Abdominal Aortic Surgery Protocol
April 2002 (Boyd et. al.,)

(For Endovascular Stent Management Guidelines, click HERE

AAA Page Index:

Preop Assessment/ Optimization
    -Co-Morbidities
    -Diabetic (Insulin) Protocol
    -Beta Blockade Protocol
Operative Management
    -Renal Preservation
    -Fluid Management
    -Cross Clamp
Emergence/ Post-op   

Preoperative Assessment

A. Identify Lesion:
    Occlusion vs Aneurysm
    Infra- vs Supra- Renal

B. Assess Co-Morbidities:
    Cardiac: use Am Coll Cardiology Guidelines
    Pulmonary: SOB hx to direct ordering of PFT (FEV<1 r/o surgery)
    Diabetes: managed per Glycemic Management protocol
    Renal Function: preop 'lytes, BUN, Creatinine: all patients
    Hematologic: CBC, PT, PTT, and T&C x 4: all patients

C. Preoperative Optimization
    Insulin – per Glycemic Management protocol
    B-blockade- per perioperative beta blockade protocol
    Nicotine Patch & smoking cessation recommendations
    Bronchodilators per hx or PFTs
    ASA –surgeons discretion; part of post op order set

Operative Management:

A. Preinduction Lines/ Monitors/ Meds

    Target= Normothermia:
        -Room Temp > 75F until patient draped
   
     -Bair Hugger as early as possible
        -NS line w/  fluid warmer 
    Triple Transducer set up
    IVAC Dopa / NTG
    Neo (phenylephrine) Drip
    Arterial line-
        -Suggest check cuff pressures bilaterally before placement
    Central line-
        -introducer/Slick cath – for easy conversion to SGC
        -Swan-GC:
        -for all suprarenal cross-clamp
        -Renal insufficiency (Cr > 2.0)
        -EF <30%

B. Epidural: Mid to high thoracic
    -? preop confirmation of placement in higher risk cases (pulm or cardiac)

C. Antibiotics: by protocol completed > 20 min prior to incision
    -Cephazolin 1 gm or 
    -Clindamycin 900mg (diluted, over 30-60 min) if penicillin or cephalosporin allergy


Intraop Events:

A. Induction: Staff Preference
B. Maintenance: Staff Preference

C. Renal preservation
Key  is hemodynamic management. There is significant volume depletion from bowel prep.
Optimize:
    -fluids,
    -cardiac output, & 
    -perfusion pressure for each patient individually. 
Urine output (UO) is only & therefore key marker of renal system health.
        - If no urine output then reassess hemodynamics via CVP / SGC /or potentially TEE in selected cases.
        - Lasix, mannitol or dopamine: No evidence of any benefit. In fact loop diuretics and dopamine may be detrimental in this situation.
        -Keep surgeon informed if UO low.


D. Fluid Management
Monitor Urine Output q 30 minutes
if < 0.5 cc/kg/hr: discuss with surgeon

E. Epidural: use throughout the case

    -0.0625% Bupivicane with narcotic (fentanyl vs. dilaudid)
    -goal is to utilize PCEA intraop


F. CrossClamp Managemen

Preparation:
    -Generate UO > 0.5 cc/kg/hr via hemodynamic management
    -Heparin 75 u/kg per surgeons request
During crossclamp:
    -after clamp if UO < 0.2cc/kg/hr discuss with surgeon
    -Manage BP with NTG / anesthetic
    -HCO3 only routinely during suprarenal or >2hr infrarenal
Unclamp:
    -Hyperventilate
    -Volume resuscitate

Protamine: 0.5mg/100 mg heparin at surgeons discretion

Repeat Antibiotics at 3 hrs following first dose


G. Emergence
Goal: Intraoperative extubation. Must satisfy the following criteria:

    -Skin to skin operative time < 5 hrs
    -Core temp > 35.5 C
    -Hemodynamic stability
    -Pain controlled
    -Good respiratory mechanics
    -Surgeon must agree with the plan

If these criteria are not met, patient will go to PACU intubated where ventilator protocol & propofol sedation will be utilized as indicated.  Goal is to extubate in 4 hrs.


Postop Management

Utilize PCEA to minimize # of devices pt is attached to and encourage earlier mobilization on the floor
Diabetics: see Glycemic Management protocol

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