Optimizing Patients for Urgent Surgeries – Non-Elective Surgery Triage

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Urgent surgeries — such as appendectomies, cholecystectomies, are common. Sometimes the patients are healthy and other times they are a train wreck. When they are of the latter sorts, the goal should be the optimize the patient for surgery so they are prepared to undergo the stress of surgery.

Understanding the classifications of semi-urgent, urgent, and emergency surgeries informs us of the time that we have to optimize a patient. For example…

It is the weekend call shift with limited resources. The surgeon schedules a laparoscopic cholecystectomy on a patient. Great, you go and look up the patient and find out that:

  • She’s scheduled for a CABG (coronary artery bypass graft) aka open heart surgery next week
  • There’s no echo, angiogram report, no cardiology note on the patient
  • BP 160/110, HR 115
  • Diabetic
  • On the kidney transplant list

So what do you do? The surgeon insists that it is urgent and must be done that day (later you find out that he has scheduled long cases for the next day).

Well, first the goal is to optimize the BP and HR so the BP is below 140/90 and HR below 100. We titrated in metoprolol to effect. We waited for vitals to stabilize before we went. Unfortunately, the surgeon later insisted that it was an emergency case so we had to go on the weekend.

However, was it really an emergency case? Could the case go the next day when there are more resources?

Without additional information, the goal for the patient was to do a slow induction, maintain perfusion, and gentle emergence.

Based on Non-Elective Surgery Triage (NEST), the acute cholecystitis could’ve been scheduled the next day on a Monday where there are more resources.

Non-Elective Surgery Triage (NEST) Level
Non-Elective Surgery Triage (NEST) Classification
Posted in Anesthesia.