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ANESTHESIA For VASCULAR SURGERY

ANESTHESIA For VASCULAR SURGERY

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ANESTHESIA For VASCULAR SURGERY

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  1. ANESTHESIA For VASCULAR SURGERY Mark Welliver MS, CRNA Significant contributions from original by Gwenn Randal MSN, CRNA

  2. Outline • Introduction • Carotid endarterectomy (not covered) • Peripheral vascular surgery • Bypass grafting • Embolectomy • Abdominal aortic surgery • Endovascular Surgery • Thoracic aortic surgery

  3. Vascular Surgery Patients • Coexisting diseases: • CAD 40-80% • Htn • Diabetes • Smokers • CNS; carotid disease, stroke • Renal • 50% of post op mortalities d/t MI • If the surgical site is sclerotic so are other areas

  4. Carotid Vascular surgery • Consider carotid vascular disease coexisting • CEA Covered next spring in trauma course

  5. Peripheral Vascular Surgery • Bypass grafting for occlusive disease or aneurysms • Upper or lower extremities • Endogenous vessels or synthetic (Gortex) • Anesthesia options: • General • Regional

  6. Peripheral Bypass • Potential for blood loss; type and cross 2U • 2 large bore IV access (#18 minimal) • Consider central line; fluids and CVP (PA?) • Fluid warmers with blood tubing • Colloids available; Hespan, albumin • A-line for unstable or ASA 3,4 • Heating blankets (burn risk) • Serial H&H, Abgs

  7. Peripheral Bypass • Femoral-popliteal and lower; • general, spinal, epidural • Ileo-femoral and lower; • general, spinal, epidural • Axillo-femoral; • General, regional, local

  8. Peripheral Embolectomy • Potential for significant blood loss • Type and screen minimal • Large bore IV access • Often MAC with local • Duration?

  9. Abdominal Aortic Surgery • Aorta below diaphragm • Bypass grafting for occlusive disease or aneurysms • Over sew or synthetic grafts (Gortex) • Anesthesia option; General alone or with epidural catheter adjunct

  10. Abdominal Aortic Aneurysm • Common in older adults >60 (5-7%) • Appears to be a genetic link because this type of aneurysm tends to run in families. • Usually occurs in people with atherosclerosis. • Symptoms: abdominal, groin, back pain, syncope, flank mass, or paralysis • Diagnosis: routine physical find, abdominal ultrasound.

  11. Abdominal Aortic Aneurysm Society of Vascular Surgery and the International Society for Cardiovascular Surgery have characterized abdominal aneurysms as: -suprarenal -juxtarenal -pararenal -infrarenal 90-95% of AAAs involve the infrarenal abdominal aorta.

  12. Aneurysms True aneurysm Involves dilation of all 3 layers of the vessel wall: (outer) Tunica externa- fibrous connective tissue (middle) Tunica Media- smooth muscle/elastic tissue (inner) Tunica interna- epithelial layer, squamous cells False aneurysm Caused by disruption of 1 or more layers of the vessel wall.

  13. Abdominal Aortic Aneurysm • <4cm--- u/s q 6 months • 4-5cm– elective repair w/low operative risk and good life expectancy. • 5-6 cm– need repair (mortality rate 0.9-5%) • 6-7 cm– threshold for rupture (mortality as high as 75%).

  14. Overview • Large incision in the abdominal wall, just below your breastbone to top of the pubic bone • Aorta clamped • Aneurysm cut open • Plaque and clotted blood removed • Aortic graft sewn in place- functions as a conduit for blood flow

  15. Management • Potential for blood loss; type and cross 2U • large bore IV access (#18 minimal) • Central line; fluids and CVP (PA?) • Fluid warmers with blood tubing • Colloids available; Hespan, albumin • A-line • Vasodilator gtts and vasopressors • Clamping issues… • Heating blankets (burn risk) • Serial H&H, ABGs

  16. Endosvascular Surgery • Performed under local, mac, ga, regional • Radial a-line & IV’s in right arm • Left arm & both groins used for surgical access • Patients are discharged in 1-2 days post-op • Approved September 2000 by FDA. • Disadvantages: • Endoleaks- (failure to exclude the AAA) • Require follow-up eval’s w/serial CT scans • Demands more office visits than open

  17. Endovascular grafting (EVR) • Catheter tip inserted through a groin artery into abdominal aorta using fluoroscopy • Catheter’s tip holds a deflated balloon. • Balloon inflated, graft opens to span the length and width of the artery. • Devices at both ends of the graft secure it to the inner wall of aorta to strengthen it and keep from rupturing • May not be available at all hospital facilities. • ADV: much less invasive

  18. Endovascular Stent Grafts Indications • Severe COPD • Severe cardiac disease • Active infection • Medical problems that preclude operative intervention. • 1.5cm neck of aorta to pass graft between the renal arteries and the aneurysm • Anatomy/ braches/graft selection factors

  19. Thoracic Aortic Surgery • Aneurysms • Dissection • Occlusive disease • Trauma (covered in neuro/trauma) • Coarctation (covered in Pediatrics)

  20. Risks • Most often requires CPB • Large blood losses • Hypertension pre-op, hypotension intra-op • Myocardial ischemia • Renal ischemia • Spinal ischemia • Death

  21. Aneurysms • Rupture-death #1 risk. >6cm 50% rupture w/in one year. • Surgical repair 2-5% mortality risk • Leaking = >50% mortality • Thoracic aneurysms: tracheal &/or bronchial compression/deviation, Laryngeal nerve compression

  22. Thoracic Aneurysm • Ascending-between aortic valve & innominate • Arch- between innominate & l. subclavian • Descending- distal to l. subclavian

  23. Classification of thoracic aneurysms

  24. Anesthetic Management • Ascending Aorta: • Similar to cardiac surgery utilizing CPB • Consider fem-fem bypass(risk rupture w/sternotomy • Special considerations: • Long aortic cross clamp times • Large blood loss • Right radial A-line (why?)

  25. Anesthetic Management • Aortic Arch: • Similar to cardiac surgery utilizing CPB median sternotomy • Goal- cerebral protection • Hypothermia • Thiopental infusion • Maintain flat EEG • Corticosteroids • Free radical scavengers

  26. Anesthetic Management • Descending Aorta: • Usually without CPB • L. thoracotomy incision • One lung anesthesia • PA cath, A-line, Many large bore ivs, TEE, Cell saver, SSEP • Cross Clamping issues: • ↑SVR, myocardial ischemia, CHF, ↓CO, • Limit fluids pre-clamping • ↑anesthetic depth • Ntg, nitroprusside gtts primed & ready • Clamp Release issues: • SEVERE HYPOTENSION,↓SVR • Preload w/fluids(crystaloid,colloid) before release, vasodilators OFF • ABGs acidosis (bicarb, ↑min. vent.) • Paraplegia risk d/t thoracolumbar artery injury • Renal failure

  27. Aortic Occlusive Disease • Incorporates Aortobifem grafting with/without peripheral thromboendarterectomy • Tx; same as above with focus on location • Rarely a localized phenomena