Management of the patient presenting for emergency laparotomy

Practical approach for safe anesthesia in a COVID-19 patient scheduled for emergency laparotomy

“…Emergent laparotomies comprise of a diverse group of surgical pathologies, frequently presenting in patients with attendant co-morbidities. This review highlights salient management principles for patients scheduled for emergency laparotomy[ 1 2 3 ] along with outlining a practical, evidence-based approach on safeguarding healthcare workers (HCW) while managing such a patient with COVID-19 disease. Given the contagiousness of SARS-CoV-2 virus, limiting unnecessary/prolonged exposures of HCWs to patients is essential.…”

“…Delays in surgical damage control in favour of optimization are deleterious. [ 1 2 3 ] Hence, the goal should be to judiciously optimize without delaying surgery and the extent of optimization should be determined by the surgical urgency. Hypovolemia is common due to dehydration, reduced intake, losses from drains/stomas, fever, redistribution of fluid between compartments, bleeding, retention in bowels, etc.…”

“…Hence, where regional techniques are not feasible, non-conventional methods for pain relief such as intravenous infusions of lidocaine, ketamine, or MgSO4 may be considered as alternatives to opioids. [ 2 ]…”

“…In view of higher propensity for development of acute lung injury in these patients, protective lung ventilation strategy should be used along with avoidance of permissive hypercapnia if the patient already has pre-existent metabolic acidosis. [ 2 ] Maintenance of anesthesia can be with volatile anesthetics in oxygen and air or with total intravenous anesthesia (TIVA). One should be aware that TIVA increases the number of fomites in the theatre.…”

“…Active chest physiotherapy, deep breathing exercises and early ambulation will minimize PPCs. [ 2 ] Continuation of goal-directed therapy with optimal analgesia, fluid management, early mobilization and optimization of nutrition will aid in postoperative recovery,[ 24 ] though a laparotomy patient who is COVID positive is likely to have a stormy postoperative course, as viral illness is known to worsen subsequent to reduction in cell-mediated immunity caused by surgical stress. [ 5 ] Removal of the epidural catheter should be done when platelet count and coagulation status are acceptable with due considerations to anticoagulants administered in the postoperative period.…”