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Anesthesia for Vascular Surgery

Seminar Outline. Preop issuesBeta-blockersCoronary stentsIntraop managementCrossclamp pathophysiologyRenal ProtectionSpinal Cord Protection Endovascular ApproachPostopPain Management. Seminar Outline. Preop issuesBeta-blockersCoronary stentsIntraop managementCrossclamp pathophysiologyR

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Anesthesia for Vascular Surgery

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    1. Anesthesia for Vascular Surgery NB This is a seminar & NOT a formal lecture.NB This is a seminar & NOT a formal lecture.

    2. Seminar Outline Preop issues Beta-blockers Coronary stents Intraop management Crossclamp pathophysiology Renal Protection Spinal Cord Protection Endovascular Approach Postop Pain Management Seminar will follow this outline, open to questions but not everything about vascularSeminar will follow this outline, open to questions but not everything about vascular

    3. Seminar Outline Preop issues Beta-blockers Coronary stents Intraop management Crossclamp pathophysiology Renal Protection Spinal Cord Protection Endovascular Approach Postop Pain Management

    4. Beta-blockers ACC/AHA Update NB Class I = good general agreement, Class IIa= well established, Class IIb = less well established Evidence A = multiple studies, B = single, C = consensusNB Class I = good general agreement, Class IIa= well established, Class IIb = less well established Evidence A = multiple studies, B = single, C = consensus

    5. b-blocker study summary My approach based on studiesMy approach based on studies

    6. Seminar Outline Preop issues Beta-blockers Coronary stents Intraop management Crossclamp pathophysiology Renal Protection Spinal Cord Protection Endovascular Approach Postop Pain Management

    7. And then there was CARP Need to know a few refs & this is 1 of them Not high risk ptsNeed to know a few refs & this is 1 of them Not high risk pts

    8. CARP body count

    9. CARP long term survival

    10. More specifically, stents and vascular surg

    11. Stents clot, so approach to PCI

    12. Seminar Outline Preop issues Beta-blockers Coronary stents Intraop management Crossclamp pathophysiology Renal Protection Spinal Cord Protection Endovascular Approach Postop Pain Management

    13. Vascular Anesthesia Goals Stable hemodynamics & preserve myocardial function Maintain O2 carrying capacity ie. Vol & Hct Protect renal function Maintain body temp Correct biochemical abnormalities that develop i.e., lytes, ph

    14. Intraoperative Myocardial Ischemia

    15. ECG Ischemia Detection Can increase sensitivity by moving red lead to V5 & brown to V4Can increase sensitivity by moving red lead to V5 & brown to V4

    16. Effect of X-Clamp NB supra is Tx for ruptured AAANB supra is Tx for ruptured AAA

    17. Therapeutic Options Afterload reduction Volatile - easy, fast SNP - difficult (foil, pump), overshoot Preload reduction GTN - myocardial benefit Shunts and/or partial bypass

    18. Seminar Outline Preop issues Beta-blockers Coronary stents Intraop management Crossclamp pathophysiology Renal Protection Spinal Cord Protection Endovascular Approach Postop Pain Management

    19. Renal Protection Fluids Mannitol Dopamine N-acetyl Cysteine (NACC) Tang YI & Murray PT. Best Practices & Research Clin Anesth 2004;18:91-111.

    20. Renal Protection (Fluids) Etiology of ARF pre-renal azotemia ATN 20 (i) ischemia & (ii) nephrotoxins Kidneys receive 20 25% CO Autoreg RBF & GFR @ MAP 85 180 MAP 60 70 is on steep desc part curve Htn right shifts curve Lost in ATN no studies of extra fluid vs normal vasc Supranormal CVT - dec C/O (ARF) Shoemaker Chest 1988:94:1176-86.

    21. Renal Protection (Mannitol) Conceptually inc tubular flow & wash out debris Na-K-Cl pump medullary O2 req Free radical scavenger Human studies No D U/O @ 24 hrs No D CrCl @ 24 hrs Zacharias et al, The Cochrane Library Issue 1, 2006 Morbidity: high dose may cause ARF

    22. Renal Protection (Dopamine) Low dose stim DA-1 & DA-2 rec renal a. vasodilation RBF Na reabsorp natriuesis Periop Studies U/O @ 24 hrs by 0.33 ml/min (95% CI 0.05 0.60) No D CrCl @ 24 hrs No D free H20 clearance Zacharias et al, The Cochrane Library Issue 1, 2006 Morbidity: tachyarrhythmias, ischemia, etc

    23. Renal Protection (Fenoldopam) Pure DA-1 agonist not available in Can In animals preserves RBF during hypotension under GA No effect contrast nephropathy with CRI Stone et al JAMA 2003:290:2284-91. Maintained CrCl vs dec in control in infrarenal aortic Sx pts (n = 28) Halpenny et al EJA 2002;19:32-39.

    24. Renal Protection (NACC) Antioxidant useful in acetaminophen toxicity Initial role in prevention of contrast nephropathy (not reproduced) Tepel M et al, NEJM 2000;343:180-4. No benefit in preventing ARF in infrarenal aortic Sx in pts with normal renal fx Hynninen MS et al, A &A 2006:102:1638-45.

    25. Seminar Outline Preop issues Beta-blockers Coronary stents Intraop management Crossclamp pathophysiology Renal Protection Spinal Cord Protection Endovascular Approach Postop Pain Management

    26. Spinal Cord Blood Supply

    27. Spinal Cord Blood Supply (2)

    28. Spinal Cord Blood Flow

    29. Spinal Cord Summary Low thoracic levels dependant on variable blood supply Anterior fibres more at risk than posterior May be source of significant back bleeding when aorta opened

    30. Spinal Cord Protection Decrease X-clamp time Partial bypass Decrease spinal cord perfusion pressure (SCPP = MAP - SCP) using drain

    31. X-Clamp & Outcome in TAA

    32. Neurologic Complications From surgical text. Showing effect of time and adjunct being partial bypass.From surgical text. Showing effect of time and adjunct being partial bypass.

    33. Partial Bypass

    34. CSF Drainage 10 mm Hg comes from animal studies only.10 mm Hg comes from animal studies only.

    35. CSF Drainage - Background Linear regression from this one study.Linear regression from this one study.

    36. CSF Drainage & Paraplegia NB studies not prospecitve & randomized especially 2 strong positive onesNB studies not prospecitve & randomized especially 2 strong positive ones

    37. CSF Drainage Indications: involvement T9-T12 (artery of Adamkiewicz) Involvement of arch vessels (origin ant. spinal a.) Previous TAA if AAA repair or vice versa Symptomatic spinal ischemia

    38. CSF Drainage Complications: n= 1486 Subdural hematoma = 2 with paraplegia Meningitis (fatal) = 1 Cina CS et al. J Vasc Surg 2004;40:36-44

    39. Seminar Outline Preop issues Beta-blockers Coronary stents Intraop management Crossclamp pathophysiology Renal Protection Spinal Cord Protection Endovascular Approach Postop Pain Management

    40. Stent Procedures

    41. Endovascular Surgery

    42. Endovascular Stents Anatomic prerequisites: Aneurysm morphology Distal access artery caliber Proximal & distal landing zones need 2 cm without major vessel

    43. Submarine analogy Endoleaks at junctionsEndoleaks at junctions

    44. Surgical Complications Conversion to open 1 3% Endoleak 2 10 % Migration 1 5% Thrombosis 1 5% Rupture < 1 % at 5 yr

    45. Stent Survival

    46. Endovascular Surgery

    47. Endovascular Surgery (2)

    48. Endovascular Surgery (3)

    49. Endovascular LHSC (1)

    50. Endovascular LHSC (2) NB both differences and similaritiesNB both differences and similarities

    51. Endovascular LHSC (3) LOS not diff due to wide SDLOS not diff due to wide SD

    52. Seminar Outline Preop issues Beta-blockers Coronary stents Intraop management Crossclamp pathophysiology Renal Protection Spinal Cord Protection Endovascular Approach Postop Pain Management

    53. Postop Epidural & Outcome

    54. Postop Epidurals (2) Mortality = NS Majority aortic but not allMortality = NS Majority aortic but not all

    55. Postop Epidurals (3) MI just sigMI just sig

    56. Postop Epidurals (4) Cochrane Library Aortic Surgery Randomized, controlled 13 studies, 1224 pts; 597 epi vs 627 sys Dec VAS pain scores Dec t IPPV (20%), CV C/Os, MI, GI C/Os, renal insuff No diff mortality

    57. Seminar Outline Preop issues Beta-blockers Coronary stents Intraop management Crossclamp pathophysiology Renal Protection Spinal Cord Protection Endovascular Approach Postop Pain Management

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