Anesthetic management of intoxicated patients undergoing emergency surgery

In the hot summer, the scorching air makes workers from all walks of life physically and mentally exhausted. After get off work, three or five friends get together to eat some barbecue and drink some cold beer at the food stalls to relax. But danger also appears inadvertently, and the operating room at night also starts to get busy at this time. In winter, many elderly patients suffer from lower limb fractures due to slips, while in summer, young and middle-aged patients always suffer from injuries and fractures due to falls or car accidents due to drunkenness. Although these patients do not have many diseases like the elderly, as the pillars of the family, they need to be paid more attention. So what does alcohol mean to patients and anesthesiologists in the story that Guan Gong can scrape bones after drinking? How to manage drunk patients? Let's learn and discuss together.

Good anesthesia management begins with a full preoperative evaluation. In addition to routine evaluations of drunk patients, it is also necessary to focus on evaluating the drinking history, including age, amount of alcohol consumed, and frequency of drinking, to determine whether the patient has long-term alcohol intake and alcohol damage to tissues and organs. At the same time, the current state should also be judged, that is, the amount of alcohol consumed this time, whether the patient is conscious, whether he can cooperate, which stage of acute alcohol poisoning he is in, and whether there are protective reflexes such as coughing and vomiting. Alcohol poisoning causes the patient to tolerate pain and can mask other traumatic injuries, so any head or spinal cord injuries must be ruled out before surgery. Severe alcohol poisoning should postpone surgery and the harm caused by alcohol poisoning should be dealt with first.

For patients who are conscious and can cooperate, spinal anesthesia and nerve block can meet the needs of surgery, and general anesthesia should be avoided as much as possible, because the patient's retention of spontaneous breathing and vomiting reflex during surgery can reduce aspiration reflux caused by general anesthesia. However, care should be taken to prevent hypotension and nausea and vomiting caused by spinal anesthesia and alcohol. Antiemetic drugs can be used to prevent vomiting and agitation that may occur during surgery, and drugs that cause nausea and vomiting should also be avoided.

The biggest risk of choosing general anesthesia is aspiration and reflux. The stomach should be emptied as much as possible before induction. Gastric lavage can be performed to remove alcohol and food residues. However, gastric lavage still cannot completely guarantee that all gastric contents are aspirated, so endotracheal intubation is the safest choice. For patients with difficult airways, awake endotracheal intubation with preserved breathing and reflexes should be decisively chosen. The key to successful intubation is good local anesthesia, but stimulation of the larynx and below the larynx (including cricothyroid membrane puncture) may cause nausea and vomiting, so special attention should be paid during the operation.

Some experts suggest preparing two endotracheal tubes. When the first one enters the esophagus by mistake, the balloon can be inflated to separate the digestive tract and the airway, and then removed after successful intubation. For patients who do not have a difficult airway, rapid sequence induction can increase patient comfort. Adequate pre-oxygenation should be ensured before induction. The mandible can be lifted and the cricoid cartilage can be manually pressurized to compress the trachea and esophagus, reduce the amount of gas entering the stomach, and thus avoid aspiration and reflux. In terms of drug selection, succinylcholine is best avoided because it causes muscle contraction, thereby increasing intragastric pressure, leading to further reflux.

Intraoperative Management

In addition to routine testing of blood pressure, electrocardiogram, and finger pulse oxygen, due to the effect of alcohol on vasodilation of skin blood vessels, attention should be paid to the protection of body temperature during surgery. At the same time, since alcohol inhibits the secretion of antidiuretic hormone, the patient's urine volume increases, and intraoperative bleeding occurs, the monitoring of patient volume should also be paid more attention, and central venous pressure should be tested when necessary. Blood sugar levels should also be continuously tested during surgery, because alcohol often accelerates glucose consumption and affects liver function. Diuresis can accelerate alcohol metabolism, and 10-20 mg of furosemide can be injected intravenously, but sufficient circulating volume should be ensured first.

Postoperative Management

Ensure that the patient is fully awake before extubation and prepare the suction device. If vomiting occurs, suction should be performed promptly. Possible causes of postoperative agitation should be promptly addressed, adequate analgesia should be ensured, and stimulation from a full bladder or urinary catheter, hypothermia, etc. should be excluded. Consider that the patient is still in the excitement or ataxia phase of alcohol intoxication due to incomplete metabolism of ethanol. For delayed postoperative awakening, after excluding common anesthesia factors, the effect of alcohol should be considered, because patients with a blood alcohol content of 500 mg or more per 100 ml will be in a coma.

Finally, I would like to remind all my colleagues that although the work is hard, you should avoid excessive drinking. Although wine is good, you should not drink too much.

Qiao Linfeng, Anesthesia and Surgery Center, Jiaozuo People's Hospital

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