Term 3 Week 10 (w/c 2/7/12)
Welcome to this weeks Gasclass.
For the final week of this term we remain in theatre. You have been assigned to the Tuesday vascular list, where a 75 year old man has been listed for an elective Endovascular Aortic Aneurysm Repair (EVAR).
Today’s task is to list concerns and considertations relevant to anaesthesia for EVAR.
You go and see the patient. He is a 70 year old man with an asymptomatic 7cm Abdominal Aortic Aneurysm. This has been identified whilst having an ultrasound examination of his renal tract.
The patient has had 3x MI the last being 4 years ago when he underwent PCI with insertion of 3 coronary stents. At that time his echocardiogram revealed severe LV dysfunction. He continues to smoke 40 cigarettes a day. He is hypertensive treated with Ramipril and Bisoprolol. ECG reveals Q waves in lead 3.
What other information would you like before you embark on anaesthesia?
Thank you for your comments.
He has an exercise tolerance of approximately 2 miles on the flat at 1 mile on walking up a hill. A dobuamine stress test in 2009 revealed no ST changes. His FEV1 is 1.2 and FVC 2.3 FEV1/FVC 52%.
The procedure will be performed in an adapted room in the middle of the radiology department.
What are the anaesthetic options? What is your anaesthetic plan?
Following discussion with the patient you decide to undertake the procedure using a combined spinal & epidural technique. The procedure appears to be progressing well when after 2 hours the patient suddenly develops shortness of breath, becomes restless, tachycardic and hypotensive. There is no evidence of rupture. The surgeons do however have concerns regarding blood flow into the legs and may need to perform a crossover graft.
What are your thoughts now? How will you now manage the patient?
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