Core Topics in Vascular Anaesthesia

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1 Core Topics in Vascular Anaesthesia

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3 Core Topics in Vascular Anaesthesia Edited by Edinburgh Alastair F. Nimmo Edinburgh

4 CAMBRIDGE UNIVERSITY PRESS Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo, Delhi, Mexico City Cambridge University Press The Edinburgh Building, Cambridge CB2 8RU, UK Published in the United States of America by Cambridge University Press, New York Information on this title: / Cambridge University Press 2012 This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published 2012 Printed in the United Kingdom at the University Press, Cambridge A catalogue record for this publication is available from the British Library Library of Congress Cataloging-in-Publication Data Core topics in vascular anaesthesia / [edited by], Alastair F. Nimmo. p. ; cm. Includes bibliographical references and index. ISBN (Hardback) I. Moores, Carl. II. Nimmo, Alastair F. [DNLM: 1. Anesthesia. 2. Vascular Surgical Procedures. WG 170] dc23 ISBN Hardback Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Every effort has been made in preparing this book to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use.

5 Contents List of contributors Preface vii vi 1 Arterial disease and its management 1 Rod T. A. Chalmers 2 Preoperative risk assessment of vascular surgery patients 10 John Carlisle and Michael Swart 3 Co-existing disease in vascular surgery patients 22 John Carlisle 4 Reducing perioperative cardiac risk 32 Craig Beattie and Bruce Biccard 5 Anaesthesia in the vascular surgery patient 48 6 Monitoring in the vascular surgery patient 52 Suzy O Neill and Chris P. Snowden 7 Intravenous fluid therapy 62 Michael F. M. James and Ivan A. Joubert 8 Haemostasis and thrombosis 71 Gary A. Morrison and Alastair F. Nimmo 9 Transfusion and blood conservation 92 Alastair F. Nimmo and Danny McGee 10 Anaesthesia for elective abdominal aortic aneurysm surgery 101 Richard Telford 11 Anaesthesia for thoracoabdominal aortic aneurysm surgery 108 and Alastair F. Nimmo 12 Anaesthesia for endovascular aortic repair surgery 119 Maged Argalious 13 Anaesthesia for emergency abdominal aortic surgery 137 Alastair F. Nimmo 14 Anaesthesia for aorto-iliac occlusive disease and lower limb revascularisation procedures 146 Alastair J. Thomson 15 Anaesthesia for lower limb amputation and the management of post-amputation pain 161 Charles Morton and John A. Wilson 16 Anaesthesia for carotid artery disease 170 Mark D. Stoneham 17 Anaesthesia for vascular surgery to the upper limb Surgery for vascular access in renal dialysis 188 Index 194 The colour plates are situated between pages 120 and 121. v

6 Contributors Maged Argalious Associate Professor of Anesthesiology, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA Craig Beattie Bruce Biccard Department of Anaesthetics, Nelson R. Mandela School of Medicine, University of Kwazulu Natal, Republic of South Africa John Carlisle Consultant Anaesthetist, Torbay Hospital, Torquay, UK Rod T. A. Chalmers Consultant Vascular Surgeon, Royal Infirmary of Michael F. M. James Professor of Anaesthesia, University of Cape Town and Groote Schuur Hospital, Western Cape, Republic of South Africa Ivan A. Joubert Head of Clinical Unit (Critical Care, Department of Anaesthesia), University of Cape Town and Groote Schuur Hospital, Western Cape, Republic of South Africa Danny McGee Specialist Practitioner in Blood Transfusion, Better Blood Transfusion, Scottish National Blood Transfusion Service, Edinburgh, UK Gary A. Morrison Charles Morton Alastair F. Nimmo Suzy O Neill Consultant Anaesthetist, Freeman Hospital, Newcastle upon Tyne, UK Chris P. Snowden Consultant Anaesthetist, Freeman Hospital. Newcastle upon Tyne, UK Mark D. Stoneham Consultant Anaesthetist, Nuffield Department of Anaesthesia, Oxford, UK Michael Swart Consultant Anaesthetist, Torbay Hospital, Torquay, UK Richard Telford Consultant Anaesthetist, Royal Devon and Exeter Hospital, Exeter, UK Alastair J. Thomson John A. Wilson vi

7 Preface Vascular surgery and anaesthesia have undergone great changes during the past decade so that this book is very different from previous books describing the anaesthetic and perioperative management of vascular surgical patients. Endovascular repair has been widely adopted for the elective repair of abdominal aortic aneurysms and is increasingly being used in the treatment of ruptured aneurysms. Advanced fenestrated and branched stent grafts have been introduced for the treatment of suprarenal and thoracoabdominal aneurysms, and hybrid repair the combination of endovascular and open surgery now offers another alternative to the treatment of complex aneurysms. However, all of these procedures are accompanied by their own risks for the patient and challenges for the surgeon and anaesthetist. The number of elderly patients with comorbidities presenting for vascular surgery and their expectations of what medical care can provide have increased and many patients continue to require open surgery. This book provides extensive coverage of the current perioperative management of both endovascular and open vascular surgical procedures including aneurysm surgery, carotid surgery and revascularisation and amputation for limb ischaemia. Patient assessment before surgery, and monitoring during surgery, have advanced greatly in recent years. Cardiopulmonary exercise testing (CPET) has become widely used, often as part of anaesthetist-led pre-assessment clinics which aim to help the surgeon and patient decide whether the benefits of intervention outweigh the risks. The chapter on preoperative risk assessment gives a clear description of the role of CPET in patients being considered for surgery. Advances in intraoperative monitoring that are discussed include the use of transoesophageal echocardiography and minimally invasive cardiac output monitoring. Our understanding of normal haemostasis and how it is disturbed during surgery has also advanced greatly, while new anticoagulant drugs have been introduced and the risks of blood transfusion have become more widely appreciated. The causes, diagnosis and treatment of coagulation abnormalities in vascular surgery patients are described including the value of point-of-care testing of haemostasis. Modern transfusion practice and blood conservation are discussed as is the controversial area of intravenous fluid therapy during surgery. Much has been published in recent years on reducing the risk of perioperative cardiac complications and on the benefits and risks of drug therapy including betablockers, coronary artery stents and coronary artery bypass grafts before vascular surgery. However, this also remains an area of controversy. The chapter on reducing perioperative cardiac risk provides a clear review of the literature and recommendations for practice. The contributing authors are acknowledged experts in their fields and we would like to thank them for the time and effort that they have put into producing contributions that are not only informative but also interesting and stimulating. And, finally, we would like to thank our publishers for their support and patience. vii

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