Exploratory Laparotomy (Emergent)
Patient phenotype
Acute abdomen — perforated viscus, ischemic bowel, ruptured AAA, gunshot/trauma. Often septic, hypovolemic, full stomach. Age varies wildly.
Procedure
Midline incision, exploration, source control. Length highly variable (45 min for perfed appy → 6+ hours for bowel resection + washout). Often needs vasopressor support throughout.
Anesthetic plan
RSI GETA. A-line pre-induction if hemodynamically unstable. CVC if pressors expected to last > 2 hours or need for CVP/ScvO₂. Massive transfusion protocol activated if surgical bleeding likely. Avoid N₂O (bowel distension).
Setup
- ·2× 16-gauge PIVs minimum, blood tubing primed
- ·A-line — pre-induction if shock
- ·CVC if pressors ≥ 2-3 mcg/kg/min equivalent or fluid status unclear
- ·Type & cross 4 units PRBC, FFP available
- ·Rapid infuser (Belmont / Level 1) ready
- ·Forced air warmer + fluid warmer
- ·Foley with hourly UOP
Biggest concerns by phase
Resuscitation status — under-fluid is more dangerous than over-fluid here
Septic + hypovolemic patient looks borderline OK at rest, then crashes on induction. Goal: at least 30 mL/kg balanced crystalloid before induction unless cardiogenic concern. Lactate, base deficit, MAP trend > one-time vital sign.
RSI in shock — drug choice + dose reduction
Standard induction doses cause cardiovascular collapse in shock. Etomidate 0.1–0.2 mg/kg or ketamine 0.5–1 mg/kg with sux 1–1.5 mg/kg or roc 1.2 mg/kg. Pre-position vasopressors (phenylephrine, norepinephrine) drawn. Be ready to start NE infusion immediately.
Hypothermia + coagulopathy + acidosis (lethal triad)
Long laparotomy + open viscera + cold IV fluids = rapid heat loss. Aim core temp ≥ 36 °C. Use warm fluids, BAIR all surfaces possible, room temp up. Below 35 °C, platelet function drops, factor activity drops 10% per °C.
Massive transfusion + 1:1:1 ratio
If transfusion exceeds 4 units in 1 hr or 10 units in 24 hr, activate MTP. Give PRBC : FFP : platelets ≈ 1:1:1. Replace cryo if fibrinogen < 200. Avoid LR (calcium chelation by citrate = hypocalcemia + worsened coag).
Hypocalcemia from citrate + transfusion
Each unit of PRBC contains ~3 g citrate. Liver normally clears it; in shock or rapid transfusion the citrate binds calcium → ionized hypocalcemia → cardiac dysfunction, prolonged QT. Replace empirically: CaCl₂ 1 g per 4 units PRBC.
Don't extubate — go to ICU intubated
Even if vitals look 'OK,' the patient resuscitated through major surgical insult is at high risk for re-deterioration. Standard practice: ICU intubated overnight, wean per ICU protocol after sedation and pressor wean. Discussion with surgeon + ICU before emergence.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
Your patient is a 65-year-old male with a perforated diverticulum. BP 85/50, HR 120, lactate 6.2, K 5.8, getting his second 30-mL/kg bolus on the way to OR. Surgeon wants to start now. Walk me through induction.
What an examiner probes for
- ▹Acknowledges resuscitation incomplete + risk vs. surgical urgency
- ▹Drug choice: etomidate vs. ketamine + dose-reduced + sux/roc rationale
- ▹Pre-positioned vasopressor + a-line pre-induction
- ▹K+ + acidosis management (avoid sux? — actually OK at K 5.8 if RSI urgency)
You've given 6 units PRBC, 4 FFP, 1 6-pack platelets. INR is 1.8, fibrinogen 140, ionized Ca 0.9, temp 35.2. Surgeon says they need 'a few more units, we're almost done.' What's your plan?
What an examiner probes for
- ▹Cryo for fibrinogen < 200
- ▹CaCl₂ for ionized hypocalcemia
- ▹Active warming — fluid warmer, BAIR, ambient temp
- ▹Communicate with surgeon: lethal triad recognized, may need damage control → ICU
Sources
- Miller's Ch 81 (trauma)
- ASA MTP guidelines
- ATLS 10e
Anatomy reference
Sourced reference images. 4 matches for "abdomen peritoneum bowel".
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