The document provides guidance on fluid management for emergency laparotomy patients. It emphasizes the importance of aggressive preoperative resuscitation to correct dehydration, hypovolaemia, hypoxia and acidosis in order to reduce high peri-operative mortality rates. The protocol involves structured clinical assessment, measurement of vital signs and urine output, and administration of IV fluids and electrolytes to optimize the patient's condition prior to anesthesia and surgery. Goals of preoperative resuscitation are to provide adequate tissue perfusion without harming the patient.

1. Fluid management in
Emergency laparotomy
Prepared by-
Dr. Mithun Chowdhury
Train in Anesthesiology, analgesia & intensive care
Sylhet MAG OSMANI MEDICAL COLEEGE HOSPITAL .
Medical officer
Park view medical college hospital

2. Introduction
 Laparotomy (Lapara =‘flank’ , tomy= ‘a cut’)
Procedure with large incision to abd. Wall to gain access to
abd. Cavity. Emer. Laparotomy used for abdominal pain –
to find cause of problem & may to treat etc.
 Abdominal emergencies are frequent cause of death in the
hospitals of developing countries.
This protocol doesn’t involve any expensive monitoring & is based on -
 Structured clinical assessment,
 Simple measurements and treatment options, which are
available in any hospital.

3. Body fluid : lies inside the body in different compartments ,
performing the function of carring nutrients to tissue ,maintaining
circulation , body temperature etc.
Compartments

4. Preoperative management is usually
prescribed by a surgeon in surgical
ward.
Anesthetist are rarely involved in
preoperative management and
frequently only meet the critically ill
patient in theatre.

5.  In spite of the correct surgical diagnosis, the
critical condition of these patients is
frequently not recognized.
 Profound dehydration, hypovolaemia,
hypoxia and acidosis are often overlooked
and not corrected.
 As a result peri-operative mortality in this
group of patients is very high.

6.  These patients sometimes require > 10 liters of
IV fluids in first 24 hrs. (excluding intra-
operative fluids).
 Medical & nursing staff may lack the
confidence to infuse such volumes.
 However treating this group of patients with
aggressive resuscitation reduces the mortality
significantly.

7.  The main goal of fluid resuscitation in emergency
laparotomy is to provide adequate tissue
perfusion without harming patient .
 Intra/per operative control totally put into
practice of anesthesiologist & needs different
expertise.
 Post operative management put into
anesthesiologist /surgeon or both .
 To be considered patient status, amount of fluid
& timing, intra operative event ,type of fluid etc.
Objective

8. Patient status:
 Late presentation with poor condition as with
perforated or obstructed bowel
Degree of dehydration & electrolyte imbalance
are related to duration .
 Dehydration
prolong fasting (no replacement )
Vomiting/ diarrhoea
Fever
High environmental temperature
Third space loss (non functional extra cellular volume as
bowel lumen , peritoneal cavity, ascitis etc. )

9. Cont.
 Amount & colour of urine. Profound dehydration &
hypovolaemia will result in oliguria or even anuria.
 Gastric content (on NG tube) colour (blood, bile,
fecal etc.) & amount

10. Examination:
ABCD framework for both examination and initial
management.
Airway-is not usually a problem.
Breathing - Increased respiratory rate (RR) - early
warning sign (acidosis ,hypoxia, pain, anxiety ,pyrexia )
SaO2 & RR recorded regularly.

11.  Circulation(CVS): usually significantly compromised due to
hypovolemia.
-heart rate (HR)
-blood pressure (BP)
-pulse - weak / well filled
-capillary refill time: very accurate in children and
young adults, less reliable in very
anaemic or old patients.
-core-peripheral temperature gradient (measurement of
central to peripheral skin temperature gradient ).

12.  Dehydration & Disability :
-Severe thirst,
-Decreased skin turgor,
-Dry tongue,
-Sunken eyes,
-Sunken fontanelle in a newborn.
-mental status : apathetic / agitated.

15. Management :
 Target -optimize patient’s condition and maximize survival.
-early effective resuscitation improves tissue perfusion.
 Preoperative resuscitation & early surgery :
earlier the surgery better the result
 Most patients will benefit from 2 - 4 hours preoperative
resuscitation.

16. Management plan ( following ABC
framework )
Initial management
 Airway & Breathing
 Provide oxygen with the face mask at 2-4 l/min &
monitor.
 Circulation
 insert iv cannula, preferably 16G or 18G
 take a sample for Hb, electrolytes & consider cross
matching
 Infuse first litre of N/S or Hartmann’s rapidly over 15 min.
During the following hour give 2 L, watching clinical signs.
Key point :Every patient with an ‘acute abdomen’ is severely dehydrated
unless proven otherwise

17.  Insert indewelling Foley’s catheter : measure
& record the initial amount & colour (conc) of urine
in the bag and discard it.
 Cross matching: If initial Hb% is < 12g/dl & the
patient is severely dehydrated and hypovolemic, --
probably severely anaemic.(Hemoconcentration)

18. Cont.
 Request urgent surgical opinion.
 Antibiotics prescribed should be administered iv as soon
as possible
 Insert NG tube
 Check temperature
 Key point - it is important to realize that these
patients do not only have an abdominal
problem, but multiple organ impairment.

19. Further management:
 Assess the patient after each 1 - 2 L of fluids.
 Whenever possible warm the fluids
 Fluid: Crystalloids and/ or colloids
NS( ! Hyperchloremic acidosis)
Hartmann’s solution (better)
 The correct volume of fluid is more important than the
type.
Tip: No glucose 5% or 10% for preoperative fluid resus!

20. Assessment of resuscitation :
• HR
• BP
• Capillary refill time
• RR
• Improving peripheral temperature
• Filling of neck veins
• Urine output
• CVP measurement ( as indicated )

21. Follow up :
 Repeat Hb after 4-5 L of IV crystalloid or 1.5 - 2 L of colloid
( ! Further blood transfusion )
 Severe anaemia (Hb < 4g/dl), which is frequently
accompanied by hypoproteinemia, there is a significant risk
of pulmonary edema.
blood should be transfused in early stages of fluid
resuscitation.
• Over transfusion - avoided

22. Inotrope :
Increases myocardial Force of contraction .
commonly used : Noradrenalin , Adrenalin , dopamine
Indicated in - Septic condition
Electrolyte replacement:
K+ : derangement causes Cardiac arrhythmia.
Na+ : control body fluid & affect muscle function.
After initial resuscitation, when the patient is passing
good volumes of urine, it is justified to add 20 -40 mmol
of KCl to each litre of IV fluids.

23. Complication secondary to hypovolemia :
 Cardiovascular : Hypovolaemia , Dehydration , Sepsis & septic shock
 Respiratory : Hypoxia , Tachypnoea , Atelectasis
 Blood : Anaemia = If septic - potential coagulopathy
 Renal : Oliguria or anuria due to acute renal failure
 CNS : level of consciousness, confusion , Anxiety , Pain , intoxication
 GI : Full stomach, Abd distension, Bowel perforation or obstruction
 Metabolic : Pyrexia, Hypothermia, Acidosis, Electrolyte disturbance, Hypoglycemia
Keypoint - make sure that patients are not operated on while
still hypovolaemic, hypoxic, and oliguric.

24. The correct timing of anesthesia
& surgery :
Ideally following resuscitation & before anesthesia, the patient will
be stable with a
 pulse < 100/min,
 systolic BP > 90 mmHg
 established urine output and
 good capillary return.
Patients require GA with intubation &
ventilation

25. Anesthesia in emergency laparotomy
Prepare “emergency” drugs :
 Ephedrine or metarminol or other vaso-pressor,
ready and diluted in the syringe.
 Atropine
 In high risk patients prepare diluted adrenaline :
(concentration 1:10 000, 100mcg/ml)
(concentration 1:100 000, 10mcg/ml)

26. Induction :
 Preoxygenation is followed by RSI.
 Thiopental sodium / ketamine can be used.
 In hypotensive patients, ketamine is a better
choice.
 This should be followed by suxameth, non-
depolaraising muscle relaxant and an opioid
analgesic.

27. Maintenance :
 In hypotensive patients maintenance with a
ketamine infusion (500mg ketamine/500ml of
fluid) has some advantages over halothane
which can cause hypotension and arrhythmias,
especially in patients with electrolyte
imbalance.
 It has been suggested that keeping inspired
oxygen level around 80% intra-operatively and
for 2 hours after surgery might reduce the
incident of wound infection and post operative
nausea and vomiting (PONV).4,5

28.  If hypotension follows induction of anesthesia, it
should be treated with rapid infusion of fluids and
ephedrine or adrenaline boluses.
 During anesthesia make sure that the patient
receives an adequate amount of fluids and use
ephedrine or adrenaline as your second line of
treatment.
 In septic patients who are unresponsive to
inotropes, hydrocortisone 100 mg should be
considered.

29. Post-operative period :
 Patients are best managed in a recovery area, and then in a
HDU if possible.
 Supplementary oxygen (3-4 L/min) should be continued for
the first 24 hours if available.
 Careful monitoring of basic physiological parameters (RR, HR,
BP, SaO2, urine output, temperature) is essential over next 24
hrs.
 Signs such as tachypnea, tachycardia, hypotension,
hypoxia, oliguria, changed mental state or hypothermia
should trigger immediate review by the medical staff.

30. IV fluid requirements :
 Intravenous fluid requirements will remain high in the
immediate post-operative period.
 Patients will continue to have third space loss and
residual fluid deficit from the preoperative period.
 Therefore fluid requirements will be above the
maintenance amount of 3 litres per day.
 Often 4 - 6 litres are required in the first 24 hrs.

31. Summary :
Finding the right balance between
appropriate pre-operative resuscitation
but not delaying surgery unnecessarily
seems to be the key to successful treat-
ment of sick patients with abdominal
emergencies.

32. References
 1. Wilson J, Woods I, Fawcett J et al. Reducing the risk of
major elective surgery: randomized controlled trial of
preoperative optimization of oxygen delivery. British
Medical Journal 1999;318:1099-103
 2. Kern JW, Shoemaker WC. Meta-analysis of
hemodynamic optimization in high-risk patients. Critical
Care Medicine 2002;8:1686-92
 3. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed
therapy in the treatment of severe sepsis and septic
shock. New England Journal of Medicine 2001;345:1368-
77Update in Anaesthesia 11

4.Smith & Maidenhead's Text book of Anesthesia-6th
edition