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POST OP OPEN ABDOMINAL AORTIC ANEURYSM repair
ALL OPEN AORTAS COME TO THE ICU FOR AT LEAST 48 HOURS OF POST OP MONITORING BECAUSE THEY ARE A HIGH RISK POPULATION AT HIGH RISK FOR COMPLICATIONS
Arterial Embolism
- This is a high risk population who often have diseased aortas filled with plaque. The plaques and break off during manipulation and cross clamping of the aorta
- It is important that YOU speak with the vascular team when the patient arrives to find out about the procedure and know whether or not the DP and PT pulses were present by palpation, by doppler, or absent at the end of the case
- it is essential that YOU feel their pulses upon arrival and know what they feel like at baseline
- The pulses can become weak when these patients are under-filled or cold coming out of the OR and so begin by giving a fluid bolus
- if they lose a pulse that was previously present - page vascular surgery and let your ICU attending/fellow know
Bleeding (usually not subtle)
- it is essential that YOU examine the abdomen when they arrive to the intensive care unit
- Bleeding complications and abdominal compartment syndrome happen more commonly with ruptured abdominal aortic aneurysms but can happen, albeit rarely, with elective cases too
- if the the abdomen is rapidly explanding - page or have someone page your attending/fellow and vascular surgery
STEmi and nstemi
- This is a high risk population. Yes, patients can arrive to the ICU pot-op and have STEMIs and NTEMIs and have to proceed to the cath lab.
- When this happens they are often just awakening still from their anaesthetic and so the first clue is often on the monitor
- This is why we get ECGs on all vascular patients upon arrive as needed
ISchemic COlon
- The first thing is to have a high index of suspicion. Ischemic colon is not uncommon. Patients often have a pre-existing occluded Inferior Mesenteric Artery (IMA) and/or lose their IMA at the time of surgery due to the most common location of these aneurysms (see photo above).
- Remember, it is important to know where the cross clamp was. If it was supr-renal and particularly supra-celiac - the entire bowel will be at risk (and everything else below the celiac which is ALL the intraabdominal organs and possibly even the spinal cord (see section on TEVAR)
- Additionally, these patients often have many risk factors including proximal or distal atherosclerosis of the Celiac and SMA arteries and are very vulnerable to hypovolemia and vasocontricting agents (vasopressors). All this is say, this is the one complication we see most often and it can be catastrophic resulting in bowel resections, graft infections, prolonged stays in hospital and death.
- Often patients will develop foul diarrhea and a rising lactate. That said, a dead bowel produced no lactate as there is no longer any cellular metabolism. All of these patients have epidurals in situ and so you cannot rely upon pain as a marker.
- The clinical picture of ischemic bowel in this population is unusually high fluid and pressor requirements. They will at first respond to fluids but then their response progressively dissipate. Tachycardia for no other reason can also herald this. Rising WBC beyond POD1. Fever POD 1-3. None of these are particularly specific and so you have to rely on your clinical gestalt and watch these patients closely
- To that end, this is why we put a cap on vasopressors of 6ug/min. We want to be called if the patient is requiring more because this may be heralding something ominous. This is also why monitor lactate (q2h ABG) which is why we order this on admission.
- if ischemic colon is suspected, start broad spectrum antibiotics to cover the enteric pathogens (Ceftriaxone/Flagyl, Tazocin, or Meropenem). Translocation into the blood stream and peritoneal cavity can happen. Seeding of the aortic grafts is a catastrophic complication
- The potential for ischemic colon is another reason why it is ok to shy away from crystalloids in these patients. Crystalloids start to redistribute within seconds. Where ever there is inflammation, crystalloids will leak through gap junctions in the blood vessels and cause/worsen edema. If the bowel is ischemic, it will add to bowel edema and which will further impair bowel blood flow.
STEmi and nstemi
- Yes, we have intentionally put this here again. Perioperative MI is common. It can happen at any time but particularly within the first 48 hours post operatively.
- All patients should get a baseline troponin and then daily x 3.
- All patients should get a baseline ECG and then again the following morning
Acute kidney injury
- No kidney is 100% safe during or after an open aortic aneurysm repair because it is mandatory to place a cross clamp on the aorta in order to stop the blood flow to perform the repair.
- There is no question that when the cross clamp is supra-celiac, supra-renal, or intra-renal the kidney(s) will have absolute ischemic time while the cross clamp is on. That said, even when the cross clamp is infra-renal turbulent flow and embolic phenomena can occur and cause low flow and renal infarcts.
- Our job is to make sure these patients do not suffer a pre-renal insult-to-injury. They need enough fluids!
- That said, they do not require over-resuscitation. Please keep in mind that kidneys can suffer in many ways and they don't suffer silently. Giving too much fluid can cause renal venous congestion and impair renal perfusion and GFR.
- Additionally, too much fluid can overfill the heart and have an impact on contractility (recall the Frank-Starling Law). An overfilled heart is also primed for afib (see next). The loss of atrial contraction is going to decrease the cardiac output by at least 30% and worsen renal perfusion
Atrial Fibrillation
- Atrial Fibrillation (Afib) in the ICU is common in all patients (hence why it has a section unto itself in this survival guide). That does not imply we can be complacent about it because it can decrease the cardiac output by at least 30%, but in our sick ICU population that number is probably closer to 50%.
- During and after open aortic aneurysm repairs they receive a significant amount of IV fluid which can cause some anatomical stretch of the atria. Additionally, this is a huge stress to a body and so there are always elevated levels of catecholamines and inflammatory mediators, not to mention the exogenous catecholamines we have to sometimes add to the mix. If that were not enough, these patients can become intravascularly dry (hence why we harp on IV fluids for these patients), which can result in hypotension, further endogenous catecholamines, and reflex tachycardia (recall that your cardiac output is dependent upon Stroke Volume and Heart Rate)
- All this to say, Atrial Fibrillation is not uncommon in this population. Unless they had pre-existing afib, it is usually transient, and it will settle down once the fluid and hemodynamic shifts settle
- Patients DO NOT need to be anticoagulated for this. They DO need rate control. Because their hemodynamics fluctuate, the best drug from rate control (in most ICU patients) is Amiodarone because it is hemodynamically neutral.
- If this happens to you at night, trouble shoot why it is happening (are they under-filled, over-filled, or neither and it is just happening because it can). Give them a bolus of 150mg or 300mg of Amiodarone and run an infusion until we can reassess things in the morning
Ileus
- During an anterior (Laparotomy) approach to aortic aneurysm repair, the bowel has be handled and moved out of the way in order to access the aorta. The bowel doesn't appreciate this and will protest by quitting.
- Ileus is extremely common and is the reason that some patients will come out of the ORs with an NG in situ and why we do not allow them to eat for ~48 hours. In fact, these patients are managed with epidural anesthesia in order to avoid having systemic opioids contribute to their ileus.
- We all agree that it is important for post operative patients to eat, but it is more important they do not vomit and aspirate. They are to be strictly NPO until they are ready (nausea has settled, passing gas, mobilizing)
Shock Liver
- This is uncommon - we will only see this complication if the aortic cross clamp is placed above the celiac artery (most aneurysms are lower)
- Do not despair, the liver is resilient and should bounce back but do not be surprised if liver enzymes (AST and ALT) peak in the thousands
- We need to be extra diligent about monitoring the INR and Fibrinogen and correcting any coagulopathies in these patients
- Liver enzymes, INRs and Fibrinogen have to be ordered daily until this starts to settle