Management of the Critical Ill Vascular Surgery Patient
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Management of the Critical Ill Vascular Surgery Patient

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  • 1. Management of the Critical Ill Vascular Surgery Patient Critical Care Program Part III, Chapter 86 Giancarlo Piano, John Alverdy, Christopher Zarins 詹志洋 2002/2/21
  • 2. Program  Introduction  Preoperative management  Intra-operative management  Postoperative management  Special consideration  Test Critical Care Program 2 2002/2/21
  • 3. Athersclerotic Arterial Disease  A major world health problem.  A leading cause of death.  Affects one in four peoples. Critical Care Program 3 2002/2/21
  • 4. Peripheral Arterial Disease  Older  More systemic diseases  Lower life expectancy Critical Care Program 4 2002/2/21
  • 5. Preoperative Management of the Vascular Patient  Indices of anesthetic risk  ASA classification  Limited for vascular patients Critical Care Program 5 2002/2/21
  • 6. Pre-op Mx – Risk Score ? Critical Care Program 6 2002/2/21
  • 7. Preoperative Mx  Cardiac complications account for > 50% surgical mortality Ann Intern Med 1989;110:859  Indices of surgical risk and cardiac risk  Goldman Risk Index  12-lead ECG  Exercise Testing ECG  Limited, under-estimation J Vasc Surg 1989;9:437 Critical Care Program 7 2002/2/21
  • 8. Intraoperative Management  General considerations  Primary objective: cardiopulmonary protection  Invasive heart and lung monitoring  Intraoperative hypotension: a frequent problem Critical Care Program 8 2002/2/21
  • 9. Intraoperative Mx  Aortic surgery  Clamping and unclamping  Kidney blood flow  “Unclamping shock” J Vasc Surg 1988;7:785 Critical Care Program 9 2002/2/21
  • 10. Intra-op Mx  Mesenteric and renal vascular surgery  Volume  Substantial fluid sequestration  Infra-inguinal vascular surgery  Mx of underlying diseases  Life expectancy is notably lower Critical Care Program 10 2002/2/21
  • 11. Long-term Survival 100% 80% Survival Rate 60% 40% 20% 0% 30-day 1-year 5-year 10-year 15-year DAA TAA AAA PAD Critical Care Program 11 2002/2/21
  • 12. Postoperative Management  General consideration  ICU monitoring for most patients  Most complications occur in the early postoperative period  Reperfused vascular bed  Short-acting sedatives and/or narcotics  Thermal conservation  Hypothermia frequently occur following vascular surgery Critical Care Program 12 2002/2/21
  • 13. Postop Mx – Cardiopulmonary System  End points for minimizing cardiac risk  Oxygen tension (PaO2 > 75 mmHg);  Oxygen content (hb > 10 g/dL);  Mean arterial pressure  Coronary vasodilatation  Lowest left ventricular end-diastolic pressure  Heart rate Critical Care Program 13 2002/2/21
  • 14. Postop Mx – Renal Function  High mortality rate (50% to 75%) for acute renal failure in vascular surgery patient …  Two goals  Renal blood flow  Cardiac output, mean pressure, intravascular volume …  A brisk diuresis (1 to 1.5 mL/kg/h)  Preventing tubular occlusion from desquamated cells  Reperfusion syndrome Critical Care Program 14 2002/2/21
  • 15. Postop Mx – Others  Assessment of peripheral vasculature  Doppler signals  Recorded at hourly intervals ?  Infection  Nutrition  First 24 to 48 h – unnecessary  >5 days  nutrition support Critical Care Program 15 2002/2/21
  • 16. Drugs Commonly Used  Heparin  Dextran  Mannitol  Thrombolytic agents Critical Care Program 16 2002/2/21