Title of Guideline

Contact Name and Job Title

Directorate & Speciality
Date of submission
Date on which guideline must be reviewed
Explicit definition of patient group to which it
applies
Abstract

Key Words
Statement of the evidence base of the
guideline has the
guideline been peer reviewed by colleagues?
Evidence base: (1-5)
1a
meta analysis of randomised
controlled trials
1b
at least one randomised
controlled trial
2a
at least one well-designed
controlled study without
randomisation
2b
at least one other type of welldesigned quasi-experimental
study
3
well designed nonexperimental descriptive studies
(ie comparative / correlation and
case studies)
4
expert committee reports or
opinions and / or clinical
experiences of respected
authorities
5
recommended best practise
based on the clinical
experience of the guideline
developer
Consultation Process
Target audience

Management of the emergency laparotomy

patient:
A practical guideline
Dr V C Banks Consultant AICU & Anaesthetics,
Dr J Mole Consultant Anaesthetist
Dr G Pipe SPR Anaesthetics
Specialist Support and Digestive Diseases
and Thoracics directorates.
December 2013
December 2016
Patients undergoing an Emergency Laparotomy
The emergency laparotomy patients have a high
mortality and this guideline helps with the
preparation, resuscitation and care of
Emergency Laparotomy patients.
Emergency Laparotomy
Septic surgical patient
Critical Care
Yes,
Evidence base is level 2 as well as national best
practice

Consulted with surgical directorate, anaesthetics

and critical care departments.
Doctors, Anaesthetists and Surgeons involved in
the care of patients undergoing Emergency
Laparotomy

This guideline has been registered with the trust. However, clinical guidelines are guidelines
only. The interpretation and application of clinical guidelines will remain the responsibility of the
individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when
using guidelines after the review date.

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EmergencyLaparotomyGuidelineNUHVCBv3

Management of the emergency laparotomy patient: a practical

guideline

Pre-operative care: (see Appendix 1: Emergency Surgery Admission

Booklet)
INITIAL RISK ASSESMENT BY CLINICIAN (A&E/ WARD)
1. Full history, examination and baseline investigations
FBC, U&E, LFTs, Coagulation, Lipase, Glucose and G&S
hcg in ALL females of reproductive age
Blood cultures if febrile
ABG including lactate
ECG, consider troponin
Urinalysis/ MSU
Hourly Early Warning Scores

2. Is this patient HIGH RISK of significant Morbidity/ Mortality?

(any of the risk factors) 1
SIRS >2 + 1 organ dysfunction
Lactate > 2
EWS > 4
Long term steroids/immune-suppressed
Age 70
Age > 50 and;
Creatinine > 130mol or dialysis dependent
Diabetes
Significant CVS/Respiratory disease
Urgent surgery/Re-do laparotomy
Predicted PPOSSUM mortality > 5%
ASA 3 + 1 organ dysfunction
ASA 4/5
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EmergencyLaparotomyGuidelineNUHVCBv3

3. Recognise and Treat Sepsis

Septic patients have a much higher mortality than other patients

undergoing emergency surgery 2
Once a patient has been identified as septic, give appropriate
antibiotics within 1 hour of diagnosis of sepsis, every hour delay
in antibiotics increases mortality.3 Consult with microbiology
guidelines as per Intranet.
Source control is very important. Early senior surgical input is
required to decrease time to theatre. In surgery, the longer a septic
patient remains without source control, the higher the mortality.
Reassess the patient regularly - BEWARE LOW RISK patients
can deteriorate rapidly to become HIGH RISK. Review EWS.
Provide analgesia within an hour of first medical assessment if
required.
Consider NG tube if bowel obstruction likely.

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EmergencyLaparotomyGuidelineNUHVCBv3

4. Timelines if HIGH RISK PATIENT 1

Refer to Surgical Registrar to review within 30 mins
Discussion with Consultant - within 1 hour of Surgical
Registrar review
Book CT scan (indicate HIGH RISK status)
CT scan reported - within 5 hours of booking

5. If Surgery is indicated for HIGH RISK PATIENT

Calculate estimated PPOSSUM score
(http://www.riskprediction.org.uk/)
Inform Theatre Co-coordinator & 3rd on Anaesthetist QMC/
2nd on NCH
STATE: High Risk status, EWS, PPOSSUM score & Lactate
3rd on call to discuss case with Consultant and Critical Care
Arrival in theatre within 1 hour of decision to operate

6. Timelines for LOWER RISK PATIENT 1

(Beware patients often deteriorate and become HIGH RISK)
Discussed with Consultant - within 12 hours of Surgical
Registrar review
Time CT scan reported within 24 hours of MRCS review
Time reviewed by Consultant within 24 hours of admission

7. If Surgery is indicated for LOWER RISK PATIENT

Calculate estimated PPOSSUM score
(http://www.riskprediction.org.uk/)
Inform Theatre Co-coordinator & on call Anaesthetist
STATE: Lower Risk status, EWS, PPOSSUM score &
Lactate
Arrival in theatre within 12 hours of decision to operate

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EmergencyLaparotomyGuidelineNUHVCBv3

Management of the emergency laparotomy patient: a practical

guideline

Anaesthesia
Pre-operative care
1. Emergency anaesthetic service should be consultant led at all
times 4

2.
3.
4.
5.

a. If PPOSSUM score > 10% mortality Consultant

Anaesthetist and Surgeon involvement is mandatory
b. No SHO/CT to anaesthetise an emergency laparotomy
patient on their own
c. High risk patients to have a consultant anaesthetist present
or anaesthetist whom the responsible consultant knows to be
competent to undertake the case
Plan ahead and discuss procedure with surgical team and options
for limiting surgery if instability
If Estimated Blood Loss expected to be > 1.5L cell salvage should
be available
Post-operative care should be planned as far as possible preoperatively
Critical care needs to be involved early, preferably before surgery
or other major interventions, such as prolonged interventional
radiological procedures.

Intra-operative care
1. Ventilation
If likely ITU admission insert size 8 coett tube for females
and size 9 for men (unless unable)
Aim for SaO2 > 94% 5
Consider PEEP of at least 5cmH2O
Aim for Tidal Volume 5-7 ml/kg (Ideal Body weight)
Consider pressure control ventilation to minimise peak
airway pressure
Aim Pmax < 30cmH20
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EmergencyLaparotomyGuidelineNUHVCBv3

2. Antibiotics prophylaxis
Consider escalation/addition - (consult microbiology)
Antifungal if re-laparotomy or significant peritoneal soiling
(800mg Fluconazole)
Gentamicin if systemic sepsis (3-5mg/kg) (Check not
already given elsewhere)
3. Please use Goal Directed therapy with a cardiac output monitor &
invasive lines if major Emergency surgery 6

Aim Stroke Volume Variation < 10%

Aim MAP > 65 mmHg
Aim UO + 0.5ml/kg/hr
CVP > 8 mmHg
Haematocrit > 30%
Saturation central venous O2 >70% (ScvO2)
Lactate < 2
BM> 4
Have a low threshold for inotropes/vasopressors to avoid
excessive fluid administration ( Noradrenaline infusion
5mg/40mls Normal Saline)

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EmergencyLaparotomyGuidelineNUHVCBv3

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