Laparotomy

Anesthesia Implications

Position: Supine, arms extended
Time: 2-4 hours (long)
Blood Loss: High (200 – 500 ml)
Post-op Pain: High (7-10)
Maintenance Paralytic: Yes

Get clarity – speak to the surgeon and ask what the surgery is being performed for. This will help gauge the length of the procedure, need for a gastic tube, need for an epidural, etc.

Time – the length of these procedures varies widely (avg 1-4 hours). This is another good question for the surgeon.

Pain – there’s quite a bit of pain after these procedures. Some surgeons will request an epidural. Make sure you’re prepared.

Blood loss – These cases vary quite a lot between minimal to high blood loss. This will be highly dependent on the patients condition and reason for the laparotomy.

Hemodynamics – Many of these patients will be very sick (eg ischemic bowel, sepsis). Anticipate difficulty maintaining a healthy hemodynamic status.

Hydration – Open abdominal cases have the greatest third space losses. Recommendations are 10-15 ml/kg for the first hour and 5-10 ml/kg thereafter.

High Blood Loss (general considerations): Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.

Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.

High post-operative pain (general considerations): Plan ahead to treat pain in the postoperative period. If not contraindicated, consider hydromorphone or other long-acting analgesics along with adjuncts such as Ofirmev and/or toradol. Where possible, give during the operative period to limit pain in the postoperative period. Where applicable, consider peripheral nerve blocks and/or epidural interventions.

Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.