Pre‐optimisation of patients undergoing emergency laparotomy: a review of best practice

Abstract

Summary Although the concept of pre‐operative optimisation is traditionally applied to elective surgery, there is ample opportunity to apply similar principles to patients undergoing emergency laparotomy. The key challenge is achieving meaningful improvements in a patient's condition without introducing delays to time‐sensitive surgery, which may be required in a matter of hours. Optimisation can be considered in two parts: that of the patient's condition; and that of the care pathway. Optimising the patient's condition is less about improving long‐term pathology, and more about correcting physiological derangement, such as electrolyte and fluid balance, blood loss, prompt treatment of sepsis, and ensuring appropriate continuation of medication in the peri‐operative period. Optimising the care pathway involves ensuring that the system is designed to deliver reliably the appropriate interventions, such as prompt antibiotics, and access to computed tomography scanning and the operating theatre with minimal delay.

Documentation of individualized preoperative risk assessment: a multi-center study

“…Additionally, because the ASA-PS score does not inform clinicians about organ-specific risk, appropriate, targeted preoperative medical optimization, and perioperative medical management remains uninformed. Though our study was not designed to demonstrate that preoperative risk assessment improves outcomes, prospective surgical risk assessment has been shown to decrease mortality in patients undergoing both elective (NCEPOD, 2011 ) and emergency surgery (Poulton et al, 2019 ). Whether the cause of reduced mortality is due to better informed perioperative medical management or patients deciding not to have surgery following informed shared decision-making remains unclear (Hall et al, 2012 ).…”

Immediate Post-laparotomy Hypotension in Patients with Severe Traumatic Hemoperitoneum

“…Blood pressure management is crucial during surgery, as intraoperative hypotension can cause severe complications, such as myocardial infarction and stroke [1][2][3][4]. Immediate post-laparotomy hypotension (PLH) is a precipitous drop in blood pressure caused by the sudden release of abdominal tamponade after laparotomy in cases of severe hemoperitoneum.…”

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.…”