Perioperative Management of a case of Thoracoabdominal Aortic Aneurysm
CCCF ePoster library. rashid s. Oct 2, 2017; 198140
Dr. saima rashid
Dr. saima rashid
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Perioperative Management of a case of Thoracoabdominal Aortic Aneurysm.

Rashid, Saima1; Hamid, Muhammad1

1. Department of Anesthesiology, Aga Khan University Hospital, Karachi, Pakistan.

Introduction: Thoraco abdominal aneurysm repair is a complex vascular surgery with high post-operative morbidity and mortality. The patient in this case report  was diagnosed as a case of thoraco-abdominal anuerysm on CT angiogram. Case report: A 56 year old gentleman, ASA IV, presented for repair of De Bakey type III, dissected thoraco-abdominal aortic aneurysm. pre operative investigations were normal. Aneasthesia was induced with Midazolem, Etomidate, Fentanyl and Rocuronium after applying the standard monitoring. Before induction lumbar drain was inserted and the transduced pressure was 13 mm Hg. a left radial arterial line was placed. A left sided double lumen tube of size 37 was tried initially but due to compression of left main bronchus by the aneurysm the tube was placed on the right side .After two attempts an ETT size 8.5 was passed with a bronchial blocker. central venous and swans ganz catheter were inserted. One lung ventilation was established.  Anaesthesia was maintained with 40% oxygen and Isoflurane (0.9-1.3). A total of 1000 micrograms of fentanyl was administered throughout the case. A TEE probe was placed for monitoring of left ventricular function. The patient was heparinized; common femoral artery and vein were cannulated and then cooled to 20⁰C. In the process,  The aneurysm was then opened longitudinally. A 28mm Vascutek Dacron was anastomosed end to end. The operative findings revealed a very large dissecting aneurysm starting flush with left subclavian artery. The CSF pressure was continuously monitored during the procedure and CSF was passively drained when the pressure exceeds 13 mm Hg. During the case 10-20 mls of CSF was drained to maintain the pressure between 9-13 mm Hg. The patient was then shifted to CICU where he kept ventilated. He was then weaned from ventilator and extubated on fourth post op day but was reintubated on sixth post op day for  drowsiness due to raised serum ammonia levels. Gradually the GCS restored to 10/10. Afterwards the patient had sepsis, acute kidney injury and ventilator associated pneumonia. Blood cultures were positive for carbapenem resistant klebsiellapneumoniae. Tracheal cultures revealed acenitobacter. Antibiotics were started after taking ID on board. Tracheostomy with insertion of PEG was performed for prolong ventilation. Finally the patient was weaned off from ventilator and discharged home after approximately two and a half months. Conclusion: We presented a patient who underwent extent II TAAA repair, using permissive hypothermia, LHB, CSF drainage, and cold crystalloid renal perfusion.  This technique offers the potential benefit of providing protection against brain, cardiac, renal, visceral, and spinal dysfunction without having to use adjuncts such as LHB, CSF drainage, selective perfusion of renal and visceral arteries, regional spinal cooling, or sequential aortic clamping.

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