Anesthesia Management in Laparotomy of Gastric Perforation Peritonitis: A Case Report and Literature Review

Gastric perforation has the potential to induce acute peritonitis, leading to intense pain and a significant mortality risk. A female patient, aged 67, presented with symptoms of intense abdominal pain affecting all regions of the abdomen and extending to the shoulder. The pain does not alleviate with rest and is aggravated by physical activity and coughing. The Chest X-ray examination revealed the presence of cardiomegaly, characterized by an enlarged heart and aortic elongation. The Abdomen X-ray examination revealed the presence of a pneumoperitoneum. Laparotomy may be conducted in individuals with gastric perforation to identify the pneumoperitoneum's underlying aetiology. The utilization of a concurrent administration of spinal anaesthesia (SA) and general anaesthesia (GA) demonstrates the effective reduction of hemodynamic impact during pneumoperitoneum while avoiding any associated adverse effects.


Introduction
Gastric perforation is a complex penetration of the wall of the stomach, large intestine, and small intestine, resulting in the intestine's contents flowing into the abdominal cavity. 1 Acute peritonitis from gastric perforation can result in excruciating discomfort.Seventy per cent of peptic ulcer disease-related deaths result from gastric perforation.The patient's mortality rate is frequently correlated with the perforation's diameter.Gastric resection or suturing of the perforation site are steps in managing gastric perforation after urgent surgery. 3 anaesthesiologists. 4Individuals scheduled to undergo laparotomy have the option to receive either general anaesthesia or regional anaesthesia. 5 a study conducted by Ghodki PS (2014) 6 , it was demonstrated that the utilization of a concurrent administration of spinal anaesthesia (SA) and general anaesthesia (GA) effectively mitigates the hemodynamic consequences of pneumoperitoneum. 7This combination approach was found to be devoid of any adverse effects.
Utilizing both methodologies yields enhanced stability in cardiocirculatory function compared to the exclusive use of general anaesthesia. 6This article presents a case report on peritonitis resulting from gastric perforation surgery performed under the administration of both general and spinal anaesthesia.

Case(s)
A     Regional anaesthesia is widely acknowledged for its ability to mitigate the adverse effects associated with general anesthesia, including but not limited to nausea, vomiting, sore throat, tooth injury, sedation, postoperative atelectasis, and hypoventilation. 15,16The potential adverse effects of general anaesthesia, including airway trauma, myalgias, and sore throats, can be mitigated through regional anaesthesia.Furthermore, regional anaesthesia has been shown to facilitate expedited cognitive recovery and oral intake during the immediate postoperative phase. 17 Regional anesthesia offers several potential advantages, including expedited recuperation and efficient management of postoperative pain.laparotomy procedures for patients exhibiting compromised cardiopulmonary function due to its minimal impact on cardiopulmonary function.The administration of regional anesthesia has potentially resulted in adverse effects, including significant hypotension and discomfort in the shoulder region due to irritation of the diaphragm. 18gional anesthesia is widely acknowledged for its ability to mitigate the adverse effects associated with general anesthesia, including but not limited to nausea, vomiting, sore throat, tooth injury, sedation, postoperative atelectasis, and hypoventilation.The potential adverse effects of general anesthesia, including airway trauma, myalgias, and sore throats, can be mitigated through regional anesthesia.Furthermore, regional anesthesia has been shown to facilitate expedited cognitive recovery and oral intake during the immediate postoperative Regional anesthesia offers several potential advantages, including expedited recuperation and efficient management of postoperative pain.

Regional anesthesia has been employed in
Regional anesthesia has been employed in laparotomy procedures for patients exhibiting compromised cardiopulmonary function due to its minimal impact on cardiopulmonary function.The administration of regio has resulted potentially resulted in adverse effects, including significant hypotension and discomfort in the shoulder region due to irritation of the diaphragm. 19Previous studies have demonstrated that regional anesthesia can decrease metabolic response.
Patients with stomach perforation may undergo laparotomy to determine what led to the development of pneumoperitoneum.Additionally, a laparotomy might be therapeutic by sealing the punctured organ. 3The choice of anaesthesia modality for a laparotomy procedure is contingent upon several factors, including the patient's age, overall health status, general well-being, and the available resources and expertise of the surgical team, including surgeons, anaesthetists, and nurse Nuh et al MEDICAL AND HEALTH SCIENCE JOURNAL 2023 AUGUST, VOL 07 (01) Page 15 of 20 67-year-old female patient presented with symptoms of intense abdominal pain affecting all regions of the abdomen and extending to the shoulders, which had been ongoing for 5 hours before admission to the hospital.The pain sensation does not improve during rest periods but intensifies with physical activity and coughing.The patient also experiences a sensation of abdominal tightness and rigidity resembling a solid wooden surface.Pain is concomitant with symptoms such as muscular debility, abdominal distension, queasiness, lightheadedness, and perspiration characterized by decreased body temperature.The patient also disclosed a lack of bowel movements and flatus within the past 24 hours.

Figure 1 .
Figure 1.The abdominal region was subjected to a plain X-ray examination, which revealed the presence of a pneumoperitoneum, as depicted inFigure 2.

Figure 1 .
Figure 1.In the first admission, enlarged heart was seen, cardio thorax ratio was 58%.

Figure 2 .
Figure 2. Abdominal x-ray showed pneumoperitoneum.The patient is in a fasted state for 6 hours.The patient was premedicated with oral Ondansetron 4 mg and intravenous lactated ringer's solution 500 ml.Noninvasive blood pressure, oxygen saturation, electrocardiogram (ECG), and urinary catheter were monitored with oxygen intake.The initial vital signs were listed below: blood pressure (BP) 170/70 mmHg; heart rate (HR) 91 bpm; SpO2 99%.ECG showed a sinus rhythm of 91 Bpm.The patient was pre-oxygenated with 100% with 3lpm flow.Bupivacaine 0,5% 3 ml was injected as spinal analgesia.After approximately 10 minutes, rapid induction of general anesthesia for intubation was conducted with 1% propofol 100 mg, fentanyl 80 mcg, midazolam 1 mg, and Atracurium Besylate 20 mg.The patient was intubated using no.7 cuffed endotracheal tube.The cuff was inflated, and the tube was fluxed after checking bilateral air entry.Sevoflurane 1,5% was given as inhalation analgesia.The patient was

Nuh
et al MEDICAL AND HEALTH SCIENCE JOURNAL 2023 AUGUST, VOL 07 (01) Page 18 of 20