Anesthesia for Vascular Emergencies

Preoperative Assessment - Vascular Vitals

• Immediate Assessment (ABCDE): Prioritize Circulation. Secure airway (RSI often needed due to full stomach risk), ensure oxygenation/ventilation.
• History (AMPLE): If patient condition allows; focus on anticoagulants, allergies, last meal.
• Key Investigations:
  • Stat Labs: Crossmatch (minimum 4-6 units), FBC, comprehensive coagulation screen (PT/INR, aPTT, fibrinogen, TEG/ROTEM if available).
  • Imaging: FAST scan for AAA rupture/trauma; CT Angio if stable enough.
• Risk Stratification:
  • ASA status (often ASA IV/V E).
  • Cardiac: RCRI. Urgency: Emergent.
• Hemodynamic Goals & Resuscitation:
  • Large-bore IV access (2 x 14-16G).
  • Ruptured AAA: Permissive hypotension (SBP 80-90 mmHg) until proximal control. Avoid aggressive crystalloid resuscitation.
  • MTP Activation: Anticipate massive blood loss. 📌 MTP: PRBC:FFP:Platelets 1:1:1.
• Consent: Implied consent for life-saving surgery if patient unconscious/incapacitated.

⭐ The lethal triad in trauma (acidosis, hypothermia, coagulopathy) is highly relevant in ruptured AAA.

Specific Emergencies - Rupture & Race

Intraoperative Management - OR Balancing Act

• Monitoring & Access:
  • Invasive: Arterial line (BP, ABGs), CVC (access, CVP); PA catheter (severe cardiac dysfunction).
  • IV Access: ≥2 large-bore (14-16G) or rapid infusion catheter.
• Fluid & Blood Management:
  • Permissive Hypotension: SBP 80-90 mmHg (pre-control in rAAA).
  • MTP:
    • Activate early.
    • Ratio 1:1:1 (PRBC:FFP:Platelets).
    • Warm products.
  • Cell salvage: Use if appropriate.
  • TXA: 1g IV load, then 1g/8h (within 3h injury).
• Anesthetic Techniques:
  • Standard: GA with RSI.
  • Induction: Etomidate/Ketamine (hemodynamic stability).
  • Maintenance: Volatile or TIVA.
  • Regional: Usually contraindicated (unstable, coagulopathy).
• Vasopressors/Inotropes:
  • Noradrenaline (first-line). Vasopressin (adjunct for refractory shock).
  • Inotropes for myocardial dysfunction.
• Special: One-Lung Ventilation (OLV):
  • If thoracic aorta involved (e.g., TAAA repair).

⭐ Goal-directed fluid therapy using dynamic parameters (e.g., SVV, PPV) is preferred over static pressure monitoring in managing major hemorrhage.

Postoperative Care - Aftermath Alert

• Immediate ICU Transfer & Continued Resuscitation: Vital for ongoing stabilization.
• Pain Management: Multimodal approach.
  • Opioids, regional techniques (if suitable post-op).
  • Paracetamol, NSAIDs (use cautiously).
• Complication Monitoring: Vigilance is key.

  • Reperfusion Injury: Hyperkalemia, acidosis, rhabdomyolysis.

  • Abdominal Compartment Syndrome (ACS): Bladder pressure >20 mmHg with organ dysfunction.

  • Acute Kidney Injury (AKI).

  • Myocardial Infarction, Stroke.

  • Limb ischemia (post-revascularization).

• Ventilatory Support & Weaning: As clinically indicated.

⭐ Monitoring for abdominal compartment syndrome is crucial after ruptured Abdominal Aortic Aneurysm (rAAA) repair, especially with massive fluid resuscitation.

High‑Yield Points - ⚡ Biggest Takeaways

• Rapid Sequence Intubation (RSI) is crucial for aspiration risk in emergencies like ruptured AAA.
• Permissive hypotension pre-clamp for ruptured AAA; manage hypertension post-clamp.
• Essential: Large-bore IVs, arterial line for monitoring and massive transfusion readiness.
• Aortic cross-clamping: abrupt ↑afterload/BP. Declamping: ↓SVR, hypotension, metabolic washout.
• Prioritize goal-directed fluid/blood product resuscitation (often 1:1:1 ratio).
• Maintain normothermia; monitor for renal injury and coagulopathy.