Interesting case conference

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Interesting case conference

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abdominal aortic aneurysm just below renal arteries

to biforcation but no evidence of dissection

Interesing case coference

Dx. Abdominal aortic aneurysm โรงพย�บ�ลล��พ#นำ conservative treatment ม�ติลอด

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Interesing case conference

PH : ปฏิ�เสธ underlying disease

ม�ประวั�ติ� chronic smoking ปฏิ�เสธ ประวั�ติ� alcoholic

drinking ปฏิ�เสธประวั�ติ�แพ$ย� เคยผู้*�ติ�ด ใส$ติ�!งอ�กเสบ 30 ป+

ก*อนำ

Interesing case conference

Physical examination V/S : BP=170/100 in all extermities PR=74/min ,

Temp=36.5C ,RR=15/min General appearance : an old woman with normal

conciousness body weight =30 kgs ,height=145

cm HEENT : no pale conjunctiva ,no

juandice

Interesting case conference

Heart : normal heart sounds,regular rhythm , no murmur

Lung : normal contour, no tachypnea normal breathing sounds Abdomen : pulsatile mass ขนำ�ดประม�ณ 4cm*4cm just below umbilicus , no abdominal

distension BS active Extremities : no deformity,normal pulse in all

extremities

Interesting case conference

Airway assessment Interinciser gap > 3 cm thyromental distance >5

cm mal l ampati

cl assi fi cati on : I I neck movement : no

limitation

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Impression : Abdominal aortic

aneurysm with impendingrupture

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Work up CBC : Hb = 13.5 g% Hct=42.3 Wbc=7300 Plt =212000 Electrolyte : Na =126 K=3.4 Cl =93 CO2=24 BUN=5 Cr =0.6 FBS =132

Interesting case conference

Work up ( Cont. ) PT=10.3(11.8) ,

PTT=31.4(31.0) Ca =9.5 , Mg=1.28 , P=2.8

UA: Sp.gr. 1.010 , Wbc = 8-10/HPF

Rbc = 1-3/HPF

Interesting case conference

Work up( Cont. ) CXR: widening mediastinum

R/O Thoracic aortic aneurysm

EKG : inverted T in V1 -V3

Trop T : negative CT abdomen :

Interesting case conference

Set OR emergency for aneurysmorhappy ร�บ set case เวัล� 1630. นำ . วั�นำทิ�! 25/05/03

NPO time เวัล� 900. นำ. วั�นำทิ�! 25/05/03

Interesting case conference

Problem list 1. Infrerenal AAA 2. Old age 3. Hyponatremia 4. R/O HT 5. Widening mediastinum R/O

Thoracic aneurysm 6. Abnormality of EKG 7. Moderate renal insufficiency

Interesting case conference

Anesthetic consideration 1. P reoperative evaluation 2 . Preoperative preparation

& 3 . Mornitoring 4 . Anesthetic technique 5 . Intraoperative complication 6 . Postoperative care

Interesting case conference

1. Preoperative evaluation LLLLLLLLLL LLLL LLL LLLL LLL LLLLL LLLLLLLLLLL L L LLL:

LLLLLLLL BUN ,Cr : CCr =33.9 Coagulation profile

Interesting case conference

Urine analysis CXR : Widening

mediastinum EKG : Inverted T 2. Preoperative preparation

& Premedication Cross maching No premedication

Interesting case conference

3. Mornitoring LLLLLLLLLL2

LLLL EKG

LLL L- LLLL

Interesting case conference

3. Mornitoring (cont.) Temp I/O 4. Anesthetic technique LLLLLLL LLLLLLLLLL

LLLLLLLLL LLLL L LLLLLL LLLLLLLL LLL LL,

l anti l e agent

Interesting case conference

4. Anesthetic technique ( Cont.) LLLLLLLLL L LLLLLLLLLLL LLLLLL 5. Intraoperative complication 6. Post operative care Pain control

Abdominal aortic aneurysm

L LLLLLLLLLLLL LLLLLLLLL L LL;,, ,LLLLLLLL LLL LLLLLLLLLLL

LLLLL LLLLLLLLLL LLLLL LL LLLLLLLLLLLLLLL

LLLLL LL LLL LLLLLLL LLLLLLL LLLLLLL , infection, syphilis, Marfan syndro

LL

The diameter and rate of expansion of AAA

AAA 4 to 5 cm. In diameter is not w ell defined , and significant controve rsy exists regarding surgical repair

Surgical repair is recommened if s uch aneurysms become symptomati

-c , expand more than 0.5 cm. In a 6 month period , diameter 5 cm. or gre

ater

Aortic cross- clamping Most abdominal aortic

reconstruction require clamping at the infrarenal level

Ischemic complication may result i n renal failure , hepatic ischemic an d coagulopathy

Thoracic and supraceliac cros- s clamping may increase left ventri

cular wall stress ( resultant acute l eft ventricular dysfunction and/or

myocardial ischemia )

ภาพ systemic hemodynamic response to aortic cross-clamping

Physiologic changes (cross-clamping ) Hemodynamic changes ;

increase arterial blood pressure

increase left ventricular wall tension and seg mental wall motion abnormalities

increase pulmonary artery occlusion pressure

increase central venous pressure

increase coronary blood flow

decrease cardiac output and ejection fraction

decrease renal blood flow

Metabolic changes decrease total body oxygen consumpti

on decrease total body carbon dioxide pro

duction decrease total body oxygen extraction increase mixed venous oxygen saturat

ion increase epinephrine and norepinephri

ne respiratory alkalosis metabolic acidosis

Therapeutic interventions (cross-clamping)

Afterload reduction ; sodium nitroprusside , inhalation anestheti

cs , amrinone Preload reduction ; nitroglycerine ,

shunts and left heart bypass Renal protection ; Mannitol , low do

se dopamine , fluid administration Other ; decrease minute

ventilation , sodium bicarbonate

Aortic unclamping

The hemodynamic responses to unclamping depend on the level of aorti

c occlusion, the total occlusion time, th e use of diverting support and the intra

vascular volume Humoral factors and mediators which m

ay also play a role in organ dysfunction after aortic occlusion include lactic acid

- -, renin angiotensin, oxygen free radical s, neutrophil, prostaglandins, activated

-complement, cytokines and myocardial depressant factors

ภาพ aortic unclamping

Physiologic changes ( aortic unclamping )

Hemodynamicschanges ; decrease myocardial

contractility decrease arterial blood press

ure decrease central venous pres

sure decrease venous return decrease cardiac output

LLLLLLL L; i ncr ease t ot al body oxygen co

LLLLLLLLL LLLLLLLLLLLLLLL , ,

activated complement , myocardia- l depressant factors

LLLLLLLL LLLLL LLLLLL LLLLLL LLLLLLLLLL

LLLLLLLLL LLLLLLLL

Therapeutic interventions (aortic unclamping )

LLLLLLLL LLLLLLLLLL LLLLLLLLLLL

LLLLLLLL LLLLLLLLLLL increase fluid administration LLLLLLLL LLLLLLLLLLLLLLL

LLLLL - reapply cross clamp for severe hy

LLLLLLLLL

Anesthetic management

Preoperative considerations High incidence of coexistent cardiac, re

nal, pulmonary disease, hypertension, diabetes

Severe hypertension, myocardial ische mia, aortic valve regurgitation, left ventr

icular failure may be precipitated The location of the lesion The procedure of complicated by the po

tential for large intraoperative blood los ses

Intraoperative monitoring central venous or pulmonary artery c

atheter direct arterial blood pressure and NIB

P - two lead ECG or modified V5 ECG temperature I/O pulse oximetry - two dimensional TEE

Anesthetic drugs and techniques

Combined techniques most commonly employ a lumbar or lo

w thoracic epidural catheter Induction of general anesthesia

should controll such that stable hemodynamics are maintained d

uring loss of conciousness, laryn goscopy and intubation , the im mediate postinduction period

Induction, intravenous hypnotic agents ( t hiopentone , etomidate, propofol ) or a sho

- rt acting potentopioid ( such as fentanyl- 3 8 microgram/kg) and halogenated age

nts may be admi ni steredi n l owconcentr ati onbefore i ntubati on

- - - - Esmolol(1025mg),sodiumnitroprusside(525microgram),nitroglycerine(50100microgram),andphenylephrine(50100microgram)shoul dbL LLLLLLLLL LLL LLLLL LLLLLLLLLLLLLL L

uri ngi nducti on Anestheti c mai ntenance may be

accompl i shedwi tha combi nati onof a p otent opi oi dandani nhal edanestheti c

Epidural local anesthetics are used the same balanced technique and reduce t

he opioid dose ( but avoiding significa nt hypotension at the time of aortic un

clamping) Extubation of the trachea is generally

not attempted in patients with suprac - eliac aortic cross clamp times greater than 30 minutes, patients with poor ba

seline pulmonary function , or patients requiring large volumes of blood or cry

stalloid during surgery

Routine use nasal airway afte r induction but before systemic

heparinization in all patients fo r whom extubation is planned

Hypertension and tachycardia are aggressively controlled dur -ing emergence by use of short

acting agents , such as esmolol , nitroglycerine, and sodium nit

roprusside