4. Past History
Underlying disease
HT
losartan (100)1/2*1
Hypothyroid
lovothyroxin(100)1/2*1
IHD
ASA(81)1*1
Atorvsastatin(40)1*1
EF :69% ผล echo ปี 2560
ไม่เคย CAG
No Smoking
No alcohol drinking
No drug and food allergy
No family history of MH
No previous surgery
Functional Class 2
5. Physical Examination
• General Apprance : A man of his age Full consciousness , well co operation
• Vital sign : BT 36.8 C RR 20/min HR 96/ min BP 112/88 SpO2 100%
• BW : 69 kg HT : 160 CM BMI : 23.4 kg/m²
• HEENT : mild pale conjunctiva , aniteric sclerae
• CVS : Audible S1S2 no Murmur
• RS : Equal Breath sounds both lung no adventitious Sound
• Abdomen : pulsatile mass at abdomen with mild tender active bowel sound
• EXT : nodedma both leg
• Neuro E4V5M6, puipill 2 mm rtlbe, motor grade V all
6. Airway Examination
• Mouth poening : ≥2FB
• Denture : no
• Mallapati : 2
• Thyromental : ≥6 cm
• Hyomental : ≥2 FB
• Neck movement : no limitation of neck movement
19. Abdominalaorticaneurysm
A 50% increase in diameter compared with normal, or greater than 3 cm in diameter
65% of all aneurysms of the aorta and 95% are below the renal arteries
Incidence 8% in elderly men
Risk factors : increasing age, smoking, family history of AAA and atherosclerosis disease
Fusiform type
Saccular type
Eccentric
Concentric
20. Pathogenesis
• Degenerative
Adventitial elastin degradation (elastolysis)
Associated with smoking
• Inflammatory
Chronic inflammation → destruction of connective tissue in the aortic wall
Takayasu arteritis, Giant cell arteritis, Polyarteritis nodosa
• Aneurysm associated with arterial dissection
• Traumatic
Almost → pseudoaneurysm due to perforation
• Developmental and congenital anomalies
Embryonic defect : Congenital AAA
Collagen disease : Marfan syndrome, Ehler danlos syndrome
• Infectious (Mycotic) : Bacterial, Fungi, Tuberculosis and Syphilis
• Drug abuse : Chronic amphetamine use
21. Abdominalaorticaneurysm
Risk factors
Nonmodifiable risk factors
Advanced age (>50 years)
Gender (male)
Family history
Modifiable risk factors
Smoking
Obesity
Hyperlipidemia
Hypertension
Atherosclerotic arteriopathy (e.g. CAD)
22. Abdominalaorticaneurysm
Clinical features
• Most AAAs are asymptomatic and often discovered incidentally
• Abdominal pain
• Pulsatile abdominal mass
• Large AAA → Mass effect on related structures
GI compression → vomiting
Ureteral compression → urinary symptoms
Iliocaval compression → venous complications
• Most AAAs become symptomatic secondary to growth or rupture
23. Abdominalaorticaneurysm
• Risk of rupture is directly related to the luminal diameter of aortic aneurysm
• Rupture of an AAA is most often lethal with a mortality rate of 75%
• Major management goal is to identify and treat AAAs before they rupture
24. Abdominalaorticaneurysm
Indications for AAA intervention
• Current evidence-based guidelines suggest repair when aneurysm diameter exceeds
5.0 cm. (women) and 5.5 cm. (men)
• Rapid aneurysm growth: greater 10 mm per year
• Symptomatic nonruptured AAA
25. Abdominalaorticaneurysm
• Open AAA repair is first described in 1951
It is still considered a high-risk surgical procedure
Mortality rates range from 1.5 – 5.8%
Clinical outcomes have improved as a result of advances in
anesthetic and surgical techniques
• Endovascular aneurysm repair (EVAR) was pioneered in 1986
A mainstay of treatment for AAA
More than 50% AAAs undergo EVAR in this era
Endovascular versus open AAA repair
26. Abdominalaorticaneurysm
• High-quality RCT comparing endovascular to open AAA repair
EVAR: Short-term survival benefit (perioperative period)
No significant difference in mid- to long-term mortality
Open AAA repair has proven long-term durability
EVAR carries a higher risk of repeat intervention
• The decision depends on multiple factors – aortic anatomy, urgency, patient
preference and surgical expertise
Endovascular versus open AAA repair
30. Preoperative evaluation
• Stratified and minimize perioperative mortality and morbidity risk
Cardiovascular assessment
Renal function assessment
Cerebrovascular assessment
Pulmonary function assessment
Preoperative renal dysfunction→ Most important predictor of
acute renal failure
Adequate hydration
Avoidance of...
Hypovolemia
Hypotension
Low urine output
Avoid nephrotoxic drugs
31. Preoperative evaluation
• Stratified and minimize perioperative mortality and morbidity risk
Cardiovascular assessment
Renal function assessment
Cerebrovascular assessment
Pulmonary function assessment
• History of stroke or TIA
• PE : Neurological examination and carotid bruit
• Duplex imaging of the carotid arteries or angiography
of the brachiocephalic and intracranial arteries
• Carotid endarterectomy
Severe stenosis of one or both common or internal
carotid artery
• Chronic HT → Shift cerebral autoregulation
32. Preoperative evaluation
• Stratified and minimize perioperative mortality and morbidity risk
Cardiovascular assessment
Renal function assessment
Cerebrovascular assessment
Pulmonary function assessment • To decrease the incidence of respiratory
complications
○ Smoking cessation
○ COPD
Bronchodilators
Antibiotics
Chest physiotherapy
Pulmonary Function Studies
34. Choice of anesthesia
General anesthesia with cuffed endotracheal tube with controlled
ventilation
General anesthesia is the most commonly employed technique
35. Monitoring
Standard monitoring Special monitoring
●Standard I
●Standard II
○EKG
○Pulse oximetry
○NIBP
○Temperature
○ETCO2,
ETO2
○Airway pressure
○Intake/Output
○Blood sugar
●Invasive monitoring
○Invasive arterial blood pressure
○CVP
○PAC
○TEE
●ABG
36. 2 4
3
1
Acute hemodynamic
changes with aortic cross-
clamping and unclamping
Attenuate ischemic
reperfusion injury
Provide intraoperative and
postoperative analgesia
Maintain organperfusion and
oxygenation
Anesthetic
consideration
44. • During emergence
• Prevent hemodynamic variations outside the patient’s normal range
NTG
Esmolol
Other beta-adrenergic blocking agents
• If appropriate, the trachea should be extubated at the end or surgery
• Prophylactic beta-blockade should be continued if tolerated
Unstable patients → short acting agent such as esmolol
stable patients → LONG acting agent such as metoprolol
45. Postoperative care
Postoperative management
• Continuous BP monitoring
• Regular assessment
ABG
Hct
Serum electrolytes
Coagulogram
lower limb arteries: clinical, doppler
• Thromboembolic prophylaxis
• Pain control
48. Intraoperative
Monitor : NIBP,EKG,SpO2
BP 130/104 HR 94 RR 22
Induction and intubation
Fentanyl 50 mcg
Etomidate 14 mg
proprofol 100 mg
Cisatraculium 10 mg
ETT no 8.0 cuffed mark 22 by C-MAC
Local A-line
IV Access
IV NO 18G RA LL
IV NO 20G RA LA
CVP : rt internal jugular v.
Monitor Temperature : oropharynx
Maintenance :
NO : O2 : Sevoflurane
Fentanyl
Cisatracurium
49. SUMMARY
Operation Time 11.20-15.25
Operation : Open repair abdominal aortic aneurysm
Blood loss : 3500 ml
Fluid : NSS 2700 ml
Acetar 1900 ml
Blood component
PRC 1438 ml
FFP 1020 ml
Urine output
before clamp 25 ml/ hr
During clamp 10 ml /hr
after de clamp 200 ml/hr
Remain intubation to ICUSX
