Nursing management pre-post TEVAR/EVAR · - Assessment and Building a plan discharge ... Clinical risk and nursing management ... -Paresthesia or paresis

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Nursing management pre-post TEVAR/EVAR

พว.ปราณ ทองใส พยาบาลช านาญการพเศษ โรงพยาบาลศรราช

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http://stepjourney.wordpress.com/2010/04/06/abdominal-aorta-anastomoses/

Aortic Anatomy

Aorta disease

http://images.google.co.th/images?gbv=2&hl=th&sa=1&q=thoracic+aortic

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Acute aortic diseases

• Acute aortic dissection (AAD)

• Intramural hematoma (IMH)

• Penetrating aortic ulcer (PAU)

• Ruptured TAA

• Traumatic aortic injury

1. Nonspecific medial degeneration การลดลงของ elastin ในชน media และลดลงของ collagen ในชน adventitia

2. Aortic dissection เปนภาวะฉกขาดของผนงชน intima ลกถงชน media ท าใหผนงชน media แยกตวออกจากกนและเซาะไปตามความยาวของหลอดเลอดแดงใหญ aorta ท าใหหลอด เลอดแยกออกเปน 2 ชอง

http://medical-dictionary.thefreedictionary.com/false+aneurysm

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Pathogenesis and Risk factors

3. Genetic disorders Marfan syndrome, Ehlers - Danlos syndrome ,Familial aortic aneurysms Congenital bicuspid aortic valve

4. Infection 5. Aortitis การอกเสบอาจมสาเหตจาก systemic

autoimmune disorders เชน Takayasu’s arteritis, giant cell arteritis และ rheumatoid aortitis

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Pathogenesis and Risk factors

การรกษา • การผาตดแบบเปด (Open repair หรอ Conventional

surgery)

• การผาตดสอดใสหลอดเลอดเทยมชนดขดลวดหมกราฟตผานทางหลอดเลอดแดง (Thoracic Endovascular Aortic Aneurysm Repair : TEVAR/EVAR)

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Aortic diseases

คอการใสหลอดเลอดเทยมชนดขดลวดหมกราฟต (stent graft) ผานทาง femoral arteryหรอ iliac artery เพอน า stent graft ไปวางแทนทหลอดเลอดโปงพอง เพอใหเลอดไหลผานหลอดเลอดเทยมโดยไมเขาไปใน aneurysm sac

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TEVAR/EVAR)

• Thoracic aortic aneurysm,

• Abdominal aortic aneurysm

• Traumatic aortic transection,

• Aortic dissection,

• Penetrating atherosclerotic ulcer

• Ruptured thoracic aneurysm

• Mycotic aneurysm

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TEVAR/EVAR)

1. Minimally invasive surgery

2.Reduce major morbidity

3. Reduce blood loss/transfusion

4.Less time than open surgery

5. Reduce hospitalization stay

6. Quicker return to normal life

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Advantages of TEVAR/EVAR

http://images.google.co.th/images?gbv=2&hl=th&sa=1&q=thoracic+aortic 7/11/2016

TEVAR/EVAR)







1.Physical Assessment Pain assessment -Ascending aorta : ปวดทหนาอกหรอดานหลงกระดก หนาอก

-Descending aorta : ปวดทหลงหรอหนาอกซกซาย

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Nursing management in preoperative

Pain assessment

Abdominal Aortic Aneurysm : ปวดทอง ราวไปหลง หรอปวดหลง สวน rupture AAA ปวดทองรนแรง ความดนต าและคล าได pulsatile mass ททอง

http://www.foamem.com/2015/03/25/abdominal-aortic-aneurysm-clinicalhighlightsupdates/

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• Ascending aortic aneurysm :กด SVC(หนา แขนบวม) ,sternum และกระดกซโครงและอาจเกด aortic regurgitation

• Aortic arch aneurysm :กดหลอดลม หลอดอาหาร ถาเกด Aorto-esophageal fistula จะอาเจยนเปนเลอดสด

หรอหลอดกดเลอดทไปเลยงสมอง อาจเกด stroke

• Descending aortic aneurysm :ปวดหลง กลนล าบาก เสยงแหบ ไอเปนเลอด phrenic nerve paralysis

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Clinical manifestation กดเบยดอวยวะขางเคยง

http://images.google.co.th/images? hl=th&um=1&q= aortic

ปวดอยางรนแรงมากทนททนใด ลกษณะการปวดเหมอนของมคม ตด เฉอน แทงหรอฉกขาด

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Aortic dissection

http://images.google.co.th/images?%20hl=th&um=1&q=%20aortic



Physical Assessment : pulmonary - Signs and symptoms breathing difficulty,

orthopnea, cyanosis skin color, anemia

Adrenergic stimulation

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Physical Assessment : blood circulation • Vital signs, blood perfusion

• Blood pressure all limb extremities

• Assess peripheral pulse pedal pulse sites (posterior tibial , dosalis pedis)

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Physical Assessment :Neurologic status Stroke : obstruction of innominate artery or left

common carotid artery

Paraplegia : obstruction of intercostal arteries

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Physical Assessment :Emotional status

Stress or anxiety : disease and operation , financial

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Physical Assessment Signs of shock in aortic dissection or rupture :

Syncope ,hypotension ,Shock ,cardiac tamponade

Organ ischemia • Extremity

• Visceral organ

• Spinal cord

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2.Patient history

-Cormobid disease : DM,HTN,CAD,MI,COPD,CKD ,PVD, Aortic valve disease, Marfan’s syndrome, Ehlers-Danlos syndrome, Turner’s syndrome

-Previous surgery :Coronary artery disease, Thoracic surgery

-Medication, and usage of drug and smoking

-Allergy

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Planning and Goals

• Reduce risk of Aneurysm rupture and prevent cardiogenic shock

• ผปวยมความพรอมในการผาตด

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Reduce risk of Aneurysm rupture/ cardiogenic shock - Administer beta blockers and antihypertensive as

prescibed maintain SBP 110-120 mmHg, mean BP 70-80 mmHg

- Pain control (morphine sulphate)

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Reduce risk of Aneurysm rupture/ cardiogenic shock - Monitoring hemodymamic signs and symptoms and

blood perfusion - Prevent straining during deafecation - Maintain a calm environment and reduce psychologic

stress and bedrest or absolute bed rest

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ผปวยมความพรอมในการผาตด

- Infection control

- Information Psychosocial support

- Assessment and Building a plan discharge

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Complication post op TEVAR/EVAR

1.Renal failure

2.distal embolisation

3.endoleak

4. Secondary intervention

5. Conversion to open surgery

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6. Graft migration

7. Strut fracture and graft wear

8. Graft limb occlusion

9. Graft infection

10.Femoral incision morbidity

11.Hip and buttock claudication

Complication post op TEVAR/EVAR

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Endoleak blood can leak through endograft into the old aneurysm sac.

Classification of time period

1. Primary endoleak : endoleak within 30 day post implantation

2. Secondary endoleak :endoleak after 30 day post op

Nursing management post operative TEVAR/EVAR

https://en.wikipedia.org/wiki/File:Aneurysm_endovascular.jpg 7/11/2016

//upload.wikimedia.org/wikipedia/commons/e/e3/Aneurysm_endovascular.jpg

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Clinical risk and nursing management Clinical risk Trigger/signs management

Endoleak Incidence 10-15%

-Chest pain or -Abdominal pain -Hypertension -Hemoptysis (TEVAR)

-Observe signs Chest pain or -Abdominal pain

-BP all extremities -Monitor blood perfusion and distal pulse - Control blood pressure - CTA as protocol

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-Local or generalized tonic clonic. - Convulsion or -seizure

- Monitor Conscious /Neurological signs - Maintain optimum hemodynamic and Oxygenation - Prevent and correct Atria fibrillation -Prevent hyperglycemia -Correct acid – base

Stroke Incidence 2.8%-10% -Wires are often moving across plaque-laden aortic zones and embolization. -TEVAR + carotid bypass

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Paraplegia from SCI Incidence 0%-13% - stent graft covered of critical posterior intercostal artery -Perioperative hypotension - Complicated endovascular stent

- Hypotension -Paresthesia or paresis -CSF pressure >10 mmHg

- Monitor Conscious /Neurological signs for SCI q 1hr -Maintain MAP 80-90 mmHg -Continuous monitoring CSF pressure ( keep 8-12 mmHg.) &record q 1 hr. -If CSF pressure 10 -15 mmHg. Release CSF 5 ml./

time -If CSF pressure > 15 mmHg. Release CSF 10 ml./

time -Don’t Release CSF > 60 ml. in 6 hr. or 300 -400 ml./day

-Head up 30°venous drainage -Optimize iv fluid

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Acute kidney injury incidence about 2% -Contrast induced nephropathy - Coverage renal arteries

- Hypotension - Serum creatinine of at least 0.3 mg/dl or a 50% increase from base line - Urine flow <0.5 ml/kg/hr for more than 6 hr

-Adequate volume Replacement in 12 hr. - maintaining optimum hemodynamic And oxygenation -I/O balance - Record urine output - Follow up kidney function

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Acute Limb ischemia 0%-5% -Femoral artery dissection from cannulated or emboli - kinking of components or poor outflow

- poor peripheral perfusion - distal pulse drop from baseline -Hypotension

- 6 P Assessment Assessment : Pulse, Pain, Pallor, Poikilothermia, Paresthesia, Paralysis -BP lower limb extremities - Keep warm - maintaining optimum hemodynamic and oxygenation

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Clinical risk and nursing management

Clinical risk Trigger/signs management Bleeding -Heparin solution flush via catheter or stent graft - Arterial trauma

-Abnormal coagulation -Intraoperative bleeding

-Assessment Dorsalis pedis pulse ,skin perfusion -Observe bleeding and -hematoma -F/U lab CBC, Coag - Monitor and record v/s

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Ineffective of breathing

- Under GA and early extubation - Hx. Smoking ,COPD

- maintain O2 mask/ cannula to keep O2 sat ≥ 95% -Monitor characteristic -of breathing and respiratory rate - Monitoring O2 sat - follow up ABG and chest CXR

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-Cardiac arrhythmia New ST elevate or Q wave -Hypotension

Monitoring hemodynamic signs and symptoms and sign of cardiac ischemia : chest pain or angina, arrhythmia, ECG change, hypotension , poor blood perfusion and oliguria

Cardiovascular Complications (MI, arrhythmias, HF ) Incidence 2%-5% Previous heart surgery :Coronary artery disease

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Gastrointestinal dysfunction - Stent grafts overlying the visceral arteries - Dislodgment of thrombotic and atheromatous deposits, with microembolization into the superior mesenteric artery or IMA

-NG content coffee ground - Abdominal distention ,nausea, vomiting

-Observe bowel Ilieus - Monitoring ischemia, bowel obstruction and paralytic ilieus - Proton pump prophylaxis - stress management

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Pain Transverse incision right groin

- Discomfort

- HT, HR - Pain score > 3

-Assessment pain score (pain rest and pain move) - Morphine /Fentanyl injection and observe side effect

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-Infection

-Body temp. > 37.5 -Tachycardia - signs inflammation at puncture site

-Antibiotic post -implantation -Observe signs infection -Body temp q 4 hr.

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Rehabilitation and discharge

Ambulation: in first day post op follow program cardiac rehabilitation if not have complication Discharge : D-METHOD -Disease and operation -Medication : Anti Hypertensive drugs - anti-platelet is specially underwent hybrid operation (TEVAR + carotid bypass) : prevent stroke

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Rehabilitation and discharge

- Environment -Treatment -Outpatient refer -Diet low salt to prevent endotension or Aneurysm

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Follow up

*Adjust Anti Hypertensive drugs *CT angiogram program :CTA is recommended prior to discharge. Further follow-ups at,6 month ,12 months then annual yearly

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Thank you for your attention

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Nursing management pre-post TEVAR/EVAR · - Assessment and Building a plan discharge ... Clinical risk and nursing management ... -Paresthesia or paresis