Aortic Dissection

 

Disease:

Causes

·      Trauma

·      Atherosclerotic ulcer

·      Sympathomimetic drugs or pregnancy

·      Connective tissue disease

Classifications

Stanford:

·      Type A: ascending. Rx surgery

·      Type B: descending (distal to left subclavian artery). May ± stent.

De Bakey:

1.    Entire aorta

2.    Ascending aorta

3.    Descending (distal to left subclavian)

Svensson:

·      Multiple subtypes

·      Dissection vs haematoma vs ulcer etc

Complications

Involves the heart:

·      Aortic regurgitation

·      Tamponade

·      AMI (coronary dissection)

Involves large vessels:

·      Stroke

·      Limb ischaemia

·      Gut ischaemia

·      Spinal cord ischaemia

Treatment

·      Stanford Type A: surgery

·      Stanford Type B: stent if organs compromised

 

Anaesthesia issues:

Haemodynamic goals

·      Minimise wall stress = HR 60 + SBP 100 + euvolaemia

·      Do not give vasodilator before beta blockade

·      Good: opioid, labetalol, esmolol, phentolamine, nitrates

·      Bad: inotropes, hydralazine, pericardiocentesis (exsanguination)

·      Induction: cardiac style

Bleeding

Vascular access:

·      2 x IVC – UL, LL

·      2 x A-line – RUL + femoral

·      CVC

Blood products:

·      CSL max 2L

·      O-negative if urgent

·      Crossmatched if can wait

·      Cell salvage if available

Brain monitoring

Reasons: 1) insufficiency 2) DHCA

 

Electrical:

·      Unprocessed EEG

·      Processed EEG (BIS)

Perfusion:

·      Transcranial doppler

Oximetry:

·      Cerebral oximetry (NIRS)

o    Bilateral forehead stickers

o    Normal 60-80

·      Jugular venous bulb sats

 

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