VASCULAR ANAESTHESIA

Anaesthesia for vascular emergencies

Shayanti M Ghosh Iain J McCullagh

Learning objectives
After reading this article, you should be able to: C outline the anaesthetic management of emergency ruptured aortic aneurysm C select an appropriate anaesthetic technique for a patient with acute limb ischaemia requiring revascularization C describe airway management in the event of haematoma formation following carotid endarterectomy

Abstract
Emergent vascular surgery is classied as being high risk and includes ruptured abdominal aneurysm repair, acute ischaemic limb revascularization and postoperative haematoma evacuation following carotid endarterectomy. These procedures are frequently performed out of normal working hours on patients who have signicant comorbidities. A detailed preoperative assessment and adequate preoptimization is usually precluded. As expected, associated morbidity and mortality rates are considerably higher than for the equivalent elective surgery. The anaesthetic technique employed should be carefully selected and applied as this plays a vital role in minimizing morbidity. Overall management can be challenging and requires experienced anaesthetic and surgical input from the outset.

Abdominal aortic aneurysm (AAA) repair

In the haemodynamically stable patient urgent radiological evaluation (ultrasound or computed tomography) to exclude aortic rupture or dissection is required. In patients diagnosed with ruptured AAA, hypotension, tachycardia, altered conscious level, cyanosis and skin mottling may be present. This group requires immediate transfer to theatre and urgent surgical repair. Surgical management options The possible surgical approaches in the emergent patient are the traditional open laparotomy and endovascular aneurysm repair (EVAR). The availability of endovascular expertize, adequate equipment and anatomy of the aneurysm will inevitably determine the approach used. EVAR has been shown to decrease procedural mortality compared to open aortic repair (OAR). However, little is known about long-term survival and outcome.3 Anaesthetic management This incorporates the following during the perioperative period:  maintenance of haemodynamic stability  preservation of an adequate circulating volume  management of coagulopathy and haemostasis  maintenance of a normothermic state  adequate pain control. Prior to induction Intravenous access and invasive monitoring: two wide-bore cannulae (at least 16G) should be sited. Rapid haemodynamic changes and the potential for hypotension and myocardial ischaemia mandate the need for invasive monitoring of arterial and central venous pressure. An arterial line (radial or brachial) and urinary catheter should be inserted. Central venous cannulation (CVC) pre-induction may be necessary if it is impossible to gain peripheral access but this should otherwise be deferred until a cross-clamp has been placed on the aorta. Initial bloods: baseline bloods (full blood count, coagulation screen and electrolytes) should be obtained as the rst cannula is placed and sent for urgent laboratory testing. Early liaison with the blood bank and haematologist is vital. Eight units of blood should be cross-matched, together with fresh frozen plasma (FFP). Anticipate the need for platelet therapy. Type-specic or O negative blood may be used if a full cross-match is not available in time.

Keywords Abdominal aortic aneurysm; acute limb ischaemia; carotid

endarterectomy; induction; monitoring; postoperative care Royal College of Anaesthetists CPD Matrix: 3A05, 2A05

Vascular surgical patients are typically elderly and suffer comorbidities affecting multiple organ systems. These include: hypertension, ischaemic heart disease, congestive heart failure, cerebrovascular disease, diabetes mellitus and renal impairment. At least 50% of this patient population are current or ex-smokers with an associated high incidence of chronic obstructive pulmonary disease (COPD).1 Atherosclerotic disease is the predominant underlying cause responsible for compromised peripheral blood ow or embolic phenomena. Elective aortic surgery is associated with a mortality of 4.0%.2 In contrast hospital mortality approaches 50% in the emergent, non-optimized patient. Operations may be long with marked uid shifts, requirements for transfused blood and blood products and vasoactive drug therapy. There may be signicant impairment of cardiac, renal and lung function. Anaesthetic management under such circumstances can be challenging, even for an experienced anaesthetist.
Shayanti M Ghosh FRCA BSc MBBS is a Specialist Trainee in Anaesthesia on the Northern Deanery Rotation, UK. Conicts of interest: none declared. Iain J McCullagh MBChB FRCA FFICM EDIC is a Consultant in Anaesthesia and Intensive Care at The Freeman Hospital, Newcastle Upon Tyne, UK. Conicts of interest: none declared.

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Monitoring: ve-lead electrocardiography (ECG) is preferable (and aids detection of ST segment changes) together with mandatory non-invasive blood pressure and pulse oximetry monitoring. A rapid uid infusor should be run through and attached and cell salvage ready for the rst incision. A forced air warming device, nasogastric tube and temperature probes should be prepared. A cardiac output measurement device to assess haemodynamic change, myocardial function and guide uid and vasopressor therapy may be benecial. Suitable devices include transoesophageal echocardiography (TOE), oesophageal Doppler or pulse contour analysis monitoring. Fluid therapy and analgesia: colloids or crystalloids can be used pre-induction to maintain a systolic blood pressure (SBP) of between 90 and 100 mmHg. Further bleeding may be provoked by hypertension, coughing or straining and should be avoided. Intravenous morphine (1e2 mg boluses), fentanyl (25 mg boluses) or alfentanil can be titrated to effect for pain. Induction An on-table rapid sequence induction (RSI) must be performed with the patient prepped, surgical drapes on and surgeons scrubbed. An increased incidence of awareness in emergency anaesthesia is a well-documented phenomenon4 and the induction agent of choice should achieve rapid loss of consciousness with minimal haemodynamic compromise. Barbiturates (thiopentone up to 5 mg/kg) or ketamine (1.5 mg/kg) are suitable induction agents. Propofol (0.1e0.4 mg/kg) may also be used with caution, but the risk of hypotension is greater. Etomidate remains a popular choice with regard to haemodynamic stability despite growing concerns regarding endogenous steroid suppression.5 Whatever is used cardiovascular collapse may ensue and vasopressors and rapid uid infusion are likely to be needed. Surgery can proceed once endotracheal intubation has been conrmed using capnography. Application of the aortic cross-clamp: the initial surgical goal is to clamp the aorta above the aneurysm as quickly as possible. The haemodynamic response to cross-clamping the aorta is an increase in arterial pressure, systemic vascular resistance and afterload. Glyceryl trinitrate or an increase in anaesthetic depth of anaesthesia may be required to attenuate the hypertensive response to cross-clamping. Intraoperative considerations These include the following:  blood loss  coagulopathy  renal impairment  hypothermia. Bleeding and coagulation: anticipate massive blood loss with a need for cross-matched packed red cells, FFP and platelets. Intravenous calcium gluconate (10 mmol) may improve haemostasis. It is also an effective inotrope. Intraoperative cell salvage can minimize homologous blood transfusion requirements. Coagulopathy secondary to massive haemorrhage,

haemodilution, hypothermia and prolonged surgery is not uncommon and treatment should not be delayed. Near patient testing using a Haemocue device and, if available, a thromboelastograph (TEG), allows rapid assessment of coagulation status and should be used in conjunction with regular laboratory testing of coagulation to guide treatment. An international normalized ratio (INR) of less than 1.5, platelet count of more than 50 109/litre, brinogen levels of over 1.5 g/dl and ionized calcium more than 1.0 mmol/litre are appropriate goals in the management of coagulopathy. Renal failure: renal failure following AAA surgery has an incidence of 4.5% with a high associated morbidity and mortality. Prolonged cross-clamp times, intraoperative hypotension and massive haemorrhage are proven operative risk factors. Preservation of renal function is assisted by avoidance of hypotension and nephrotoxins. Surgical measures include minimizing suprarenal clamp times. No convincing evidence exists to support the use of proposed renal protective agents such as loop diuretics, mannitol or dopamine. Haemodynamic instability: this may be signicant following aortic unclamping and should be anticipated. Metabolic acidosis with resultant vasodilatation, hypovolaemia and myocardial stunning are all contributory factors in the development of circulatory instability. The options outlined in Box 1 should be considered. Hypothermia: normothermia should be maintained. Warming should ideally begin prior to the anaesthetic induction and continued throughout the perioperative period. Warmed intravenous uids and inspired gases should be used. A forced air warming mattress is another useful method although placement over the lower limbs in the presence of an aortic cross-clamp should be avoided. Postoperative care The patient should be extubated on the intensive care unit after a period of controlled ventilation and warming, and once biochemical and haematological parameters have been corrected and inotropes have been successfully weaned.

Measures used in the management of haemodynamic instability

C C

Give blood products where a deciency is identied Depending on the haemodynamic picture, start an infusion of either: adrenaline (0.01e0.5 mg/kg/minute) or noradrenaline (0.04e0.4 mg/kg/minute) dobutamine (2.5e10 mg/kg/minute) and titrate to response Give a bolus of calcium gluconate (up to 10 ml of 10%) Ongoing uid replacement with isotonic crystalloid or colloid

C C

Box 1

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VASCULAR ANAESTHESIA

Key factors associated with a favourable outcome in emergency endovascular aneurysm repair
C C C C

Hypotensive haemostasis Patient immobilization at time of stent placement Swift diagnosis and treatment of acute coronary syndrome Predominant use of a local anaesthetic technique

Box 2

Endovascular aneurysm repair (EVAR): local anaesthetic techniques, neuraxial blockade (epidural, combined spinal epidural, spinal) and general anaesthesia are all appropriate anaesthetic options. Patient anxiety, pre-existing comorbidities and haemodynamic stability are all determinants of the anaesthetic technique employed. A target controlled propofol infusion, short-acting phenylpiperidine opioid and benzodiazepines can facilitate EVAR performed under local or neuraxial blockade. As with open repair, full monitoring (including ve-lead ECG) and meticulous attention to blood pressure and temperature control, uid balance, management of coagulopathy and pain control is vital. Adherence to these principles can inuence a positive outcome as highlighted in Box 2.6

Cardiology/American Heart Association (ACC/AHA) guidelines classify peripheral revascularization as high-risk surgery.7 The main aetiological factor is atherosclerosis with embolism and thrombosis leading to acute peripheral arterial occlusion. Acute thrombosis of a bypass graft and trauma are other important causes. An acutely ischaemic limb is both limb- and life-threatening: 30-day amputation rates of between 10% and 30% have been reported with an overall mortality rate of greater than 15%.6 Anaesthetic management options include general anaesthesia (with or without regional anaesthesia), local anaesthesia with sedation and regional anaesthesia (with or without sedation). The anaesthetic technique of choice will be determined by likely duration of surgery, the need for controlled ventilation, anticoagulation status and patient cooperation (Table 1). Preoperative considerations As with the other vascular emergencies, the urgency for intervention often precludes a detailed patient work-up. A coagulation screen and platelet count should be checked before neuraxial blockade is performed. Patients with acute limb ischaemia may be fully heparinized. Protamine can be used for heparin reversal in discussion with the surgical team. The recommended dosage is 0.5e 1 mg intravenous protamine sulphate for every 100 IU of heparin. Monitoring and equipment Ideally two large-bore cannulae (at least 16G) should be inserted in addition to an arterial line. The avoidance of hypothermia is essential and the patients temperature should be monitored. Patient and uid warming devices may be useful. Central venous pressure monitoring is rarely needed. Intraoperative management Severe reperfusion injury is a feature of arterial circulation restoration. Signicant complications of reperfusion include:

Acute limb ischaemia

Complete acute limb ischaemia will result in tissue necrosis and resultant risk of limb loss unless prompt evaluation and diagnosis are made followed by rapid revascularization. The latter is usually achieved by means of surgical reconstruction, catheter thrombolysis or thrombectomy. The American College of

Anaesthetic management options for emergency revascularization procedures

Mode of anaesthesia General ( regional) Considerations Rapid sequence induction with cricoid pressure will be required in the unstarved patient Controlled ventilation likely given prolonged surgery times and high incidence of cardiorespiratory disease Main contraindications include: C full heparinization/anticoagulation C localized infection C septicaemia C hypovolaemia C Patient refusal Coagulation prole and platelet count must be reviewed pre-procedure Epidural anaesthesia may improve graft ow and viability in the early postoperative period8 May be suitable for patients with major comorbidities undergoing single leg revascularization who may not tolerate neuraxial blockade induced hypotension Consider: C sciatic ( femoral nerve blocks) for lower limb procedures C brachial plexus block for vascular procedures involving the upper limb C continuous catheter techniques for prolonged procedures

Regional ( sedation)

Local/nerve blocks

Table 1

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hyperkalaemia, acidebase disturbances, myocardial depression, acute arrythmias or even cardiac arrest. Myoglobinuria and acute renal failure may follow at a later stage.

initial CEA surgery may be sufcient and supplemented as required. The surgeon should be scrubbed and ready to perform a surgical tracheostomy if needed. Excessive blood loss requiring transfusion is uncommon. Postoperative issues Patients are usually transferred to critical care postoperatively. It is usual practice to leave patients intubated at least overnight if airway oedema is present. A

Evacuation of haematoma post-carotid endarterectomy (CEA)

Haematoma formation requiring evacuation has an incidence of 1e4% following CEA. Progressive neck expansion is the presenting feature with or without subtle voice changes and the development of hoarseness. There is the attendant risk of airway compression and possible life-threatening airway obstruction. Initial management Administer high-ow oxygen and sit the patient upright if possible. Airway oedema is likely to be present and can be managed using nebulized adrenaline (5 mg, 5 ml of a 1:1000 solution) and intravenous dexamethasone (8 mg). Impending complete airway obstruction This may occur in the recovery area or at a later stage on the ward. Senior surgical staff should be alerted. A difcult airway trolley must be readily available. Immediate evacuation at the bedside may be required. Sterile gloves should be worn and stitch cutter used to remove skin sutures immediately. Two layers of sutures usually need to be cut to get to the haematoma. The haematoma is then manually evacuated to relieve the mass effect on the airway. This is followed by application of constant gentle pressure. Signicant airway swelling may preclude endotracheal intubation using direct laryngoscopy and there may be insufcient time for awake breoptic intubation. Emergency cricothyroidotomy or surgical tracheostomy may be indicated. Induction and intraoperative management A difcult intubation is likely and inhalational induction may preferable to intravenous induction in the presence of airway obstruction. An ongoing effective regional block, if used for the

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