Emergency laparotomy is a common surgical intervention, with 30,000-50,000 such procedures performed annually in the UK. The procedure is associated with high risk of complications and high mortality. Emergency laparotomies are a diverse group of surgical procedures, where advanced age of patients, their baseline ASA physical status, the urgency of the need for surgery, as well as the need for postoperative management in an anaesthesiology and intensive care unit have an impact on perioperative mortality (1, 2). Improvement of treatment outcomes in this group of patients may be achieved by better identification of high-risk patients and improved intra- and postoperative anaesthetic care, increased postoperative supervision in anaesthesiology and intensive care setting in particular. The initiative of improving the quality of surgical treatment in patients after emergency laparotomy led to the formation of groups of experts on emergency laparotomy, who publish their reports every few years (Emergency Laparotomy Network, National Emergency Laparotomy Audit – NELA, and the Emergency Laparotomy Collaborative – ELC) (3).

The indications for emergency laparotomy are broad. Advances in diagnostic imaging and minimally invasive surgical techniques reduced the need for exploratory laparotomy, with diagnosis and prediction of surgical extent possible already before the surgery in most cases. The most common indications for laparotomy are presented in table 1.

Patients with GI perforation, peritonitis and GI obstruction are the most common group requiring emergency laparotomy. Expectant conservative treatment and patient monitoring are appropriate in some cases, such as adhesion-related obstruction with no symptoms of bowel ischaemia, limited abscess that can be punctured and drained under imaging guidance (e.g. ultrasonography), or malignant bowel obstruction in the absence of peritonitis or perforation, when treatment using stents may be implemented. Colon perforation extending from the ileocaecal valve to the border of the intraperitoneal rectum causes symptoms of bacterial peritonitis, which is often referred to as faecal peritonitis. The symptoms are violent in the case of full-thickness bowel rupture and spillage of faecal contents into the peritoneal cavity (7). Large amount of bacteria released from the colon cause septic shock. Mandatory antibiotic therapy involves both empirical and targeted treatment after obtaining bacterial culture findings (8). Empirical treatment should be implemented in the initial stage of acute abdominal symptoms due to perforation. The choice of treatment strategy depends on whether the infection is community- or hospital-acquired, as well as on the type of pathogen resistance to treatment in a given hospital ward (9, 10). The 2016 Guidelines of the Surviving Sepsis Campaign have been updated to include a bundle of interventions in the first hour from sepsis recognition. According to the authors of the bundle, the following interventions should be undertaken within 1 hour of sepsis diagnosis: measurement of blood lactate levels, collecting blood for culture, initial broad-spectrum antibiotic therapy, fluid therapy: administration of 30 mL/kg crystalloid or, for hypotension or blood lactates ≥ 4 mmol/L, vasopressors in the case of hypotension not responding to the initial fluid therapy to maintain MAP ≥ 65 mm Hg (11). The 2016 sepsis and septic shock care bundles proposed by the experts on sepsis and septic shock are summarised in table 2. See table 3 for the updated guidelines.

Anaesthetic management begins with risk assessment involving medical history, physical examination and complementary tests. Routinely performed tests include laboratory blood testing (including pregnancy test in a selected group of patients), arterial or venous blood gas, lactate levels, chest radiography, electrocardiography and, usually, abdominal CT. Patients after surgery due to GI obstruction, presenting with sepsis due to bowel perforation or ischaemia develop deep hypovolaemia, which may in turn lead to secondary organ pathologies, such as acute renal damage and atelectasis. Recent (2016) guidelines of the Working Group on Sepsis-Related Problems recommend early antibiotic therapy in the first hour of treatment to reduce mortality due to septic shock (12, 14). A similar recommendation to administer antibiotic within first hour of sepsis recognition is suggested by the NELA working group. Preoperative fluid resuscitation with 30 mL/kg body weight of intravenous fluids to achieve MAP > 65 mm Hg is another recommendation of the Working Group on Sepsis-Related Problems. Fluid resuscitation requires remeasurements to achieve its goals. It should be emphasised that in most cases of emergency laparotomy fluid resuscitation should not delay surgical treatment, but should be run in parallel in the pre- and intraoperative period. Sepsis, which is common in this group of patients, is a condition involving the following pathophysiological processes: venous and arterial vasoplegia, tissue oedema due to redistribution of fluid from vessels to tissues as a consequence of damage to the vascular endothelium and impaired myocardial contractility (15). The multifactorial relationships of fluid balance, as well as significant fluid shifts between fluid spaces and fluid loss emphasise the importance of early fluid therapy, as well as monitoring and assessment of fluid balance. Assessment of fluid balance in this group of patients poses difficulty, and fluid overload may worsen the general condition of the patient. Therefore, great importance is attached to the monitoring of cardiac output and early administration of vasopressors.

Anaesthetic management focuses on rapid and reliable securing of airways to minimise the risk of aspiration of gastric contents into the lower respiratory tract, stabilisation of cardiovascular function during rapid induction of anaesthesia and perioperatively, optimisation of the amount and type of intravenous fluid therapy, protective intraoperative mechanical ventilation, as well as postoperative analgesia and other postoperative care.