Epidurals & open AAA repair
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Arch Guillotti
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Don't do them.
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Any reason why?
The only AAA repairs I've done as a baby attending have been endovascular. If I was doing an open, I'd ask surgeon if he wanted one and/or would do one if requested. But (as I was trained) I would not run it during the case.
How about when the surgeon fully supports it?
Arch Guillotti
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I would do it, so long as they understand the risks.
Mostly local custom, surgeons just don't really want them for whatever reason.
During residency our program used to place them for endovadcular AAA's.
http://www.sciencedirect.com/science/article/pii/S0741521499701047
We don't in PP. But do for open AAA. That is a BIG incision.
http://www.sciencedirect.com/science/article/pii/S0741521499701047
We don't in PP. But do for open AAA. That is a BIG incision.
We do it sometimes. One of our surgeons uses no heparin for a regular infrarenal repair. We do them in his. The others (who use heparin)go back and forth. Sometimes they don't mind waiting in the event of a bloody catheter and sometimes they do. I just ask.
how many run the epidurals during the case?
for simple infrarenal aneurysms/repairs i run 1/8 bupi... if it's suprarenal i wait until unclamped and then start the gtt.
for simple infrarenal aneurysms/repairs i run 1/8 bupi... if it's suprarenal i wait until unclamped and then start the gtt.
I do them. I run fentnyl in the epidural during the case and when they are unclamped and I don't need pressors I start to run it and turn the iso off and let them close up and pull out the tube. Works well and give nice recovery room hemodynamics. I also give 3 mg duramorph before they head off to the vicu for the night. Haven't been burned yet but those open cases have really disappeared and we do maybe 15 a year as a group. I do a lot more aorto bi fems. Much smaller incision and I tend to just do tap blocks. Blaz
I ask because I did residency at a place where epidurals weren't used (even though the vascular surgeons were ok with it) and fellowship where epidurals were used. I don't use the epidural until the cross clamp is on, and then bolus with 2% lidocaine to decrease the afterload. Using that approach, I have not had to use vasodilators and minimal vasoactive agents after. Then once the clamp is off and things are stable I start the infusion. I've found it to be an extremely smooth technique.
Some of my colleagues think we shouldn't be placing epidurals in case something (like spinal cord injury) happens. Even though the likelihood of the epidural being the cause is low, it's not zero. No epidural means something else is blamed. I'd hate to give up on a nice technique for that reason though.
Some of my colleagues think we shouldn't be placing epidurals in case something (like spinal cord injury) happens. Even though the likelihood of the epidural being the cause is low, it's not zero. No epidural means something else is blamed. I'd hate to give up on a nice technique for that reason though.
I agree. We just don't do that many open AAA's anymore. Over the past few years I have only done 2 or 3 a year. We do do alot of perc repairs. Probably 2 or 3 a week. As for running the epidural, if I trust the surgeon I will start it early, if I don't I wait until after they unclamp and things are stable, I always try to get it going and get some level before waking up.
Open AAA repair = yes, epidural
Open or endovascular TAAA repair = no epidural, but yes to lumbar drain per surgeon request
Open or endovascular TAAA repair = no epidural, but yes to lumbar drain per surgeon request
During residency one of our attendings that did a lot of the big vascular cases HATED regional techniques and he got the vascular surgeons to thinking that regional was evil so we never did them. We got a few new vascular surgeons that actually ask for regional sometimes now (one of them likes to do all of his fem-distal bypasses under epidural). Said attending is never scheduled to do the cases where regional is suggested or requested by the surgeon. One of the guys likes to do his high risk carotids under regional only (cervical plexus block) and prior said attending always somehow is around telling the residents that there is no need for regional. Kind of funny actually. A little precedex and a good cervical plexus block is a smooth case. Sorry, that was kind of off topic. I love epidural for open belly cases but just never did them for AAA and so would probably have to find the right surgeon that was familiar with the risks of epidural in these cases.
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Deep cervical plexus block under ultrasound - pretty cool block.
I place them for open AAA provided the pt is not on any preop blood thinners which will need to be restarted within 24hrs.
Sounds EXACTLY like an attending where I trained. You didn't do residency in Cleveland, did you?
