4. History
Past history :
• History
– ▸ Allergy : -
– ▸ Medication : HCTZ (25)1*1 o pc , Enalapril(5)1*1 น pc , 2IRZE+4IR (start
18/8/59)
– ▸ Past illnesses: HT
– ▸ Last meal : npo 24.00
– ▸ Event/environment : -/no History of surgery
Diagnosis : Infrarenal AAA
TB pleural/peritoneum
Operation : Open repair AAA
History
5. Physical examination
BW 70 kg HT 165 cm
Vital signs : BT 36.7 c , HR 90 bpm, RR 20 /min, BP
131/81 mmHg
Airway : Mallampati class 2
Heart : normal S1S2 , no murmur
Lungs : clear
Abdomen : soft, not tender, +-pulpated pulsatate mass
Nervous system : E4V5M6, pupil 2 mmRTLBE
Extremities : no edema
22. The indications for repair of AAA
• Symptomatic aneurysm of any size
– abdominal, back or flank pain, evidence of embolization, frank
• Asymptomatic aneurysm ≥5.5 cm
• Rapidly expanding AAA
• AAA associated with other arterial disease
• Infected AAA
• Complications following endovascular repair necessitating
early or late conversion to an open AAA repair
27. Preoperative assessment, management, and
investigation
patients presenting for abdominal vascular surgery have a
high incidence of co-morbidities:
• Coronary artery disease often with impaired ventricular function
• Hypertension
• Pulmonary disease (often related to smoking)
• Renal impairment
• Diabetes mellitus
28. Preparation prior to induction
Patient
• Insertion of two wide bore cannulae
• Baseline bloods (blood count, electrolytes, coagulation screen)
• Arterial line (if time permits)
• Insertion of urinary catheter
Equipment
• Rapid fluid infusor (Level 1 infusor)
• Cell salvage equipment
• Forced air warming device
• Invasive lines and cardiac output monitors
• Nasogastric tube and temperature probe
29. Drugs and Fluids
• 6 - 10 units of cross matched blood, FFP and platelets
• Routine anaesthetic drugs, crystalloids and colloids
• Inotropes (adrenaline 1:100 000, ephedrine 3mg/ml)
• Vasopressors (metaraminol 0.5mg/ml, phenylephrine 100 mcg/ml)
Other
• Intensive Care Unit informed
Preparation prior to induction
30. • Organ protection
• Physiologic change aortic cross-
clamp/unclamp and management
•Choice of anesthesia
• Monitoring
Intraoperative management
37. Prevention of Pulmonary Complications
• The most effective preventive measure is postoperative
lung expansion.
• continuous positive airway pressure (CPAP) or incentive
spirometry.
• postoperative thoracic epidural.
• Benefit of low tidal volumes (6 to 8 mL/kg) in patients
with acute respiratory distress syndrome.
• In randomized trials,
• EVAR has not demonstrated reduced risk of pulmonary
complications when compared with OAR.
38. Prevention of Perioperative stroke
• Patients with symptomatic carotid stenosis benefit from
carotid revascularization before major vascular surgery.
• Risk factors include atrial fibrillation and discontinuation of
antiplatelet therapy.
50. Anaesthetic management of EVAR
The anaesthetist should consider:
• The problems of anaesthesia in the angiography suite
• The requirement for short periods of apnoea
• Prolonged bilateral femoral occlusion resulting in ischaemic pain
• The risk (1%) of conversion to an open procedure
