Anaesthetic considerations during hepatic trauma surgery

Abstract

The acute care of trauma patients poses unique challenges for both the anaesthesiologist and the surgeon. Current treatment concepts focus on the prevention of tissue ischaemia, rapid control of haemorrhage, haemostasis and maintenance of tissue perfusion. Successful resuscitation must also address the lethal triad: metabolic acidosis, coagulopathy and hypothermia, which characterize acute, fatal haemorrhagic shock, followed by circulatory system failure. The key elements include appropriate monitoring and mechanical and pharmacological protection of the vital organs to support the patient and restore perfusion. The goals for early resuscitation (prior to definitive control of haemorrhage) are: control of the airway and ventilation, expeditious control of haemorrhage maintaining a systolic blood pressure above 80 mmHg, limited use of crystalloid fluid and maintenance of haematocrit 25%–30%. The early use of plasma achieves normal clotting studies, and the possible use of cryoprecipitate and/or factor VIIa, if the patient is already coagulopathic, platelet count > 50000, stabilized core temperature of > 35°C and gradual conversion to deep general anaesthesia-analgesia are necessary. After the definitive control of haemorrhage, complete resuscitation is achieved by titrated administration of fluids until the following parameters are met: normal or hyperdynamic vital signs, haematocrit > 20%, normal serum electrolytes, normal coagulation function, Platelet count > 50000, restoration of adequate microvascular perfusion:-pH=7.40 with normal base deficit, normalized serum lactate, normal mixed venous oxygenation, normal or high cardiac output and normal urine output. The early management of patients who have major trauma and the prompt collaboration between the surgeon, the anaesthesiologist, the radiologist, the haematologist and the ICU can contribute to a positive outcome.