Hrev_master [Healthcare in Low-resource Settings 2014; 2:727] [page 19] Anaesthesia for acute abdomen in developing countries Yvonne O. Buowari Department of Anaesthesiology, University of Port Harcourt Teaching Hospital, Nigeria Abstract Acute abdomen is an emergency that requires immediate surgical intervention. In developing and low-income countries, there is limited modern drugs and medical equipment and personnel. General anaesthesia is admin- istered for emergency abdominal surgeries. Ketamine is used in hospitals without trained personnel in the administration of anaesthe- sia. In other hospitals in developing countries with anaesthetist, ketamine is used for induc- tion of anaesthesia and muscle relaxant administered to facilitate endotracheal intuba- tion and maintain anaesthesia with inhala- tional agents to avoid awareness under anaes- thesia. Introduction The term acute abdomen denotes an episode of severe abdominal disorder, which requires urgent intervention usually best treated by sur- gery, and encompasses a spectrum of surgical, medical, and gynaecological conditions ranging from trivial to life threatening conditions.1-4 The incidence of acute abdomen during pregnancy is 1 in 500-635 pregnancies.3 Many medical and gynaecological diseases manifest as acute abdomen, therefore it is sometimes difficult to differentiate them.1 Acute abdomen usually manifests by pain, emanating from the perineum, hollow intes- tinal viscera, mesentery, or pelvic organs and may be caused by inflammation or by a mechanical process such as obstruction, acute distension, or vascular disturbances. Patients presenting with abdominal emergencies often come to hospitals in Africa very late especially if payment for treatment is required. They have often been sick for some days with a per- forated or obstructed bowel. It is due to high environmental temperature and third space loss (fluid in the body, which is not available to the circulation for example oedema, ascites or other collections). The possibility of drug or herb ingestion should be considered by asking about visit to the local healer or ingestion of local or traditional medications.5 Resuscitation and preoperative optimiza- tion are likely to improve outcome. If pro- longed, this develops into hypovolaemia, hypokalaemia, hypochloraemia, and metabolic alkalosis.4 The outcome and survival of the patient depends on the surgical disease, extent of the surgery, urgency, degree of preparation and anaesthetic technique. Anaesthetic considerations All emergencies are considered as full stom- ach and usually the preoperative fasting guide- lines are not feasible with the risk of regurgi- tation and vomiting. The patient may have underlying poorly controlled medical illness. There may not be adequate time for detailed history taking. The patient may be dehydrated, hypo- volaemic from bleeding or vomiting with elec- trolyte derangement. Every patient with an acute abdomen is severely dehydrated unless proven otherwise.5 Hypotension and tachycar- dia will follow as the vascular volume decrease in relation to the size of the vascular bed.6 Abdominal distension occurs from intestinal obstruction or other causes of acute abdomen; it splints the diaphragm and decreases respira- tory reserves.7 If the abdominal distension is long standing, a chest infection may have developed.7 Preoperative assessment Preoperative diagnosis of acute abdomen is crucial to minimise the morbidity and mortali- ty especially where the diagnostic facilities are limited.4,8 The main purpose of the preopera- tive treatment is to optimize the patients’ con- dition and maximise their chance of survival.5 Effective preoperative assessment requires accurate identification of pare-existing prob- lems, risk assessment, preoperative prepara- tion, plan of anaesthetic technique and antici- pation of difficulties that might result during or after anaesthesia.7 Resuscitation and optimization Treatment depends on the cause.9 Through appropriate planning, the patients’ preopera- tive condition can then be optimized.7 The first step in the resuscitation process is to obtain reliable venous access with large bore intra- venous cannulae in a peripheral vein. Optimization of the patient is done as far as possible to allow surgical intervention with minimal risk to the patient. Nasogastric tube should be connected for gastric decompression to remove fluid and air from the stomach to lessen the likelihood of aspiration of gastric contents into the tracheo- bronchial tree during the induction of anaes- thesia.2,4,6,7,10 The nasogastric tube should be connected to a reservoir that the effluent can be measured and allowed to drain freely.11 In some developing countries like Nigeria, an uribag is connected to the nasogastric tube. In some very poor settings, latex disposal gloves are used. Resuscitation may run concurrently with surgery. Fluid and electrolyte disturbances as well as the metabolic imbalances should be corrected prior to the theatre.7,12 Timely decision to carry out surgery when reasonable correction of electrolyte and fluid deficiencies has been achieved should be made.12 The goals of preop- erative fluid management are to restore vascu- lar and intestinal volumes, to correct elec- trolyte and acid-base balance, normalise sys- temic vascular resistance and optimise oxygen delivery. Whole blood or packed cells may be used to restore circulating red blood cells.6 Urine output is a good indication of renal and tissue perfusion and should be monitored. Choice of anaesthesia In an abdominal emergency, it is always assumed that the stomach is full and that an emergency rapid sequence crash induction technique with cricoid pressure and intuba- tion of the trachea is carried out.4,11-14 The endotracheal intubation is to prevent aspira- tion.15 Rapid sequence induction also balances the risk of losing control of the airway against risk of aspiration. The report of the investiga- tion results should be known prior to induction of anaesthesia especially haemoglobin estima- Healthcare in Low-resource Settings 2014; volume 2:727 Correspondence: Yvonne Omiepirisa Buowari, Department of Anaesthesiology, University of Port Harcourt Teaching Hospital, 11 Ihediohanma Street, Mile 2 Diobu, Port Harcourt, Rivers State, Nigeria. Tel./Fax: +234.803732440. E-mail: dabotabuowari@yahoo.com Key words: acute abdomen, anaesthesia, keta- mine, developing countries. Received for publication: 13 December 2013. Revision received: 28 August 2013. Accepted for publication: 1 September 2013. This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0). ©Copyright Y.O. Buowari, 2014 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2014; 2:727 doi:10.4081/hls.2014.727 No n- co mm er cia l u se on ly [page 20] [Healthcare in Low-resource Settings 2014; 2:727] tion, urinalysis, serum electrolyte, urea, and creatinine. Cardio stable drugs will be used. Because the vital organs of the body such as liver and kidney can be damaged by electrolyte imbalances and dehydration, lower doses of intravenous anaesthetic drugs should be used. Technique of anaesthesia Induction Rapid sequence induction with the applica- tion of cricoid pressure will be used at the induction of anaesthesia. Drugs with little or no depressant properties on the cardiovascular and respiratory system will be used. The major- ity of patients requiring laparatomy will pres- ent an aspiration risk and therefore, require intermittent positive pressure ventilation. The nasogastric tube is aspirated and removed. The patient is preoxygenated with 100% oxy- gen by facemask for five minutes ketamine is used as the induction agent which is readily available in developing countries as has good cardiovascular and respiratory stability and a potent analgesic. A major feature that distin- guishes ketamine from other intravenous anaesthetics is stimulation of the cardiovascu- lar system.16 Ketamine increases the sympa- thetic nervous system and circulatory levels of adrenalin and adrenaline consequently leading to heart rate, cardiac output, blood pressure, and central venous pressure.17,18 The respirato- ry rate may be increased and the laryngeal reflexes relatively preserved.18 Ketamine is an effective agent in poor risk patients and those with a tendency to hypotension example rela- tive hypovolaemia and shock.19 Salivation is increased requiring therefore antisialogue premedication is recommended prior to the use of ketamine.14,20,21 It is difficult to detect the patient when sleep commences, as the patient appear to gaze into space and not close their eyes for several minutes. There is no loss of eyelash and corneal reflexes.14 Loss of verbal response in conscious patients can be used to determine when the patient starts sleeping. There is dissociation from the surroundings.12 Ketamine causes vivid and unpleasant dreams, hallucinations, and delirium following its use14 which often are frightening20 which may be reduced by the concurrent use of benzodi- azepines.16,18,20 Intubation is facilitated by the administration of suxamethonium, a depolar- izing muscle relaxant. The greatest danger during the induction of anaesthesia is vomit- ing or regurgitation of gastric contents into the pharynx and into the tracheobronchial tree.6 To aid and prevent this complication, an assistant is required at induction of anaesthe- sia to apply cricoid pressure once conscious- ness is lost after administration of the induc- tion agent. Fasciculations may increase intra- abdominal pressure and induce regurgitation.6 Once the trachea is intubated by direct laryn- goscopy, it is connected to the breathing cir- cuit and intermittent positive pressure ventila- tion commenced. Confirmation of correct placement of the endotracheal tube is done by the absence of cyanosis, auscultation for breath sounds, equal chest movement with positive pressure ventilation and fill of the reservoir bag. In patients with pre-existing tachycardia or hyperthermia, atropine or gly- copyrrolate is omitted.6 The nasogastric tube is put in place after anaesthesia has been induced and the patient intubated. Maintenance Atracurium of pancurium may be used for muscle relaxation. Atracurium has minimal cardiovascular effects and it releases hista- mine.21 To prevent awareness under anaesthe- sia, an inhalational agent is administered. The depth of anaesthesia is hard to assess when using ketamine infusion for maintenance of anaesthesia. Two disadvantages that may be encountered with technique are hypertension and hallucinations. If the patient is moribund, ventilation is done with 100% oxygen and a small dose of ketamine. Shocked patients need small doses of drugs but a higher concentra- tion of oxygen.14 The most important monitor- ing of the patient is clinical including pulse, blood pressure, color, respiration, pupil size, lacrimation in addition to monitoring the sur- gical field, blood loss, urine output, and fluid input.13 Reversal and recovery The end of surgery is the beginning of the next challenging period13 and requires plan- ning to ensure that the sequence of timing of cessation of the inhalation agent, reversal of muscle relaxant with atropine and neostig- mine return of spontaneous ventilation, suc- tion of the mouth and pharynx and extubation of the patient occur smoothly. The assistant must be ready to start suction and tilt the table if required.13 There has to be some return of neuromuscular function before patients can be reversed with neostigmine and atropine.14 Extubation is done only return of airway reflex- es. The patient is extubated until the protec- tive reflexes have returned, as the risk of regurgitation is present.22 In the absence of a nerve stimulator, the presence of adequate neuromuscular function at the end of anaes- thesia may be crudely determined by grip strength, the patient being able to lift their head off the pillow for at least five seconds and the ability to generate a tidal volume between 15 and 20 mL/kg.23 The patient in recovery should continue oxygen, have continuous monitoring of the airway, breathing and circu- lation and be given analgesia as required. Postoperative care In the recovery ward, the patient should be given oxygen and vital signs monitored and analgesics given.12 The postoperative respira- tory problems are those related to hypoventila- tion. Although the intestinal obstruction has been relieved, there may still be significant abdominal distension that will inhibit diaphragmatic motion and the patient may develop hypoxia and hypercapnia. As the patient gradually regains respiratory adequacy, ventilation returns to normal and the patients can be extubated.6 If a drain site was put in place in the course of surgery, effluent from it should be noted and documented such as color, smell, amount and presence or absence of blood. In some developing countries, uribag is used as it does not soil the beddings, is trans- parent and graded. Where there is no recovery room/ward as in rural hospitals, the patient should be monitored closely. The patient must be transported on a trolley with supporting sides and which easily tips into the head down position with facilities for oxygen delivery. Intravenous fluid, antibiotics, and analgesics should continue. Blood transfusion is given when necessary. The required level of postop- erative care will be influenced by the patients’ general condition.4 Prognosis The prognosis of the patient with acute abdomen depends on the time of presentation, presence, or absence of peritonitis, onset, and progression of symptoms, age of patient, aetio- logical factor, level of care, preoperative opti- mization, and resuscitation and the pre- mormid condition of the patient. Conclusions Acute abdomen is an emergency and a diag- nostic dilemma. It is regarded as a full stomach and associated with shock, sepsis, electrolytes and fluid deficits and losses, compromised res- piration, acid/base balance. Treatment depends on the cause but the patient must be resuscitat- ed by the administration of intravenous fluid, nasogastric aspiration, close monitoring of pulse and blood pressure. In hypotension and patients in shock, ketamine is the better induc- tion agent. The patient must be intubated to prevent aspiration and regurgitation. The prin- ciples of the management of intestinal obstruc- tion are provision of analgesia, intestinal decompression, intravenous fluid therapy and if appropriate surgery. The care of the patient Review No n- co mm er cia l u se on ly [Healthcare in Low-resource Settings 2014; 2:727] [page 21] includes routine observations, airways, state of the cardiovascular and respiratory system, oxy- gen therapy, analgesia, urine output, and early ambulation postoperatively to prevent deep venous thrombosis. The postoperative manage- ment of the acute abdomen patient includes postoperative pain relieve and monitoring post- operative pain management is essential for improved mobility, patient comfort, enhanced breathing and prevention of gut immobility. Other aspects of the treatment include adminis- tration of antibiotics and sometimes intensive care admission. Good understanding of how to handle emergencies helps reduce morbidity and mortality. 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