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Care of the Vascular Patient Stacey Becker, RN Angela Allen, ACNP.

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Presentation on theme: "Care of the Vascular Patient Stacey Becker, RN Angela Allen, ACNP."— Presentation transcript:

1 Care of the Vascular Patient Stacey Becker, RN Angela Allen, ACNP

2 Open Abdominal Procedures Used to Treat the Following: AAAs (Abdominal Aortic Aneurysms) TAAs (Thoracic Aortic Aneurysms) TAAAs (Thorocoabdominal Aortic Aneurysms Renal Artery Aneurysms Renal Artery Stenosis or Renovascular Hypertension Aortoilliac Occlusion Superior Mesenteric Artery Stenosis Removal of Infected Graft

3 Primary Procedures-Open Open AAA repair Open TAA repair Open TAAA repair Aortobifemoral bypass Renal artery bypass NAIS (Neo-aortoillac system) SMA bypass

4 Aneurysms 1.5 times the diameter of the adjacent non- aneurysmal vessel Usually begin treatment of AAA in a good risk candidate at 5 cm-endovascular and closer to 5.5 cm for open repair Usually begin treatment of TAA in good risk patient around 6.0 cm for endovascular and 6.5 or greater for open repair

5 Aneurysm Classification Infra-renal AAA Juxta-renal AAA Supra-renal AAA

6 Intraoperative-Open All are done under General Anesthesia Average time of operation is 2-6 hours Usual incision is midline for abdominal and thorocoabdominal if also involving thoracic aorta Thoracic procedures have lumbar spinal catheter to provide spinal cord protection Estimated Blood Loss is cc Aggressive blood products and fluids are given

7 Open AAA Repair Transperitoneal Retroperitoneal

8 Aortobifemoral Bypass

9 TAAA Open Repair

10 Postoperative Care-Open All open procedures go to the ICU first Stay in the ICU until extubated and can protect their airway Many require vasoactive drips Huge fluid shifts take place in the immediate post op period with monitoring of such Pain control is an issue Without complications, transfer to the floor POD #1 (uncomplicated AAA or ABF) to POD #5-7 (TAAA)

11 Postoperative Care-Open Vital Signs every 8 hours Neurovascular Checks every 8 hours-this includes all pulses. Note this population has high risk for decreased pulses or limb failure. Contact the team with any changes I and O Record every 8 hours

12 Postoperative Care-Open Out of the Bed Post op Day #2 Ambulate in the Hallway TID Post op Day #3 Physical Therapy Consult- Nursing should walk patient if safe to ambulate PT will make recs regarding home care and placement, many will need inpatient rehab Aggressive Pulmonary Toliet

13 Postoperative Care-Open Clear liquid diet on POD #4 NPO is NPO, no ice chips Advance diet to regular day or evening prior to discharge Patients often will have decreased appetite for 6-8 weeks

14 Postoperative Care- Open Mid abdominal Incision with Staples May have incisions in the groin Vascular Team will take down dressing on POD # 1 and usually leave open to air Clean and dry Staples remain in for 2 weeks post op

15 Open Complications Wound Complications-need to keep clean and dry. Acute Renal Failure-incidence can be as high as 40% of the population Cardiac-All should be on pre op Beta Blockade to be discharged home with same protection Pulmonary-encourage incentive spirometry Spinal cord ischemia Colon ischemia

16 Endovascular Repair of AAA and TAA EVAR techinque was introduced in the 1990s through clinical trials Decreased Operative Risk These repairs are beneficial in that they have decreased LOS and recovery time, are able to treat a higher risk patient and most are back to all normal activities within one month These devices need to be followed long term and CTs are obtained at one month, six month, and every year intervals


18 Thoracic Endovascular Repair

19 Intraoperative-Endovascular Average OR time is 2 hours Procedure is done under MAC anesthetic so patients are awake throughout Estimated Blood Loss is cc Thoracic endografts have lumbar catheters placed for spinal cord protection Most common complication is difficulty with access

20 Endovascular Graft-Incision Site

21 Postoperative Care Endovascular Endovascular AAAs go straight to non monitored regular bed Endovascular TAAs with spinal drain go to the ICU until drain can be pulled Patients arrive on floor awake and usually with minimal pain

22 Postoperative Care Endovascular Vital signs every 4 hours x 2, then q 8 hours-most will run a fever which is post implant syndrome Neurovascular checks every 4 hours x 2, then q 8 hours-this includes all pulses. Let team know of any changes I and O every 8 hours Clear liquids day of surgery and then advance to regular POD #1 Out of Bed day of surgery One dose of Ancef post operatively

23 Postoperative Care-Endovascular LOS- 1 Day-patients should be ready to go home the morning after surgery. 2 Day LOS if have spinal drain Patients resume home meds and beta blocker Follow-up is in one month with CT scan No restrictions on activity except no driving while on pain meds

24 Endovascular Repair of Aneurysms- Complications Wound-small incisions in groin are at place that can harbor infection. Must keep clean and dry. Must frequently change dressing if draining Cardiac-protected by beta blockade pre and postoperatively Lower extremity ischemia Urinary Retention

25 Thoracic Outlet Syndrome 3 Types- Venous, Arterial, Neurogenic 95% is Neurogenic Compression in the Thoracic Outlet largely induced from the scalene muscle relationship to the brachial plexus Goal of operation is to decompress nerves via scalenectomy, lysis of fibrous tissue around nerves, and usually removal of first or cervical rib

26 Thoracic Outlet Syndrome-Post op Low neck incision Frequent use of a JP drain Major post op issue is pain control Some have paravertebral catheter to infuse local anesthetic that are converted to home pump for pain control Respiratory complications could suggest pneumothorax or hemothorax

27 Thoracic Outlet Syndrome-Post op There are no upper extremity restrictions Discharged with script to begin Physical Therapy in 2 weeks Follow-up in 4 weeks

28 Barriers to Discharge Activity Level Urinary Retention Pain control Nausea and Vomiting Initiation of Coumadin Wound Complications

29 Barriers to Discharge Placement of Patient in Inpatient Rehab or SNF Patient or Family Reluctance Awaiting Home Health Care Inadequate Resources Awaiting Final Recs from Consulting Service

30 Questions

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