Anaesthesia for ruptured abdominal

aortic aneurysm
Anton Leonard FRCA MRCPI
Jonathan Thompson BSc (Hons) MD FRCA

Key points
Ruptured abdominal aortic aneurysm (AAA) is degradation of elastin fibres appears to be an
Aortic aneurysms occur
commonly fatal, with an overall mortality rate early feature of aneurysm formation while
because of imbalance
of 65%.1 The mortality rate for patients who collagen disruption is the ultimate cause of between aortic wall matrix
survive to reach hospital and undergo emer- rupture. Collagen/elastin homeostasis is nor- metalloproteinases and their
gency surgery is 36%, compared with 6% for mally maintained by a delicate equilibrium inhibitors.
elective repair.2 between matrix metalloproteinases (MMP) and
Preoperative fluid
their tissue inhibitors; if disrupted, proteolysis resuscitation should aim to
Epidemiology and natural occurs leading to aneurysm formation. Other treat myocardial ischaemia
history factors involved in aneurysm formation or unconsciousness rather
included chronic inflammatory infiltrates, than to normalize circulating
Abdominal aortic aneurysms (AAAs) occur smooth muscle cell apoptosis and increased volume or arterial pressure.
predominantly in male cigarette smokers aged production of pro-inflammatory cytokines. The Glasgow Aneurysm
.65 years and are the 13th most common Score can help stratify
cause of death in the USA. Chronic cigarette perioperative risk and
smoking is the single most important risk thereby supplement clinical
Medical management
factor in both the development and progression decision making.
of AAA. The prevalence of AAAs (aortic Certain medical therapies have been investi- Intra-abdominal
diameter . 30 mm) in chronic smokers is more gated in an attempt to reduce the progressive hypertension is common
than four times that in lifelong non-smokers, expansion of AAAs. Both tetracyclines and following ruptured
and the average rate of aneurysm growth in indomethacin prevent the progression of AAAs abdominal aortic aneurysm
smokers is 2.8 mm per year versus 2.5 mm per in animal models, through inhibiting MMPs. (AAA) repair and intra-
year in non-smokers. The most common cause Statin therapy reduces the expression of abdominal pressure
of AAA is atherosclerosis; rare causes include MMP-9 and has been associated with a monitoring is recommended.
Marfan syndrome, salmonella, brucellosis, reduction in the growth of infra-renal AAAs in The inter-hospital transfer of
tuberculosis, and Takayasu’s disease. animals. However, none of these has been haemodynamically stable
AAAs are usually asymptomatic but expand shown to be effective in humans and the defini- patients with a ruptured
over time and the risk of spontaneous rupture tive treatment for AAAs remains surgical AAA does not seem to
increases (Fig. 1). Morbidity and mortality rate repair. affect outcome adversely.
are lower after elective compared with emer-
Anton Leonard FRCA MRCPI
gency surgery; therefore, community screening
Specialist Registrar/Honorary Lecturer in
programmes are increasingly advocated. The Presentation and diagnosis Anaesthesia
Multicentre Aneurysm Screening Study demon- University Division of Anaesthesia
strated a 53% reduction in mortality in UK Patients present with signs and symptoms Critical Care and Pain Management
ranging from lower abdominal or lumbar pain UHL NHS Trust
men aged 65–74 years who attended for
Leicester Royal Infirmary
regular screening ultrasound and underwent in the presence of a pulsatile abdominal mass, Leicester LE1 5WW, UK
elective surgery when the aneurysm diameter to collapse, shock and coma. The differential
Jonathan Thompson BSc (Hons) MD
reached 5.5 cm.3 Conversely, the UK Small diagnosis includes ruptured viscus, acute
FRCA
Aneurysm Trial confirmed no benefit in elec- pancreatitis or bowel ischaemia. If patients are
Senior Lecturer in Anaesthesia and
tive surgery for very small AAAs (,5.5 cm haemodynamically stable, they may be trans- Critical Care
diameter).4 ferred for computerized tomography to Division of Anaesthesia
Critical Care and Pain Management
diagnose the rupture and determine suitability
Department of Cardiovascular Sciences
for endovascular repair. Free intra-peritoneal University of Leicester and UHL NHS
Pathophysiology Trust
rupture almost invariably results in cardio-
Leicester Royal Infirmary
The development of AAAs results from vascular collapse and death. Retroperitoneal
Leicester LE1 5WW, UK
alterations in the aortic wall connective tissue. rupture has a much better prognosis as a result Tel: þ44 0116 258 5291
Elastin and collagen fibres provide most of of the tamponade, which limits further Fax: þ44 0116 285 4487
E-mail: jt23@le.ac.uk
the tensile strength of the aortic wall. The haemorrhage.
(for correspondence)
doi:10.1093/bjaceaccp/mkm050
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 8 Number 1 2008 11
& The Board of Management and Trustees of the British Journal of Anaesthesia [2008].
All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Anaesthesia for ruptured abdominal aortic aneurysm
Fig. 1 Risk of abdominal aortic aneurysm (AAA) rupture per year based
on aneurysm size at last ultrasound. The risk of AAA rupture increases
exponentially with increasing aneurysm diameter (Data derived from Reed
WW, Hallett JW Jr, Damiano MA, Ballard DJ. Learning from the last
ultrasound: a population-based study of patients with abdominal aortic
aneurysm. Arch Intern Med 1997; 157: 2064– 8.).
Patient selection and risk stratification
Emergency surgery for ruptured AAA is associated with a high
mortality. Even patients who survive the initial procedure are at
high risk of complications (e.g. renal, cardiac, respiratory, haema-
tological or gastrointestinal failure); prolonged ICU and hospital
stay are common. There may be clinical scenarios where attempted
resuscitation and surgery would be futile and scoring systems have
been applied to patients with a ruptured AAA in an attempt to stra-
tify perioperative risk. The POSSUM and APACHE II scores are
widely used in other settings but do not accurately predict outcome
in ruptured AAA patients. The Hardman index for ruptured AAA
was published in 1996 and contains five preoperative variables
with a range of possible scores of 0 –5 (Table 1). It was originally
Table 1 Scoring systems for predicting immediate outcome after surgery for
ruptured abdominal aortic aneurysma
Glasgow Aneurysm Score Hardman index
Points Points
Age of patient 1 Age . 76
(points = no. of yrs)
17 Shock 1 Serum creatinine . 190 mmol/l
7 Myocardial disease 1 Haemoglobin , 9 g/dL
10 Cerebrovascular disease 1 Myocardial ischaemia on ECG
14 Renal disease 1 A history of loss of
consciousness after arrival to
hospital
a
Glasgow Aneurysm Score: age in years is added to the other variables to produce a
total score. Myocardial disease: Previous myocardial infarction and/or ongoing
angina. Cerebrovascular disease: includes all grades of stroke including transient
ischaemic attack. Renal disease: serum urea . 20 mmol/l and/or creatinine of .
150 mmol/l. The best cut-off value for GAS in emergency repair is 84 indicating a
mortality of 65%.9
Hardman index: 1 point is assigned for each preoperative variable present, so the
possible score ranges from 0–5. A total score of  2 is consistent with a mortality
rate of . 80%.6
12 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 8 Number 1 2008
suggested that the presence of three Hardman variables was
associated with 100% mortality.5 Recent studies have predicted a
mortality of 80% with Hardman index  2.6 The Glasgow
Aneurysm Score (GAS) is based on the retrospective case note
analysis of 500 patients who presented with ruptured AAA to one
of four Glasgow general surgical units between 1980 and 1990
(Table 1). It has been applied to both elective and emergency
aneurysm repair.7
Recent data suggest that the GAS is useful in predicting post-
operative mortality in both elective and emergency AAA repair:
postoperative mortality was 1.4% in patients with a GAS , 78.8
and 8.7% in those with a GAS . 78.8 following elective repair.8
Corresponding mortality figures were 28% and 65% following
emergency repair using a slightly higher cut-off score of 84.9
Overall, it should be recognized that scoring systems have their
limitations and should only be used to supplement clinical judg-
ment. They may be used to compare results from different centres.
Preoperative management
Ruptured AAA is a surgical emergency and a rapid preoperative
evaluation is required. There are certain situations where surgery
may be inappropriate, e.g. those who have already suffered a
cardiac arrest or patients with terminal illnesses. In the past,
patients with severe cardiorespiratory disease may have been
refused elective surgery but with the increasing availability of
endovascular techniques many of these patients are now receiving
surgery.
Successful anaesthetic management often requires two experi-
enced anaesthetists. A brief and targeted preoperative assessment
should be made. Most patients will have extensive atherosclerotic
and smoking related diseases. Many patients have significant cor-
onary artery disease which is not always obvious from history and
examination. Diabetes, hypertension and renal impairment are also
common. Blood pressure should be checked non-invasively in both
arms as there may be brachiocephalic and subclavian artery steno-
sis. If there is a difference in readings, the higher reading should
be used. While this is occurring, the second anaesthetist must
oversee the preparation of drugs, equipment and theatre ensuring
an adequate supply of blood and coagulation products. We would
recommend at least 10 units of red blood cells as well as platelets,
fresh frozen plasma, and cryoprecipitate. Hospitals should have a
system for issuing these blood products without delay (e.g. without
waiting for laboratory coagulation results); near-patient testing
may also have a role.
The first response of many anaesthetists confronted with a
patient with a ruptured AAA is to administer intravenous fluids
rapidly to restore blood pressure to near normal levels. However,
excessive administration of fluids prior to clamping of the aorta
will increase bleeding through thrombus dislodgement and dilution
of clotting factors.10 It is reasonable to avoid any form of red cell
transfusion preoperatively unless the patient is unconscious or dis-
plays signs of myocardial ischaemia. If pain is severe, small

increments of intravenous morphine may be administered whilst
arrangements for surgery are being made. It is worth considering
siting an epidural catheter preoperatively in patients with a con-
tained leak provided that coagulation results are satisfactory and
the patient is haemodynamically stable. The advantage of this is
that epidural analgesia may facilitate weaning; postoperative
coagulopathy is common and may contraindicate epidural insertion
for 48 –72 h.
Anaesthetic management
Induction
Induction of anaesthesia in patients with a ruptured AAA may be
associated with cardiovascular collapse because of: (i) the cardio-
depressant effects of intravenous and inhalational agents; (ii) relax-
ation of the abdominal muscles reducing the tamponade effect;
(iii) intermittent positive pressure ventilation reducing venous
return; and (iv) a reduction in sympathetic tone. Therefore, induc-
tion of anaesthesia should be performed with the patient on the
operating table, fully prepared for surgery and with blood for trans-
fusion present in theatre. In the absence of cross-matched blood,
group specific or group O blood should be used. Large volumes of
i.v. fluids may be required rapidly; therefore, warmed circuits
should be primed with fluids and/or cross-matched blood, prefer-
ably using a rapid infusion device. Direct arterial pressure monitor-
ing is preferably instituted before induction of anaesthesia but
central venous access can be deferred at this stage unless no other
venous access has been secured.
No specific anaesthetic agent or technique has been shown to
significantly improve outcome; the main objectives are to maintain
anaesthesia with cardiovascular stability and normothermia as far
as possible. A modified rapid sequence induction using a carefully
titrated dose of induction agent followed by succinylcholine is
appropriate. In an effort to reduce the required dose of induction
agent, opioids (e.g. fentanyl, alfentanil) may be administered.
Maintenance
Anaesthesia is usually maintained with a balanced technique using
volatile agents/opioids and neuromuscular blockade. Nitrous oxide
will reduce arterial pressure in patients who have reduced myo-
cardial contractility or increased levels of sympathoadrenal activity,
both of which are frequently present in patients with a ruptured
AAA. For these reasons, some anaesthetists avoid its use. High
dose opioids (e.g. fentanyl 5–20 mg kg21) are often used.
Aortic cross-clamping
The physiological response to aortic cross-clamping depends on a
number of variables, including preoperative left ventricular func-
tion, collateral circulation and the level of the cross-clamp. Once
the aorta is cross-clamped, increased afterload may cause hyperten-
sion proximal to the clamp. This may be attenuated by increasing
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 8 Number 1 2008
Anaesthesia for ruptured abdominal aortic aneurysm
the depth of anaesthesia, or the administration of vasodilators (e.g.
GTN). This also allows intravascular fluid loading in preparation
for clamp release.
Restoration of the circulation at cross-clamp release is
accompanied by a sudden decrease in afterload and severe
ischaemia-reperfusion injury. This can cause profound hypoten-
sion, lactic acidaemia, myocardial ischaemia, and cardiovascular
collapse. These may be attenuated by maintaining mean arterial
pressure and expanding the circulating volume, facilitated by
administration of vasodilators during cross-clamp application.
Even so, hypotension normally occurs and vasoconstrictors and/or
inotropic drugs are usually required.
Monitoring, blood transfusion, and thermoregulation
Minimum standards of monitoring recommended for ruptured
AAA repair include ECG (CM 5 configuration), CVP, arterial line,
body temperature and urine output. Pulmonary artery flotation
catheters are rarely used. Every hospital should have a protocol for
the administration of blood products in these cases because it is
not practical to wait for the results of coagulation tests before
requesting them. Because of the limitations of standard coagulation
tests, many centres are assessing the role of thromboelastography
(TEG) in emergency vascular surgery. TEG reliably demonstrates
both hypercoagulability and fibrinolysis, both of which are fre-
quently underestimated with conventional coagulation tests; it is
potentially useful in any situation where there is a rapidly changing
haemostatic profile and is widely used to determine transfusion
practice for liver and cardiac surgery. In the UK, 55% of hospitals
are now using red cell salvage techniques for elective aortic
surgery;2 the figure in emergency cases may be lower because of
practical difficulties in the emergency situation. Perioperative
hypothermia occurs frequently because of the open abdomen,
patient exposure, blood loss, and the large volumes of i.v. fluids
transfused. All attempts should be made to maintain patient temp-
erature intraoperatively by the use of warming blankets and
warmed fluids.
Maintenance of renal function
Patients are at risk of developing renal impairment because of: pre-
operative hypotension and hypovolaemia; aortic clamping causing
direct renal ischaemia; a large embolic load; and postoperative
blood loss. To avoid postoperative renal impairment, every effort
should be made to maintain adequate perfusion pressure and limit
the duration of supra-renal clamping. Many anaesthetists adminis-
ter drugs such as mannitol, furosemide or dopamine to prevent
renal failure but there is no convincing evidence that they improve
outcome. The main priority is to maintain an adequate extracellular
fluid volume intra- and postoperatively.
13
Anaesthesia for ruptured abdominal aortic aneurysm
Postoperative care
All patients should be transferred to ICU postoperatively where
supportive care includes optimization and maintenance of circulat-
ing volume. Re-warming will continue until normal body tempera-
ture is achieved and respiratory support is usually required for up
to at least 24 h and frequently several days. Renal function, coagu-
lation, haemoglobin, and acid-base balance are monitored closely.
Renal replacement therapy is required in a significant proportion of
patients and those with a coagulopathy may require continuing
blood product transfusion. Other important issues include an
anticipated prolonged ileus and analgesia.
Patients are particularly prone to developing intra-abdominal
hypertension (intra-abdominal pressure  12 mmHg) and abdomi-
nal compartment syndrome (ACS, defined as IAP  20 mmHg).
Factors which contribute to the development of ACS include
anaemia, prolonged hypotension, cardiopulmonary resuscitation,
hypothermia, severe acidosis (base deficit  14 mEq) and aggres-
sive fluid resuscitation (4l h21). These patients may benefit from
laparastoma or mesh closure of the abdominal wall with delayed
secondary surgical closure after 2–3 days. Performing a mesh
closure initially in these patients reduces the incidence of multi-
organ failure when compared with patients who require a second
operation for ACS in the postoperative period.11 Monitoring of
IAP should be considered in all patients and consideration given to
parenteral nutrition if ileus is prolonged.
Endovascular abdominal aortic
aneurysms repair
Endovascular aneurysm repair (EVAR) is increasing in popularity
amongst both vascular surgeons and interventional radiologists as
it avoids the need for a laparotomy in a group of patients who
usually have significant co-morbidity. At present, there are no
large, multi-centre, prospective, randomized data assessing the effi-
cacy of EVAR in the treatment of ruptured AAA but many small
series have demonstrated a trend towards decreased mortality com-
pared with open repair. Most centres pioneering the use of EVAR
use spiral CT to diagnose a rupture and demonstrate AAA size and
morphology. This also serves to exclude other causes of acute
abdomen and predict endograft size. Some are concerned that the
extra time required for imaging may adversely affect outcome but
recent research suggests this is not the case.
There is still some uncertainty regarding the most suitable
location to perform an emergency EVAR. The angiography suite
offers optimal imaging technology; however, radiology depart-
ments are often sited away from the main operating department
and monitoring and resuscitation facilities may be limited. With
the development of endovascular techniques, haemodynamic
instability is no longer an absolute indication for laparotomy under
general anaesthesia. EVAR may be performed under local anaes-
thetic with or without sedation, regional or general anaesthesia.
14 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 8 Number 1 2008
Conversion to general anaesthesia may be required in up to 25% of
cases. There are several reasons for this:
1. Patients with a ruptured AAA have pain and restlessness due to
an expanding retroperitoneal haematoma. This is aggravated by
endovascular instrumentation.
2. The use of an intra-aortic occlusive device to achieve haemo-
stasis may cause acute lower limb ischaemia.
3. If the internal iliac artery is occluded, buttock pain may occur.
4. Respiratory insufficiency due to an expanding retroperitoneal
haematoma.
5. A femoro-femoral artery cross-over is sometimes performed
after EVAR if lower limb ischaemia develops.
Some retrospective studies suggest good outcome with local
anaesthetic but there are no prospective data to show that any one
anaesthetic technique is superior.
Inter-hospital transfer
In recent years, there have been calls for the centralization of vas-
cular services into larger units. This is related to local variations in
the availability of vascular expertise, theatre and ICU services.
Clearly, the interhospital transfer of a patient with a ruptured AAA
for surgery in a larger unit is likely to be hazardous but does it
affect overall outcome?
In one study, 52 cases who received treatment in a tertiary
referral centre during 1995–2002 were reviewed. Patients trans-
ferred from community hospitals before surgery had lower 24 h
mortality than those presenting directly to the tertiary referral unit
(10% vs 41%).12 These results are consistent with the 2005
NCEPOD report,2 as well as research undertaken in Scotland.13
Whilst recognizing that patients deemed too unstable for transfer
were excluded, these data suggest that the outcome in patients
stable enough for transfer is at least comparable. Nonetheless, the
decision to transfer must be made on a case-by-case basis.
Alternatively, pressures to centralize vascular services have led
to the concept of a mobile vascular surgical team, whereby a team
based in a tertiary referral centre would travel to smaller units
within a region to perform emergency surgery. Patients would be
transferred back to a central vascular intensive care facility in the
postoperative period. Although patients would require ongoing
mobile intensive care management, they may be more stable after
surgery. This concept is not widely developed in the UK and the
issue of transfer is currently being debated.
Acknowledgements
We would like to thank Mr Robert Sayers MD FRCS (Ed) FRCS
(Eng), Reader in Surgery and Honorary Consultant Vascular
Surgeon, University of Leicester, and UHL NHS Trust, for helpful
advice on the manuscript.

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Please see multiple choice questions 9– 13
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