Chapter 38

Question 1

What are symptoms of thoracic aorta aneurysms?

Answer 1

Most common asymptomatic; May have deep diffuse chest pain that can extend into the interscapular area

Question 2

What are symptoms of ascending aorta/aortic arch aneurysms?

Answer 2

Angina (decrease blood flow), hoarseness (compression of laryneal nerve), dysphagia (pressure on the esophagus), JVD, facial/arm edema

Question 3

AAA symptoms

Answer 3

Most Common Asymptomatic, usually found on unrelated routine exams or unrelated diagnostic testing, pulsatible massin the preiumbilical (slightly left), Bruits (difficult to hear in obese), Mimics pain associated with ab or back pain (nerve compression), Epigastric discomfort (bowel compression), may spontaneously embolized plaque and will cause blue toe syndrome (patchy mottling toes c pulse)

Question 4

Aortic Aneurysm Complications

Answer 4

Most serious comp is rupture. Rupture in retroperitoneal space bleeding may be tamponaded by surrounding organs preventing exsanguination and death (MB severe back pain, flank ecchymosis) Rupture in thoracic or ab cavity will cause massive hemorrhagic and death; Pt will experience shock (tachy, low bp, pale, clammy, low urine output, altered loc, ab tenderness)

Question 5

Aneurysm Diagnostics

Answer 5

Chest/Abdominal X-rays, ECG r/o MI, Echocardiogram (aorta valve function), Ultrasound (screening, monitor size), CT scan (most accurate), MRI, Angiography (anatomical mapping of aortic system; abs and below)

Question 6

Collaborative Treatment: Surgery considerations

Answer 6

Initiated when size >5.5cm in men and >5.0 cm in women; surgery intervention may occur soon in younger low risk pts, or if it grows more than 1cm per year, if it becomes symptomatic, or if the risk of rupture is high
Existing Carotid and or coronary artery obstructions must be clear before surgery. For ruptures emergency surgery is done. Elective: pt must be hydrated (coagulation, hct, or f/e must be corrected preop)

Question 7

Collaborative Treatment: conservative

Answer 7

initiated for small aneurysms (less than 5cm); Factor mods: lower BP, annual monitoring for size (US, CT, MI)

Question 8

Etiologies: Arterial Aneurysms

Answer 8

Congential, Mechanical (hemodynamic), Traumatic (blunt injury), Inflammatory (noninfectious: KS, Lupus) Infectious, Pregnancy, anastomotic/postgraft aneurysm

Question 9

Thoracic aortic aneurysm

Answer 9

85% of all cases caused by atherosclerosis; ages:40-70; Most common site for dissecting aneurysms; 1/3 die from rupture

Question 10

AAA risk factors

Answer 10

Higher in men, caucasians, and elderly; most are below the kidneys ; only 40% experience any symptoms

Question 11

Aneurysms consideration before surgery

Answer 11

Electrolytes balance, systolic bp 100-120, controlled BP with meds or sodium nitroprusside to lower bp

Question 12

Stent endovascular repair surgery complications

Answer 12

migration, endoleak (seeping blood into old aneurysm), rupture, aortic dissection, bleeding, renal artery occlusion (migration comp) graft thrombosis, incisional site hematoma, incisional infection; Will need routine exams and CT scans for the rest of your life

Question 13

EVAR

Answer 13

Only used for AAA; reduces hospital stay, anesthesia, limits blood loss, decreased morbidity and mortality risk, faster physical activity, reduced costs

Question 14

Aneurysm Preop interventions

Answer 14

Bowel prep, skin cleansed with antimicrobial day before, IV ABx immediately before incision is made, Beta-blockers (preop), Inform pt that they will be in ICU for 24-48 postop

Question 15

Aneurysm Postop interventions

Answer 15

ICU 24-48 post op; Endotrachea tube for ventilation, arterial line, central venous pressure CVP or pulmonary artery PA catheter, peripheral IV lines, foley, possibly NG tube, ECG, pulse, O2 sat, chest tubes if thorax is opened during surgery; Pain meds via epidural catheter or PCA

Question 16

Graft Patency (aneurysm post op interventions)

Answer 16

Adequate BP necessary, prolonged hypotension may result in graft thrombosis; Admin of IV fluids and blood components is important for blood flow; CVP/PA readings and urine output are monitored HOURLY to assess hydration and perfusion immediately post op; Severe HTN may cause leakage of blood or rupture at suture line; Give IV diuretics or IV antiHTNs as indicated

Question 17

Cardiovascular Status (aneurysm post op interventions)

Answer 17

cardiac dysrhythmias may occur due to F/E imbalances(iv fluids), hypoxia (O2) hypothermia, or myocardial ischemia; Interventions: 1. montior ECG 2. F/E and ABGs monitoring 3. GIVE O2 4. IV anti-dysrhythmic and antiHTNs 5. Electrolytes PRN 6. Adequate pain control &. resume cardiac medications

Question 18

Infection (aneurysm post op interventions)

Answer 18

Infection is rare but serious comp; interventions: give board-spectrum ABX, assess temp and report elevated ASAP, Monitor WBCs, ensure adequate nutrition, assess the surgical incision for signs of infection, All lines and catheters require strict aseptic technique, Meticulous perineal care for pt with foley, surgical site must be clean and dry

Question 19

GI status (aneurysm post op interventions)

Answer 19

paralytic ileus (rarely last more than 4 days) may develop in open AAA sx, if NG present record amt and character of output, if NPO provide oral care and ice chips, Assess bowel sounds, Passing flatus signals return of bowel function*, Encourage ambulation (promotes bowel return) Rare cases: bowel temporary ischemia or infarction may result, s/s include absent bowel sounds, fever, ab distention, diarrhea, and bloody stools; If bowel infarction occurs immediate reoperation is needed to restore blood flow with likely resection of infarcted bowel

Question 20

Neurological status (aneurysm postop interventions)

Answer 20

ASCENDING AORTA/AORTIC ARCH involvement monitor upper signs assessing loc, pupil size/response to light, facial symmetry, tongue deviation, speech, upper extremity movement, and quality of hand grasps. DESCENDING AORTA involvement will require assessment of lower extremities
Record all assessments and report changes from baseline

Question 21

Peripheral Perfusion Status (aneurysm postop interventions)

Answer 21

location of aneurysm directs area of interest; check all peripheral pulses hourly for several hours and then routinely; Ascending aorta involvement: assess carotid, radial, and temporal artery pulses. Descending aorta: assess femoral, popliteal, posterior tibial and dorsalis pedis pulses; When assessing pulses mark locations with marker so that other may locate, Doppler might be needed to assess peripheral pulses; Check temp, color, capillary refill, and sensation/movement of extremities; Lower extremity pulses may be absent for a short time after surgery due to vasospasm and hypothermia; A decreased or absent pulse with a cool, pale, mottled or painful extremity may indicate embolization or graft occlusion REPORT immediately; always compare preop baseline with decreased pulses first

Question 22

Renal Perfusion Status (aneurysm postop interventions)

Answer 22

postop pt has foley; Record hourly urine outputs, and record daily weights until pt resumes regular diet; CVP/PA pressures reveal info about hydration; Evaluate BUN and crt levels DAILY for signs of renal failure; Irreversiable renal failure may occur after aortic surgery esp. in high risk pts (dm)

Question 23

Why does renal failure occur with aortic surgery?

Answer 23

Caused by decreased renal perfusion from embolization of aortic thrombus/plaque to one or both of the renal arteries; This causes ischemia. Hypotension, dehydration, prolonged aortic clamping during surgery, or blood loss can lead to decreased renal profusion

Question 24

Post Op teaching for aortic surgery

Answer 24

Gradually increase activities after returning home; fatigue, poor appetite, and irregular bowel habits are common; Pt should avoid heavy lifting for 6 weeks after surgery; Any redness, swelling, increase pain, and drainage from incision, fever over 100F should be reported; Teach to look for changes in color, warmth of extremities, teach how to palpate peripheral pulses and to assess changes in their qualitiy; Sexual dysfunction in male patients is common after aortic surgery. preop document sexual baseline and refer to urologist if ED occurs