Preoperative assessment and preparation are vital to successful anesthesia administration, reduced intraoperative complications and rapid postoperative recovery.1 However, in cases of emergency surgery, patient preparation is minimal or even nonexistent.2 Given the lack of preoperative care in emergency surgery, anesthesia providers face a variety of challenges, including elevated risk of aspiration, complex trauma-related injuries and diverse patient-specific health risks.2 Anesthesiology practitioners may need to take extra steps such as provision of additional medications or alternative anesthetic drugs.3,4 As anesthesia providers are already responsible for perioperative patient monitoring and avoiding complications, emergency surgery can make an anesthesiologist’s job even more difficult.
One of the most common problems for an anesthesia provider is prevention of aspiration of gastric contents in emergency surgery.2 During general anesthesia, respiratory and gag reflexes that normally prevent food and gastric juices from entering the lungs are suppressed.5 Thus, food, stomach acid, blood or saliva can enter the trachea, causing the substance to enter the lungs and cause life-threatening respiratory issues.5 Because of this risk, patients undergoing general anesthesia are encouraged to refrain from eating or drinking for several hours before surgery. In emergency surgery, though, patients may not have fasted before a procedure, or they may have experienced trauma or stress that could slow gastric emptying.2 Additionally, emergency surgery patients often have health conditions such as pregnancy, diabetic neuropathy or renal failure that further increase the risk of aspiration.2 Anesthesia providers take measures to prevent gastric aspiration in emergency surgeries, including preoperative starvation; decreasing gastric acidity with oral antacids or H2 blockers; and reducing gastric volume with a nasogastric tube, medications or pressure at the cricoid cartilage in the neck.2,6 Though aspiration can cause fatal hypoxia (oxygen deprivation) or pneumonitis (inflammation of the lung tissue), it occurs relatively infrequently.7,8 Therefore, drugs that decrease gastric volume and acidity like antacids, H2 blockers and prokinetic drugs are not indicated for routine use.2 Indeed, a study by Borland et al. found that routine prophylactic administration of drugs to avoid aspiration in pediatric patients was unwarranted.9 It is the duty of the anesthesia provider to assess the necessity of these medications in patients with higher aspiration risk (e.g., patients who use opioids, have dyspepsia, are morbidly obese, etc.).8
In trauma-related emergency surgeries, risk of aspiration is only one of many obstacles faced by anesthesia providers.8 Before a procedure, anesthesia providers must confirm a trauma patient’s preanesthetic history and perform a physical examination to establish drug contraindications.2 For the procedure itself, anesthesiologists must choose between two forms of airway control in trauma patients. Indications for endotracheal intubation are head injury, shock, airway obstruction, combativeness, general anesthesia, chest trauma, post-resuscitation hypoxia and cardiac arrest.2 Meanwhile, tracheostomy (i.e., an incision in the windpipe) may be necessary for trauma patients with disruption to the floor of the mouth, larynx or cervical trachea.2 Anesthesia providers may need to make additional choices regarding trauma patients’ care during surgery, including deciding between spinal versus epidural anesthesia.4 Also, constant monitoring for blood loss is crucial to a trauma patient’s intraoperative care.2
Anesthesia care for emergency surgery may also occur under unique circumstances. These situations include obstetric care,2 pediatric emergency surgery2,9 and surgery for patients with extreme hypothyroidism10 or risk factors for cardiac arrest.11 Depending on the type of patient and the patient’s current condition, the anesthesiologist may need to make quick and calculated decisions about medication provision and vital signs monitoring.
Overall, anesthesia for emergency surgery requires significantly increased precautions. Because of time limits and absence of preoperative care in emergency surgery, anesthesia providers must be on the lookout for aspiration risk, trauma and complex circumstances. Future research should delineate the best practices for patients undergoing different types of emergency surgeries, as well as precautions for patients with multiple traumas.
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3. Kopp Vincent J, MD, Mayer David C, MD, Shaheen Nicholas J, MD. Intravenous Erythromycin Promotes Gastric Emptying Prior to Emergency Anesthesia. Anesthesiology: The Journal of the American Society of Anesthesiologists. 1997;87(3):703–705.
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