Scribd Logo
Upload

Welcome to Scribd!

  • 404 views

    Abdominal Aortic Aneurysms-Edit

    Uploaded by

    randika
    The document discusses anesthetic considerations and management for abdominal aortic aneurysm (AAA) repair surgery. It covers pre-operative risk assessment and optimization, intra-operative techniques like different clamping positions and hemodynamic management, and post-operative complications like cardiac, lung, renal and spinal cord issues. New developments discussed include fast-track programs aiming to reduce complications and length of stay through measures like early feeding and mobilization. Specific medications mentioned that may provide benefits are milrinone for its cardiovascular effects and dexmedetomidine for hemodynamic stability and potential organ protective properties.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    Abdominal Aortic Aneurysms-Edit

    Uploaded by

    randika
    404 views32 pages
    The document discusses anesthetic considerations and management for abdominal aortic aneurysm (AAA) repair surgery. It covers pre-operative risk assessment and optimization, intra-operative techniques like different clamping positions and hemodynamic management, and post-operative complications like cardiac, lung, renal and spinal cord issues. New developments discussed include fast-track programs aiming to reduce complications and length of stay through measures like early feeding and mobilization. Specific medications mentioned that may provide benefits are milrinone for its cardiovascular effects and dexmedetomidine for hemodynamic stability and potential organ protective properties.

    Original Description:

    kjbxv

    Original Title

    Abdominal Aortic Aneurysms-edit

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The document discusses anesthetic considerations and management for abdominal aortic aneurysm (AAA) repair surgery. It covers pre-operative risk assessment and optimization, intra-operative techniques like different clamping positions and hemodynamic management, and post-operative complications like cardiac, lung, renal and spinal cord issues. New developments discussed include fast-track programs aiming to reduce complications and length of stay through measures like early feeding and mobilization. Specific medications mentioned that may provide benefits are milrinone for its cardiovascular effects and dexmedetomidine for hemodynamic stability and potential organ protective properties.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    404 views32 pages

    Abdominal Aortic Aneurysms-Edit

    Uploaded by

    randika
    The document discusses anesthetic considerations and management for abdominal aortic aneurysm (AAA) repair surgery. It covers pre-operative risk assessment and optimization, intra-operative techniques like different clamping positions and hemodynamic management, and post-operative complications like cardiac, lung, renal and spinal cord issues. New developments discussed include fast-track programs aiming to reduce complications and length of stay through measures like early feeding and mobilization. Specific medications mentioned that may provide benefits are milrinone for its cardiovascular effects and dexmedetomidine for hemodynamic stability and potential organ protective properties.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 32

    Agus Setiyana, m.d.

    Semarang , 05/12/12
    What`s new ?
    In what`s field
    Anesthesia
    Surgical
    GA
    Open repair
    RA
    EVAR
    Locoregional
    Laparascopic repair
    Fast track
    Organ protection

    ICU
    Tailored perioperative mgt
    Fast track
    Anesthetic goals ;
    Minimize patient morbidity & mortality
    Mortality has decreased rapidly since 1960`s
    Elective AAA repair 30 day mortality rate

    > 25 % in the mid 1960`s

    1.8 - 8.4 % mortality rate today

    Advances in pre op preparation & anesthetic management


    are largely responsible
    Maximize surgical benefit
    Achieve above goals in the most cost effective
    manner
    Pre-op considerations
    Aortic disease is indicative of other vascular disease
    AAA surgery has high risk of periop myocardial
    ischemia..
    Coronary artery disease.
    MI
    Stable or unstable angina
    LV dysfunction/CHF
    Atrial fibrillation
    Arrhythmias;
    Pacemakers in situ!
    Peripheral vascular disease

    Carotid artery disease:


    always listen for carotid bruits & ask about TIA/CVA
    symptoms
    Other co morbidities:
    COPD
    HTN
    DM
    perioperative insulin
    Renal dysfunction
    Often exacerbated by
    periop angiograms,
    IV contrast
    NAC may help
    Preparations work up:
    Functional status/ exercise tolerance :
    severity of cardiopulmonary status

    ECG
    TTE, TEE
    DSE
    Thallium scanning
    CAG
    Carotid USG
    ( H/o stroke/ TIA )

    PFT/ ABG :
    in pts with moderate to
    severe pulmonary disease
    PFTs may help guide preop
    medical therapy for optimal
    pulmonary status & estimate risk
    Pre operative
    Myocardial protection
    Preop use of -Blocker
    Preop statins
    Lung optimalisation
    Smoke cessation
    Sputum drainage
    Intra op:
    ECG : II, V5, V6 with ST analysis
    ABP, CVP
    Two large-bore peripheral IVs
    (or central introducer sheath)
    Additional monitors: TEE, PAC
    ACT , BGA
    Use of minimally invasive monitoring if possible
    APCO

    Scv o2/ Sv o 2
    SV, SVV,SVR
    Intra op concerns
    Open repair
    - organ preservations
    pre, durante, post cross clamping ;
    - heart,lung, ren, spinal cord, sphlanich
    - urogenithal

    - bleeding ; use of blood salvage & ultrafiltration


    - trombho embolous event
    - avoid hypothermia
    Cross clamp!
    Cross-clamping of the aorta : significant cardiac stress
    Acute left ventricular strain produces a major
    cardiovascular stress; magnitude is related to clamp
    position
    MAP may increase only 2% with infrarenal
    5% with suprarenal
    up to 54% with supraceliac placement
    Cross clamping placement
    Aortic cross clamp physiology
    Preload Afterload

    Thoracic

    Supraceliac

    Suprarenal

    Infrarenal
    Aorta clamping : also EF IHD
    Drug management;
    Tailored clinical presentation & monitoring
    for clamping
    NTG
    Nipride
    Milrinone
    Beta blocker
    for unclamping
    Fluids
    Catecholamines
    vasopressors
    Anesthetic technique choices
    Tailored with
    Patient condition
    Type of surgery
    Urgency of operation
    * No single technique superior upon others *
    # Most suggest ; emphasis on hemodynamic
    stability, not speed of onset
    o Balanced anesthesia narcotic base
    o Combined anesthesia
    Post operative issues
    Cardiac complication
    Very high risk
    Iscemic cardiac event as a major cause
    Arryrthmia 3%
    MI 1,4 %
    CHF 1%
    Coronary revascularisation shoud be considered prior to
    AAA repair
    Lung
    ARDS
    8 12 % after AAA repair
    50 % mortality
    Doubling of lung water content
    Redistribution of blood

    Vasodilatation

    Capillary leakage

    Reperfusion injury
    Superoxide radicals, neutrophis, etc
    Renal
    Transient renal insufficiency
    50 % after thoracic clamp
    28 % after suprarenal clamp
    10 % after infrarenal clamp
    Dialysis-dependent renal failure in 2-3 % regardless of
    aortic clamp position
    Mech of injury : ATN et causa;
    RBF
    GFR
    Ischemia reperfusion
    Renal protection
    Maintain adequate intravascular volume
    Maintain CO
    Use endovascular technique
    Avoid nephrotoxins
    NSAIDs, aminoglycosides,
    Cross clamp time <50 min
    Cooling ( temperature drift )
    Other techniques ;
    Mannitol, loop diuretics,
    Fenoldopam,low dose dopamine!?
    dexmedetomidine
    Spinal cord issues
    Perfusion pressure = Anterior spinal artery pressure
    minus CSFP/CVP

    Supraceliac cross clamp


    anterior spinal artery pressure
    CSFP
    CVP
    Spinal cord protection
    1. Increase anterior spinal arterial pressure
    Aorto-femoral shunting
    Maintain proximal hypertension
    2. Decrease CSF-pressure
    Avoid cerebral vasodilators (nipride,)
    CSF drainage (controversial) +/- steroids
    3. Decrease CVP
    Phlebotomy
    NTG
    4. Esoteric measures
    Cooling (temperature drift)
    O2-radical scavengers (n-acetylcysteine, mannitol,
    SOD, allopurinol, )
    What`s new ?
    Fast track programme
    Aims =
    To reduce periprocedural ischaemic complication
    To reduce rate post op medical complications
    To facilitate early rehabilitation
    How =
    1. Patient education & instruction pre op
    2. Shortening of pre op fasting
    3. No bowel washout
    4. Increased temperature of OT to 22 C
    5. Pain control
    6. Early enteral feeding & ambulation
    7. Restriction of IV fluid application
    Medications
    Milrinone
    Phosphodiesterase inhibitors type III
    Cardiac myocites : positive inotropy
    positive lusitropy
    positive chronotropy
    positive dromotropy
    Vascular smooth muscle cells :
    vasodilatation

    * Inotropy with afterload reduction *


    both PVR & SVR
    Dexmedetomidine

    an alpha2 adrenoceptor agonist


    as adjunct to anesthesia
    perioperative hemodynamic stability
    dose dependent
    centrally - mediated sympatholysis
    Neuro protection
    Reduces the release of noradrenalin in the brain
    Modulates the balance between pro-apoptotic and anti
    apoptotic protein
    Reduces the release of excitatory neurotransmitter such
    as glutamate

    Cardio protection
    By reducing the release of noradrenalain
    BP
    heart rate
    the requirement of oxygen & nutrition of the heart
    Protec cardiac from ischaemia
    Nefro protection
    Did not alter renal function
    Associated with an urinary output
    through ;
    Inhibition of renin release
    Increased GFR
    Increased of sodium & water excretion
    matur
    nuwun

    You might also like