Patient Preparation for

Emergencies Surgeries

Lila Tri Harjana

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 Overview
Goal of preop evaluation:
To identify and optimize conditions that increase
perioperative morbidity and mortality in emergencies
surgeries
Consists of:
What is Emergency Surgery
Preoperative Management in Emergency Surgery
Perioperative Risk Assessment in Emergency Surgery
Common Problem in Emergencies Surgeries
Preparation

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 What is
Emergency Surgery ?
National Confidential Enquiry into Patient Outcome and Death (NCEPOD)
IMMEDIATE Immediate life, limb or organ-saving intervention
resuscitation simultaneous with intervention. Normally within minutes of
decision to operate. Life-saving or limb or organ saving
URGENT Intervention for acute onset or clinical deterioration of
potentially life-threatening conditions, for those conditions that may
threaten the survival of limb or organ, for fixation of many fractures and
for relief of pain or other distressing symptoms. Normally within hours of
decision to operate.
EXPEDITED Patient requiring early treatment where the condition is not
an immediate threat to life, limb or organ survival. Normally within days
of decision to operate.
ELECTIVE Intervention planned or booked in advance of routine
admission to hospital. Timing to suit patient, hospital and staff

http://www.ncepod.org.uk/classification.html
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 What is
Emergency Surgery ?
is a medical or trauma emergency for which immediate
surgical intervention is the only way to solve the
problem successfully
Life Saving and to prevent further damage
Unprepared Patient
Short of Time for Preparation
Good Team Work and Good Resources are the
important key to decrease mortality and morbidity

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Type of Surgery

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How to manage it ?

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Primary Survey INITIAL
ASSESSMENT
A- airway
B- breathing LIFE SUPPORT
C- circulation
D- disability RESUSCITATION
STABILIZATION
E- exposure
Evaluate
Adequacy of resuscitation
Secondary Survey
Emergency
Surgery
Definitive Therapy

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 Patophysiology

Purpose of Surgery

Co morbid

Resource
Outcome

Multidiscipline
team work

Communications
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 Laboratory Work Up
Routine laboratory tests in patients who are
apparently healthy on clinical examination and history
are not beneficial or cost effective.
A clinician should consider the risk-benefit ratio of any
ordered lab test.
When studying a healthy population, 5% of patients
will have results which fall outside the normal range.
Lab tests should be ordered based on information
obtained from the history and physical exam, the age
of the patient and the complexity of the surgical
procedure Zambouri A. Preoperative evaluation and preparation for
anesthesia and surgery. Hippokratia. 2007;11(1):1321.
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 Indications for
specific preoperative test

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 Common Co morbid

the National Confidential Enquiry into Patient Outcome and Death (2011)

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 Perioperative Risk Assessment
in Emergency Surgery
Perioperative risk is a function of the
preoperative medical condition of the patient,
the invasiveness of the surgical procedure and
the type of anesthetic administered.
The ASA grading system was introduced originally
as a simple description of the physical state of a
patient
Emergency surgery increases risk dramatically,
especially in patients in ASA class 4 and 5

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 Physical Status
American Society of Anesthesiology

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 Perioperative Risk Assessment
in Emergency Surgery
Surgical complications occur at least one
complication in 17% of surgical patients
Surgery-related morbidity and mortality generally
fall into one of three categories: cardiac,
respiratory and infectious complications
The overall risk for surgery-related complications
depends on individual factors and the type of
surgical procedure
Zambouri A. Preoperative evaluation and preparation for anesthesia
and surgery. Hippokratia. 2007;11(1):1321.
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the National Confidential Enquiry into Patient Outcome and Death (2011)
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 Pre Operative Strategy
For High Risk Patient
Eliminate The Risk

Control The Risk

Change The Strategy

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 Common Problem
in Emergencies Surgeries
Unprepared (Non-Fasting) Patient
Pain
Diabetes
Cardiovascular Problem
Respiratory Problem

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 Unprepared Patient
Preoperative fasting
a prescribed period of time before a procedure when
patients are not allowed the oral intake of liquids or
solids.

Perioperative pulmonary aspiration

aspiration of gastric contents occurring after induction
of anesthesia, during a procedure, or in the immediate
period after surgery.
Is one of the most feared complications of anesthesia

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 25

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Period of Fasting

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10

0
0 0.5 1 1.5 2 2.5
Gastric Volume ml / kg BW
Block Course DM Anestesiologi dan Reanimasi FK UNAIR
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 Engelhardt T, Webster NR.Pulmonary aspiration of gastric contensts in Anaesthesia. Br K Anaesth
1999;83453-60

Large mortality of 62 % in 47 patients after aspiration

Cameron JL, Mitchell WH, Zuidema GD, Aspiration pneumonia. Clinical outcome following documented
aspiration. Arch Surg 1973;10649-52
 Prevention of
pulmonary aspiration
of gastric contents
Gastric Content Intervention
Reducing gastric volume by NG Tube and
Prokinetic drugs
Decreasing gastric acidity by Non particulate oral
antacid or H2-receptor antagonists

Rapid Sequence Induction (RSI)

Cricoid Pressure

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 Pain
Pain is the most common reason for presentation to the ED
and many patients will self medicate for pain before
attending
Initial stabilization requires immediate assessment of the
presenting symptoms and vital signs and consideration for
placement of an IV for titration of pain medication
The barriers of Pain Management in ED are include ethnic
and racial bias, gender bias, age bias, inadequate
knowledge and formal training in acute pain management,
opiophobia, the ED environment, and the ED culture.
In the ED setting, analgesia should be simple to administer,
patient- and condition-specific and, where appropriate,
based on local-regional rather than systemic techniques

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 Diabetes
Perioperative morbidity and mortality are greater in diabetic than in non-
diabetic patients, and
Neglect of the long term complications of diabetes is likely to be more
harmful than the short term uncontrolled of blood glucose levels.
Ideally, should be carefully assessed for symptoms and signs of peripheral
vascular, cerebrovascular and coronary disease, and it have a higher
incidence of death after MI than non-diabetics
Myocardial ischemia or infarction may be clinically silent if the diabetic
has autonomic neuropathy, and 8%-31% of type 2 diabetics have
asymptomatic coronary artery disease on stress testing
A high index of suspicion for myocardial ischemia or infarction should be
maintained throughout the perioperative period if unexplained
hypotension, dysrhythmias, hypoxemia or ECG changes develop

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 Diabetes
Adequate control of blood glucose concentration (< 180 mg/dL)
must be established preoperatively and maintained until oral
feeding is resumed after operation
Oral hypoglycemic agents are withheld the day of surgery for an
agent with a short half-life and up to 48 h preoperatively for a long
acting agent such as chlorpropamide
A combination of glucose and insulin is the most satisfactory
method of overcoming the deleterious metabolic consequences of
starvation and surgical stress in the diabetic patient
Complications of perioperative hyperglycemia include dehydration
(as a result of osmotic diuresis), impaired wound healing, inhibition
of white blood cell chemotaxis and function (associated with an
increased risk of infection), worsened CNS and spinal cord injury
under ischemic or hypoxic conditions and hyperosmolarity leading
to hyperviscosity and thrombogenesis

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 Diabetes
Hypoglycemia [a glucose < 50 mg/dL (2.8 mmol/L) in adults
and < 40 mg/dL (2.2 mmol/L) in children] may develop
postoperatively due to residual effects of longacting oral
hypoglycemic agents or insulin preparations given
preoperatively, in addition to perioperative fasting
Recognition of hypoglycemia in the perioperative period
may be delayed because anesthetics, analgesics, sedatives
and sympatholytics agents alter the usual presenting
symptoms of hypoglycemia
These symptoms generally begin with confusion, irritability,
fatigue, headache and somnolence and may progress to
seizures, focal neurologic deficits, coma and death

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 Cardiovascular Problem
The American College of Cardiology (ACC) and the American Heart
Association (AHA) published a task force report on Guidelines for
Perioperative Cardiovascular Evaluation for Noncardiac Surgery
Patients risk factors are usually subdivided into three categories:
major,
intermediate and
Minor
Patients with major predictors have a five times greater
perioperative risk, so only vital or emergency surgical procedures
should therefore be considered for these patients
Exercise tolerance is a major determinant of perioperative risk

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 Patient-Related Predictors for
Risk of Perioperative Cardiac Complications

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 Myocardial Infarction
Previous Myocard Infarction (MI) within 6 months of proposed surgery is a
contraindication to elective anesthesia and surgery

A small infarction without residual angina and with a good functional status
allows essential non-cardiac surgery as soon as 6 weeks after the ischemic episode

On the contrary, a patient with a large infarct, residual symptoms and ejection
fraction <0.35 has a high probability of a further cardiac event, even 6 months
after the infarction

The period from 6 weeks to 3 months is of intermediate risk; this period is

extended beyond 3 months in cases with complications such as arrhythmias,
ventricular dysfunction or continued medical therapy

Myocardial infarction (0,7% - 3,15%), pulmonary edema, ventricular fibrillation,

primary cardiac arrest, or complete heart block are defined as major perioperative
cardiac complications and the mortality rate of MI remains at 40% to 70%

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 Hypertension
Hypertension has been associated with the development of CAD,
CHF, LV hypertrophy, renal insufficiency, cerebrovascular disease
Preoperative and History of hypertension increased postoperative
death to 3.8 4 times
(Browner WS, et al. JAMA 1992;268:252. ; Howell SJ, et al. Aneasthesia1996;51:1000)

Patient with hypertensive crisis (BP>180/110) must be interviewed

and examined carefully to determine whether there is acute or
chronic, and end-organ damage (Hypertensive Emergency)
If patient with hypertensive emergency is also needed emergency
surgery, the IV anti-hypertensive therapy should immediately
initiated based on a logical first choice by the likely etiology and the
patients co morbidities

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Papadakos PJ, Franklin KM. Management of Perioperative Hypertension.
Anesthesiology News Special Edition. October 2015

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 Hypertension
If the BP is , DO NOT TOO FAST
Both SBP and DBP must be reduced
15% reduction during the first hour (is 25%
safe???)
Gradual reduction thereafter (25% of initial BP)
Any reduction in BP can cause ischemia (careful
and close monitoring)

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 Respiratory Problem
The role for preoperative pulmonary function testing
remains uncertain and Spirometry may only be useful when
there is uncertainty about the presence of lung
impairment
Postoperative pulmonary complications (PPCs), that
approximately 20-30% of patients undergoing major, non
thoracic surgery, increase patient morbidity and mortality
and prolong the length of hospital stay after surgery
PPCs are pneumonia, atelectasis, bronchitis,
bronchospasm, hypoxemia, respiratory failure with
prolonged mechanical ventilation or exacerbation of
underlying chronic lung disease

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 The Risk Factors for PPCs
Procedure-related risk factors: Smoking (1.4 - 4.3 time
primarily based on how close the higher than
surgery is to the diaphragm (i.e. upper nonsmoking)
abdominal and thoracic surgery are the
highest risk procedures (10%-40%)) Age >60 years
Length of surgery (> 3 hours) and Obesity
general anesthesia (vs. epidural or
Presence of obstructive
spinal)
sleep apnea
Emergency surgery
Poor exercise tolerance
Underlying chronic pulmonary disease or poor general health
or symptoms of respiratory infection status

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 Respiratory Problem
Significant Obstructive or restrictive pulmonary disease
places the patient at increased risk, and determination of
functional capacity, response to bronchodilators and/or
evaluation for the presence of CO2 retention through arterial
blood gas may be justified
The asthmatic condition should be under control and free of
wheezing, with a peak flow > 80% of predicted, and treatment
must not be discontinued
History of Asthmatic attack should be carefully assessed,
because airway reactivity persists for several weeks after an
asthmatic episode

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 Respiratory Problem
Complication in patients with chronic obstructive
pulmonary disease (COPD) mostly by co-morbidities
(e.g. cardiovascular disease, unrecognized cor
pulmonale) rather than by airway obstruction
COPD / asthma patient who need oxygen therapy and
/ or hospitalization in the past 6 months are assumed
to be at greater risk
COPD patient may have chronically fatigued
respiratory muscles, that may be caused by impaired
nutrition, electrolyte and endocrine disorders, and
should be corrected before surgery
Patients with obstructive sleep apnea (OSA) are prone
to postoperative hypoxemia
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Thanks

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