Dr Kapila Hettiarachchi Lead - Anaesthesia and SICU SBSCH- Peradeniya

Part 1A – Questions related to emergency anaesthesia Date: 20th April Discuss the problems associated with anaesthetizing a patient with severe pre eclampsia for emergency Caesarian section. Date: 15th December A patient with severe pre eclamptic toxaemia needs an emergency Caesarean section. Give short account of the anaesthetic problems you would anticipate in the perioperative period. Date: 3rd April List the problems you would encounter in giving general anaesthesia for a patient with pre eclamptic toxaemia presenting for emergency caesarian section. Date: 1st December, Outline briefly the pre-operative management of an eclamptic mother presenting for an emergency caesarean section.

Part 1A – Questions related to emergency anaesthesia Date: 4th December, Describe the anaesthetic management of a patient who needs general anaesthesia for emergency Caesarean section for severe foetal distress. Date: 22nd March, A 34 year old lady is brought to the operating theatre with severe foetal distress for an emergency caesarean section. Outline your anaesthetic management.

Part 1A – Questions related to emergency anaesthesia Date: 15th November Describe the anaesthetic management of a mother with severe bleeding after normal delivery, presenting for exploration of the uterus. Date: - 19th April Describe the peri-operative anaesthetic management of a mother for evacuation of retained products following post partum haemorrhage. Date: - 1st December A 30 year old multipara after normal delivery at term, is brought to the operating theatre with vaginal bleeding. Her systolic blood pressure is 60 mmHg and her pulse rate is 130 beats per minute. (a) List the important steps in the resuscitation of this patient. (b) Outline briefly your anaesthetic management for emergency surgery. Date: 10th February Describe the problems in anaesthetising a patient with ante-partum haemorrhage for a caeserean section.

Part 1A – Questions related to emergency anaesthesia Date: 15th November Describe the anaesthetic management of a 7-year-old child (20-Kg) requiring urgent surgery for torsion of testis. Date: 4th April Describe the anaesthetic management of a 6-year-old child (15-Kg) presenting with bleeding tonsil, one hour following tonsillectomy. 20th April Discuss the anaesthetic management of an adult for repair of an open eye injury following a road traffic accident. Date: 15th December A previously healthy 25-year-old patient with a stab injury of the right lower chest presents for emergency laparotomy. How would you anaesthetise this patient ?

Problems Limited time Risk of aspiration Potential difficult airway Hypovolemia Co-existing diseases

Problems Sedation and analgesia Hypothermia Coagulopathy

Limited time to prepare Decisions made quickly with the life threatening situation Little time for extensive diagnosis Minimal patient history, Investigations

Causes for full stomach 1. Inadequate fasting time 2. Pregnancy 3. Intestinal obstruction 4. Pain

Causes for full stomach 5. Intra-abdominal mass 6. Obesity 7. Head and neck trauma 8. Unable to protect airway – Head injury, Vocal cord injury

Risk of aspiration

Complications of aspiration Aspiration pneumonitis Aspiration pneumonia ALI / ARDS Sepsis Death

Potential difficult airway Risk factors 1. Trauma to face, spine 2. Obstruction to upper airway – epiglottitis, abscess, goitre, tumour 3. Pregnancy 4. Obesity

Complications of difficult airway Aspiration Hypoxia Trauma to upper airway Potential spinal cord injury in cervical injury Barotrauma

Hypovolemia Blood loss or/& electrolyte loss Fluid/ blood resuscitation prior & during surgery Crystalloid, colloid, blood & blood product can be used to correct hypovolaemia

Clinical indices of extent of blood loss GradeMildModerateSevere Percentage %2030>40 Volume loss (L)11.5>2 Heart rate (BPM) >140 BP (mmHg)Orthostatic hypotension SBP <100SBP <80 UOP (mL/h) <10 SensoriumNormalRestlessImpaired State of peripheral circulation Cool and paleCold, pale and slow capillary refill Cold clammy, peripheral cyanosis

Complications of Hypovolaemia  Difficult intravenous access  Hypovolemic shock  Haemorrhagic shock  Metabolic acidosis  Multi-organ failure  Death

Co-existing diseases  Unknown medical conditions in unconscious patient  Medical conditions not optimised – DM, HT, IHD, Asthma  Limited time to optimise & elicit further medical history

Sedation and analgesia  Use with caution due to hypovolaemia, uncertain diagnosis, head injury, and in difficult airway  Pain relief is inadequate

Coagulopathy Causes 1. Massive blood loss – major trauma, obstetric haemorrhage 2. Patient on anticoagulant therapy require emergency Surgery 3. Dilution coagulopathy

Complications of coagulopathy  Uncontrolled bleeding  Haemorrhagic shock  Death

Intraoperative management  Awareness  Hypothermia

Awareness  High risk surgeries – Trauma  Hypovolemia  Pregnancy – specially in Emergency LSCS

Hypothermia Contributing factors 1. Hypovolaemia 2. General and regional anaesthesia 3. Cold surrounding, cold fluid, cold antiseptic solution 4. Head injury 5. Burn 6. Extreme age 7. Surgery exposes large area of skin & abdomen or thorax from which heat is lost

Problems with hypothermia  Increase oxygen requirement  Myocardial depression  Risk of ventricular fibrillation, T< 28 O C  Decreased conscious level T < 30 O C  Reduced drug metabolism  Prolonging effect of anaesthetics agents  Reduced urine output

Pre-operative management Objective permit correction of surgical pathology with minimum risk to the patient

To achieve that Adequate and accurate preoperative assessment with attention to specific problems

Preoperative management  Find out 1. likely surgical diagnosis 2. Magnitude of the proposed surgery 3. Urgency of the surgery

Preoperative management  Medical problems  Drugs  Allergy  Past surgeries  Past anaesthesia

Preoperative management Measures to empty stomach  Postpone operation if permissible  Adequate fasting  Gastric suction  Acid prophylaxis – iv Ranitidine 50mg min before induction  Prokinetics – iv metoclopramide 10mg

Preoperative management  Airway evaluation for RSI  Anticipate for difficult airway Check for features of difficult airway

Preoperative management  Assessment of volaemic state HR BP Capillary refilling time CVP UOP

Preoperative management  Investigations Haemoconcentration High BU High serum sodium / electrolytes

Preoperative management  What is optimal time for surgery ? When all deficits have been corrected However, resuscitation may go hand in hand with surgical intervention

Preoperative management  Preparation 1. iv access – two large bore 2. Group and cross match 3. iv fluid, blood 4. Obtain investigations if time permits 5. Emergency drugs 6. Appropriate monitoring devices

Intraoperative Management Mode of anaesthesia  GA  RA  Combined anaesthesia  Peripheral nerve blocks

Airway management  RSI  Awake fire optic /video assisted intubation  Inhalational induction  Emergency cricothyroidotomy  Tracheostomy under LA

Monitoring  ECG  NIBP / IABP  SpO 2  ETCO 2  Temperature  UOP  CVP

Maintenance of anaesthesia  Change according to the situation – eg. BP fluctuation  Use regional blocks to reduce requirement of anaesthetic agent

Fluid therapy  Volume status must be continuously monitored and fluid therapy consistently titrated in response to ongoing changes  Requirement 1. Adequate iv access 2. Intra-osseous if difficult iv access 3. CV access

Fluid therapy  Warm all resuscitation fluid  Pressurised devices – Rapid IV infuser  Fluid- Crystalloid Colloid

Fluid therapy 1. After volume status stabilised 2. Second priority is the restoration of blood oxygen carrying capacity  Packed cells  Whole blood 3. The third priority is normalisation of coagulation status  FFP  Platelets  Cryoprecipitate

Post operative management Decision for extubation depends on patients haemodynamic status In stable patients  Before extubation perform direct laryngoscopy, NG tube aspiration  Reversal given  100% oxygen

Post operative management  Prolong shock / hypotensive state  Severe sepsis  Severe IHD  Overt gastric aspiration Indications for ICU admission

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