoring equipment
● Nerve stimulator
● Defibrillator

Table 4 Inhalation Agents

Figure 1: Airway Equipment

Table 2 Airway Equipment

● Suction Device
● Oral/Nasal Airways
● Laryngoscopes
● Endotracheal Tubes ● Muscle relaxants (Table 5) - Suxamethonium is still the
● Syringe/clamp/tape choice for emergencies. Non-depolarising relaxants are now
● Introducer/Stylet many, and may be short, medium or long acting, with specific
● Bougie advantages and disadvantages. Vecuronium, atracurium and
● Magill’s Forceps rocuronium are rapidly overtaking pancuronium in many places.
● Laryngeal Mask Airway d-tubocurarine, alcuronium and gallamine are still used in some
● Cricothyroid Insufflation Equipment countries.
● Cricothyroid Equipment ● Other essential drugs include atropine, neostigmine,
adrenaline, ephedrine, an anti-hypertensive, a bronchodilator, a
For children, is all the equipment of the appropriate type and diuretic, an anti-emetic, and emergency resuscitation drugs
size? (atropine, calcium, adrenaline, lignocaine) (Table 6).
● Drugs - There are so many, and the choice between them is ● Local anaesthetics - lignocaine, bupivacaine, ropivacaine,
often based on arguments which may be relevant in some cinchocaine.
environments and not in others
Pre-Operative Assessment and Resuscitation
● Intravenous induction agents (Table 3) - thiopentone is still
A systematic approach is best - it avoids overlooking important
the commonest agent world-wide, challenged by ketamine in
matters. For the patient requiring emergency abdominal surgery,
some places, propofol in others.
with few exceptions, there is time to assess properly, and to
● Inhalational agents (Table 4) - ether and halothane are resuscitate, before induction of anaesthesia. Most sensible
common in many parts of the world, enflurane, isoflurane, surgeons understand this. Even in the few surgical emergencies
sevoflurane in others. where time to surgery is critical, the anaesthetist must still have
● Hypnotics - diazepam remains common, but midazolam is essential information before proceeding.
more useful in anaesthesia because of its more rapid onset and Bear in mind that patients (and surgeons) do not tolerate
shorter duration of action. unnecessary delays. If the patient needs investigations and/or
● Opioids - morphine is still widely used, and pethidine less resuscitation, organise it yourself, then you know it has been done
frequently. Fentanyl is increasingly used in anaesthesia because properly. Don’t “leave it to someone else”. If surgery has to be
of its short duration of action. delayed for resuscitation, agree on a time with the surgeon (see
case insert).
● Other analgesics such as paracetamol or indomethacin
suppositories.
Update in Anaesthesia 45

Table 5 Muscle Relaxants ● Respiratory abnormalities

● Cardiovascular abnormalities
Investigations may not be available, or not available in the time
frame. Haemoglobin, urea, creatinine, electrolytes, Chest X-Ray
and ECG are still the most useful.
Investigations may be clinical, or laboratory. Clinical
investigations are part of physical examination, and include the
“bedside forced expiratory volume”, measured with a spirometer,
or by listening to rapid exhalation. Laboratory investigations
should always be requested if they will help to identify a problem
which can be corrected. Once ordered, they must be checked and
acted upon. Once again, they may or may not influence a clinical
decision to delay the operation, or to proceed.
Of the more commonly available investigations, Haemoglobin
value must be interpreted in the context of the usual Hb of the
population (which may be 8-9gm/dl in some areas, 12-13gm/dl
in others) as well as in the context of bleeding or dehydration. A
Hb of 8gm/dl in a bleeding or dehydrated patient may really be
5gm/dl when resuscitation is complete, and vascular volume is
expanded, so blood transfusion may be indicated early.
Table 6 Resuscitation Drugs
Blood sugar (or urinalysis for glucose) should always be
measured to allow correction in the diabetic, and to detect diabetic
ketoacidosis masquerading as an abdominal emergency.
Urea and Creatinine and Electrolytes may be helpful, but
should be interpreted in the context of the clinical picture, and
information about whether the patient has pre-existing renal
failure.
Elevation of urea and creatinine may simply indicate dehydration
There are some situations where the patient must go to theatre
and poor renal blood flow, or it may indicate acute or chronic
immediately - they include severe foetal distress, uncontrollable
renal failure. Fluid resuscitation should proceed whatever the
internal haemorrhage, rapidly expanding intracranial lesion (e.g.
cause, to ensure renal blood flow is improved.
extradural haematoma). In these situations, history, examination,
resuscitation have to be done “on the run” and with no delay. In Serum sodium, potassium, chloride and bicarbonate may be
most other situations, a short delay for resuscitation is best for “normal” or “abnormal”. The first step in the acute abdominal
the patient. emergency is again expansion of intravascular volume and fluid
resuscitation. If renal function can be restored, the kidneys will
A good approach is to divide pre-operative assessment and
correct the electrolyte disturbance.
resuscitation into two phases - initial (rapid), and definitive (when
there is more time). In the history, essential questions are: Chloride and bicarbonate tend to balance each other - if one goes
up the other goes down. Hypochloraemia (as in pyloric stenosis)
● When did you last eat or drink? (But regard these patients
will correct with normal saline infusion, but be made worse with
as having a full stomach anyway.)
Hartmann’s solution, because of the lactate, which is converted
● Have you any allergies?
to bicarbonate. A low bicarbonate usually indicates metabolic
● Are you taking any medications, smoking, drinking, using
acidosis due to poor perfusion, and corrects as the circulation
drugs or remedies?
improves.
● Have you had any problems with previous anaesthetics?
● Heart problems, chest problems, kidney or liver problems? Administration of bicarbonate is not often advisable, because it
● Diabetes? combines with hydrogen ions and results in formation of carbon
● Heartburn or reflux? dioxide which must be excreted by increased ventilation. Its
● Fits, faints, or funny turns? acidosis-correcting effect is thus short-lived.
● Bleeding tendency? Arterial blood gases are the only accurate way of obtaining:
● Pregnancy?
● Infectious disease? - especially HIV/AIDS, Hepatitis, ● PaO2 (Oximetry is a substitute provided perfusion is good)
Malaria, TB ● PaCO2 (End tidal CO2 is a substitute but in the critically ill
In the physical examination, look particularly for evidence of patient, there may be a wide gap between the ETCO2 and the
higher PaCO2, not the normal 6mmHg)
● Difficult airway
46 Update in Anaesthesia

● pH Resuscitation must be aggressive before and during anaesthesia.

The only excuse for induction prior to resuscitation is if the patient
● HCO3 (which may differ from that measured with serum
has a condition which cannot improve without surgery. This may
electrolytes)
include massive intra-abdominal haemorrhage. Even then,
● Identification of whether an acid-base disturbance is an resuscitation must begin before anaesthesia is induced.
acidosis or alkalosis, whether either is primarily metabolic or
Which fluids should be used in resuscitation depends on the cause
respiratory, and whether there is secondary compensation for the
of the problem, and what is available. (Table 7). In an adult with
primary disturbance.
intra-abdominal bleeding, the choice is clearly blood and plasma
Chest X-Ray is often useful in patients with abdominal expanders such as Haemaccel or Gelafundin or Gelafusin or
emergencies when history and examination are not clear cut, Dextran, supported by crystalloids - normal saline or Ringer
particularly in obese patients. Look carefully for pneumothorax, lactate (Hartmann’s) solution. In a patient with intra-abdominal
haemothorax, effusion, evidence of stomach or bowel in the chest, sepsis, the same approach may be needed, but blood transfusion
abnormalities in the lung fields (basal atelectasis is common), will depend on the haemoglobin level once vascular volume has
size and outline of the cardiac shadow. been restored. In an adult with bowel obstruction who is not
ECG may indicate ischaemia, atrial or ventricular enlargement, shocked, saline or Hartmann’s solution may be adequate. In an
abnormalities of electrolytes (as in the peaked T waves of infant with pyloric stenosis, saline is required initially, and
hyperkalaemia), arrhythmias. Hartmann’s solution will make the hypochloraemic metabolic
alkalosis worse.
Assess the risk for this patient. Were they perfectly healthy
before the emergency, or did they have mild systemic disease, What fluids to give, and how much, depends on the cause of the
significant systemic disease, or life-threatening systemic disease emergency. Every patient with shock is an opportunity to revise
now complicated by an emergency? your cardiovascular pathophysiology.
Table 7 Intravenous Fluids
Be aware of common conditions in the population which will
influence resuscitation and anaesthesia, as well as postoperative
care. These may include:
● Diabetes
● Ischaemic heart disease, cardiac failure, hypertension
● Valvular heart disease
● Asthma, chronic respiratory disease
● TB - especially of pleura and pericardium
* as lactate
● HIV/AIDS
● Malaria
Tissue perfusion of the whole body depends on an adequate
● Anaemia
cardiac output. Cardiac output depends on:
● Liver disease, renal disease
● Myocardial contractility, which is influenced by
Identify, pre-operatively if possible, those patients who will
- End diastolic ventricular volume
benefit from close observation and care post-operatively in the
- End systolic ventricular volume
High Dependency or Intensive Care Unit. You may be responsible
- Myocardial integrity
for care of the patient there. If not, make sure the handover is
good, and that you are available to help if there are problems. ● End diastolic volume, or the volume of each ventricle before
it contracts, is influenced by
Resuscitation goes hand in hand with assessment
- End systolic volume
● Airway problems such as in severe facial injury must be - Preload
managed before induction of anaesthesia.
● End systolic volume, or the volume of each ventricle at the
● Oxygen should always be given to the critically ill patient. end of contraction, is influenced by
- End diastolic volume
● Breathing problems such as asthma or pneumothorax must
- Afterload
be treated before induction of anaesthesia.
● Preload - venous return to the atria depends on blood
● Circulation problems such as hypovolaemia, or cardiac
volume, vascular capacitance (matching of blood volume to
tamponade must be treated before induction of anaesthesia.
vascular capacity), posture, venous valves, limb muscle activity,
● Other emergencies, such as hyperglycaemia and electrolyte intrathoracic pressure changes, functioning cardiac valves, normal
or acid-base abnormalities must have treatment commenced atrial contraction, and a reasonable heart rate to allow time for
before induction of anaesthesia. ventricular filling.
● Consider the need for a nasogastric tube. Decide when to ● Afterload - ejection of the stroke volume into the aorta is
insert the urinary catheter. influenced by the ability of the arterial bed to receive the volume,
so that vasoconstriction requires extra cardiac work to generate
the pressure required to eject the blood.
Update in Anaesthesia 47

● Myocardial integrity depends on the cardiac muscle having

glucose and oxygen to allow it to function properly. It will be Dextran given rapidly, until the pulse rate is down, the blood
impaired if there is myocardial ischaemia, some electrolyte pressure is up, nail bed perfusion has improved, and the
imbalances, or if there are toxins (from sepsis) affecting it, or if patient’s mental state has improved.
it is exposed to high concentrations of some anaesthetic agents If colloids are not available, use a crystalloid such as normal
(intravenous or inhalational). saline or Hartmann’s solution. Higher volumes of crystalloids
In an abdominal emergency, the main problem resulting in poor will be required because of their rapid distribution throughout
tissue perfusion may be the extracellular fluid space. Once the patient has acceptable
vital signs and looks better, run saline or Hartmann’s solution
● Hypovolaemia (as in haemorrhage) rapidly while getting ready for theatre. If you do the
● Hypovolaemia plus vasodilatation (as in sepsis) resuscitation, the patient may be ready for induction of
● Hypovolaemia plus vasodilatation plus myocardial anaesthesia in 1-2hours. If you delegate the resuscitation
depression (as in sepsis). and wait for a phone call, the patient may never survive to
In all cases, apart from giving oxygen, the most important thing get to theatre.
to do is to correct the hypovolaemia, start antibiotics, then review
and rethink. In sepsis, use of a “vasopressor” may be wise after Preparation of the Patient for Theatre
correction of the volume deficit. Although there are several
Two questions which arise after assessment of the patient has
available, the cheapest and most useful is the catecholamine
been completed, and resuscitation is underway, are what about
adrenaline. If the patient is moribund, intermittent doses of 0.1-
fasting and what about premedication?
0.5mL of 1:10,000 adrenaline may buy time until an infusion of
3-12mcg/minute can be set up (3mg adrenaline in 50mL normal In an abdominal emergency it is always assumed that the stomach
saline run at 3-12mL/hour). is full, and that an emergency rapid sequence (“crash”) induction
and intubation of the trachea will be carried out. There is no need
Note that in a resuscitated patient, it may take several hours for
to fast, but there is a need to decide whether emptying the stomach
urine output to improve, even though the perfusion, blood pressure
by nasogastic tube is advisable - as in bowel obstruction, when
and pulse rate improve rapidly. In every patient, monitor the
vomiting or regurgitation of large amounts of fluid may result in
effects of the drug used to check that the desired effects are being
aspiration or hypoxia.
achieved.
Pre-medication should be restricted to use of opioids
How fast fluids should be administered depends on the estimated
intravenously for analgesia, and atropine if ether or ketamine are
deficit and the time available to ensure the circulatory volume is
to be used. Hypnotics should not be given, because they increase
adequate before induction of anaesthesia. Always use large bore
the risk of regurgitation and aspiration in these patients.
IV cannulae - more than one if necessary. The aim is to have a
Antiemetics will not be effective. Antacids and H2 antagonists
patient who is conscious, pink, well perfused, with a reasonable
are most effective for the emergency patient with an empty
pulse and blood pressure prior to induction. Particular care is
stomach, which is rare.
required in the very young and the very old.
Make sure that any resuscitation measures commenced are
Case Insert continued up to the time of induction of anaesthesia.
A 30 year old male has been admitted with peritonitis, thought Induction of Anaesthesia
to be due to bowel perforation from typhoid, present for 3 There are two phases, the “countdown” to induction, and
days. He is shocked, with a temperature of 38oC, a pulse of induction itself. The “countdown” is the short period of checking
120/minute, BP 70 mmHg systolic, poor nail bed capillary that everything is ready, and nothing has been missed. (Table 8).
return, respiratory rate 30/minute, confused. There are no This is when the patient is on the operating table, the assistant is
facilities for immediate investigations of any sort. Urinary ready to do anything required, including hand you the sucker,
catheterisation results in 20mL of concentrated urine. The apply cricoid pressure reliably and effectively, and tilt the table
surgeon wants to operate immediately. The anaesthetist does head down on request. The anaesthetic machine, equipment and
not say “Yes”, or “call me when the patient is resuscitated”. drugs have been prepared and checked. The intravenous line(s)
The anaesthetist does ask the surgeon to assist in resuscitation is running well. The surgeon is scrubbed and the nurses waiting.
following the ABC sequence, planning to resuscitate with The monitors are checked, and readings noted. 100% oxygen
oxygen, IV fluids, and administer antibiotics. has been administered for 5 minutes. Now it is time to start the
This patient could be deficient in fluids to the extent of at induction sequence, informing the patient that they will feel sleepy
least 8-10 litres or more, (2 litres per day x 3 days of shortly, and that pressure will be applied to their throat (Table 9).
maintenance fluids plus fluid lost by vomiting/diarrhoea, plus The intravenous induction agent is given slowly until the patient
fluid pooled in the bowel and peritoneal cavity). Induction does not respond, bearing in mind that the circulation time may
of general anaesthesia in this state will probably cause death. be slow in these patients. Cricoid pressure is applied
The first priority is restoration of intravascular volume with suxamethonium is given, and tracheal intubation performed as
a colloid such as Haemaccel/Gelofundin/Gelofusin or soon as the fasciculations start to fade. The cuff is inflated, and
the patient ventilated with a few breaths of 100% oxygen while
checking the position of the tube. The tube is then secured.
48 Update in Anaesthesia

If at this stage you are unable to intubate or ventilate the patient,

tell the surgeon, and start the protocol you worked out before
you started. Maintain oxygenation, maintain cricoid pressure
and follow the sequence shown in Table 11.

Table 10 Is the Tube in the Trachea

● See it pass through the cords

● Chest moves uniformly
● Hear bilateral breath sounds
● No noise over epigastrium
● Capnography trace
● Free air on aspiration of ETT
● O2 saturation/colour maintained
Figure 2: Cricoid pressure
Table 11 Failed Initial Intubation
How do you know the tube is in the trachea? ( Table 10). Because
you saw it pass through the vocal cords, heard bilateral breath ● Call for help
sounds, with no noise over the epigastrium, and the chest moved ● Maintain cricoid pressure
uniformly up and down. What else is useful? Capnography is the ● Ventilate with 100% O2
gold standard, disposable colour-change discs are the next best. ● If you can ventilate
Without either of these, aspiration of the endo-tracheal tube with - Reposition head
a large syringe will reveal easy aspiration of air if the tube is in - Manipulate larynx
the trachea, with a vacuum if it is in the oesophagus. - Suction larynx
- Use introducer or bougie
Table 8 Pre-Induction ‘Countdown’
- Reintubate with smaller ETT
● If you can’t ventilate
● Patient
- Consider LMA
● Surgeon
- Consider cricoid insufflation
● Assistant to Anaesthetist
- Consider cricothyroidotomy
● Machine Check
- Consider waking patient up
● Airway Management
● Breathing Equipment
● Circulation Equipment Maintenance of Anaesthesia
● Anaesthetic drugs are drawn up Maintenance of anaesthesia (Table 12) may be achieved with
● Resuscitation drugs are available nitrous oxide, oxygen and a volatile agent. If there is no nitrous
● Intravenous oxide or it is contra-indicated, an air/oxygen mixture and volatile
● Pre-Oxygenation agent can be used. If there is no oxygen, just air and volatile
● Vital Signs agent, bearing in mind that the amount of the anaesthetic agent
● Monitors required will be higher than if it is used with nitrous oxide. If
there is no air, oxygen and volatile agent can be used. A non-
depolarising muscle relaxant and intermittent positive pressure
Table 9 Induction Sequence ventilation allows the best conditions for the surgeon. If there
are no relaxants, controlled or assisted ventilation will still assist
● Give 100% oxygen the surgeon.
● Complete pre-induction ‘Countdown’
● Assistant ready The maintenance phase requires observation and monitoring of
● Thiopentone +/- fentanyl the patient, and of the surgery, with particular attention to fluid
● Suxamethonium and blood loss. If major surgery is proposed, or if the patient was
● Cricoid pressure dehydrated or hypovolaemic, measurement of urine output is a
● Endotracheal tube insertion good guide to renal perfusion. Keep a careful record of anaesthetic
- Cuff up agents, monitored variables, fluid and electrolyte balance.
- Check position Potential anaesthetic problems that may occur are the
- secure tube development of high or low airway pressure, desaturation of
● Non-depolarising relaxant haemoglobin, abnormalities in the capnometry trace, hypotension,
● O2/gas/vapour hypertension or arrhythmias. For each scenario, have a plan of
● Check vital signs/monitors how to find the cause of the problem in a logical way. (Table 13).
● Check patient safety
Update in Anaesthesia 49

Other forms of monitoring in the critically ill patient might include

Table 12 Maintenance of Anaesthesia
an arterial line for BP and blood gas sampling, and occasionally
a pulmonary artery catheter, which may show that despite a high
● Maintain Anaesthesia
CVP, the left atrial pressure, as reflected by the pulmonary
- Agents/gas mixture
capillary wedge pressure, is low.
- Opioids
- Relaxants Neuromuscular function monitoring is helpful in those patients
- Monitor who do not breathe well after reversal of muscle relaxants.
- Vital Signs
In situations where they are available, monitoring of inspired
● Monitor
and expired oxygen, nitrous oxide and volatile agent should be
- Blood loss
used. Airway pressure, tidal and minute volume measurements
- Fluid/blood replacement
likewise should be used if available.
- Urine output
Reversal of Anaesthesia
Monitoring The end of surgery is the beginning of the next challenging period
The most important monitoring of the patient is clinical, including for the anaesthetist. It requires planning, like it did before
pulse, blood pressure, colour, respiration, pupil size, lacrimation, induction. A “countdown” (Table 14) ensures that the sequence
in addition to monitoring the surgical field, blood loss, urine of timing of cessation of the volatile agent, reversal of the muscle
output, fluid input. Heart sounds are useful to monitor particularly relaxant with atropine and neostigmine, return of spontaneous
in children. ventilation, suction of the mouth and pharynx, and extubation of
the patient occur smoothly (Table 15). Again, the assistant must
Table 13 Checking Problems be ready to start suction, and tilt the table if required.

● High Airway Pressure Table 14 Reversal ‘Countdown’

- Misplaced airway/ETT
- Blocked airway/ETT ● Check Equipment
- Kinked airway/ETT ● Check drugs
- Bronchospasm ● Assistant ready
- Tension pneumothorax ● Turn off agents
- Sticking valve ● Give 100% oxygen
● Low airway pressure ● Suction
- Where is the leak ? ● Reverse relaxant
Desaturation of Haemoglobin ● Check Observations
- Oxygen supply failure ● Wait for adequate breathing
- Oxygen delivery failure ● Wait until patient wakes up
- Poor ventilation ● Extubate
- Poor perfusion ● Give 100% O2 by mask
- Artefact ● DO NOT LET THE PATIENT MISS
● Abnormal CO2 trace A BREATH
- Ventilator problem
- Circuit problem Table 15 Reversal Sequence
- Circulatory problem
- Air embolism ● Check
- Artefact - Vital signs/monitor
● Hypotension - identify cause and treat - Surgeon is finishing
● Hypertension - identify cause and treat - Assistant ready
● Arrhythmias - identify cause and treat - Time of last dose of relaxant
- Signs of reversal
The next important set of instrument monitors are pulse oximetry, ● Check “Countdown” complete
end tidal CO2 monitoring, ECG and temperature. ● Extubate
If available, CVP monitoring may be a useful guide, particularly ● Turn patient on side
in the patient who you think has had adequate fluid/blood ● Check airway is clear
replacement, but who remains hypotensive. Supported by a high ● 100% O2
CVP reading, this may be an indication for adrenaline infusion ● DO NOT LET THE PATIENT MISS
rather than more fluid, provided all other causes of hypotension A BREATH
have been looked for (e.g. pneumothorax, excess anaesthetic ● Check vital signs/monitors
agent). ● ALL HANDS to move patient
● Transfer to recovery
50 Update in Anaesthesia

A final check of observations, and the patient’s ability to maintain later which the surgeon believes may be due to the anaesthetic.
their airway, ventilation and oxygenation, and movement to the You can also encourage early mobilisation and chest
bed or trolley and transfer to Recovery can proceed. But a number physiotherapy to minimise postoperative complications such as
of things can go wrong at this stage. There may be inadequate atelectasis, pneumonia, and deep venous thrombosis.
muscle relaxant reversal, and more reversal agent may be
required, or extubation may have to be delayed; extubation may Table 18 Post Operative Pain relief
be followed by regurgitation or vomiting and aspiration; there
may be laryngeal spasm. On the circulatory side, hypotension ● Opioids
may occur while attention is concentrated on airway and - Titrate intravenously to start
breathing. A plan for each of these events must have been made, - Continue SCI or IMI regularly or
so that no time is lost in detecting and correcting the problem. IV infusion
- Wean to simple analgesics
Recovery Room Care ● Regional - epidural
Care in the Recovery Room must equal that during anaesthesia ● Monitor pain on a 0-10 scale
until the patient is capable of looking after their own airway and ● Top-up before mobilisation
breathing, and is fully conscious. Again, use a systematic approach ● Check for side effects
(Table 16). Any problems must be identified and treated rapidly - Respiratory depression
(Table 17). - Sedation
- Nausea/vomiting/itching
Table 16 Recovery Care - Confusion/hypotension
- Urinary retention
● Check vital signs/monitors Regional Anaesthesia
● Check level of consciousness
● Continue oxygen Occasionally, there may be a surgeon, an anaesthetist with only
● Check wound facilities for regional anaesthesia, and a patient requiring
● Check urine output emergency abdominal surgery who cannot be moved to another
● Check respiratory rate, sedation, pain score hospital. Can anything be done with regional anaesthesia?
● Check temperature The options available are not ideal forms of anaesthesia for
● Give analgesics as required IV emergency abdominal surgery, but if resuscitation is carried out
● Check fluids and IV sites and the same principles followed as have been described above,
possibilities include:
Table 17 Some recovery Problems ● Spinal anaesthesia
● Epidural anaesthesia
● Inadequate breathing ● Abdominal field block
● Regurgitation/vomiting/aspiration ● Para-vertebral block
● Laryngeal spasm ● Splanchnic block
● Hypotension
● Not waking up Spinal and epidural blocks have been described superbly in
previous issues of Update (see Further Reading). They must not
be used in patients who have not been fully resuscitated.
The patient in Recovery should continue to receive oxygen, have
Abdominal field block is best carried out by paravertebral
continuous monitoring of airway, breathing and circulation, and
intercostal block, first described by Sellheim in 1906, or
be given analgesia as required. Specific problems require a plan.
paravertebral block, described by Kappis in 1912. Abdominal
If the patient fails to breathe adequately, is it due to inadequate
field block was first carried out by Schleich in 1899. Posterior
reversal of relaxants, to the persistence of anaesthetic agents and
splanchnic block was described by Kappis in 1919. These blocks
opioids? Have they continued to bleed or lose fluid since the
have significant complications, and should only be attempted by
anaesthetic finished, and become hypovolaemic? If the patient
those with excellent anatomical knowledge and technical skills.
fails to wake up, is it because of the drugs given, hypoxia, carbon
dioxide retention, hypoglycaemia, hypothermia, or a medical Further Reading
complication? Dobson MB Anaesthesia at the District Hospital 2nd. Edition, WHO
Postoperative Care Geneva 2000 ISBN 9241545275
Oberoi G, Phillips G Anaesthesia and Emergency Situations - A
The anaesthetist is often the best resource a surgeon has to advise
Management Guide, McGraw Hill Sydney 2000 ISBN 0074707671
on post-operative problems such as pain relief (Table 18),
management of nausea and vomiting, fluid and electrolyte Casey WF Spinal Anaesthesia - A practical guide, Update in Anaesthesia
replacement. Get in the habit of visiting all emergency patients 2000:12
in the ward. You may be able to help, and you can make a note Visser L Epidural Anaesthesia, Update in Anaesthesia 2001:13
of any problems recorded on your anaesthetic record or the
Mackenzie I, Wilson I The Management of Sepsis, Update in Anaesthesia
recovery record, as well as picking up anything that developed
2001:13