University of California San Francisco â€" East Bay.doc.doc ...
University of California San Francisco – East Bay
PROTOCOLS FOR DIVISION OF VASCULAR SURGERY
I. INTRAVENOUS FLUIDS:
Avoidance of intravascular volume depletion, replenishment of sodium and potassium
losses preoperatively and sodium loading prior to arteriographic and operative
procedures are crucial to prevent renal failure in vascular patients.
1. All inpatients are to get IV with D5 ½ normal saline (with or without
potassium depending on potassium and creatinine) starting at 8:00 p.m.
the night prior to arteriography.
2. Fluids are to run at 80-125 ml per hr nominally depending on weight of
patient and clinical condition. Continue IV fluids until adequate p.o.
intake is established. (Post-angiogram IV orders by Radiology are
usually inadequate and must be checked and/or modified).
3. If patient has severe congestive heart failure, discuss with attending
physician and cardiologist to determine rate and need for fluid
4. Patients with renal insufficiency (creatinine > 1.3):
If creatinine is > 1.8, check with attending to determine if an arteriogram
should be done at all. IVPB (12.5 gm) Mannitol should be given on call
to Radiology. An additional 12.5 gm should be sent to Radiology to be
given after the contrast. Check with attending physician for indications
and dose. Follow-up BUN/Cr should be obtained the next morning.
Keep patient hydrated.
5. If patient reports history of contrast allergy, administer Prednisone 50 mg
p.o. q6h starting 24 hours before. Send Benadryl 50 mg IV push to x-
ray and hang Tagamet 300 mg IVPB on call to radiology.
6. All patients should have pulses documented prior to procedure, and a
post procedure note documenting their vascular and neurologic status.
Be particularly alert for evidence of brachial plexus problems after
7. Prior to angiography the patient’s condition, labs, chest x-ray, and EKG
need to be reviewed as if they were going to the operating room.
8. Bed rest with hip straight x 6∀ ( if femoral access employed) with or
without compression at puncture site, then light activity for a few days
B. Preoperative Fluid Therapy
1. Inpatients receive intravenous fluids the night prior to surgery to avoid
volume depletion and subsequent hypotension at the time of anesthetic
2. Type and amount of IV fluid depend on the procedure and the patient’s
3. Procedures involving significant blood loss, aortic cross-clamping, renal
a. Patients to receive D5 Ringer’s Lactate starting at 8:00 p.m. the
night prior to surgery at a rate of 75-150 ml/hr with potassium as
needed. Old, debilitated or small patients (< 50 kg) receiving
bowel preps will need hydration begun earlier, at appropriately
b. Patients with myocardial compromise may need to be placed in
intensive care unit for Swan-Ganz catheter placement the night
before the operation with possible optimization of cardiac
performance. Aortic cases receive Swan-Ganz catheters
preoperatively, usually prior to induction. Consult with attending.
c. Individualize the rate of fluid administration to the size of the
4. Other procedures (fem-popliteal bypasses, carotid, minor procedures,
amputations, etc.) require maintenance fluid appropriate to patient’s size
starting at 8:00 p.m. the night prior to surgery with potassium as needed.
More fluid may be needed if the patient has third space losses, unusual
insensible losses, or is already volume depleted.
5. No one goes to the operating room for elective surgery without having
received intravenous fluid in preparation for surgery.
A. Cardiac Medications
At the time of admission it is important to obtain and record an accurate list of the
patient’s current medications.
1. Routine cardiac medications are given the morning of surgery with a sip
of water. This usually includes digitalis preparations, calcium channel
blockers, long-acting nitrates, and other antiarrhythmic agents.
B. Antihypertensive Medications
These are usually given in the morning of operation with sips of water.
1. Diuretics are stopped 24 hours prior to surgery.
2. Always check potassium level of patients on admission. Anyone on long-
term diuretics will be potassium depleted even with normal potassium
levels. The most sensitive indicator of this is not serum potassium level
but the serum bicarbonate level. If the patient is slightly alkalotic she/he
will need potassium replacement prior to surgery.
1. All patients undergoing procedures in which a prosthetic patch or graft
may be placed or the groin is to be entered require preoperative
prophylactic antibiotics. Except in unusual circumstances, all vascular
procedures get preoperative antibiotics.
2. Antibiotics are started on call to the operating room and continued for 24
hours postoperatively. For patient with prosthetic patches or grafts,
antibiotics should be given until the intravascular monitoring lines and
Foley catheter have been removed, plus one day. If there is any
drainage from an incision involved in the operation, antibiotics are to be
continued. If the WBC or differential are not normal, antibiotics are
continued. Consult attending regarding the timing of oral antibiotics
substitution. Patient should be observed one day off antibiotics prior to
3. Should a patient have pre-existing urinary tract infection or other sources
of bacteremia preoperatively ( such as severely decayed teeth, umbilical
infection, foot ulcers, or infection over saphenous vein), this must be
treated preoperatively and brought to the attention of the attending
surgeon. The skin in the area of the proposed operation should be
carefully inspected. Hibiclens showers should be ordered on all
inpatients the night before surgery.
4. ANCEF 2 grams IVPB q8 hours is the usual prophylactic antibiotic
employed, unless there is a history of serious allergic reaction to
penicillin. In these cases Vancomycin is the usual alternative. If the
patient has a documented infection sensitive to a specific antibiotic, that
antibiotic should be ok.
Carotids and vertebral bypass patients receive 80 mg (baby) aspirin p.o. the
evening before operation, as do patients undergoing distal lower extremity
bypasses. Those patients already taking aspirin or other Thromboxane inhibitor
(Motrin, Ibuprofen, Clinoril, etc.) do not need a baby aspirin. Don’t combine ASA
with coumadin. Note that almost all vascular patients go home on ASA unless
there is a cogent reason not to.
III. PREOPERATIVE ORDERS
1. Operative consent form must be filled out and consent obtained and
2. NPO after midnight. This may be appropriately modified for afternoon
3. Preoperative Hibiclens or Betadine shower.
4. Appropriate bedtime sedation should be ordered.
5. Void on call to operating room. If a Foley catheter will be necessary, this
normally can be placed after the induction of anesthesia for patient
6. Type and cross-match for major vascular cases, type and screen for
carotids and vertebrals and minor vascular procedures. This will
generally have been ordered at the time the case is scheduled, but in
emergent situations six units of packed cells are routinely ordered for
aortic reconstructions and two units of packed cells for distal and in-situ
lower extremity operations
7. Prophylactic antibiotics.
8. Usual oral blood pressure and cardiac medications should be given with
a sip of water the morning of operation.
9. Insulin orders for diabetics: In general one-half of the normal insulin
dose is given in the morning, and the remaining one-half dose is given in
the recovery room. Until the patient is able to resume oral intake, sliding
scale insulin is administered. This same regime is used for diabetics
10. Cholesterol evaluation: All vascular patients require cholesterol and
triglyceride work-up on first admission to service, if not already done by
the patient’s referring physician. If the levels are elevated, consult the
dietician and obtain a lipoprotein phenotype.
IV. SPECIFIC PREOP ORDERS
1. Patient should have preoperative CT scan, with IV contrast, and
neurology consult. (If CT scan can be done immediately following an
angiogram, a second dye load can be avoided).
2. An ENT consult should be obtained for vocal cord examination if the
patient has had a previous carotid or neck surgery, ipsilateral or
contralateral. Note character of voice pre-op.
3. Redo carotids require cell saver.
B. Femoral-Popliteal-Tibial Bypass Surgery
1. Venous Mapping - schedule with Dave Sayers after arteriogram, prior to
2. If open foot lesions are present, broaden the spectrum of IV
antibiotics. Discuss with attending.
C. Aortic or Intra-abdominal Revascularizations
1. Pulmonary preparation is important, as most of the patients are smokers.
A spirometer should be ordered and preoperative teaching given.
Baseline blood gases and spirometry with and without bronchodilators
should also be considered. PFT’s may be needed, especially in thoracic
aortic operations. Check with attending.
2. Bowel preparation - 4 l Golytely should be given the evening before
operation and then normal saline enemas until clear the morning of the
operation If visceral ischemia is felt to be a potential hazard, then
formal mechanical bowel prep with antibiotics may be indicated.
Check with attending.
3. Accurate preoperative weights are necessary.
V. SPECIFIC PROTOCOLS
A. Urokinase: Intra-arterial or intravenous
1. The infusions are started in x-ray by the interventional radiologist, but
during the infusion patient must be monitored in the ICU.
2. Catheter is positioned under fluoroscopy directly into the thrombus.
3. Prior to starting the infusion the following coagulation parameters are
obtained: prothrombin time, partial thromboplastin time, platelet count,
4. These are monitored q 6 hrs for the first 24 hours, and q 12 hours
thereafter or at any sign of bleeding.
5. The rate of infusion will be determined by the interventional radiologist
and your vascular attending (usually 1-4K units/min).
6. Attending is called if fibrinogen level decreases below 100 mg percent or
there is any sign of bleeding to discuss stopping infusion.
7. Infusion is continued for 24 to 72 hours with repeat arteriograms
every 6 to 24 hours of as indicated clinically. The end point of
infusion is failure to achieve clinical success at 72 hours,
complications related to infusion, or clearance of clot.
8. Aspirin should not be used during the Urokinase infusion. Heparin is
given to minimize catheter induced thrombosis.
9. There should not be any IM injection or arterial punctures. Venous
punctures sites should be held with pressure for 15 minutes.
B. Deep Vein Thrombosis
1. Baseline platelet count, PT, PTT.
2. Ask attending re: intravenous loading dose of Heparin 100-150 units
per kilo given as bolus.
3. Bed rest for 7 days with the leg elevated above the level of the heart.
4. At the same time start continuous heparin infusion via IVAC.
5. The dose of Heparin necessary will vary with size of patient and the
extent of the thrombotic process. As a rule approximately 15u/kg/hr is a
good starting dose. Patients with extensive thrombotic problems (PE,
iliofemoral DVT, advanced thrombosis) may need as much as 20-30
6. Check the PTT 8 hours after starting the infusion and q6h until level is
stable at 2-2.5 times control PTT and daily thereafter.
7. Continue treatment in routine cases for 7-10 days depending on clinical
8. Platelet counts are needed every other day during heparin therapy.
Be alert for the development of thrombocytopenia.
9. Check with attending regarding use of Coumadin. Order PT to establish
baseline and to determine therapeutic dosage. Coumadin generally is
started on the third day of heparin treatment if it is therapeutic.
10. When the leg edema is reduced, the patient is measured for a custom
fitted, below knee, elastic Jobst stockings with 30-35 mm Hg
compression pressure. (Check pulses to insure adequate arterial inflow
prior to ordering any compression stocking). Make 2 pairs (or 2
stockings if one leg is involved). Have the stockings mailed to the
patient’s home address. (It takes several weeks for these to be made).
C. Balloon Angioplasty
1. LES - Baseline to measure preangioplasty pressures.
2. Patient receives fluid as for arteriography night prior to procedure.
3. Patient is given 1 grain of aspirin orally night prior to procedure and
1 grain daily thereafter.
4. Occasional patients may need heparin post angioplasty. Check with
5. LES done prior to discharge.
D. Postoperative Arteriography
Check with the attending regarding the need to obtain prior to discharge in all
patients who have had:
• vertebral reconstruction
• aortic arch surgery
• disobstruction of completely occluded ICA
• bypass of the branches of the aortic arch, visceral or renal vessels
• any bypass where a completion arteriogram could not be performed
E. Postoperative Surveillance
Consult attending on follow-up duplex examinations after vascular reconstructions.
GUIDELINES FOR VASCULAR ACCESS
Objectives: To provide durable hemodialysis access for patients with end stage renal
1. A Green Service surgery resident/ staff member will evaluate patient
ASAP and immediately insure that no arterial or venous punctures or
cannulations are done in the upper extremities. Subclavian central
venous lines should not be placed and an IJ catheter should be used
when needed if possible. Assess upper extremity arterial blood
pressures in both arms and visually describe the brachio-cephalic
venous system under tourniquet control. Review with staff prior to writing
a consult. Communicate with nephrology fellow.
2. All patients will require pre-operative upper extremity vein and axillo-
subclavian venous duplex to assure adequacy of venous outflow.
3. All patients will receive segmental arm and finger pressures with
4. If a duplex exam could not be performed or is not available, an
arteriogram and/or venogram should be done. Consult attending before
you do this.
5. The evening prior to surgery all patients should have a Hibiclens,
Betadine, or other antimicrobial scrub.
6. Patient should be dialyzed before surgery. Please coordinate with
7. Once patient is medically stable, either a primary radial artery/cephalic
vein arteriovenous fistula (end of vein to side of artery) or a PTFE bridge
shunt will be constructed.
8. PTFE grafts will not be inserted until intercurrent infection processes are
9. Unless contraindicated, perioperative antibiotic will be Vancomycin, to be
ordered by the operating surgeon.
10. All incisions should be closed in at least two layers. The skin over the
graft must be air-and water-tight, and a 4-0 interrupted nylon vertical
mattress stitch should be employed.
11. A completion arteriogram will be done to document technical perfection
of the anastomosis and outflow.
12. The tunnel maturation period for a new PTFE loop fistula is 18-21 days;
primary A-V fistulas require 4-6 weeks to arterialize.
13. All patients post fistula construction should have a duplex evaluation at
3 - 5 days, 21 days, 6 weeks, 12 weeks, and every 3 months after that
indefinitely. Under ideal circumstances, duplex exam should precede all
first attempts to use fistula-- with estimation of fistula flow rate.
14. Keep operated extremity elevated prn if swelling is present to avoid
breakdown of the incisions and hand ischemia.
VASCULAR ACCESS COMPLICATIONS
1. Thrombosed Fistulas and PTFE Grafts
To be admitted by the medical service on call and evaluated by the
surgical team on call. Every attempt to revise an existing fistula grafts
will be made. If possible, a duplex scan will be performed prior to
revision to assess possible factors such as arterial or venous stenosis as
an etiologic factor in graft failure.
2. Timing of Revision of Uncomplicated Thrombosis of Grafts
In the absence of the need for urgent dialysis that could only be done via
the graft, #1 should be done prior to revision which will be scheduled
during normal elective operating time.
If just cause can be given (by medicine chief resident of higher) for the
revision to be done as an emergency case, it will be done in order with
other emergency cases, realizing that the triage of care might preclude
immediate operative intervention.
3. Infected Grafts
Cases will be individualized. If surgical intervention is needed, it will be
done as an emergency. A permacath or other device can be inserted at
the same time if needed.
Depending on the site(s) and size of graft and/or anastomotic
aneurysms, some will need revision. Consult you attending.
To facilitate timely arteriography and to assure that the information provided by this study
is useful, please adhere to the following guidelines.
1. Consult your surgical attending before requesting arteriographic studies;
2. Senior level residents (3rd year and above) should preferably confer with
the radiologist regarding what information is needed;
3. During off hours and night-time, a house officer must accompany the
patient to the angio suite and stay with the patient until completion of the
ROUTINE POSTOP ORDERS
1. IV D5- ½ N.S. w/20 mEq KCI @ 1. Condition
75 - 125 cc/hr
2. Demerol 50-75 mg IM q 3-4 h prn 3. Vital signs q 1 h w/neurocheck till
pain. stable, then q 4 h
3. Tylenol #3 1-2 tab p.o. q 3-4 h prn 4. Activity - up with assistance
5. Diet - clear liquid when fully awake,
4. Patient’s current medications ( in all then resume normal diet as patient
cases, review and continue all pre- requests, or by day #1.
op medications, if appropriate).
6. CBC. lytes in PAR & AM
5. Dextran 40 in N.S. @ 50 cc/hr x 3
hr then D/C 7. Jackson-Pratt flat drain, left or right
neck, to bulb suction
6. One baby aspirin each day p.o.
8. Call HO if:
7. The most important aspect of
postoperative management both in • BP syst > 160 or < 90
terms of avoiding postop cardiac or • Resp > 28 or < 10
cerebral morbidity is in ensuring normal • No void by 4h postop
BP. If systolic BP falls below 90, notify • Bright red blood saturated
attending. If pressors needed, use a dressings
neo-synephrine drip ( 10 mg in 250 • Change in neuro status
D5W) administered via IVAC. Systolic • > 100 cc from JP
BP > 160 can usually be regulated
with a nitroglycerine or nimide drip.
Wild fluctuation in BP is just as 9. CT of head without contrast if
dangerous as severe hypertension or patient has symptoms indicating
hypotension. change in neuro status.
10. Consult ENT before second 11. Report post-op hoarseness or facial
contralateral operation/cord function weakness/asymmetry to surgeon
As for carotid endarterectomy 1. Same as for carotid endarterectomy
Port CXR in PAR
2. Check with attending about
schedule post-op single injection
arteriogram to view the L/R carotid
Aortic and /or Mesenteric Operations
1. NG tubes
a. Keep NGT patent q 2 hr.
b. Check pH q 4 hr. Keep > 5.5 with cimetidine ± antacids.
c. Ask attending whether suction or gravity drainage.
d. Keep NGT until passing flatus or stool and NG output acceptable
a. Specify TV, IMV rate, F1O2, PEEP.
b. Specify frequency of routine ABG, VS, and whom to call for
c. Suctioning as needed
3. Extubated patients
a. DB q 1-2 hr, cough as necessary.
b. Incentive spirometer q 1 hr while awake.
c. Nasotracheal suction if patient unable to cough or raise
4. In PAR
a. EKG, CXR for line and ET tube placement -- look for
b. PCW, CVP measurements q 1 hr in ICU/PAR
c. Cardiac output q 4 hr with SVR
d. Specify parameters for calls to HO for PCW, CVP, SVR, CO,
a. Bed rest while in ICU. Out of bed when hemodynamically stable.
b. Warming blanket till euthermic.
c. Air sequential stocking and/or SQ heparin while in bed.
6. Pain Management
a. Consider use of PCA with morphine as first choice and IV push
morphine as second choice (1 to 7 mg IV q 1-2 hrs prn).
b. Pain management is individualized to ensure patient’s comfort.
8. IV Fluids
a. The bulk of IV fluid should be administered as Lactated
Ringer’s solution first 24 hr. Usual D5 ½ N.S. thereafter with
appropriate potassium supplementation. Titrate rate to expected
third spacing and maintenance needs vs. PCW and urine output.
b. Specify whether to monitor certain symptoms in detail, i.e., distal
pulses (± Doppler) for grafts to iliacs or femorals, renal function
for renal bypasses, non-incisional abdominal pain or elevated
liver function tests for mesenteric grafts, etc.
c. Monitoring postoperative weight is essential following aortic
reconstructions, or any operation where there are major fluid
shifts. Be sure an accurate preoperative weight is recorded.
d. Be alert for signs of bowel infarction, i.e., abdominal pain,
diarrhea, blood per rectum, acidosis, or sepsis. Call chief
resident and attending if bowel infarction suspected.
e. Be alert to post-op pancreatitis in abdominal aortic
a. Feed 1 day after NGT removed. Begin with clear liquids, then
advance to appropriate solid diet if tolerated.
1. Liquids as tolerated after spinal anesthesia if no N/V. Solid diet
appropriate for the patient’s disease during the following day.
a. Bed rest for 6 hours after spinal or epidural anesthesia, then
out of bed when hemodynamically stable. Gradually resume
activity. Many patients will have peripheral edema on the side
operation and will need that leg elevated.
3. Routine IV maintenance fluid.
4. No pillows behind knee because it compresses the popliteal vessels.
5. Foley out as soon as can manage with bedpan, commode, or bathroom.
6. Nursing staff to check distal pulses by palpation and/or Doppler on
admission to the unit and q 1h x 12 /q 2h x 6 and call HO immediately
for loss of pulse.
7. Wound care and staple/suture removal as per aortic operations.
8. For infrainguinal (femoro-popliteal or femoral-tibial) give one baby
aspirin (80 mg) tablet per day p.o.. Start night before operation.
9. LES study two days post-op or when edema has resided and definitely
before patient leaves hospital.
10. If unexplained graft thrombosis, obtain hypercoagulable work-up (Prot C
& S, AT-III, Lupis anticoagulant, anticardiolipin Ab, PT, PTT, plt count).
1. GLOVES ARE TO BE WORN FOR ALL DRESSING CHANGES
2. Especially groins - must be inspected every day and kept dry. All groin
wounds use dry dressings until sutures are removed. Inform chief
resident of any drainage.
3. Sterile dressing technique must be used for all patients with fresh
wounds or draining wounds. Keep sterile dressing on at least 24∀ but <
48∀ from OR if wound was clean and a wound infection is not suspected.
4. Staple/ suture removal:
a. Neck: on discharge Steri-Strip
b. Abdomen: 7 days Steri-Strip if neither tension nor edema are
c. Legs: consult attending
d. Amputation stumps: 2-4 weeks.
e. For diabetics, patients with renal failure, or patients on steroids
or in poor nutrition, extend the length of time staples/sutures are
in place in abdominal and leg incisions.
f. If abdomen distended, limb/neck swollen, or inflammation
present, check with attending before removing staples/sutures.
1. Consult physiatrist (prior to amputation if possible) for immediate
prosthesis and for patient teaching.
2. No pillows supporting stump post-op.
3. Ace bandages on stump to keep swelling down, but be mindful not to
wrap an ischemic limb too tightly.
4. Subcutaneous heparin 5,000u q 12h post-op.
5. Overhead trapeze for assistance with mobility.
6. Out of bed in chair with stump supported post-op day #1
7. Consult physical therapist immediately post-op.
All women of childbearing age require a pregnancy test if scheduled for an arteriogram
or an operation.
Appropriate foot protection should be ordered for patients with lower extremity ischemia,
i.e., vascular boots, air mattress, and a foot board to keep the covers off the feet.
Review all medications twice a week.