Management of the Critical Ill Vascular Surgery Patient

1
Management of the Critical Ill Vascular Surgery
Patient

• Critical Care Program
• Part III, Chapter 86
• Giancarlo Piano, John Alverdy, Christopher Zarins
• ???
• 2002/2/21

2
Program

• Introduction
• Preoperative management
• Intra-operative management
• Postoperative management
• Special consideration
• Test

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Athersclerotic Arterial Disease

• A major world health problem.
• A leading cause of death.
• Affects one in four peoples.

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Peripheral Arterial Disease

• Older
• More systemic diseases
• Lower life expectancy

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Preoperative Management of the Vascular Patient

• Indices of anesthetic risk
• ASA classification
• Limited for vascular patients

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Pre-op Mx Risk Score ?
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Preoperative Mx

• Cardiac complications account for gt 50 surgical
  mortality
• Indices of surgical risk and cardiac risk
• Goldman Risk Index
• 12-lead ECG
• Exercise Testing ECG
• Limited, under-estimation

Ann Intern Med 1989110859
J Vasc Surg 19899437
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Intraoperative Management

• General considerations
• Primary objective cardiopulmonary protection
• Invasive heart and lung monitoring
• Intraoperative hypotension a frequent problem

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Intraoperative Mx

• Aortic surgery
• Clamping and unclamping
• Kidney blood flow
• Unclamping shock

J Vasc Surg 19887785
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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

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Long-term Survival
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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

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Postop Mx Cardiopulmonary System

• End points for minimizing cardiac risk
• Oxygen tension (PaO2 gt 75 mmHg)
• Oxygen content (hb gt 10 g/dL)
• Mean arterial pressure
• Coronary vasodilatation
• Lowest left ventricular end-diastolic pressure
• Heart rate

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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

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Postop Mx Others

• Assessment of peripheral vasculature
• Doppler signals
• Recorded at hourly intervals ?
• Infection
• Nutrition
• First 24 to 48 h unnecessary
• gt5 days ? nutrition support

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Drugs Commonly Used

• Heparin
• Dextran
• Mannitol
• Thrombolytic agents