Care of the Post Operative Vascular Patient.ppt

Care of post op vascular patient

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

2. Open Abdominal Procedures
Used to Treat the Following:
•AAA’s (Abdominal Aortic Aneurysms)
•TAA’s (Thoracic Aortic Aneurysms)
•TAAA’s (ThorocoabdominalAortic Aneurysms
•Renal Artery Aneurysms
•Renal Artery Stenosis or Renovascular Hypertension
•AortoilliacOcclusion
•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 500-4000cc
•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 CT’s are
obtained at one month, six month, and every year intervals

17. EVAR

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 50-250 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 AAA’s go straight to non
monitored regular bed
•Endovascular TAA’s 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