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Vascular Surgery - Coggle Diagram

- - - - Assessment
        
        Resp - smoker/lung disease may affect anaesthetic choice
        
        CVS - likely HTN and IHD
        
        Airway & prev anaesthetic
        
        T2DM/CKD
        
        Rapid assessment due to urgency
        
        Pre-operative functioning
        
        Last ate
        
        Medications & allergies
        
        Bloods - 2x Xmatch, FBC, coag, ABG - use POC for speed
      - Mx
        
        C
        
        2x large bore access, restrict to maintain cerebration
        
        D
        
        Titrate morphine against pain (but avoid if pt obtunded or BP crap)
        
        A&B
        
        100% O2 via NRB
      - Organisational/communication
        
        Contact blood bank & start major haemorrhage protocol if needed
        
        Discuss with vascular surgeons for surgical plan
        
        Liase with radiology suite if EVAR & check team awareness of area - equipment, machines etc
        
        Establish porters ready to bring blood products
        
        Make plans if conversion to open needed
        
        D/w ITU for post op care
        
        Contact on call consultant & theatres team
        
        D/w patient and family about prognosis
    - - Glasgow aneurysm scale
        
        IHD (+7)
        
        CVA (+10)
        
        Shock (+17)
        
        CKD (+14)
        
        Age (+x)
        
        84 = 65% mortality
      - Hardman Index
        
        Hb <90 = 1
        
        Ischaemic ECG = 1
        
        Age > 76 = 1
        
        Hx of LoC = 1
        
        2+ = 80% mortality
  - - - Monitoring
        
        A line
        
        Catheter
        
        Large bore access
      - Anaesthetic options
        
        LA +/- Sedation
        
        Pros
        
        CVS stability, Resp stability, post op analgesia, pt can cooperate wth breathing cessation
        
        Cons
        
        Ischaemic pain not covered, potential to convert to GA, no control over ventilation, requires cooperative patient
      - Preoperative
        
        Same as that for open AAA
        
        Evaluate co-morbidities (CVS/Resp/T2DM/vascular)
        
        Informed about choice of anaesthesia & risk of conversion to open (rare)
    - - Radiologist & Surgeon work together
      - Pt supine (radiolucent table)
      - Angiography of aneurysm is then done
      - Graft inserted via arteriotomy of femoral artery
      - Stent deployed and angiography done again to confirm position
      - Femoral arteries exposed (give heparin 5000u @ this point)
      - If leak observed - second stent can be inserted
    - - Neck angulation <45 degrees
      - Proximal neck diameter >30mm
      - 'Neck' length >10-15mm
      - Iliac artery diameter >6mm
    - - Reduced stress response
      - No cross clamp
      - Reduced blood loss
      - Earlier ambulation
      - Minimally invasive
      - Shorter hospital stay
    - - More expensive
      - No longer EVAR survival benefit
      - Only 70% AAA are ameanable
      - No end point to pt surveillance
  - - - +/- inflammation
  - - - None <3cm - no f/u
      - Small
        
        3-4.4cm yearly f/u
        
        4.5-5.4 3 monthly f/u
      - Large >5.5cm - referral to vascular
  - - - Clamp
        
        CVS effects
        
        Lower body perfusion depends on colaterals
        
        May increase BP/myocardial strain/ischaemia
        
        Sudden increase upper body SVR
        
        Effects unpredicatable
      - Postclamp
        
        Vasodilation (volatiles/nitrates)
        
        Maintain BP ~30% of normal
        
        Slowly increase circulating volumes
        
        Wean vasodilators prior to clamp release, BP >110mmHg
      - Preclamp
        
        Aline and CVC
        
        CO monitor
        
        Epidural (rectus sheath catheters)
        
        Low volume low BP preclamp
        
        Incision - transverse T10 or midline
        
        Heparin 5000 - no ACT
        
        Warm upper body only
      - Clamp release
        
        CVS effects
        
        Return of ischaemic metabolites (H+/K+/CO2)
        
        Ischaemia reperfusion injury
        
        Sudden drop in SVR - hypotension
        
        Good communication required
        
        Sequential reperfusion of legs
  - - - Maintain BP, avoid swings
- - - - More selective use of shunts
      - Greater BP stability
      - Cerebral state assessment intra and immediate post op
      - Shorter hospital stay
    - - Oppourtunity for training
      - ?Loss of neuroprotective effects of GA
      - Increased stress (pt and surgeons)
      - Operation may be technically more difficult
  - - - subcut along posterior border of SCM 10-15ml LA
      - Risk injection into EJV
    - - Needle @ midpoint of posterior of SCM - single pop. 10-15ml LA. Deep to investing fascia of neck
      - Risk damage to vascular structures
    - - C6/7, C7/T1 - not popular due to risk - alters pul function
    - - 5ml just before C2-4 transverse process
      - Complications
        
        Intravascular injection - vertebral artery is close
        
        Intrathecal injection
        
        Phrenic nerve block - avoid in pts with resp disease or contralat phrenic nerve palsy
        
        Horner's - due to stellate ganglion block (C6-T1) - ptosis miosis, anhydrosis & enophthalmos
        
        Recurrent layrngeal nerve palsy - more commonly due to surgeon blocking the carotid sheath (cant be done by skin)
  - - - Transducing needle above cross clamp
      - Measures retrograde flow from CoW
  - - - ABC
      - 100% O2 from circuit via facemask
      - Same will happen with shunt removal
      - BP @ or above awake levels
      - Surgeon to insert shunt asap
      - May need GA if uncooperative
      - Pt should wake up
- - - - High risk (>5%)
        
        Emergency intraabo, long operations, high blood loss - AAA (emergency), peripheral vascular, amputations
      - Intermediate risk <5%
        
        Head & neck, thoracic, intraabdo, major ortho, major urology, CEA
    - - Shuttlewalk (>400m good)
      - CPEX - VO2 >15ml/kg/mn good
    - - Cardiology referral
    - - aspirin/statin/b blocker/ACE-is/BP control
  - - - CCF
      - CVA
      - IHD
      - IDDM
      - Risk of surgery
      - Raised Cr
      - 0 score = 0.5% risk MI/death/arrest
        
        3 score = 11% risk