EVAR:

 

General issues:

Hostile environment

·     Ionising radiation

·     Moving table

·     Moving C-arm

Surgical conditions

·     Require immobility + periodic apnoea

·     Duration highly variable

·     If <2h: spinal + sedation

·     If >2h: relaxant GA

 

Organ protection:

Renal protection

Risk factors:

·     Patient: CKD, heart failure, T2DM, renovascular disease

·     Surgery: contrast load, clamp height, clamp time

·     Anaesthesia: ↓DO2, nephrotoxins, massive transfusion

Preserve the vessels:

·     Fenestrated graft

·     Re-anastomosis

Preserve DO2:

·     ↑mAP: volume + pressor

·     ↑SpO2

·     ↑Hb

Long list of things that don’t work:

·     Dopamine (renal dose 1-3mcg/kg/min)

·     Mannitol

·     Frusemide

·     NAC

·     Methylprednisolone

Spinal protection

Risk factors:

·     Surgery: TAA, clamp height, clamp time, affects Adamkiewicz a.

·     Anaesthesia: inadequate DO2

Monitoring:

·     MEP

·     SSEP

Preserve the vessels:

·     Fenestrated graft

·     Re-anastomosis

Preserve DO2:

·     ↑mAP: volume + pressor

·     ↓CSF pressure: lumbar drain if high risk

·     ↑SpO2

·     ↑Hb

Lumbar drain:

·     Indicated if high risk (e.g. complex TEVAR)

·     Transducer at level of insertion

·     Max 10cmCSF

·     Max 30mL/h drainage (risk of SDH, coning)

·     Keep in situ 72 hours (high risk period)

·     Monitor in ICU

·     Prophylactic antibiotics

 

Feedback welcome at ketaminenightmares@gmail.com