The document discusses anaesthesia for emergency surgery. It defines different categories of emergency based on the urgency of the surgery from immediate to elective. Issues related to emergency anaesthesia include limited preparation time, risk of aspiration, potential difficult airway, hypovolemia, coagulopathy, and co-existing medical problems. Anaesthesia for trauma surgery focuses on the primary survey, risks of hypothermia and aspiration, and uses rapid sequence induction. Anaesthesia for non-trauma emergency surgery emphasizes pre-operative optimization, and may use regional techniques like epidurals or awake fibreoptic intubation depending on the clinical situation.

1. PRESENTER: AMALINA AMINUDDIN
Anaesthesia for Emergency
Surgery

2. Content
▪ Definition
▪ Issues related to emergency surgery
▪ Anaesthesia for trauma surgery
▪ Anaesthesia for non-trauma surgery

3. NCEPOD Classification of Intervention
Category Description Target time to
theatre
Example
Immediate Immediate life/limb or
organ-saving intervention
Resuscitation simultaneous
with surgical treatment
Within
minutes of
decision to
operate
Ruptured aortic aneurysm
Major trauma to abdomen or thorax
Fracture with major neurovascular deficit
Compartment syndrome
Acute myocarial infraction (AMI)
Urgent Acute onset or deterioration of
conditions that threaten life,
limb or organ survival; fixation
of fractures; relief of distressing
symptoms
Within hours
of decision to
operate and
normally once
resuscitation
completed
Compound fracture
Perforated bowel with peritonitis
Critical organ or limb ischaemia
Acute coronary syndromes (ACS)
Perforating eye injuries
Expedited Stable patient requiring early
intervention for a condition that
is not an immediate threat
to life, limb or organ survival
Within days of
decision to
operate
Tendon and nerve injuries
Stable & non-septic patients for wide range
of surgical procedures
Retinal detachment
Elective Surgical procedure planned or
booked in advance of routine
admission to hospital
Planned Encompasses all conditions not classified
as immediate, urgent or expedited.

4. Emergency Anaesthesia
▪ To identify and , if time
permits, correct major
physiological abnormalities
preoperatively.
▪ Be prepared for potential
complications arising as a
consequence of anaesthesizing
a patient in suboptimal
conditions.

5. Issues Related to Emergency
Anaesthesia
1. Limited time for preparation
2. Risk of aspiration
3. Potential difficult airway
4. Hypovolemia
5. Coagulopathy
6. Co-existing medical problems

6. 1. Limited time for preparation
⚫ Anticipate potential difficulties – unable to formulate a
suitable perioperative plan to avoid or minimize crisis
⚫ To ensure patient is medically fit and stable for surgery and
anaesthesia via preoperative optimization
⚫ Deciding the appropriate equipment, number of staff who will
be during administration of anaesthesia related to individual
comorbidities and type of surgery
⚫ Achieving a fully informed patient and to obtain consent
regarding planned anaesthetic technique

7. 2.Risk of Aspiration
▪ May have delayed gastric emptying/abnormal
peristalsis
▪ Rate of gastric emptying influences the risk of
PONV.
▪ Slowed by: anxiety, pain, mechanical obstruction, labour, drugs
(opioids, anticholinergic)
▪ Increased by: gastric distension, drug (metoclopramide)
6 hours Solid food, formula milk, other milk
4 hours Breast milk
2 hours Clear non-particulate and non-carbonated fluid

8. Complications of
Aspiration
▪ Aspiration
pneumonia
▪ Aspiration
pneumonitis
▪ ARDS
▪ Severe sepsis
▪ Death

9. 3.Potential
Difficult Airway
▪ Risk Factors
▪ Faciomaxillary trauma
▪ Cervical spine trauma
▪ Upper airway obstruction
(abscess, tumours, goiter)
▪ Morbidly obese
▪ Pregnancy

10. 4.Hypovolemia
▪ Blood loss
▪ GI loss – usually accompanied with electrolyte
imbalance
▪ Requires resuscitation with crystalloid, colloid
or blood before and during surgery.
▪ Complications:
▪ Difficult IV access
▪ Shock
▪ Multiorgan failure
▪ Cardiac arrest, death

11. 5.Coagulopathy
▪ Massive blood loss – major trauma; obstetric
haemorrhage
▪ Patient on anticoagulants requiring emergency
surgery
▪ Dilutional coagulopathy
▪ Complications:
▪ Uncontrolled bleeding
▪ Shock
▪ Death

12. 6.Co-existing Medical Conditions
▪ Unknown medical condition in unconscious patients
▪ Limited time to elicit further medical history
▪ Conditions not optimised – bronchial asthma, HPT,
IHD, CCF, DM

13. Anaesthesia for Trauma Surgery
▪ Primary Survey – Airway,
Cervical Spine Control, Breathing
▪ Assume all trauma patient at risk of
cervical spine injuries until proven
otherwise.
▪ Do not try to intubate with a cervical
collar in place.
▪ Perform manual in line immobilization
during intubation.
▪ Insert chest drain simultaneously
/before mechanical ventilation started
if signs suggestive of pneumothorax or
surgical emphysema

14. Anaesthesia for Trauma Surgery
• Primary Survey - Circulation

15. Anaesthesia for Trauma Surgery
▪ Circulation
▪ Difficult peripheral IV access🡪
external jugular/ femoral vein.
▪ Early use of blood products in
those with massive bleeding.
▪ Warm IV fluids 🡪avoid
hypothermia.
▪ Adverse effects of hypothermia:
▪ Gradual decline in heart rate
and cardiac output.
▪ Left-sided shift of
oxyhaemoglobin dissociation
curve – reduced peripheral O2
delivery.
▪ Shivering compounds lactic
acidosis.
▪ Impair coagulation.
▪ Disability
▪ Rapid neurological
assessment
▪ Pupil size and reaction to
light.
▪ GCS
▪ Exposure/
Environmental Control
▪ Undress patient completely
▪ Protect from hypothermia with
warm blankets
▪ Secondary Survey
▪ A detailed head-to-toe survey
of a trauma patient is not
undertaken until vital signs
are relatively stable.

16. Anaesthesia for Trauma Surgery
▪ Risk of aspiration of
gastric content must be
weighed against risk of
delaying an urgent
procedure.
▪ Nasogastric /orogastric
tube : decompress stomach
and to provide a low
pressure vent for
regurgitation
▪ Rapid sequence
intubation
▪ Regional Anaesthesia
▪ May be considered as an
adjunct.
▪ Often impractical due to
preoperative urgency,
haemodynamic instability
and coagulopathy.

17. Rapid Sequence Induction
▪ Aim to minimise
duration of time between
loss of consciousness and
tracheal intubation (period
during which patient is at
greatest risk of aspiration).
▪ Pre-oxygenation to
denitrogenate the lung
and to maximise oxygen
reservoir so that onset of
hypoxia will be delayed.
▪ Requires a skilled assistant
to perform cricoid
pressure (Sellick’s
manoeuvre).

18. Rapid Sequence Induction
▪ Pre-calculated dose of IV anaesthetic induction agent
▪ Neuromuscular blocking agents without waiting to
assess the effect of induction.
▪ As soon as the jaw is relaxed or fasciculation has
stopped, direct laryngoscopy and tracheal intubation are
performed.
▪ Maintain cricoid pressure till confirm correct placement
of ETT
▪ Disadvantage of RSI:
▪ Haemodynamic instability if the dose of induction agent is
excessive (hypotension, circulatory collapse) or inadequate
(hypertension, tachycardia).

19. 7 Ps of RSI
• Preparation - MMMAALESSSS
• Preoxygenation
• Preintubation optimization/ Premedication
• Paralysis with induction
• Positioning + cricoid Pressure
• Placement with proof
• Post-intubation management

20. Intraoperative Monitoring
Indications for
postoperative ICU
admission and ventilation
▪ Standard monitoring
▪ Insertion of arterial line
for IABP and ABG
monitoring
▪ Unstable haemodynamic
status
▪ Head injuries requiring
cerebral protection
▪ Overt gastric acid
aspiration
▪ Severe chest injuries
▪ Massive blood loss with
DIVC with massive
blood transfusion
Anaesthesia for Trauma Surgery

21. Anaesthesia for Non-Trauma
Surgery
▪ Pre-operative Management
▪ History and physical examination to assess pre-morbidities
▪ Relevant investigations
▪ Optimise patient’s conditions
▪ Volume status / fluid deficit
▪ Electrolytes
▪ Haematological indices – Hb, platelet, coagulation profile
▪ Fasting time

22. Anaesthesia for Non-Trauma Surgery
▪ Rapid sequence induction
▪ Awake fiberoptic intubation
▪ Regional anaesthesia
▪ Subarachoid anaesthesia
▪ Epidural anaesthesia
▪ Combined spinal and epidural anaesthesia
▪ Nerve blocks
▪ A common surgical misconception that subarachnoid or
epidural blocks are safer than GA for patients in poor
physical conditions.

23. Awake Fibreoptic Intubation
▪ A gold
standard
for difficult
oral
intubation

25. Regional anaesthesia
Epidural Spinal
High dose ( 10-20ml) Low dose ( 1.5- 2ml)
Slow onset ( 25-30m) Fast onset ( 5min)
Do not cause significant
neuromuscular block
Cause significant
neuromuscular block
Possible for multiple
dosage
Single dose only
can be given at various
point of backbone
Below L1/L2 level ( avoid
spinal cord damage)

26. Combined spinal epidural
Two method :
▪Two- level technique
▪Epidural catheter inserted first
and tested, then spinal done
one/ two interspace below level
of epidural
▪+: able to test epidural catheter
▪-: trauma/ discomfort from
multilevel injection
▪Single level insertion:
▪Needle –through-needle
technique (using epidural
needle as introducer for spinal
needle)

27. Benefits of CSE