Endovascular AAA Stent under Spinal?

[BLADEMDA]

Endovascular AAA Repair: Spinal vs. General Anesthesia

Michael Sornson, MD, Anesthesiology, 06:51PM Jul 9, 2012

drmike

Today, in our practice, we are primarily choosing to use a long acting spinal for our elective endovascular AAA repairs. This is a change from how we did these cases in residency and during my first couple years of private practice. Most of my earlier cases were done under GA plus an arterial line and central line. With the advancement of less invasive surgical techniques (i.e., endovascular AAA repair, rather than open), we are primarily doing these cases under a long acting spinal, arterial line and two large bore peripheral intravenous lines. We have had very good success and have avoided complications that may have appeared with GA . . . as these patients often have several co-morbidities (i.e. COPD).

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[BLADEMDA]

1. I routinely give Heparin within 30-45 min after induction so are you concerned about an SAB here?

2. Our patients have an average age of 75. This means a 27G pencil point needle isn't an option unless you are planning on an Epidural needle stick followed by the needle. I utilize a 22 Whitacre in this patient population rather freqeuntly as it makes a ONE PASS SAB much more likely and therefore less traumatic. I have NEVER blood patched a 75 year old patient after a 22 Whitacre stick in my entire career nor has my Group (this is well in excess of 25,000 spinal sticks). The incidence of H/A after a 22G Q puncture in an elderly popluation over age 75 is very low as well (0.2%) but it isn't zero.

3. The author doesn't mention the LMA/GA technique which is a sound one. LMA's preserve Pulmonary Function better than an Endotracheal tube. In addition, an LMA is more conducive to a TIVA Propofol technique for a fast Vascular Surgeon.

4. MAC- As Vascular Surgeons get faster and faster with stent deployment why not just start with a MAC and add an LMA if needed?

 

[BLADEMDA]

Singapore Med J. 2011 Dec;52(12):874-8.
A randomised controlled study comparing the effects of laryngeal mask airway and endotracheal tube on early postoperative pulmonary functions.

Sharma R, Dua CK, Saxena KN.
Source

Department of Anaesthesiology and Intensive Care, Lady Hardinge Medical College, Shaheed Bhagat Singh Marg, New Delhi 110002, India. [email protected]

Abstract

INTRODUCTION:

Classic laryngeal mask airway (LMA) has long been used for airway management. General anaesthesia has been associated with a significant decrease in pulmonary functions during the postoperative period. The decrease in pulmonary functions has been found to be greater with the use of a tracheal tube (TT). In this study, we compared the effects on pulmonary functions during the early postoperative period when the airway was managed using an LMA versus a TT.
METHODS:

A total of 20 patients in each group received either LMA or TT for airway management. Postoperative pulmonary functions were recorded at 30 and 60 minutes after removal of the airway device in patients undergoing peripheral limb surgeries. Forced vital capacity (FVC) , forced expiratory volume during the first second (FEV1), vital capacity, FEV1/FVC, peak expiratory flow rate and percentage saturation of oxygenated haemoglobin were compared. Postoperative coughing and hoarseness were also recorded.
RESULTS:

Pulmonary functions were significantly decreased in both groups at 30 and 60 minutes postoperatively. The decrease in the TT group was significantly greater than that in the LMA group at both 30 and 60 minutes. The FEV1/ FVC was not significantly changed, indicating a restrictive pattern. Patients in the TT group had a significantly higher incidence of coughing at both 30 and 60 minutes.
CONCLUSION:

The use of LMA instead of TT for airway management during peripheral limb surgeries causes less depression of pulmonary functions during the early postoperative period. The incidence of coughing is also significantly lower.

 

[BLADEMDA]

http://www.gm-medical.com/content/file/15%20-%20Berry%20et%20al.pdf


http://www.ncbi.nlm.nih.gov/pubmed/12027846



http://www.ncbi.nlm.nih.gov/pubmed/19226293

 

[BLADEMDA]

For those of you out there who are convinced a Propofol Infusion is Better than a Sevo/Des inhalational anesthetic under LMA please take a look at this study from 2010:

http://www.anesthesia-analgesia.org/content/early/2010/10/21/ANE.0b013e3181fdf5d4.full.pdf

Perhaps, a Propofol Infusion without an LMA is actually just equal to a Sevo/LMA technique in terms of post op pulmonary function? The study above certainly raises some questions (they used an ETT in the study above).

 

[Mman]

I have found doing these under spinal leads to a not insignificant number of patients that have difficulty breath holding for the surgeon to get the images they need. In other words, they are uncomfortable laying on the fluoro table and need adequate sedation to tolerate the position, but end up being unable to cooperate with a prolonged breath hold without moving.

 

[BLADEMDA]

Br J Anaesth. 2011 Feb;106(2):272-6. Epub 2010 Nov 9.
Lung function after total intravenous anaesthesia or balanced anaesthesia with sevoflurane.

Tiefenthaler W, Pehboeck D, Hammerle E, Kavakebi P, Benzer A.
Source

Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria.

Abstract

BACKGROUND:

We investigated the effects of total i.v. anaesthesia (TIVA) and balanced anaesthesia (BAL) with sevoflurane on postoperative lung function in patients undergoing surgery in the prone position.
METHODS:

Sixty patients, aged 21-60 yr, undergoing elective lumbar disc surgery in the prone position were randomly allocated to undergo TIVA (propofol-remifentanil) or BAL (fentanyl-nitrous oxide-sevoflurane). Forced vital capacity (FVC), forced expiratory volume in 1 s, mid-expiratory flow (MEF 25-75), and peak expiratory flow were measured before and after general anaesthesia.
RESULTS:

Both groups were similar with respect to patient characteristic data and preoperative lung function parameters. Irrespective of the type of anaesthesia administered, lung function parameters decreased after operation, with the decrease in FVC being greater after TIVA than after BAL with sevoflurane.
CONCLUSIONS:

In patients emerging from general anaesthesia, postoperative reduction in FVC is greater after TIVA than after BAL with sevoflurane.

 

[BLADEMDA]

I have found doing these under spinal leads to a not insignificant number of patients that have difficulty breath holding for the surgeon to get the images they need. In other words, they are uncomfortable laying on the fluoro table and need adequate sedation to tolerate the position, but end up being unable to cooperate with a prolonged breath hold without moving.

And if the goal is preservation of Lung Function then giving Propofol IV/via Infusion appears to be no better (? maybe worse) compared to Sevoflurane. I'm convinced from my personal experiences that if you can get by with an LMA then that is the way to go over a Spinal here. That said, most of our AAA stents are still getting an ETT, A-line, and Large bore IV.

 

[sevoflurane]

And if the goal is preservation of Lung Function then giving Propofol IV/via Infusion appears to be no better (? maybe worse) compared to Sevoflurane. I'm convinced from my personal experiences that if you can get by with an LMA then that is the way to go over a Spinal here. That said, most of our AAA stents are still getting an ETT, A-line, and Large bore IV.

Yep. That's what I do. I can hold breaths... and if there is a catastrophic AAA rupture that needs to go from endovascular to open... I don't want a spinal getting in the way.

That being said, I've only been involved in one endo AAA that we had to open.

If the CT/ CT angio looks like it's a straightforward stent deployment... a spinal is fine. If the anatomy/AAA is big and tricky... there is no way I'm putting in a spinal. Just my preference.

Also depends on the surgeons you are working with...

 

[edelweiss]

When I was a resident we did many of these under epidural +/- sedation, with A-line and large-bore IV. Most people who came from PP either thought the epidural was 1) overkill (why use neuraxial + heparin when you can do propofol bolus and tons of groin local), or 2) dangerous.

It was effective although I cannot say it was better than GA. I had to convert some of them to GA, usually for length of procedure.

 

[Mman]

And if the goal is preservation of Lung Function then giving Propofol IV/via Infusion appears to be no better (? maybe worse) compared to Sevoflurane. I'm convinced from my personal experiences that if you can get by with an LMA then that is the way to go over a Spinal here. That said, most of our AAA stents are still getting an ETT, A-line, and Large bore IV.

I'm too lazy to look it up, but I'm betting the idea of preserving lung function with an LMA requires the patient to be spontaneously breathing through the LMA. And you can't do that for this case because the surgeon needs breath holds to shoot the fluoro images. So in this case you are comparing positive pressure ventilation in a paralyzed patient with an ETT compared to an LMA. I'm not convinced the LMA is going to give any sort of better outcome. And if you had to convert to open emergently, I'd rather have the ETT.

 

[BLADEMDA]

I'm too lazy to look it up, but I'm betting the idea of preserving lung function with an LMA requires the patient to be spontaneously breathing through the LMA. And you can't do that for this case because the surgeon needs breath holds to shoot the fluoro images. So in this case you are comparing positive pressure ventilation in a paralyzed patient with an ETT compared to an LMA. I'm not convinced the LMA is going to give any sort of better outcome. And if you had to convert to open emergently, I'd rather have the ETT.

http://www.ncbi.nlm.nih.gov/pubmed/19226293

Click on the above study. LMA is still better than an ETT in preserving Pulmonary function even in mechanically ventilated patients.

That said, I'm still intubating my AAA stents. No spinals as of yet. LMA I would consider

Last 100 stents at my hospital had zero converted to an open procedure.

 

[gasattack3]

Yep. That's what I do. I can hold breaths... and if there is a catastrophic AAA rupture that needs to go from endovascular to open... I don't want a spinal getting in the way.

That being said, I've only been involved in one endo AAA that we had to open.

If the CT/ CT angio looks like it's a straightforward stent deployment... a spinal is fine. If the anatomy/AAA is big and tricky... there is no way I'm putting in a spinal. Just my preference.

Also depends on the surgeons you are working with...

This seems like sound logic. Most of my attendings would opt for this approach, though I haven't formally done my vascular rotation yet.

 

[TrustMe]

One of my attendings from residency that did mostly vascular cases was famous/infamous for many quotes, one of which was "Pt's have a trachea for a reason.....use it." He hated LMA's (but not as much as he hated regional). Almost all pt's in his room either got a tube or nothing (local and sedation). All that being said, he was a great attending and I learned a lot from him. He was the attending that you wanted if you had a crazy-sick pt.

 

[Oggg]

+1 to breath holding problem. ETT

 

[nap$ter]

we do these c 2 LBIV's, aline, local, and dexmed.

 

[fakin' the funk]

Singapore Med J. 2011 Dec;52(12):874-8.
A randomised controlled study comparing the effects of laryngeal mask airway and endotracheal tube on early postoperative pulmonary functions.

Once again Blade, thank you for bringing the pillars of academic anesthesiology into this forum.

 

[Idiopathic]

you know, i remember doing all of these as a resident (n=8-10) with local and a little IV sedation (midaz/fent, maybe single propofol bolus) but the first one i did as an attending the surgeon looked at me like i was crazy when we told him we were ready. He said we either needed an epidural or a GETA. I did the remainder under GETA with an ETT for the rest of the year.

 

[BLADEMDA]

Once again Blade, thank you for bringing the pillars of academic anesthesiology into this forum.

And thank you for all your quality references.

 

[Green Chimneys]

Surgeons at my institution seem to have no problem with the breath holding issue, even on complex repairs. Our typical method is spinal + deep sedition with propofol and spontaneous ventilation throughout. The surgeons actually prefer it this way. I've personally only done about 15-20 so far during residency and haven't seen them open the abdomen but I know it has occasionally occurred here with conversion to GA. Just did a case today on a patient who had previous open thoracoabdominal AAA in the past and very complex aneurismal disease. They wanted to extend the graft all the way in to the L femoral in addition to tossing some coils in the aneurism in the iliac. This guy had such bad COPD that he bought a long icu stay and temporary trach after his open repair. Popped the spinal, low dose propofol, and kept score for less than 2 hours while the surgeon ninja'd all that cap in there. Patient slept like a baby, breathed like a champ, and practically looked ready to walk out the door by the time he got to PACU. Had this guy been given a GA, he'd probably still be on the vent.

 

[Planktonmd]

A spinal is not a great idea here for the breath holding issue that was mentioned above.
LMA is OK, but that story about "better conservation of lung function" is not very logical if we are going to paralyze the patient and use PPV, regardless of what Blade or the Singapore anesthesiologists he quoted might imagine.
In general I never regretted placing an ET tube in any patient.