Agus Setiyana, m.d.

Semarang , 05/12/12
What`s new ?
In what`s field
Anesthesia
Surgical
GA
Open repair
RA
EVAR
Locoregional
Laparascopic repair
Fast track
Organ protection

ICU
Tailored perioperative mgt
Fast track
Anesthetic goals ;
Minimize patient morbidity & mortality
Mortality has decreased rapidly since 1960`s
Elective AAA repair 30 day mortality rate

> 25 % in the mid 1960`s

1.8 - 8.4 % mortality rate today

Advances in pre op preparation & anesthetic management

are largely responsible
Maximize surgical benefit
Achieve above goals in the most cost effective
manner
Pre-op considerations
Aortic disease is indicative of other vascular disease
AAA surgery has high risk of periop myocardial
ischemia..
Coronary artery disease.
MI
Stable or unstable angina
LV dysfunction/CHF
Atrial fibrillation
Arrhythmias;
Pacemakers in situ!
 Peripheral vascular disease

Carotid artery disease:

always listen for carotid bruits & ask about TIA/CVA
symptoms
Other co morbidities:
COPD
HTN
DM
perioperative insulin
Renal dysfunction
Often exacerbated by
periop angiograms,
IV contrast
NAC may help
Preparations work up:
Functional status/ exercise tolerance :
severity of cardiopulmonary status

ECG
TTE, TEE
DSE
Thallium scanning
CAG
 Carotid USG
( H/o stroke/ TIA )

PFT/ ABG :
in pts with moderate to
severe pulmonary disease
PFTs may help guide preop
medical therapy for optimal
pulmonary status & estimate risk
Pre operative
Myocardial protection
Preop use of -Blocker
Preop statins
Lung optimalisation
Smoke cessation
Sputum drainage
Intra op:
ECG : II, V5, V6 with ST analysis
ABP, CVP
Two large-bore peripheral IVs
(or central introducer sheath)
Additional monitors: TEE, PAC
ACT , BGA
Use of minimally invasive monitoring if possible
APCO

Scv o2/ Sv o 2
SV, SVV,SVR
Intra op concerns
Open repair
- organ preservations
pre, durante, post cross clamping ;
- heart,lung, ren, spinal cord, sphlanich
- urogenithal

- bleeding ; use of blood salvage & ultrafiltration

- trombho embolous event
- avoid hypothermia
Cross clamp!
Cross-clamping of the aorta : significant cardiac stress
Acute left ventricular strain produces a major
cardiovascular stress; magnitude is related to clamp
position
MAP may increase only 2% with infrarenal
5% with suprarenal
up to 54% with supraceliac placement
Cross clamping placement
Aortic cross clamp physiology
Preload Afterload

Thoracic

Supraceliac

Suprarenal

Infrarenal
Aorta clamping : also EF IHD
Drug management;
Tailored clinical presentation & monitoring
for clamping
NTG
Nipride
Milrinone
Beta blocker
for unclamping
Fluids
Catecholamines
vasopressors
Anesthetic technique choices
Tailored with
Patient condition
Type of surgery
Urgency of operation
* No single technique superior upon others *
# Most suggest ; emphasis on hemodynamic
stability, not speed of onset
o Balanced anesthesia narcotic base
o Combined anesthesia
Post operative issues
Cardiac complication
Very high risk
Iscemic cardiac event as a major cause
Arryrthmia 3%
MI 1,4 %
CHF 1%
Coronary revascularisation shoud be considered prior to
AAA repair
 Lung
ARDS
8 12 % after AAA repair
50 % mortality
Doubling of lung water content
Redistribution of blood

Vasodilatation

Capillary leakage

Reperfusion injury
Superoxide radicals, neutrophis, etc
 Renal
Transient renal insufficiency
50 % after thoracic clamp
28 % after suprarenal clamp
10 % after infrarenal clamp
Dialysis-dependent renal failure in 2-3 % regardless of
aortic clamp position
Mech of injury : ATN et causa;
RBF
GFR
Ischemia reperfusion
Renal protection
Maintain adequate intravascular volume
Maintain CO
Use endovascular technique
Avoid nephrotoxins
NSAIDs, aminoglycosides,
Cross clamp time <50 min
Cooling ( temperature drift )
Other techniques ;
Mannitol, loop diuretics,
Fenoldopam,low dose dopamine!?
dexmedetomidine
Spinal cord issues
Perfusion pressure = Anterior spinal artery pressure
minus CSFP/CVP

Supraceliac cross clamp

anterior spinal artery pressure
CSFP
CVP
Spinal cord protection
1. Increase anterior spinal arterial pressure
Aorto-femoral shunting
Maintain proximal hypertension
2. Decrease CSF-pressure
Avoid cerebral vasodilators (nipride,)
CSF drainage (controversial) +/- steroids
3. Decrease CVP
Phlebotomy
NTG
4. Esoteric measures
Cooling (temperature drift)
O2-radical scavengers (n-acetylcysteine, mannitol,
SOD, allopurinol, )
What`s new ?
Fast track programme
Aims =
To reduce periprocedural ischaemic complication
To reduce rate post op medical complications
To facilitate early rehabilitation
How =
1. Patient education & instruction pre op
2. Shortening of pre op fasting
3. No bowel washout
4. Increased temperature of OT to 22 C
5. Pain control
6. Early enteral feeding & ambulation
7. Restriction of IV fluid application
Medications
Milrinone
Phosphodiesterase inhibitors type III
Cardiac myocites : positive inotropy
positive lusitropy
positive chronotropy
positive dromotropy
Vascular smooth muscle cells :
vasodilatation

* Inotropy with afterload reduction *

both PVR & SVR
 Dexmedetomidine

an alpha2 adrenoceptor agonist

as adjunct to anesthesia
perioperative hemodynamic stability
dose dependent
centrally - mediated sympatholysis
 Neuro protection
Reduces the release of noradrenalin in the brain
Modulates the balance between pro-apoptotic and anti
apoptotic protein
Reduces the release of excitatory neurotransmitter such
as glutamate

Cardio protection
By reducing the release of noradrenalain
BP
heart rate
the requirement of oxygen & nutrition of the heart
Protec cardiac from ischaemia
 Nefro protection
Did not alter renal function
Associated with an urinary output
through ;
Inhibition of renin release
Increased GFR
Increased of sodium & water excretion
matur
nuwun