Lines (Endovascular)

• PIV x 1-2; if 2, then save one for infusions only
• A-line
• male-male Luer + stopcock (to check stump pressure)
• CVC/PAC only if bad heart

Infusions (Endovascular)

• carrier (usu. NS)
• nipride and/or NTG available in room
• phenylephrine ready
• fenoldopam

Anesthetic Technique (Endovascular)

• Lumbar epidural. Continuous spinal OK if get wet tap or difficult epidural, difficult airway, etc.
• IV Sedation. Usually midaz/fent for epidural placement and intraop supplementation, propofol + ketamine infusion for maintanance.
• Keep BP in low-normal range
• May need to wake pt up, hold breath for device deployment
• Consider running fenoldopam 0.01-0.1 mcg/kg/min for renal protection, due to dye load and possible h/o CRF

Lines (Open)

• PIV x 2, large-bore
• A-line
• R radial for descending aortic surg, L radial for ascending aorta (TAAA)
• consider femoral a-line as well, if planning to do bypass
• CVC (usu. 8.5Fr introducer)
• PAC if suprarenal aneurysm
• Thoracic epidural
• TEE may be helpful, esp for high aneurysms
• Upper AND lower body warming blankets in place (but off)

Infusions (Open)

• carrier (usu. NS) - give centrally
• NTG, nipride, phenylephrine, ±dopamine, ±fenoldapam (Creatinine > 2, suprarenal clamp?)

Anesthetic Technique (Open)

• Preop
• Evaluation
• Supra- vs. infra-celiac?
• Coexisting diseases?
• Cardiac fnct
• Pulm function: PFT's?
• Renal: lytes, BUN/Cr
• Heme: PT/T, CBC
• Management
• Place PIV, a-line, thoracic epidural. Other lines after induction unless signif medical disease.
• Test epidural, document sensory block
• Address other diseases (insulin, MDI, ...)
• Induction
• "Cardiac" anesthetic - avoid HTN (rupture risk) and hypotension (ischemia)
• DLT for TAAA; L-DLT may risk hemorrhage if aneurysm eroding bronchial wall
• Large ETT for AAA, for postop pulm toilet
• Pre-Clamp (Dissection)
• Keep BP in low-normal range
• Esmolol, NTG, SNP, volatile agent (prefer des for rapid titratability)
• Anticipate clamping:
• give mannitol for (possible) renal protection even for infrarenal surgery (dec in RBF also occur with infrarenal clamping)
• passive cooling to about 34°C
• 1gm prednisone (?)
• UOP goal: >0.5 cc/kg/hr
• Clamp
• Marked inc in afterload: expect HTN, possible ischemia
• Preload may inc (suprarenal clamp --> redistribution from splanchnics) or decrease (infrarenal --> redistribution of blood to splanchnics)
• PCWP will therefore probably rise
• BP may fall if poor myocardial reserve or CAD
• Spinal cord at risk (artery of Adamkiewicz T5-8 level 15%, T9-12 60%, L1-2 25%)
• spinal cord perfusion pressure (SCPP) = distal aortic pressure - [greater of spinal CSF pressure or CVP]
• if monitoring distal pressures, aim for SCPP >= 30mmHg
• can drain CSF via lumbar drain, up to ~15cc/15 min
• goal CSFP=5-15mmHg
• risk brainstem herniation with rapid or excessive CSF drainage (limit to ~75cc)
• if not, keep above-clamp BP high-normal
• if using bypass, maintain adequate flow rate
• avoid SNP (hypotension --> dec perfusion, distal vasodilation, coronary steal?, inc ICP transmitted to spinal CSF?)
• hypothermia
• keep glucose 120-200
• Prepare for unclamping
• Unclamping
• Blood pools in extremeties (hypoxia/acidosis --> vasodilation)
• Vasoactive mediators released
• Expect hypotension: give VOLUME
• Preparation
• stop vasodilators, decrease anesthetic agent levels
• give IVF to increase PCWP 3-4 mmHg (better: use TEE as guide to fluids). Less IVF if ischemic heart.
• increase ventilation
• If severe hypotension results, reclamp and reassess
• Closure
• If stable, may be able to start low-concentration, low-rate epidural infusion
• Rewarm pt with both upper and lower body blankets.
• If DLT, check airway and change to ETT if possible
• Extubation possible (warm, stable, comfortable, breathing well, uneventful case <5hrs), but almost all will go directly to ICU intubated/sedated