Preoperative care in emergency surgery

Be prepared. Sir Robert Baden-Powell Introduction Surgical emergencies in the elderly concern mainly trauma, intra-abdominal and vascular surgery. Abdominal pain constitutes 10-15% of all complaints and the unspecific nature of initial symptoms often makes accurate diagnosis difficult. Radiological imaging is often employed in aiding diagnosis and delay in performing these investigations can impact on surgical outcomes. Delays can be attributed to unstable hemodynamic conditions, delayed presentation of the illness, lack of physical signs at first presentation and inability to obtain proper history. The overall morbidity seems to be reduced when surgery is performed within the first 24-48 hours, whilst delays are associated with complications and higher mortality rates (Ryan et al. 2015). Emergency surgery is more frequent in the elderly than in younger patients and emergency cases have higher morbidity and mortality compared to elective surgery. The increased prevalence of age-related disease and comorbidity contrasts with the ability to recover from the physiological challenges of surgery and anesthesia and, especially in the setting of emergency surgery, there may not be time for complete evaluation and correction of risk factors. Clear understanding of the importance of identifying priorities, adequate organization in care delivery and a team approach is the most valid key for ensuring the best achievable outcome. Care Priorities in Geriatric Emergencies Pre-existing conditions and/or severe anatomical injuries increase the risk of poor outcome in elderly patients. Triage is defined as the identification of the severity of injury, the degree of physiological derangement and allocation of treatment according to priorities meant to increase the maximum number of survivors. A priority-wise approach should be employed when dealing with geriatric emergencies in order to correct all life-threatening conditions and give immediate organ support when required. Airway Control During the classic Airway, Breathing, Circulation, Disability, Exposure (ABCDE) assessment it is important to bear in mind the increased risk of aspiration as elderly patients have reduced protective airway reflexes secondary to muscular and neural degenerative changes. Correction of Hypovolemia Hypovolemia is very common in elderly patients presented for emergency surgery, even in the absence of bleeding or shock (Table 11.1). The tolerance to hypovolemia is poor in this specific population mainly because of the decreased β-receptor responsiveness and inadequate increase of heart rate in response to low cardiac output.