Not your typical Ruptured AAA !!

I hope his 86 years were fruitful and fulfilling.

 

Interesting. I am writing a case of a ruptured aaa in a jehovah witness patient. The surgeons chose to do the case endovascularly. Pt survived the procedure but expired in the Icu.

 

Some allow cell saver.

 

Twice now I have had Jehovah's witnesses drop down to Hb of btw 2&3. Both pts survived and went home not really any worse off. The problem here is the age and the pathology. I'd give this guy very very little chance of survival. It would be an interesting case to perform though. Keep us posted on the outcome. Should be a short story.

 

Maybe I'm not understanding what you mean by "ruptured", but if it's really ruptured and not "contained" or 'leaking", then it's drapes up (maybe) get control ASAP with lines going in at the same time. If there is a modicum of stability to the situation, then awake lines, get the belmont and a bunch of products in line and prepare for the storm when you release the abdominal tamponade. In the few truly "ruptured" AAAs that have actually made it to the OR for me, a few have had surgical control before we had ANY IV access, let alone invasive lines.

As an aside: as an intern, I was examining a guy in the ER with chest pain who all of a sudden screamed "MY STOMACH!", turned sheet white and had his belly expand by about 100% over 30 seconds. The code was called before the vascular surgeon could run up from another part of the hospital. That is what I think of as a "ruptured" AAA.

 

Call me whatever you would like, but a ruptured AAA in an 85 y/o should be no more than a morphine drip. We cant expect everyone to live forever. Surgery is no more than $100,000+ later with the same outcome

 

sounds like you had a borderline JW.

this is another topic that comes up every 6 months or so around here it seems. here is my take on these cases.

when presented with a ruptured AAA and a meta-stable patient (SBP > 90, patient mentating, HR < 120) lines in before induction, including arterial line/MAC catheter. you cant go wrong in this scenario unless it takes you forever to get the line in. its been argued that you should do these cases with good (read: GREAT) PIVs but whats the realistic possibility of that in many of these patients.

when presented with a ruptured AAA and an unstable patient, get a preinduction arterial line unless you are on the chest. tolerate the IV status and work towards improving it.

the key for me is: surgeons in room, belly clean, drapes up BEFORE INDUCTION. treat it like a crash cesarean section in this regard. be ready to cut and clamp and give tons of volume rapidly. cant be d***ing around with an IV when you need to get potentially LITERS of volume in in <10 minutes. my 2 cents

i believe this satisfies requirements for oral board exam and real life exam

 

There was a big review article in one of the Journals of Vascular Surgery about a year and a half ago. It stated that you shouldn't waste time with an a-line... Prep, drape, tube, big neck line as they are cutting. This is the most efficient way to handle a true rupture. A-line is something after access and resuscitation. It makes sense: They are going to be hypotensive, they are going to be acidotic, they will need blood and products. I don't need a pre-induction aline for this.

Interestingly, in that same article, they say that if the patient has a "leaking AAA" aggressive fluid resuscitation (and an increase in transmural pressure) may dislodge an ongoing hemostatic plug and cause even more hemorrhage. They key factor was mental status and CT findings. If they were talking and had a "leak", then aggressive fluid management was not necessary immediately. If they ruptured and are exanguinating, then all bets are off. This is a tough position to be in as a leaking AAA can turn into a ruptured AAA > hence the importance of B.P. management (which is the real pearl of an a-line before induction).

On another note, EVAR is becoming more promissing, especially for the Jahovas witness. Less bleeding = better chance of survival in this patient population.

Is endovascular repair of a ruptured AAA the future?

I can't find the article at the moment but here is this:

http://www.medscape.com/viewarticle/723653

http://www.theheart.org/article/1028599.do

Thirty-day mortality was 11% (2 of 18) for eEVAR and 32% (6 of 19) for OAR (p = not significant). At the 6-month follow-up, mortality was 22% (4 of 18) for eEVAR and 37% (7 of 19) for OAR (p = not significant). A clinically significant early survival advantage is suggested for eEVAR in patients presenting with rAAA.

Essentially, eEVAR is easier to do in smaller countries (like Germany and Switzerland) that have one major referral center (quick to get to). Protocols are strictly followed and time to graft deployment were remarkably fast.

 

line 'em up before.... when the belly opens things are likely to get a whole lot worse fast... if they are meta-stable its only because they are meta-tamponaded

 

Emergency Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysm: The Way Forward?
Oliver T.A. Lyons; Stephen Black; Rachel E. Clough; Rachel E. Bell; Tom Carrell; Matthew Waltham; Tarun Sabharwal; John Reidy; Peter R. Taylor
Authors and Disclosures
Posted: 08/04/2010; Vascular. 2010;18(3) © 2010 BC Decker, Inc.
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Abstract and Introduction
Methods
Results
Discussion
References
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Abstract and Introduction

Abstract

We present the early results of a policy of treating all anatomically suitable ruptured abdominal aortic aneurysms (rAAAs) by emergency endovascular aneurysm repair (eEVAR), regardless of hemodynamic instability. Data were retrospectively collected from prospectively maintained databases identifying patients with rAAA from 2006 to 2007. Forty-seven patients with true rAAA were identified (87% men; median age 76 years [range 63–97 years]), of whom 18 (38%) were treated with eEVAR, 19 (40%) received open aneurysm repair (OAR), and 10 (21%) were managed nonoperatively. Fifteen of 18 (83%) eEVAR patients received an aortouni-iliac device + femorofemoral crossover, 2 patients (11%) had bifurcated devices, and 1 patient (6%) had a new iliac limb. Thirty-day mortality was 11% (2 of 18) for eEVAR and 32% (6 of 19) for OAR (p = not significant). At the 6-month follow-up, mortality was 22% (4 of 18) for eEVAR and 37% (7 of 19) for OAR (p = not significant). A clinically significant early survival advantage is suggested for eEVAR in patients presenting with rAAA.

Introduction

The mortality from ruptured abdominal aortic aneurysm (rAAA) remains high. Two recent meta-analyses of the results of surgery for rAAA showed that the average international operative mortality is approximately 48% and has shown little improvement since the 1970s despite advances in perioperative management.[1,2]

In the elective setting, an early survival advantage has been demonstrated for endovascular aneurysm repair (EVAR) over open aneurysm repair (OAR).[3,4] The first cases of emergency endovascular aneurysm repair (eEVAR) for rAAA were published in the 1990s,[5,6] and eEVAR has been demonstrated to be a valid treatment option.[7–9] Despite the intuitive advantages (no need for laparotomy and aortic cross-clamping), a benefit has yet to be demonstrated by a randomized controlled trial in the emergency setting.[10–14] The relative failure of more widespread use of eEVAR for rAAA is largely a result of anatomic limitations and a lack of specialist skills and equipment.[15,16]

Despite these considerations, the theoretical benefits of eEVAR over OAR in the emergency setting maintain the drive to demonstrate the usefulness of this technique. We examined the results of treatment of rAAA in a single center where eEVAR has been considered the treatment of choice in all anatomically suitable patients since the establishment of a dedicated consultant-led 24-hour endovascular service in 2006

 

I'm not sure what you mean by this. JWs decided individually whether to accept major or minor fractions of blood. Major fractions are RBC, WBC, FFP and platelets. Minor fractions include protein derivatives such as factor concentrates (ie cryo), albumin, interferons. Most JWs are consistent in refusing major fractions. Minor fractions and procedures such cell saver, dialysis etc are left to the individual to decide. Some JWs will accept organ transplantation including heart, liver and kidneys.

The case described should really get an EVAR. If not amenable, and the patient is fairly stable, IR could do a balloon occlusion proximal to the AAA to have control prior to incision.

 

Yes. Especially if they are 30's-40's. I would go to sleep with a couple of 16's in the AC's hooked up to a rapid infuser (I know... not all patients come to us with such nice access) That will be followed by a supa quick MAC catheter...

Sometimes, time is not a luxury we can afford.

Difficult scenario's for sure...

Anyone gone on bypass with a 16 gauge?

Been there during a thorocotomy gone bad. It was a first and hopefully my last.

 

tried it once (fender bender involving mediastinascope vs pulmonary artery), but didn't even make it on. ouch.

 

You need to be willing to adapt, my experience with these cases is that they can come flying into the OR with a surgeon is ready to cut ASAP. Trying to hold a vascular surgeon who is chomping at the bit is like trying to fend back a pack of swarming buzzards. I think you should do your best to get the access, but proceed if you can't. I basically agree with Idio's approach to treat it like a crash section. Lines aren't always a slam dunk, especially if they are in hypovolemic shock. I have started case like this before with no central line. Don't get caught up in having to have the Cordis before proceeding. A 14 gauge or a stubby 16 gauge run pretty darn good with a rapid infuser. Art line is very helpful since the patient will likely crump when the belly is cut and a NIBP will leave you flying pretty blindly.

 

Absolutely. Easy to tent the IJ and go through and through w/o a flash in hypovolemic shock. An awake patient with SV can give you a moving target.... Or short chubby necks... they can pose a problem. Or wires that meet some sort of resistance, etc. There are a lot of things that can hang you up. Point is, you need to get hemostatic control on the rupture. This is priority #1. Sometimes we have to do what is uncomfortable to us as Type A/control freak gas passers.

This applies to a-lines as well. They are often maximally vasoconstricted in an attempt to divert blood centrally. Your target can be as small as your angiocath. You hit it once and miss, they may go straight into vasospasm. Then you go to the other side, then this, then that... sometimes wasting precious time with no guarantee you will be successful in the next 5-10 minutes. Time = life.

I find a sonosite useful in the circumstance where you have no palp pulse, tachy, vasoconstricted... USD > visualize little target > angiocath under direct ultrasonographic vision. It is sometimes the faster modality... only wasting seconds rather than minutes. I've used it like this after induction while our OR nurses are running the rapid infuser.

 

big board topic for those getting ready to do the orals

i believe it is actually one of the major foci they grade you on.... Cuz they will give you impossible catch 22 scenarios.

 

Same story here. Refused albumin/cell saver/any human product. Hg was 3.8 by the time they arrived to the ICU on 2 drips. Coded by sunset.

 

Don't forget your best friend the RIC. Who needs a ****in cordis?

Get into that belly and get it under control ASAP.

- pod

 

I think someone gains a different perspective after training in the ICU. I agree, we both know what these patients turn into IF they make it to the ICU. It's hard to convince patients or families to not intervene preoperatively...especially in an emergency...not saying it would be easy for me. But I have changed my outlook a lot now that I'm back in the OR after the CCM training.

 

love the RIC. when they infiltrate its spectacular. especially at 500ml/min on the Belmont

 

Never seen it, but damn that must be impressive.

- pod

 

RICs are the bomb.

Due to a shortage of cortis kits (don't get me started on this one) and more RICs than I knew what to do with, we have been using them quite a bit. We started getting our RNs trained to put them in. That was nice, roll back to the OR for a big case, just say I want a RIC and hook it up to the belmont. Big access and volume flies in.

 

I just came back to post about the RIC and you all beat me to it ...

​

Great for converting those ER-special 20 g antecubitals to something big. Wire won't fit through a 22 g, ask me how I know.


Never seen one blow though ...

 

No MAC catheter and no RIC line. Since he's a Jehovah's Witness, if you have any need of a rapid infusion device this case is over. Two good 18g or 16g IVs are probably enough "large bore" access for this guy (two in case one blows).

A CVP (plain ol' triple lumen) and possibly a PA catheter (floated through a plain ol' PSI) could be useful for volume assessment if he makes it to the ICU with severe anemia. Any central line should be done under direct ultrasound guidance to minimal arterial puncture/blood loss.

I'd place an a-line for aortic cross-clamp if open procedure; would just use a cuff if they're doing an EVAR. Since he's not transfusable he's better off without an A-line if it can be avoided (as long as there's no planned laparotomy/aortic X-clamp).

NO lab draws, and if absolutely necessary to send labs they should go in pedi tubes.

 

admittedly ive only seen it twice and only once during big volume infusion but the arm can hold a lot of volume before you start to get alarms

 

your RNs put RICs in? Wow! Ours can barely put IVs in...

drccw

 

What does RIC stand for? Is it just a peripherally inserted short cordis?

 

I'm in a special place right now with a special population.

 

I call you real and second that wholeheartedly.

 

Rapid Infusion Catheter

Yes, its basically just a short cortis. Instead of the introducer and side port for IV access you just hook the end up to your IV line.

 

no offense, but i wouldnt trust a RIC that I hadnt put in myself or witnessed being put in by someone i know.

RICs can handle 1500ml/min, based on the package insert, which is more than a MAC or an introducer. ive also experienced that the blood volume can return to you just as quickly when i removed the stylet before I was ready to hook up the line only do that once...

 

This is exactly my thought process.... I'll put in my RIC's. They are fun to put in and if it's NOT in... you've got problems if not recognized.

MTgas2B likely has exceptional nurses and I'm sure he pulls back a good 5-10cc's before using it.

 

Ahh I see the special place and popuation now. Stay safe....

No introducers but belmont machines? I'ld rather have a belmont......

My buddy did some time in Iraq... their rapid infusers were strong able bodied corpsmen...

drccw

 

A good point worth raising. Einstein didn't have his fixed.

 

I'd like to see the EZ IO become an accepted method for rapidly securing central access. Zzzzip.

 

I was taught you had to have an 18g for a RIC, didn't know the wire would fit through a 20g. Very nice.
I can only imagine how much damage you could do with an infiltrated RIC, though! Yikes!

 

Debakey did though. Interesting story. http://www.nytimes.com/2006/12/25/health/25surgeon.html

 

He was a dead man walking and his time was up. MSO4 drip, a little Ativan, and for $20 worth of meds and $2000 for the room, he could have been saved from getting 10 people poking him all over.

DO they do ethics consults anymore?

 

great article that everyone should read. call me a heretic but I think they should have let the old geezer pass on.

 

Saw it as a second yr resident during a massive trauma using a RIC and a Level 1 rapid transfuser. You know how it was discovered? The Level 1 never alarmed, it kept on pumping full steam ahead, but the guys pressure wasn't 'responding to volume' like it had been. Then the alarm for the SpO2 went off. The waveform went flat because the thug that took a few 9mm to his liver/spleen/IVC/chest now had a severe pseudo-compartment syndrome in his arm. His arm was purple, tense, and the skin was sloughing off. Fasciotomy time!

 

We have introducers too, just not enough to put them in as much as we'd like. The RICs have been a great bridge for those that need more than a PIV and have adequate veins.

As far as our nurses putting them in. Its a small place, I can usually keep an eye on them and I know if they've gone in okay or not. It just frees me up to keep things moving faster.

 

Our Arrow spring-wire (don't have the exact measurements) that we use for salvaging a-lines fits thru a 24, if that helps...

 

The infusion rates on these are pretty low though. Pharmacokinetic studies seem to suggest time-to-central times are good.

 

I've used an IO as my only access in a crashing trauma patient once. From my n=1 drug uptake at induction seemed significantly delayed.

 

Last rites.

 

POD,
It's a pretty busy time after induction and they release the tamponade on the rupture, BUT, do you like a TEE for this case? It's one monitor that won't have you struggling for 10+ minutes like an A-line to establish.

 

TEE = waste of time.

What is it going to tell you that you don't already know/ can't deduce easily?

Hypotension is either going to be from volume depletion or lethal anemia. When they cross clamp the aorta his afterload is going to go up and when they release it it is going way down and he will be empty.

Either way, TEE isn't going to make a difference in outcome.

Honestly, I would be willing to do this case with a couple of PIVs, a BP cuff, and a couple of fingers on the radial pulse.

I would prefer an A-line for post-op management and to free up my hand from palpation during the case, but I wouldn't waste a lot of time getting it before they open the belly and get definitive control.

If he was not a Jehovah's Witness, an a-line would be more helpful (for HCT). I would waste a fair amount of time trying to get it in. I still don't see the TEE being helpful.

But then again, I am still pretty junior at all of this.

- pod

 

I pretty much agree with what you are saying. I have done cases like this before without central access. An art line is a different matter for me though, I would try my darndest to get one in although other tasks would take priority. Having a finger on the pulse sounds nice but every one of these cases I have ever been in on was a whirlwind of activity and feeling the pulse more than every now and then is unrealistic IMHO.