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Aortic aneurysms-anaesthesia PowerPoint Presentation

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On : Mar 14, 2014

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  • Slide 1 - Aortic aneurysms and anesthesia Moderator: Dr. Renu Presenters: Dr. Dipal Dr. Mridu www.anaesthesia.co.in anaesthesia.co.in@gmail.com
  • Slide 2 - Sub acute aortic dissection Expanding aortic aneurysm Stable aortic aneurysm Coarctation of aorta Atherosclerotic disease Bioprosthetic valve Graft failure Progression Pseudo aneurysm
  • Slide 3 - Anatomy of aorta:
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  • Slide 8 - Aortic Aneurysm: Definition: Dilatation of aorta containing all the 3 layers of the vessel wall that has diameter of at least 1.5 times that of the expected normal diameter of that given aortic segment. I = 5.9/100000 Age: 65 yrs n above M > F
  • Slide 9 - Pseudo aneurysms: Localized dilatation Wall : not all 3 layers, clots, connective tissue, surrounding tissue Cause: contained rupture of aorta intimal disruptions penetrating atheromas partial dehiscence of suture line
  • Slide 10 - Risk factors: Hypertension Hypercholesterolemia Prior tobacco use Collagen vascular disease Family history Smoking Diabetes mellitus Male Obesity
  • Slide 11 - Classification: Etiology: Atherosclerosis: most common cystic medial necrosis descending: distal to L Subclavian A, large and medium size vessels Theories: Inflammation, CRP, IL-6, Aspirin, Statins, cholesterol, estrogen, antioxidants,
  • Slide 12 - Classification contd.. Annuloaortic ectasia: AR, younger age Syndromes: Marfans, Ehler-Danlos, Turner Familial: 19%, younger Inflammatory: giant cell arteritis, mycotic, takayasu, syphilis Aortic dissection Trauma: deceleration, partial/ complete transection at isthmus, saccular, discrete
  • Slide 13 - Classification contd.. Location: Aortic root and Ascending aorta: 60% AR, bicuspid aortic valve Descending aorta :40 % endovascular Arch of aorta: 10% cerebral protection Thoracoabdominal: 10%, paraplegia, multiple segments
  • Slide 14 - Classification contd.. Shape: Fusiform: common atherosclerosis/ CVD longer segment dilation of entire segment Saccular: localized isolated segment localized out pouching Size: physiologic effect, consequences
  • Slide 15 - Clinical manifestations: Most asymptomatic Incidental : x-ray, ct scan, echo AR CHF Mass effect: trachea/ main stem bronchus, pulmonary veins, esophagus, rln, bone Pain due to dissection/rupture Pulsatile mass in epigastrium
  • Slide 16 - Diagnosis: X-ray chest: mediastinal widening, tracheal deviation CECT: confirm, size, suprarenal CT angiography: MR angiography: aortic root Transthoracic ECHO: aortic root, not mid/ distal ascending aorta, marfan Transesophageal ECHO USG: screening AAA
  • Slide 17 - Screening: Recommended : all men 60-85 yrs all women 60-85 yrs with CVS risk factors both with family history and age >50yrs
  • Slide 18 - Medical management: Inform and warn Discontinue smoking Avoid heavy lifting/straining ß blockers Statins ACE inhibitors Antihypertensives: 105-120 mmHg Familial: screening Serial imaging: 6mths, 1yr.
  • Slide 19 - Indications for repair: Symptoms refractory to medical treatment Evidence of rupture Increase in diameter ≥ 1cm/yr Diameter: ascending aorta≥5.5cm (5cm) descending aorta≥6.5cm (6cm) Severe aortic regurgitation
  • Slide 20 - Indications for repair contd.. Aortoannular ectasia with dilated aortic root Congenital bicuspid aortic valve:≥4cm Contained or impending rupture Earlier: marfans, family history of dissection/ aortic disease
  • Slide 21 - Pre existing medical illness Aortic valve disease Cardiac tamponade PVD: embolus, ischemia, stroke CVD: failure, ischemia, infarction, arrthymias, pulmonary edema Cardiomyopathy/ valvular disease Cerebrovascular disease
  • Slide 22 - Pre existing medical illness contd.. Pulmonary disease: postop failure, pneumonia Renal insufficiency: fluid, drugs Esophageal disease: TEE Coagulopathy: ↑ bleeding, transfusion, h’ggic cx, epidural, CSF drainage Prior aortic operations
  • Slide 23 - Airway assessment: Cervical spine: TEE Large airways mass effect: difficult intubation, OLV, airway compromise
  • Slide 24 - Perioperative morbidity Non fatal and fatal MI: 4.9% and 2.3% Long term MI: 8.9% and 9.1% Coronary artery revascularization and prophylaxis trial ACC/AHA guidelines
  • Slide 25 - Assessment of cardiovascular risk: ECG: Baseline Prior MI: risk stratification Dysrhythmias: other than sinus: risk Lacks sensitivity
  • Slide 26 - Assessment of cardiovascular risk: Exercise ECG: 30-70% cannot reach target HR Poor functional capacity, ß blocker etc If 85% of predicted maximal HR achieved: low risk Arm exercise: fatigue precedes increase
  • Slide 27 - Assessment of cardiovascular risk: Myocardial perfusion imaging: DTI: most common, non invasive, RR 4.6 2 images, steal phenomenon 3 outcomes: normal, myocardium at risk, fixed perfusion defect Eagle et al and L’italien et al: no additional stratification for pts classified as low or high risk. Classified 80% of intermediate risk into low or high risk.
  • Slide 28 - Assessment of cardiovascular risk: Ambulatory ECG monitoring: RR 2.7 Detect dysrythmias Sensitivity: in pts with high pretest probability 80-90% MI silent: periop morbidity Low cost Not in LBBB, pacemaker dependency, LVH, significant strain or digitalis
  • Slide 29 - Assessment of cardiovascular risk: Echocardiography: With 5 or > abnormal segments: 4-6 fold ↑ risk of cardiac Cx Stress echocardiography: TEE superior to transthoracic DSE: sensitivity: and specificity 80-90% Stratifies pts only with risk factors Pericardiac events unlikely if result –ve Best predictor: RR 6.2
  • Slide 30 - Assessment of cardiovascular risk: Radionuclide ventriculography: LVF at rest or exercise RR 3.7 Independent predictor of periop cardiac morbidity EF < 35% : 75-85% MI risk >35% : 19-20% However limited use
  • Slide 31 - Assessment of cardiovascular risk: Summary: DTI, AECG, DSE: high negative predictive value Low risk not = 0 risk Negative result does not guarantee pt has no CAD None has high positive predictive value
  • Slide 32 - Assessment of pulmonary risk: COPD, smoking, chronic bronchitis ABG: baseline PACO2 > 45 = higher risk PFT: FEV1<1lit/ MBC<50% Steroids short course: helpful in copd/ asthma May benefit from epidural analgesia and anesthesia
  • Slide 33 - Assessment of renal function: HTN, atherosclerosis, diabetic nephropathy, renal artery stenosis Pre and intraop dye loads: nephrotoxic Aortic cross clamping:↓ bld flow Embolic plaque Fluctuations in CO and intravascular vol ARF: abt 7%
  • Slide 34 - Assessment of renal function: Preop ARF most imp predictor of postop ARF Pathogenesis: ATN Clamp distal to Subclavian A: 85-94%↓ in bld flow Infrarenal: >30%↓ S. Creat > 2 mg% : high risk
  • Slide 35 - Pre-anesthetic assessment: Urgency of operation Pathology and extent of disease Median sternotomy/ thoracotomy/ endovascular approach Mediastinal mass effect Airway compromise/ deviation
  • Slide 36 - Preoperative medications: All cardiac, antihypertensive, pulmonary, antiseizure to continue OHA: discont, metformin(48hrs prior) Insulin: 1/3rd – ½ usual dose Warfarin: 3-7 days prior, INR Heparin infusion Aspirin, clopidogrel; Ticlopidine Anxiolytics: BDZ/opioids
  • Slide 37 - General Anesthetic management: Haemodynamic monitoring: Neurophysiologic monitoring OLV for thoracotomy Bleeding potential Antibiotic prophylaxis Temperature monitoring Blood sugar monitoring
  • Slide 38 - Haemodynamic monitoring: ECG IBP: proximal aortic pressure: R radial- Innominate A, BP: repair of arch/ prox L radial A: ACP, B/L Femoral: distal aortic pressure, avoided in PVD CVP: RAP, vasoactive drugs PAC: PAP, CO, mixed Svo2, (CPB, DHCA, partial LSHB, aortic-cross clamping) TEE: ventricular ft
  • Slide 39 - Neurophysiologic monitoring: To monitor for intraop spinal ischemia: SSEP MEP EEG Jugular venous oxygen saturation Lumbar CSF pressure Body temperature
  • Slide 40 - SSEP: Electrical stimuli to peripheral nerves and record evoked potential at peripheral nerves, spinal cord, brainstem, thalamus, cerebral cortex ↓/ disappearance of amplitude in LL v/s UL Balanced anesthesia technique, MAC <0.5 Monitors only posterior column not motor
  • Slide 41 - MEP: Paired stimuli to scalp and record evoked potential in anterior tibialis muscle ↓/ disappearance of amplitude in LL v/s UL TIVA without N-M blockade
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  • Slide 43 - Temperature monitoring: Core: Urinary catheter with temp probe PAC probe Nasopharyngeal probe Rectal probe
  • Slide 44 - OLV L thoracotomy or L thoracoabdominal approach of TAAA Adv: improves surgical exposure ↓lung contusion or torsion protects R lung in bleeding DLT/ BB Advantages and disadvantages of each If DLT- exchange at the end of Sx
  • Slide 45 - Bleeding potential Increased risk: Intrinsic disease Vascular anastomosis Extracorporeal circulation Hypothermia
  • Slide 46 - Bleeding potential contd.. Strategies: Discontinue anticoagulants/antiplatelets Large bore i.v. access Immediate availability of blood products Fluid warming unit Urine output monitoring Precise control of BP Cell salvage Bio glue Antifibrinolytics: ε-aca, traxenamic acid Factor VII A
  • Slide 47 - Drugs: Vasopressors and vasodilators Etomidate: haemodynamic stability Narcotics, NMDR, inhalational Doses ↓ 30°C, stopped:18°C, resumed at rewarming EEG/ SSEP: barbiturates/ propofol avoided, inhalational = 0.5 MAC MEP: TIVA
  • Slide 48 - Ascending TAA: Mortality: 3-5% Median sternotomy TEE: valve sparing Sx, diameter, AR post repair CPB Wheat procedure: AVR + tube graft Bentall procedure: AVR Ross procedure: PV-> AV Carbol technique: coronary reimplantation
  • Slide 49 - Arch aneurysms: Cerebral protection: embolus, ischemia DHCA Trifurcated tube grafts Elephant trunk procedure
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  • Slide 51 - Descending TAA: Mortality: 4% Lateral thoracotomy/ thoracoabdominal incision Cross clamping/ partial L heart bypass/ DHCA Spinal cord, mesenteric, LL protection Endovascular stent grafts
  • Slide 52 - Staged repair: Multiple segments Greater risk of rupture Placing of clamps Elephant trunk procedure
  • Slide 53 - Abdominal AA Mortality: 4-6% (elective), 2% in low risk Elderly Atherosclerosis, coexisting illness Risk of rupture: 3 times > F, smokers, HTN, rapid rate of expansion Classification: with and without dissection
  • Slide 54 - Crawford classification of TAAA
  • Slide 55 - Abdominal AA contd.. Renal, Mesenteric, LL, Spinal Cord ischemia Monitoring Fluid management Epidural analgesia Cross clamping/ Gott shunt/ DHCA Endovascular stent grafts Infrarenal good survival
  • Slide 56 - Aortic clamping Mortality and paraplegia related to : position and length of resected aorta condition of pt duration≥ 30 min
  • Slide 57 - AoX Passive recoil distal to clamp ­Catecholamines (and other vasoconstrictors) ­ Impedance to Ao flow Active vasoconstriction proximal and distal to clamp ­R art If coronary flow and contractility do not increase ­Preload ­Coronary flow ­Afterload ­Contractility ­CO ¯ If coronary flow and contractility increase
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  • Slide 59 - Haemodynamic changes: ↑BP ↑ Segmental wall motion abnormalities ↑ Left ventricular wall tension ↓ Ejection fraction ↓ Cardiac output ↓ Renal blood flow ↑ Pulmonary occlusion pressure ↑ CVP ↑ Coronary blood flow
  • Slide 60 - Metabolic changes: ↓ Total body oxygen consumption ↓ Total body CO2 production ↑Mixed venous O2 saturation ↓ Total body oxygen extraction ↑ Epinephrine , nor epinephrine Respiratory alkalosis Metabolic acidosis
  • Slide 61 - % change in CVS variables
  • Slide 62 - Therapeutic interventions: Afterload reduction: SNP Inhaled anesthetics Amrinone Shunts and aorto-femoral bypass Preload reduction: NTG Controlled phlebotomy Atrial to femoral bypass
  • Slide 63 - Therapeutic intervention: Renal protection: Fluid administration Distal aortic perfusion techniques Mannitol Drugs to augment renal perfusion Other changes: Hypothermia ↓ Minute ventilation Sodium bicarbonate
  • Slide 64 - Aortic unclamping:
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  • Slide 66 - Haemodynamic changes: ↓Myocardial contractility ↓ BP ↑PAP ↓ CVP ↓ Venous return ↓ CO
  • Slide 67 - Metabolic changes: ↑Total body oxygen consumption ↓ Lactate ↓ Mixed venous O2 saturation ↓ Prostaglandins ↓ Activated complement ↓ Myocardial depressant factors ↓ Temperature Metabolic acidosis
  • Slide 68 - Therapeutic interventions: ↓ Inhaled anesthetics ↓ Vasodilators ↑Fluid administration ↑ Vasoconstrictor drugs Reapply cross clamp for severe hypotension Consider mannitol Consider sodium bicarbonate
  • Slide 69 - Endovascular stent graft repair: Fabric/ synthetic tube grafts reinforced by a wire frame Requires 1 cm long non-tapered region of aorta on either end of aneurysm for landing
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  • Slide 71 - Endovascular stent graft repair: Intraop angiography/ TEE Long term benefits to be determined Problems: vessel injury intravascular migration strut # postop paraplegia intravascular leaks
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  • Slide 73 - Hypertension: Moderate: not independent risk factor Continue them: prevent rebound increase in HR, BP, avoid withdrawal Clonidine: ↓ anesthetic req, catecholamine levels, BP lability CCB: MI not affected ACE inhibitors: intraop hypotension, avoided Shorter acting drugs
  • Slide 74 - ß- blockers: ↓ mortality and morbidity with silent MI, acute MI, CHF Prevention of catecholamine induced arrhythmia, plaque disruption Blunting neurohumoral and haemodynamic effects of sympathetic stimulation ACC/ AHA: level I recommendation
  • Slide 75 - Pre-op CVS assessment… ACC/AHA Guidelines for periop CVS evaluation for noncardiac surgery Functional activity Clinical predictors of risk Deg of surg. stress
  • Slide 76 - ACC-AHA Guidelines. Functional capacity Metabolic equivalent (MET) 1 MET- 02 (Vo2) consumption of a 70kg man in a resting state (3.5 ml/kg/min) MET- daily activities Excellent (>10 METS) Good (7-10 METS) Moderate (4-7 METS) Poor (<4 METS)
  • Slide 77 - Estimated Energy Requirements for Various Activities
  • Slide 78 - Major Unstable Coronary Syndromes Recent myocardial infarction* with evidence of important ischemic risk by clinical symptoms or non-invasive study Unstable or severe† angina (Canadian class III or IV)‡ Decompensated congestive heart failure Significant dysrhythmias High-grade atrioventricular block Symptomatic ventricular dysrhythmias in the presence of underlying heart disease Supraventricular dysrhythmias with uncontrolled ventricular rate Severe valvular disease Clinical Predictors of Increased Perioperative Cardiovascular Risk
  • Slide 79 - Intermediate Mild angina pectoris (Canadian Class I or II) Prior myocardial infarction by history or pathologic Q waves Compensated or prior congestive heart failure Diabetes mellitus Renal insufficiency Minor Advanced age Abnormal ECG (left ventricular hypertrophy, left bundle-branch block, ST-T abnormalities) Rhythm other than sinus (e.g. atrial fibrillation) Low functional capacity (e.g., inability to climb one flight of stairs with a bag of groceries) History of stroke Uncontrolled systemic hypertension Clinical Predictors of Increased Perioperative Cardiovascular Risk (Contd.)
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  • Slide 84 - CNS: h/o TIA or stroke: Duplex imaging of Carotid A and angiography of Brachiocephalic and Intracranial A: if >80-90%stenosis of one or both: Consider Carotid Endarterectomy before elective operation.
  • Slide 85 - BP: Proximal: maintain 100mmHg Can upto 180-200 if no CI(intracranial h’gge) and if acceptable operating conditions. Relative hypotension(<20% of resting pressure) should be avoided unless shunts used to perfuse lower parts of body. Distal pressure maintain at 50mmHg

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