Aortic dissection, repair
Clinical Procedure
 
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Assess and document neurological deficits related to the dissection of ascending aorta (stroke or decreased conciousness related to dissection involving the carotid arteries) or descending aorta (lower limb paralysis related to dissection of anterior spinal artery). refl.in/hz

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Provide analgesia. Controlling pain will help control blood pressure and heart rate, reducing shear forces at the dissection. refl.in/hz

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Insert at least one large bore intravenous cannula prior to induction. For type A dissection, try to avoid placing lines in left arm & left IJ where possible.

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MAC line or Swan sheath for volume resuscitation

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If the patient is exsanguinating, don't persist with difficult peripheral arterial lines. Ask the surgeon to place a femoral arterial line in side their happy with following induction

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Antibiotics as per surgeons

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Antifibrinolytics will likely be used to minimise blood loss. Tranexamic acid or Aminocaproic acid.

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"High dose of TXA seems to control fibrinolytic activity, thereby reducing blood loss and requirements, which may contribute to lower morbidity and mortality in operations for acute aortic dissection." refl.in/kx
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If a double lumen tube is used it should be exchanged to a single lumen tube at the end of the case prior to transfer to ICU to allow for airway toiletting.

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May be midline sternotomy or a thoracotomy with one lung ventilation. Ask surgeon.

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Consider the presence of pericardial tamponade and whether pericardiocentesis may be indicated in the hemodynamically instable patient before or after induction.

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Deep hypothermic circulatory arrest may be performed for neuroprotection

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After 45min, risk of long term neurological injury increases markedly
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If the dissection is complicated by pericardial tamponade, releasing the tamponade will likely result in rebound hypertension. Be prepared for this and decide what agents will be used to reduce the pressure to avoid exacerbation of the dissection.

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Dec 29, 2011
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Maintain low normal systolic blood pressure to reduce shear force and low normal heart rate to reduce shear frequency

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Aug 30, 2011
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Monitor renal function and urine output. Oligo/anuria may indicate dissection of the descending aorta and may be contributed to by the use of nephrotoxic contrast dye. refl.in/hz

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Ensure crossmatch blood is available

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Notify ICU and book bed

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May 18, 2011
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Good summary of issues here refl.in/jt

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Surgical approach to ascending aorta and aortic arch repairs will be a midline sternotomy and cardiac bypass with cannulas in femoral artery or right axillary artery. If repairing the ascending aorta an aortic cannula distal to the lesion may be able to be placed. Descending aorta repair will generally be via a thoracotomy and require only aortic cross clamping. refl.in/i0

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Tear of the aorta, usually originating from disruption of the intima, followed by progressive separation of the media under pressure. Associate with high mortality, particularly if ascending aorta is involved. The aim is to facilitate surgery as quickly as possible when indicated, and minimise shear forces by maintaining low normal pulse pressure and heart rate. refl.in/jx

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