Ruptured AAA

[chmd]

Had my first ruptured AAA as an attending. He was awake and doing ok when I saw him in ED, not so much 10 minutes later when he got to OR. Nurses prepped while crna worked on Aline and I placed 9 fr. Then fent/midaz/sucs and incision.

Wondering if most people place 9fr prior to induction. Aline wasn't achieved until after incision and pressors, fwiw. Also i stabbed myself with clean needle while placing cvc.

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[sevoflurane]

If it's a true rupture, the number one thing to do is to cross clamp. I would not do pre-induction lines (including a-line).
I would intubate, flash prep and secure a cordis while the surgeon is getting proximal control. Time is of the essence in a true rupture (vs. contained rupture or leak). I am assuming he came up with multiple IV's and hopefully a 16G somewhere.

 

[chmd]

Was contained rupture

 

[sevoflurane]

Those 10 minutes are suspicious. My usual is to look at the CT and merge that with my clinical exam. I rarely, if ever, put in my lines awake for contained AAAs. Def. not for true ruptures. Most of the time I'm putting my lines in while the belly is being prepped. The exception is inadequate access in a patient who I think will be hard to place a cordis (very rare exception).
I will try to place a quick a-line pre-induction if I think I have time. If I don't, these patients usually don't have their arms tucked so I can get access to a radial or a brachial after the case gets started.

 

[sevoflurane]

That being said, if you think you have time, I don't have any hard and fast rules for lining up the patient prior to induction. Sounds like you took care of business. Great job on your first AAA as a PP attending.

 

[Wiscoblue]

The last few at my hospital went to the cath lab. stented in minutes


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[Planktonmd]

If the patient is still stable and maintaining BP: induce, intubate, let them start prepping while you place introducer and while someone is getting your blood products/ fluids ready for action.
Once the incision is made things can go downhill very quickly.
Don't waste time on the A line unless you have extra people available.

 

[Noyac]

I like Aline's. I can usually place one as fast or faster than I can place an IV. I Usually place the Aline and then induce on these cases. If they are unstable and crashing then I induce and go.

 

[Vaporized]

As far as actually cannulating the vessel, yes. But when you include prep the wrist, place sterile drape, suture, etc it takes much longer than IV. That is my experience at least.
It is interesting to hear how people handle these cases. Thus far in residency I have seen one open thoracic and one open abdominal aneurysm. Both not ruptured. We do a lot endo here.

 

[deleted162650]

But when you include prep the wrist, place sterile drape, suture, etc it takes much longer than IV

Easy fix: Ditch the sterile drape and suture. Wasting a lot of time there.

 

[Planktonmd]

Easy fix: Ditch the sterile drape and suture. Wasting a lot of time there.

Yes... Alcohol swap, #20 angiocath, tagaderm, done in 15 seconds.

 

[chmd]

Yes... Alcohol swap, #20 angiocath, tagaderm, done in 15 seconds.

Don't even need sterile gloves. Regarding the cvc, in a case like this don't need gown or drapes. Just exchange for sterile at end of case.

 

[Noyac]

As far as actually cannulating the vessel, yes. But when you include prep the wrist, place sterile drape, suture, etc it takes much longer than IV. That is my experience at least.
It is interesting to hear how people handle these cases. Thus far in residency I have seen one open thoracic and one open abdominal aneurysm. Both not ruptured. We do a lot endo here.

I wipe with alcohol and go. I can always suture it in later. Lots of tape in the interim.

 

[Noyac]

Sorry, I didn't see all the other posts stating the same thing.

 

[Vaporized]

I look forward to a more streamlined technique when I am able.

 

[amyl]

I use ultrasound for my Alines.... I find it to be faster and nicer for the awake patient. I do use sterile gloves and prep it, lido in a tb syringe. Really doesn't take that long. lido makes taping down not needed and pts happier. Same time really as tourniquet and iv placement. Besides, I'm the one that fought for my hospital to get ultrasound.... The More we bill with it the better I look, but I think it's better for the patient.

 

[Oggg]

Consider etomidate/ket for induction if they are losing so much blood they are out of it. Blood pressure can tank on incision so make sure your big lines are working before you let them cut.

 

[Ignatius J]

The great thing about ruptured AAAs is that it is actually a straight forward case.

1.) Do whatever you have to do to get the incision done as quickly as possible.
2.) Get as big of access as you can and open 'em up.
3.) Enjoy.

 

[Urzuz]

The great thing about ruptured AAAs is that it is actually a straight forward case.

1.) Do whatever you have to do to get the incision done as quickly as possible.
2.) Get as big of access as you can and open 'em up.
3.) Enjoy.

Creating an incision as quickly as possible can sometimes be a death sentence for patients. If the bleeding into the belly has tamponaded off any further bleeding, reversing your #1 and #2 would be of utmost importance. And as obvious as it sounds, being able to think ahead and preparing for the worst are of utmost importance..!

 

[Noyac]

I once saw an older partner delaying a AAA because he couldn't get an A-line in. The pt was minutes from dead. US was not readily available back then either. (Learn to feel the rope).
Sometimes you gotta go with what you got. Hopefully, it is at least some huge PIVs.

 

[Ignatius J]

Creating an incision as quickly as possible can sometimes be a death sentence for patients. If the bleeding into the belly has tamponaded off any further bleeding, reversing your #1 and #2 would be of utmost importance. And as obvious as it sounds, being able to think ahead and preparing for the worst are of utmost importance..!

If "worst case happens", see number 2.

 

[painstop]

Is anyone still giving a bolus of colloid prior to clamping or unclamping for elective open AAAs (they have become so rare with endovascular techniques that I haven't had one in a while)? If so, how much do you guys typically give?

 

[Noyac]

The only open ones I've done required lots of fluids, crystalloids and products. No hespan if that's what your asking. We have essentially removed that from our OR.

But like you, I haven't done one in awhile

 

[amyl]

I agree. Aline is a nice to have not have to have. If there's time an personnel - ok. Wouldn't hold the case up for it though. I agree with plenty of large access before incision and will hold up the case to obtain that if need be. They usually crash when you open the belly.

 

[Planktonmd]

I once saw an older partner delaying a AAA because he couldn't get an A-line in. The pt was minutes from dead. US was not readily available back then either. (Learn to feel the rope).
Sometimes you gotta go with what you got. Hopefully, it is at least some huge PIVs.

I have seen people torture patients for hours to obtain a stupid A line in a variety of elective cases!

 

[SouthSideSteve]

I have seen people torture patients for hours to obtain a stupid A line in a variety of elective cases!

That's because those people suck at Alines.

I honestly don't understand why people feel they need US for an Aline.

 

[Urzuz]

That's because those people suck at Alines.

I honestly don't understand why people feel they need US for an Aline.

Ultrasound for every arterial line is unnecessary in my opinion. On the other hand, it can be invaluable in certain circumstances, and can make difficult arterial lines tremendously easier (and quicker)

 

[pgg]

That's because those people suck at Alines.

I honestly don't understand why people feel they need US for an Aline.

95% of them go in easy. For the rare one that doesn't turn out to be a chip shot - and we ALL run into those patients occasionally - only the arrogant and callous keep torturing the patient. Get the u/s and be done with it and get on with the day. It's too easy.

I honestly don't understand why people are ao reluctant to use this tool. I suspect it's the same reason some surgeons flail around in laparoscopic procedures forever when everybody watching knows the right thing to do is to just open.

 

[Planktonmd]

95% of them go in easy. For the rare one that doesn't turn out to be a chip shot - and we ALL run into those patients occasionally - only the arrogant and callous keep torturing the patient. Get the u/s and be done with it and get on with the day. It's too easy.

I honestly don't understand why people are ao reluctant to use this tool. I suspect it's the same reason some surgeons flail around in laparoscopic procedures forever when everybody watching knows the right thing to do is to just open.

I recently witnessed a 4 hours laparoscopic inguinal hernia repair

 

[amyl]

Training program?

 

[Planktonmd]

Training program?

Yes...

 

[nimbus]

When I was a resident in the early 90s we had a laparoscopic "guru" who did lap choles in 2 1/2-3hrs. Needless to say, I got an education when I went into private practice where routines ones were 20-25min. My question then was why is the 3hr guy teaching the residents?

 

[Twiggidy]

I don't NEED an U/S for A-lines, but i use it alot lately because it's readily available, I've got experienced technique, and it moves things along faster. Although, yes, in some bad PVD patients, even the U/S will give you a headache.

Hopefully, and I know not all practices have this, but it's also not a bad idea to call a backup in so while you're doing a line, they can stabilize the patient or vice versa, you can induce and intubate and CVP while they do an A-line. OR, since there's a vascular surgeon in the room, ask he/she for help.

Lastly, in full on emergent ruptures, semi-sterile is ok IMHO, even for CVP. Just get big access and get them to sleep.

 

[chmd]

I don't NEED an U/S for A-lines, but i use it alot lately because it's readily available, I've got experienced technique, and it moves things along faster. Although, yes, in some bad PVD patients, even the U/S will give you a headache.

Hopefully, and I know not all practices have this, but it's also not a bad idea to call a backup in so while you're doing a line, they can stabilize the patient or vice versa, you can induce and intubate and CVP while they do an A-line. OR, since there's a vascular surgeon in the room, ask he/she for help.

Lastly, in full on emergent ruptures, semi-sterile is ok IMHO, even for CVP. Just get big access and get them to sleep.

Agree re semi sterile. It takes 3 minutes to slap on some chlorhexidine and some sterile gloves and place a introducer.

 

[OB1🤙]

A RIC can be your best friend in this situation.