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Anesthetic Management of Aortic Aneurysm

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Anesthetic Management of Aortic Aneurysm Aortic dissection risk factors: hypertension, aortic medial disease, Marfan syndrome, congential bicuspid aortic valves ... – PowerPoint PPT presentation

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Title: Anesthetic Management of Aortic Aneurysm


1
Anesthetic Management of Aortic Aneurysm
  • Aortic dissection
  • risk factors hypertension, aortic medial
    disease, Marfan syndrome, congential bicuspid
    aortic valves, aortic atherosclerosis, and blunt
    chest trauma

2
  • Aortic aneurysm
  • classified by etiology, location, and shape
  • most common dissecion
  • predisposing atherosclerosis, aortitis, cystic
    medial necrosis, syphilitc aortitis, trauma,
    postoperative false aneurysm, connective tissue
    disorders, and congenital aortic anomalies
  • De Bakey and Stanford classification
  • Shape fusiform and saccular

3
  • Goal
  • type and location of the lesion. one lung
    ventilation and distal perfusion
  • prepare for blood loss
  • monitor
  • hemodynamic stability

4
  • Evaluation
  • medial history, pevious chest X-ray,
    echocardiographic and angiographic stuides
  • prior lung status
  • control of BP and ejection velocity combine beta
    blockers and vasodilators

5
  • Premeditation
  • Elective beta blockers, calcium channel
    blockers, diuretics, ACEI
  • anxiolytic agent (sedative) lorazepam 1-2mg PO,
    midazolam 1-4mg iv and morphine 0.05-0.1mg/kg im
  • Emergency
  • beta-blocking agents esmolol, metoprolol, or
    propranolo
  • vasodilators nitroprusside, nitroglycerin,
    trimethaphan

6
  • Preinduction
  • big iv cathether
  • A-line
  • femeral a-line
  • pressor and vasodilator agents
  • 6 units blood
  • antithrombolytic agent (aminocaproic acid or
    aprotinin)
  • epidural catheters

7
  • Induction
  • non-emergent procedure
  • fentanyl (50-100ug/kg) or sufentanyl (10-12
    ug/kg)
  • intermediate-acting, non-depolarizing
    neuromuscular blocker vecuronium (0.1mg/kg),
    rocurinium(0.6mg/kg), or cis-atracurium
    (0.2mg/kg)
  • no pancuronium

8
  • Emergent procedure
  • rapid sequence induction
  • thiopental , propofol,or etomidate in combination
    with small dose narcotics
  • SCC, beta-blocker and vasodilator before
    laryngoscopy
  • --single , double lumen, univent

9
  • Intra-operative management
  • additional venous access
  • V5 lead, a-line, PA catheter
  • bleeding and coagulopathy

10
  • PWCP increase with cross-clamp application
  • A. LV afterload mismatch with LV dilation
  • B. myocardial ischemia
  • C.impaired LV diastolic function due to impaired
    relaxtion

11
  • Acidosis
  • sod. bicarbonate continuous infusion
    (0.05mEq/kg/min)during cross-clamping

12
  • cross clamp removal hypotension , pulmonary
    hypertension, and metabolic acidosis
  • shunt and left heart bypass, partial CPB
  • (distal 40-60mmhg)

13
  • Acid-base status,
  • renal functuin,
  • short cross-clamp time

14
Awake Aortic Aneurysm Repair in Patients with
Severe Pulmonary Disease
  • McGregor Am J Surg, Volume
    178(2).August 1999.121-124
  • BACKGROUND We report the use of retroperitoneal
    aortic aneurysm repair utilizing exclusive
    regional anesthesia (no intubation or inhalation
    anesthetic) in high pulmonary risk patients.

15
  • METHODS Six patients were retrospectively
    reviewed. Pulmonary disease was diagnosed by
    clinical history and pulmonary function tests.
    Patients received intravenous sedation and
    regional anesthesia. Retroperitoneal aortoiliac
    aneurysm repair was performed.

16
  • Regional Anesthesia.
  • Patients upright, exaggerated kyphotic position
    17-gauge epidural needle L2-3 or L3-4 interspace,
  • test dose 3cc lidocaine 1.5 and epinephrine
    1200,000
  • A 25-gauge Whitticre needle Spinal anesthesia
    with bupivicaine 0.5 (6 to 7 mg) and fentanyl
    (25 to 30 mcg),
  • epidural catheter 3 to 4 cm. A T7-8 sensory
    block was required to start the procedure
  • Inadequate bupivicaine 0.5 (10 cc) and fentanyl
    50 to 100 mcg in incremental doses.
  • During aortic dissection and cross-clamping,
    anesthesia was raised to the T5 level.
  • morphine (3 to 4 mg) for postoperative pain
    control.

17
  • RESULTS a population with several comorbidities.
    Patient age was 72 /- 4 years, and concurrent
    illnesses included coronary artery disease,
    cerebrovascular disease, and obesity. Cardiac
    ejection fraction was 46 /- 11. Smoking
    history was 62 /- 2 pack-years. All patients
    used inhaled steroids and albuterol, and 3
    required theophylline and home oxygen
  • therapy.
  • PFT severe pulmonary disease
  • FEV1 0.85 /- 0.1 L (23 /- 5 of predicted),
    FVC 1.64 /- 0.2 L (34 /- 5 of
  • predicted), and PO2 62 /- 2 mm Hg.

18
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19
  • The authors felt that the more recent use of
    supplemental epidural anesthesia was partially
    responsible for improved outcome. Epidural
    anesthesia offers many benefits, including
    inhibition of the surgical stress response,
    decrease in myocardial oxygen demand, fewer
    pulmonary complications, improved renal cortical
    blood flow, and better postoperative pain
    control.

20
  • The improvement in pulmonary status is related to
    a smaller decrease in FVC and FEV1, less alveolar
    shunting, and fewer pulmonary infections.
  • Adverse effects of general anesthesia such as
    myocardial and respiratory depression
  • pulmonary function values of less than 50 of
    predicted are a relative contraindication to
    elective aortic reconstruction. However, because
    of the limited pulmonary sequelae seen using
    retroperitoneal repair with exclusive epidural
    anesthesia, patients with severely compromised
    pulmonary function may be able to undergo
    elective surgery.

21
  • Several aspects of this study merit further
    discussion.
  • First, both spinal and epidural anesthesia were
    utilized better muscle relaxation and lower total
    doses of anesthetic and narcotic medications are
    needed.
  • Second, inhalation anesthetic was avoided by
    maintaining patients at ideal level of
    sedation.kept alert enough to protect their
    airways and answer questions, but sedated enough
    to control anxiety and agitation.

22
  • Third, thorough communication among surgeon,
    anesthesiologist, and patient is critical.
    Reassuring patients on their progress and keeping
    a calm operating room environment facilitates
    patient tolerance and success with this
    procedure.
  • Finally, this is a technically demanding
    procedure with anatomic limitations that need to
    be considered during patient selection. These
    include limited access to the right renal artery,
    inability to detect synchronous intraperitoneal
    pathology, and long-term wound complications.
  • Performing this procedure on patients more likely
    to be receiving systemic steroid therapy may
    particularly predispose to wound complications.
    Therefore, strict adherence to sterile technique
    and careful tissue handling are essential.

23
  • CONCLUSIONS
  • Results from this study suggest that patients
    with severe pulmonary disease can undergo
    elective abdominal aortic aneurysm repair under
    exclusive regional anesthesia safely and without
    pulmonary morbidity. Patient selection, and
    experienced anesthesiologist, and communication
    with the patient are critical to the success of
    this procedure. Retroperitoneal aortic repair
    with exclusive regional anesthesia should be
    considered in high pulmonary risk patients.
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