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Vascular surgery

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Post operative management of vascular surgery patients

All vascular patients

  • assess peripheral circulation including Doppler assessment of pulses and ankle brachial index. This is the ratio of the Doppler BP at the ankle to the Doppler BP in the brachial artery. In patients who have undergone aortic or extra-anatomic reconstructions neither distal pulses nor Doppler signals may be present because of vasoconstriction from hypothermia. In nearly all these patients a signal will be audible in the feet once the patient becomes normothermic (6-8 h). If the pulses remain absent at this time surgeon should be informed. Doppler signal should always be present at the level of the distal anastamosis for all reconstructions. For upper extremity of infrainguinal reconstructions a Doppler signal is nearly always audible in the wrist or foot in the immediate postoperative period
  • cardiac monitoring: increased risk of cardiac complications
  • control BP
  • respiratory management: no evidence that "prophylactic" ventilation reduces hospital stay or respiratory complications and patients can be extubated in early postoperative phase
  • analgesia

Problems common to all vascular reconstructions

Bleeding

  • major bleeding uncommon
  • wound bleeding: if superficial this is not usually associated with significant swelling and the bleeding vessel can usually be seen
  • intra-abdominal bleeding. Measurable increase in abdominal girth is a late finding: detectable only after 2-3 l of blood have accumulated. In general failure to stabilize after 2 units of packed cells over 2-3 h suggests significant bleeding

Graft thrombosis

  • incidence of early thrombosis: subclavian/vertebral 2%, aortic 3%, axillofemoral 2-25%, fem-fem 0-13%, fem-pop 5-15%, fem-tib 15-30%
  • most commonly due to technical error. Other causes include stenosis or occlusion of distal outflow vessels, low cardiac output, graft compression, small-diameter vein graft. Rarely due to hypercoagulable state
  • diagnosis is suggested by disappearance of a pulse that was initially present, disappearance of a Doppler signal or a change from a biphasic to a monophasic signal. Decrease in ankle-brachial index from initial post-op value to pre-op value is additional evidence. Clinical signs such as pallor, mottled skin, coolness of peripheries unreliable in initial post-op period
  • treatment: heparin 5000 U followed by thrombectomy and correction of any technical error

Wound infection

Graft infection

Management of specific reconstructions

Carotid reconstruction

  • BP: maintain systolic BP between 110 and 160
  • Neurological assessment: detailed baseline assessment in ICU essential before sedation
  • antiplatelet therapy
  • Complications
  • Stroke/TIA:2-5%. Post-operative neurological complications most commonly due to thrombosis of internal carotid or intracerebral embolism. Other causes: ICH, cerebral hypoperfusion due to MI, cardiac arrhythmia, severe bleeding, hypotension due to drugs
  • Headache. Mild headache common. If severe and especially if associated with symptoms of raised ICP consider ICH
  • Nerve injuries: recurrent laryngeal 6.5%, hypoglossal 6%, marginal mandibular 2% and superior laryngeal 2%. Rarely due to transection and 80% recover within 3 months
  • Thoracic duct injury in 3%

Aortic reconstruction

CXR of thoracic aortic aneurysm

Complications

  • Clinically manifest in about 2% of elective cases but in up to 60% of ruptured AAA repairs.
  • High index of suspicion required to make an early diagnosis: essential if death is to be prevented.
  • Most common symptom is diarrhoea (75%). May be bloody and usually occurs 24-48 h post op. May occur up to 14 days post op.
  • Other signs include marked increase in abdo pain, prolonged ileus with abdo distention, tachycardia, hypotension, increased fluid requirement, metabolic acidosis, raised WCC and platelets.
  • Investigation: colonoscopy
  • Treatment: if ischaemic lesions appear superficial and involve only mucosa safe to observe patient with repeat colonoscopy. Otherwise colectomy
  • proposed pathogenesis: ischaemia due to pancreatic emboli and mechanical trauma during dissection of proximal aorta near left renal vein
  • suspect in any patient who develops prolonged ileus (>5 days) or in any patient with increased abdo pain, nausea and vomiting after starting oral feeding

Renal artery reconstruction

  • large volume deficit and high urine output (>300 ml/h) common in initial post-op phase especially in patients who have undergone bilateral reconstruction
  • labile BP common
  • complications
  • renal artery stenosis/thrombosis. Signs include hypertension, renal failure, flank pain due to renal infarction. However these signs may be present when graft is patent. Equally patient may have no signs yet have an occluded graft. Anuria despite adequate hydration requires urgent investigation

Further reading

Hurst JM, Frost RJ. Vascular surgery and trauma. In Civetta 2nd ed, 1992

 


© Charles Gomersall July 1999

 

©Charles Gomersall, April, 2014 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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