Reema Ayyash, Nallavenkat Senthilvel, Joanne Knight, Andrew D Kane
{"title":"The perioperative management of frailty in patients presenting for vascular surgery","authors":"Reema Ayyash, Nallavenkat Senthilvel, Joanne Knight, Andrew D Kane","doi":"10.1016/j.mpaic.2024.11.004","DOIUrl":"10.1016/j.mpaic.2024.11.004","url":null,"abstract":"<div><div>The volume of patients who are older and living with frailty presenting for surgery is increasing. Frailty is a multifactorial clinical syndrome associated with decreased metabolic and physiological reserve across multiple organ systems. Frailty increases vulnerability to morbidity, loss of independence, and death in the perioperative period. Data suggest that frailty is prevalent within the vascular surgical population, itself a high-risk group. As a result, identifying patients living with frailty presenting for vascular surgery is of utmost importance. In this article, we discuss what is currently known about the burden of frailty in the vascular surgical population, how to identify those living with frailty preoperatively, the optimization of frailty, and their intra- and postoperative care.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 2","pages":"Pages 112-117"},"PeriodicalIF":0.2,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143163295","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Anaesthesia for endovascular aneurysm repair","authors":"Simon Hatton, Sian Jones","doi":"10.1016/j.mpaic.2024.11.002","DOIUrl":"10.1016/j.mpaic.2024.11.002","url":null,"abstract":"<div><div>Surgical repair of abdominal aortic aneurysms (AAA) can be done via an open or endovascular approach; surgical and patient factors determine which is most appropriate. Endovascular aneurysm repair (EVAR) is usually done in specialist centres with a multidisciplinary team involving surgeons, interventional radiologists and anaesthetists. Benefits of this approach include reduced physiological insult, shorter hospital stays and more favourable early mortality but it also requires lifelong follow-up, and mortality in the mid to long term is no better than open repair (OR). As a result, there was initial hesitancy by the UK National Institute for Health and Care Excellence to recommend EVAR in elective AAA repair but this was revised and can now be considered where open repair is contraindicated. Indeed, the majority of elective AAA repair is done endovascularly. Patients undergoing EVAR are usually more comorbid and frailer than OR patients and so comprehensive preoperative assessment and optimization is paramount. The often-remote location of, and associated radiation exposure in hybrid theatres can present additional challenges to the anaesthetist. General, regional or local anaesthesia can be employed, each with associated benefits and disadvantages. Intraoperative management can vary depending on patient, anaesthetic and surgical factors. Specific considerations include providing a balance between the potential for significant blood loss whilst also requiring a level of anticoagulation, the physiological changes around stent deployment and facilitating optimal imaging. Postoperatively complications are usually minimal but patients require lifelong follow-up, making it a more intrusive and expensive option compared to OR.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 2","pages":"Pages 75-81"},"PeriodicalIF":0.2,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143164502","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Postoperative care and analgesia in vascular surgery","authors":"Ahmed Mahfouz, Andrew Martin","doi":"10.1016/j.mpaic.2024.11.010","DOIUrl":"10.1016/j.mpaic.2024.11.010","url":null,"abstract":"<div><div>Patients undergoing major vascular surgery are at high risk for myocardial infarction, renal failure, respiratory complications and death. Invasive procedures confer greater risk of complication, with patients undergoing open aortic surgery being at highest risk. Endovascular procedures are less invasive, yet not devoid of potentially serious complications. Reduction of myocardial oxygen demand is key, as is stabilizing cardiovascular parameters, maintaining normothermia, adequate volume resuscitation and effective analgesia. Continuation of preoperative risk-reduction strategies including aspirin, β-blockers and statin therapies are critical, and should be continued in the postoperative period. Additionally, maintaining a high index of suspicion for procedure-specific complications is essential to reduce morbidity and mortality in these patients.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 2","pages":"Pages 90-94"},"PeriodicalIF":0.2,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143163299","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Anaesthesia for vascular surgery on the extremities","authors":"Max Clayton-Smith","doi":"10.1016/j.mpaic.2024.11.007","DOIUrl":"10.1016/j.mpaic.2024.11.007","url":null,"abstract":"<div><div>There are multiple types of procedure for vascular disease on the extremities, the majority of which are for the treatment of peripheral arterial disease (PAD). PAD is a common condition affecting 20% of people over the age of 60. Interventional treatment can be vascular, endovascular or combined (‘hybrid’) procedures by vascular surgeons and interventional radiologists.</div><div>PAD has risk factors in common with other atherosclerotic diseases which are often present, even if the patient is asymptomatic. Significant smoking histories are also common. Consequently, patients with PAD are a high-risk anaesthetic cohort. Comprehensive pre-operative assessment and investigation of the cardio-respiratory systems are essential to guide peri-operative planning. Multiple risk assessment tools are available to facilitate peri-operative decision making and risk-benefit discussions with patients.</div><div>The aim of intra-operative management is cardiovascular stability with proactive anticipation of events including haemorrhage and clamp release. Post-operatively regional anaesthesia is strongly advised particularly for patients undergoing amputation. Post-operative cardiac investigations may also be indicated.</div><div>Thoracic outlet syndrome and AV fistula formations are two specific clinical scenarios also covered in this topic.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 2","pages":"Pages 82-89"},"PeriodicalIF":0.2,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143164503","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Anaesthesia for carotid surgery","authors":"Ryan Barter, Helen Alexander","doi":"10.1016/j.mpaic.2024.11.006","DOIUrl":"10.1016/j.mpaic.2024.11.006","url":null,"abstract":"<div><div>Stroke is a leading cause of morbidity and mortality and may be preceded by a transient ischaemic attack (TIA). 20% will have a carotid stenosis caused by atheromatous plaque which can be removed by carotid endarterectomy, reducing the risk of further stroke.</div><div>Risk of stroke is highest in the immediate period following TIA and surgery is recommended within 7 days. The benefits of surgery are highest in those with more than 70% stenosis. Preoperative optimization is limited by the urgency of surgery, but assessment focuses on associated cardiac and respiratory comorbidities including blood pressure control.</div><div>Carotid endarterectomy can be performed under general or regional anaesthesia (with superficial or intermediate cervical plexus blocks) and while large trials have shown no significant difference in outcomes, there are advantages and disadvantages to each. Intraoperative blood pressure control and care with the effects of positioning is required. Smooth emergence with early neurological assessment is the aim with general anaesthesia. The main risk of surgery is postoperative stroke but there is no high-quality evidence for intraoperative shunting or cerebral monitoring in reducing this.</div><div>Other postoperative complications include cardiac ischaemia, hypertension including cerebral hyperperfusion syndrome and airway compromise due to oedema/haematoma.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 2","pages":"Pages 108-111"},"PeriodicalIF":0.2,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143163298","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Anaesthesia for open abdominal aortic surgery","authors":"Alastair Duncan, Adam Conrad Pichel","doi":"10.1016/j.mpaic.2024.11.009","DOIUrl":"10.1016/j.mpaic.2024.11.009","url":null,"abstract":"<div><div>The prevalence of abdominal aortic aneurysm (AAA) has declined in recent years and according to the annual National Vascular Registry reports (2019–23) the number of patients undergoing aneurysm repair has been steadily decreasing over the last 5 years. The UK has worked tirelessly to reduce its operative mortality rates for elective open AAA repair with the introduction of a quality improvement pro-gramme. Reducing death from ruptured aortic aneurysm has been the focus of the national screening programme. The short-term benefits of endovascular aneurysm repair (EVAR) when compared to open repair are well described, however, the long-term survival benefits, freedom form re-intervention and cost effectiveness of EVAR have been demonstrated to be dominated by open surgery. That is that people with intact AAA should be offered open surgery if medically suitable. The choice of technique for emergency AAA repair is less contentious, with the more traditional approach of open repair being rapidly overtaken by endovascular options in those who are anatomically suitable for EVAR. Technical analysis by the National Institute for Health and Care Excellence has consistently reported favourable outcomes with EVAR in the emergency setting and that it is a cost-effective treatment. In this article we provide an overview of the evidence supporting the different treatment options, outline current approaches to risk stratification, describe the key physiological changes that occur during open repair and describe an overview of the approach to perioperative management.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 2","pages":"Pages 95-101"},"PeriodicalIF":0.2,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143163300","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Risk modification and preoperative optimization of vascular patients","authors":"Ben A Goodman, Adam Pichel, Gerard R Danjoux","doi":"10.1016/j.mpaic.2024.11.011","DOIUrl":"10.1016/j.mpaic.2024.11.011","url":null,"abstract":"<div><div>Major vascular surgery is associated with a high risk of morbidity and mortality. Targeted optimization of organ systems most likely to suffer morbidity should be made prior to elective surgery. Risk modification can reduce both perioperative and long-term complications. This article summarizes currently accepted best practice for risk modification and preoperative optimization prior to vascular surgery.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 2","pages":"Pages 71-74"},"PeriodicalIF":0.2,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143163355","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Anaesthesia for ruptured aortic aneurysm","authors":"Jonathan Brown, Shilpa Munirama","doi":"10.1016/j.mpaic.2024.11.008","DOIUrl":"10.1016/j.mpaic.2024.11.008","url":null,"abstract":"<div><div>The incidence of ruptured abdominal aortic aneurysm (rAAA) has been reduced by a national screening programme targeting early identification and treatment of aneurysms. Despite these efforts, rAAA remains a common anaesthetic and surgical emergency responsible for over 5000 deaths per year in the UK. rAAA leads to complex multiorgan critical illness which requires immediate multidisciplinary collaboration and intervention. Anaesthetists play a key role in resuscitation, coordination of care and managing major haemorrhage and multi-organ sequelae of a ruptured aorta. In this article, we describe an overview of the risk factors, current guidelines, service organization, and treatment for rAAA; with focus on the perioperative anaesthetic considerations for open aneurysm repair and endovascular aneurysm repair.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 2","pages":"Pages 102-107"},"PeriodicalIF":0.2,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143163359","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Applied cardiovascular physiology","authors":"Carla Gould, Jon Hopper","doi":"10.1016/j.mpaic.2024.11.005","DOIUrl":"10.1016/j.mpaic.2024.11.005","url":null,"abstract":"<div><div>Maintaining an equilibrium between oxygen supply and demand is a principal function of the cardiovascular system. In times of altered metabolic demand, mechanisms exist to maintain the balance between supply and demand. Exercise, haemorrhage and pregnancy all lead to changes in oxygen demand and subsequently modification of cardiac output. During isotonic exercise, metabolic demands of muscle are greatly increased. Sympathetic stimulation and inhibition of the parasympathetic system lead to increases in heart rate and venous return, increasing cardiac output. This allows a proportional increase in blood flow to the exercising muscle. Cardiac output increases throughout pregnancy. In the first and second trimesters this rise is mainly due to an increase in stroke volume; however, during the later stages of pregnancy stroke volume reaches a plateau and further increase in cardiac output is mediated by a rising heart rate. In contrast, during haemorrhage, decreased venous return leads to a reduction in cardiac output, with a baroreceptor response due to the drop in arterial blood pressure. The tachycardia and vasoconstriction which follows are compensatory mechanisms in an attempt to preserve blood pressure. The Valsalva manoeuvre illustrates several aspects of reflex control of the cardiovascular system and allows non-invasive assessment and quantification of control mechanisms. Changes in stroke volume during the respiratory cycle can be used to predict fluid responsiveness and can be measured as pulse pressure variation or stroke volume variation.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 2","pages":"Pages 118-121"},"PeriodicalIF":0.2,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143163296","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Self-assessment","authors":"Vijayanand Nadella","doi":"10.1016/j.mpaic.2024.12.007","DOIUrl":"10.1016/j.mpaic.2024.12.007","url":null,"abstract":"","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"26 2","pages":"Pages 127-128"},"PeriodicalIF":0.2,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143163297","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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