Anesthesia for

Emergency
Appendectomy
 GENERAL DATA
• K.V
• 27/Female
• Married
• Filipino
• Roman Catholic
• Baggao, Cagayan
 DIAGNOSIS
• Acute Appendicitis
HISTORY OF PRESENT ILLNESS
• A 27-year-old woman presents to the
emergency department complaining of
abdominal pain, anorexia, nausea,
vomiting and low-grade fever. Her pain
began in the peri-umbilical region 6 hours
ago and has now migrated toward the
right lower quadrant of the abdomen. The
pain was steady in nature and
aggravated by coughing.
• No medications taken
• Persistence of pain prompted
consultation to his PMD.
 PAST MEDICAL HISTORY
• (-) Trauma
• (-) Allergies

• Surgical History
– Tonsillectomy at age 10
– dilatation and curettage (D&C) at age 25

• No maintenance medications
 PAST MEDICAL HISTORY
• OB history
– OB score: G1P0 (0010)
– LMP: May 20, 2020
 FAMILY HISTORY
• (-) Hypertension
• (-) DM
• (-) Heart disease
• (-) Lung disease
• (-) Genetic disorder
• (-) Bleeding disorder
 PERSONAL/SOCIAL HISTORY
• Non-smoker
• Non-alcoholic drinker
• Denies illicit drug use
 PHYSICAL EXAMINATION
• Alert, not in cardiopulmonary distress
• BP – 100/70 mmHg, HR – 110bpm, O2 sat –
99%, Temp – 38.6oC
• Weighs 57kg and is 5ft, 4in tall
• Pink palpebrae, anicteric sclerae
• (-) CLAD
• No mass or tracheal deviation
• SCE, CBS
• NRRR, no murmur, PMI at 5th LICS
• (+) RLQ tenderness upon palpation, no mass
• Full and equal pulses
 LABORATORY RESULTS
• Her serum HCG is negative
• leukocytosis (12 x 10^9/L or
12,000/microlitre) with 85% neutrophils
• Others unremarkable
 DIAGNOSTICS
• Abdominal CT Scan shows inflamed
appendix with a diameter of ~6-7mm and
has appendiceal wall thickening, findings
suggestive of acute appendicitis
 Considerations
• Adequate Running Peripheral IV Line
• Physical examination and review of the
patient’s vital signs
• Resuscitative fluids before proceeding with
anesthesia for volume depleted patients
• Tilt Test – Assess degree of intravascular
depletion
• Pregnancy Test – for possibility of
pregnancy
• Controlled mechanical ventilation, and
standard monitoring
 Considerations
• Full stomach – precaution to prevent aspiration
of gastric contents
• Passive regurgitation of gastric contents -
Cricoid pressure
• Paralysis – by administering Succinylcholine 1 to
2 mg/kg
• 2 Potential Post Operative Problem\
– Postoperative pain relief - morphine 0.1 mg/kg as
adjuvant to anesthesia
– Postoperative nausea and vomiting
• Patient’s muscle relaxation – at the end of
surgery neostigmine 0.05 mg/kg and
glycopyrrolate 0.01 mg/kg is administered
DEFINITION OF TERMS
 PREOXYGENATION

• Administration of oxygen to a patient prior to

intubation to extend 'the safe apnea time’
• Accomplished by asking her to breathe 100% oxygen
for 3 minutes prior to induction.
• rationale for preoxygenation is that in the event that a
patient cannot be ventilated or intubated, he or she
will have adequate oxygen in reserve to survive long
enough to awaken and resume breathing.
 RAPID SEQUENCE INDUCTION
• A technique of rapid induction and
intubation used to minimize the risk of
aspiration.
• Mask ventilation before endotracheal
intubation is avoided to prevent
insufflation of gas into the patient’s
stomach.
 CRICOID PRESSURE
SELLICK’S MANEUVER

• Cricoid pressure is the posterior displacement of the

cricoid cartilage against the vertebral body to
immobilize the trachea and create occlusion of the
esophagus between cricoid ring and six cervical
vertebrae
• Designed to prevent stomach contents from ejecting
during vomiting, hence reducing the risk of aspiration
into the respiratory tract
 SUCCINYLCHOLINE
• A depolarizing neuromuscular blocker
often used for rapid sequence induction
because of its rapid onset (usually <60
seconds).
• Succinylcholine can trigger malignant
hyperthermia in susceptible patients.
MALIGNANT HYPERTHERMIA
 POSTOPERATIVE NAUSEA AND
VOMITING (PONV):
• A common side effect seen in patients
undergoing general anesthesia.
• Risk factors include prior history of
postoperative nausea, motion sickness,
major abdominal surgery, nonsmoker,
female gender, and use of opioids.
 THE APPENDIX

The appendix is a narrow blind-ended tube that is

attached to the posteromedial end of the cecum
(large intestine).

Arterial supply is from the appendicular

artery (derived from the ileocolic artery, a
branch of the superior mesenteric artery) and
venous drainage is via the
corresponding appendicular vein. Both are
contained within the mesoappendix.

Sympathetic and parasympathetic branches of

the autonomic nervous system innervate the
appendix. This is achieved by the ileocolic
branch of the superior mesenteric plexus.
It accompanies the ileocolic artery to reach the
appendix.
CLINICAL APPROACH
 ASPIRATION
NPO guidelines elective Sx ( American
Society of Anesthesiologists)
• Clear liquids 2hrs
• Milk/ Light meal 6hrs
 ASPIRATION
NPO guidelines for emergency Sx
( American Society of Anesthesiologists)
• Pain, trauma, diabetes, abdominal
emergencies delay in gastric
emptying increased risk of aspiration
• Other conditions associated with
increased aspiration risk:
Ileus, obesity, pregnancy, hiatal hernia,
scleroderma, and altered mental status
which occurs following stroke.
 ASPIRATION
NPO guidelines for emergency Sx
( American Society of Anesthesiologists)
• All patients presenting for emergency
surgery should be treated as though they
have a full stomach.
• Risk of aspiration and the resulting
damage to the respiratory mucosa
increase with a gastric volume of more
than 25 mL and pH less than 2.5
 ASPIRATION
NPO guidelines for emergency Sx ( American Society of
Anesthesiologists)
• Reduce the volume and increase the pH of the gastric
contents.
Histamine receptor antagonists (ranitidine)
 decrease secretion of gastric acid
do not affect the acidity of the contents already present
in the stomach
Metoclopramide
stimulates gastric emptying
increases the lower esophageal sphincter tone
Anticholinergic drugs (glycopyrrolate)
decrease the gastric secretions
decrease the lower esophageal sphincter tone
 ASPIRATION
NPO guidelines for emergency Sx
( American Society of Anesthesiologists)
• Reduce the volume and increase the pH
of the gastric contents.
Nasogastric tube
does not guarantee gastric emptying.
 ASPIRATION
NPO guidelines for emergency Sx ( American Society of
Anesthesiologists)
Patients presenting for abdominal emergencies can also
present with ileus.
Factors predisposing for ileus include narcotics,
antacids, anticoagulants, phenothiazines, ganglionic
blockers, metabolic derangements like hyponatremia,
hypokalemia, hypomagnesemia, sepsis, infection, and
inflammation.
Ileus can also persist in the postoperative period as well.
 Small bowel function commonly recovers within a day
 Gastric motility within 1 to 2 days
 Colonic motility can take up to 5 days
 Preoperative Optimization:
Resuscitation of Blood Volume
Patients presenting with an acute abdomen
are often quite dehydrated as a result of
vomiting and loss of fluids into the intestine.
 tachycardia, oliguria, altered sensorium,
decrease in skin turgor, dry mucus
membranes, and orthostatic hypotension
 elevated hematocrit, serum electrolytes
may be abnormal since severe vomiting
can lead to metabolic alkalosis due to loss
of gastric acid.
 Preoperative Optimization:
Resuscitation of Blood Volume
• Patients should receive adequate and
appropriate volume resuscitation prior to
the induction of anesthesia.
• The anesthetic options for an open
appendectomy are general anesthesia or
central neuraxial anesthesia.
 Preoperative Optimization:
Resuscitation of Blood Volume

General Anesthesia
• Using a rapid sequence induction and
tracheal intubation (Crash induction)
• Complications include failure to ventilate due
to closure of the vocal cords, cricoid ring
fracture, esophageal rupture, and profound
hypotension.
• It involves the application of cricoid pressure
to minimize the risk of aspiration.
• Active vomiting, cervical spine injury, and
tracheal injury are contraindications to the
use of cricoid pressure.
 Preoperative Optimization:
Resuscitation of Blood Volume
General Anesthesia
Propofol
 Induction agent of choice due to its rapid
onset, short duration of action, and smooth
and pleasing emergence.
 Causes vasodilation, so its use
presupposes that the patient is well
hydrated and not demonstrating signs of
hypovolemia.
 Typical dose of propofol is 1.5 to 2.5
mg/kg for induction.
 Preoperative Optimization:
Resuscitation of Blood Volume
General Anesthesia
Ketamine (1 mg/kg i.v.) or Etomidate
(0.1-0.4 mg/kg i.v.)
Alternatives, for patients with hypotension
 Preoperative Optimization:
Resuscitation of Blood Volume
General Anesthesia
Succinylcholine (1-1.5 mg/kg i.v.)
 Rapid onset.
 Neuromuscular blocking drug of choice
in rapid sequence inductions.
 Its short duration allows the paralyzed
patient, who can neither be ventilated nor
intubated, to resume breathing promptly.
 Preoperative Optimization:
Resuscitation of Blood Volume
General Anesthesia
• Once intubation is accomplished and
proper endotracheal tube placement is
confirmed, cricoid pressure can be
released.
• If intubation is unsuccessful, cricoid
pressure should be maintained
continuously during subsequent
intubation attempts and during mask
ventilation.
 Preoperative Optimization:
Resuscitation of Blood Volume
General Anesthesia
• An open appendectomy is a short
procedure, hence the anesthetic agents
used should have a short half-life to
facilitate quick emergence.
• Desflurane and sevoflurane low blood-
gas partition coefficients, thus low
solubility in blood, and are suitable for
short procedures.
• Nitrous oxide  bowel distention and
postoperative nausea and vomiting.
 Preoperative Optimization:
Resuscitation of Blood Volume
General Anesthesia
• It is important to ensure that the patient is
awake and following commands prior to
extubation.
• If a patient vomits, the head of the bed
should be dropped ten degrees and the
pharynx suctioned.
 Preoperative Optimization:
Resuscitation of Blood Volume
General Anesthesia
• Respiratory criteria for extubation
Adequate tidal volumes, a normal
respiratory rate, and the ability to cough
and breathe deeply.
• A sustained head lift lasting 5 seconds
typically predicts that the muscle
relaxants have been successfully
reversed.
 Preoperative Optimization:
Resuscitation of Blood Volume
Neuraxial Anesthesia (Spinal)
• May be preferred in pregnant patients in
order to minimize the systemic
concentrations of general anesthetics.
• However, the sensory level required for a
routine appendectomy is T4, which is
quite high.
 Postoperative Complications
Nausea and vomiting
• Selective serotonin receptor antagonists
like ondansetron, dolasetron, and
granisetron effective in alleviating
postoperative nausea and vomiting with
minimal side effects when administered
just prior to the end of a case.
 Postoperative Complications
Nausea and vomiting
• Other classes of drugs including
anticholinergics, dopamine antagonists
and antihistamines may also be utilized,
but have significant side effects.
• Clonidine, dexamethasone, and
acupuncture have also been found to be
effective.
 Postoperative Complications
Post- operative Pain
• The goal is to minimize any potential
sensitization of the spinal cord and brain
propag
• One method of the preemptive analgesia
involves central neuraxial blockade.
• However, if a general anesthetic is used,
local field block in the area of the incision
is effective as well.
 Postoperative Complications
Post- operative Pain
Opioids
 most widely used to control
postoperative pain but have significant side
effects like ileus, respiratory depression,
nausea, and vomiting.
Nonsteroidal anti-inflammatory drugs
(NSAIDs)
 may also be used for postoperative pain
control in these patients.
Thank you!!!
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