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Nisi F, Carenzo L, Ruggieri N, Reda A, Pascucci MG, Pignataro A, Civilini E, Piccioni F, Giustiniano E. The anesthesiologist's perspective on emergency aortic surgery: Preoperative optimization, intraoperative management, and postoperative surveillance. Semin Vasc Surg 2023; 36:363-379. [PMID: 37330248 DOI: 10.1053/j.semvascsurg.2023.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 04/23/2023] [Accepted: 04/25/2023] [Indexed: 06/19/2023]
Abstract
The management of emergencies related to the aorta requires a multidisciplinary approach involving various health care professionals. Despite technological advancements in treatment methods, the risks and mortality rates associated with surgery remain high. In the emergency department, definitive diagnosis is usually obtained through computed tomography angiography, and management focuses on controlling blood pressure and treating symptoms to prevent further deterioration. Preoperative resuscitation is the main focus, followed by intraoperative management aimed at stabilizing the patient's hemodynamics, controlling bleeding, and protecting vital organs. After the operation, factors such as organ protection, transfusion management, pain control, and overall patient care must be taken into account. Endovascular techniques are becoming more common in surgical treatment, but they also present new challenges in terms of complications and outcomes. It is recommended that patients with suspected ruptured abdominal aortic aneurysms be transferred to facilities with both open and endovascular treatment options and a track record of successful outcomes to ensure the best patient care and long-term results. To achieve optimal patient outcomes, close collaboration and regular case discussions between health care professionals are necessary, as well as participation in educational programs to promote a culture of teamwork and continuous improvement.
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Affiliation(s)
- Fulvio Nisi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Luca Carenzo
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Nadia Ruggieri
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Antonio Reda
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | | | - Arianna Pignataro
- Vascular Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan Italy
| | - Efrem Civilini
- Vascular Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan Italy
| | - Federico Piccioni
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Enrico Giustiniano
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
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Giustiniano E, Nisi F, Palma S, Pisciotta W, Ruggieri N, Barbieri F, Civilini E, Maurizio C. Near-infrared spectroscopy to monitor spinal cord oxygenation in οpen thoraco-abdominal aortic surgery. A case series. HELLENIC JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2022:111-119. [DOI: 10.59037/hjves.v4i4.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
Objectives. We adopted the near-infrared spectroscopy (NIRS) technology to monitor the spinal oxygen supply through the paraspinous muscles oxygenation in agreement with the concept of “collateral network” circulation. We retrospectively investigated our database of subjects who underwent thoraco-abdominal aorta open repair assessing for the reliability of this monitoring to predict spinal cord injury.
Methods. Consecutive patients who underwent elective thoraco-abdominal aorta open repair between March 2019
and September 2021. In addition to standard monitoring, patients received the monitoring of the paraspinous muscles
oxygenation by NIRS.
Results. In one patient a significant drop of the mean arterial pressure (49 mmHg) and the spinal-cord perfusion pressure
(31 mmHg) occurred after the aortic clamping, with a contemporary lowering of the left-side oxygenation of paraspinous muscles (<40%). Both the blood pressure and the spinal cord perfusion pressure were restored within 10 minutes, but the oxygenation remained at an unsafe level (<55%) until the end of the surgery. This same patient experienced a lower-limb paralysis post-operatively. It did not happen in the other 11 cases of the sample.
Conclusions. The main finding of our retrospective analysis indicates reliability of this technology to monitor the spinal
cord oxygenation during open thoraco-abdominal aortic surgery and possibly predict spinal cord injury. Still, several
questions need to be addressed about the suitability of this technology to the anatomic and pathophysiology of the
spinal cord circulation
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Affiliation(s)
- Enrico Giustiniano
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Fulvio Nisi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Sergio Palma
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Walter Pisciotta
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Nadia Ruggieri
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Francesca Barbieri
- Vascular Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
| | - Efrem Civilini
- Vascular Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
| | - Cecconi Maurizio
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
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Marturano F, Nisi F, Giustiniano E, Benedetto F, Piccioni F, Ripani U. Prevention of Spinal Cord Injury during Thoracoabdominal Aortic Aneurysms Repair: What the Anaesthesiologist Should Know. J Pers Med 2022; 12:1629. [PMID: 36294768 PMCID: PMC9605294 DOI: 10.3390/jpm12101629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 11/06/2022] Open
Abstract
Thoraco-abdominal aortic repair is a high-risk surgery for both mortality and morbidity. A major complication is paraplegia-paralysis due to spinal cord injury. Modern thoracic and abdominal aortic aneurysm repair techniques involve multiple strategies to reduce the risk of spinal cord ischemia during and after surgery. These include both surgical and anaesthesiologic approaches to optimize spinal cord perfusion by staging the procedure, guaranteeing perfusion of the distal aorta through various techniques (left atrium-left femoral artery by-pass) by pharmacological and monitoring interventions or by maximizing oxygen delivery and inducing spinal cord hypothermia. Lumbar CSF drainage alone or in combination with other techniques remains one of the most used and effective strategies. This narrative review overviews the current techniques to prevent or avoid spinal cord injury during thoracoabdominal aortic aneurysms repair.
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Affiliation(s)
- Federico Marturano
- Department of Anaesthesia, Analgesia and Intensive Care, Vito Fazzi Hospital, 73100 Lecce, Italy
| | - Fulvio Nisi
- Department of Anaesthesia and Intensive Care Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Enrico Giustiniano
- Department of Anaesthesia and Intensive Care Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Francesco Benedetto
- Department of Anaesthesia and Intensive Care Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy
| | - Federico Piccioni
- Department of Anaesthesia and Intensive Care Unit, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Umberto Ripani
- Division of Clinic Anaesthesia, Department of Emergency Hospital Riuniti, Conca Street 71, 60126 Ancona, Italy
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Harky A, Fok M, Fraser H, Howard C, Rimmer L, Bashir M. Could Cerebrospinal Fluid Biomarkers Offer Better Predictive Value for Spinal Cord Ischaemia Than Current Neuromonitoring Techniques During Thoracoabdominal Aortic Aneurysm Repair - A Systematic Review. Braz J Cardiovasc Surg 2019; 34:464-471. [PMID: 31454201 PMCID: PMC6713370 DOI: 10.21470/1678-9741-2018-0375] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Objective Cerebrospinal fluid (CSF) drainage is a technique that has significantly
reduced the incidence of spinal cord ischaemia (SCI). We present results of
a systematic review to assess the literature on this topic in relation to
thoracoabdominal aortic aneurysm repair (TAAR). Methods Major medical databases were searched to identify papers related to CSF
biomarkers measured during TAAAR. Results Fifteen papers reported measurements of CSF biomarkers with 265 patients in
total. CSF biomarkers measured included S-100ß, neuron-specific
endolase (NSE), lactate, glial fibrillary acidic protein A (GFPa), Tau, heat
shock protein 70 and 27 (HSP70, HSP27), and proinflammatory cytokines.
Lactate and S-100ß were reported the most, but did not correlate with
SCI, which was also the case with NSE and TAU. GFPa showed significant CSF
level rises, both intra and postoperative in patients who suffered SCI and
warrants further investigation, similar results were seen with HSP70, HSP27
and IL-8. Conclusions Although there is significant interest in this topic, there still remains a
significant lack of high-quality studies investigating CSF biomarkers during
TAAR to detect SCI. A large and multicentre study is required to identify
the significant role of each biomarker.
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Affiliation(s)
- Amer Harky
- Liverpool Heart and Chest Hospital Department of Cardiothoracic Surgery Liverpool UK Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Matthew Fok
- Royal Liverpool Hospital Department of Vascular Surgery Liverpool UK Department of Vascular Surgery, Royal Liverpool Hospital, Liverpool, UK
| | - Holly Fraser
- University of Liverpool School of Medicine Liverpool UK School of Medicine, University of Liverpool, Liverpool, UK
| | - Callum Howard
- University of Manchester Faculty of Biology, Medicine and Health Manchester UK Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Lara Rimmer
- University of Liverpool School of Medicine Liverpool UK School of Medicine, University of Liverpool, Liverpool, UK
| | - Mohamad Bashir
- Manchester Royal Infirmary Department of Aortovascular Surgery Manchester UK Department of Aortovascular Surgery, Manchester Royal Infirmary, Manchester, UK
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Lindblom RPF, Shen Q, Axén S, Landegren U, Kamali-Moghaddam M, Thelin S. Protein Profiling in Serum and Cerebrospinal Fluid Following Complex Surgery on the Thoracic Aorta Identifies Biological Markers of Neurologic Injury. J Cardiovasc Transl Res 2018; 11:503-516. [PMID: 30367354 PMCID: PMC6294830 DOI: 10.1007/s12265-018-9835-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 09/10/2018] [Indexed: 12/19/2022]
Abstract
Surgery on the arch or descending aorta is associated with significant risk of neurological complications. As a consequence of intubation and sedation, early neurologic injury may remain unnoticed. Biomarkers to aid in the initial diagnostics could prove of great value as immediate intervention is critical. Twenty-three patients operated in the thoracic aorta with significant risk of perioperative neurological injury were included. Cerebrospinal fluid (CSF) and serum were obtained preoperatively and in the first and second postoperative days and assessed with a panel of 92 neurological-related proteins. Three patients suffered spinal cord injury (SCI), eight delirium, and nine hallucinations. There were markers in both serum and CSF that differed between the affected and non-affected patients (SCI; IL6, GFAP, CSPG4, delirium; TR4, EZH2, hallucinations; NF1). The study identifies markers in serum and CSF that reflect the occurrence of neurologic insults following aortic surgery, which may aid in the care of these patients.
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Affiliation(s)
- Rickard P F Lindblom
- Department of Cardiothoracic Surgery and Anesthesia, Uppsala University Hospital, SE-751 85, Uppsala, Sweden. .,Department of Surgical Sciences, Section of Thoracic Surgery, Uppsala University, Uppsala, Sweden.
| | - Qiujin Shen
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Sofie Axén
- Department of Cardiothoracic Surgery and Anesthesia, Uppsala University Hospital, SE-751 85, Uppsala, Sweden
| | - Ulf Landegren
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Masood Kamali-Moghaddam
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Stefan Thelin
- Department of Cardiothoracic Surgery and Anesthesia, Uppsala University Hospital, SE-751 85, Uppsala, Sweden.,Department of Surgical Sciences, Section of Thoracic Surgery, Uppsala University, Uppsala, Sweden
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A novel microwave sensor to detect specific biomarkers in human cerebrospinal fluid and their relationship to cellular ischemia during thoracoabdominal aortic aneurysm repair. J Med Syst 2015; 39:208. [PMID: 25686914 DOI: 10.1007/s10916-015-0208-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 11/25/2014] [Indexed: 10/24/2022]
Abstract
Thoraco-abdominal aneurysms (TAAA) represents a particularly lethal vascular disease that without surgical repair carries a dismal prognosis. However, there is an inherent risk from surgical repair of spinal cord ischaemia that can result in paraplegia. One method of reducing this risk is cerebrospinal fluid (CSF) drainage. We believe that the CSF contains clinically significant biomarkers that can indicate impending spinal cord ischaemia. This work therefore presents a novel measurement method for proteins, namely albumin, as a precursor to further work in this area. The work uses an interdigitated electrode (IDE) sensor and shows that it is capable of detecting various concentrations of albumin (from 0 to 100 g/L) with a high degree of repeatability at 200 MHz (R(2) = 0.991) and 4 GHz (R(2) = 0.975).
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Panthee N, Ono M. Spinal cord injury following thoracic and thoracoabdominal aortic repairs. Asian Cardiovasc Thorac Ann 2015; 23:235-246. [DOI: 10.1177/0218492314548901] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Objective To discuss the currently available approaches to prevent spinal cord injury during thoracic and thoracoabdominal aortic repairs. Methods We carried out a PubMed search up to 2013 using the Medical Subject Headings: “aortic aneurysm/surgery” and “spinal cord ischemia”; “aortic aneurysm, thoracic/surgery” and “spinal cord ischemia”; “aneurysm/surgery” and “spinal cord ischemia/cerebrospinal fluid”; “aortic aneurysm/surgery” and “paraplegia”. All 190 original articles satisfying our inclusion criteria were analyzed for incidence, predictors, and other pertinent variables related to spinal cord injury, and we compared the results in recent publications with those in earlier reports. Results The mean age of the 38,491 patients was 65.3 ± 4.9 years. The overall incidence of paraplegia and/or paraparesis was 7.1% ± 6.1% (range 0%–32%). The incidence of spinal cord injury before 2000, from 2001 to 2007, and 2008–2013 was 9.0% ± 6.7%, 7.0% ± 6.1%, and 5.9% ± 5.2%, respectively ( p = 0.019). Various predictors of spinal cord injury were identified, extent of disease being the most common. Modification of surgical techniques, use of adjuncts, and better understanding of spinal cord perfusion physiology were attributed to the decrease in postoperative spinal cord injury in recent years. Conclusions Spinal cord injury after thoracic and thoracoabdominal aortic repair poses a real challenge to cardiovascular surgeons. However, with evolving surgical strategies, identification of predictors, and use of various adjuncts over the years, the incidence of spinal cord injury after thoracic/thoracoabdominal aortic repair has declined. Embracing a multimodality approach offers a good insight into combating this grave complication.
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Affiliation(s)
- Nirmal Panthee
- Department of Cardiac Surgery, University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, University of Tokyo, Tokyo, Japan
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Giustiniano E, Ruggieri N. Is intrathecal lactate concentration monitoring helpful for postoperative paraplegia after descending aorta surgery? J Clin Anesth 2014; 26:506-8. [PMID: 25172505 DOI: 10.1016/j.jclinane.2014.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Revised: 03/17/2014] [Accepted: 03/21/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Enrico Giustiniano
- Department of Anesthesia and Intensive Care Unit, Humanitas Research Hospital, Rozzano 20089, Italy.
| | - Nadia Ruggieri
- Department of Anesthesia and Intensive Care Unit, Humanitas Research Hospital, Rozzano 20089, Italy
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Zangrillo A, Buratti L, Carozzo A, Casiraghi G, Landoni G, Lembo R, Pasin L, Marone EM, Melissano G, Chiesa R. Intrathecal lactate as a predictor of early- but not late-onset spinal cord injury in thoracoabdominal aneurysmectomy. J Cardiothorac Vasc Anesth 2014; 28:473-8. [PMID: 24746597 DOI: 10.1053/j.jvca.2014.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the role of intrathecal lactate as an early predictor of spinal cord injury during thoracoabdominal aortic aneurysmectomy. DESIGN Observational study. SETTING University hospital. PARTICIPANTS Forty-four consecutive patients scheduled to undergo thoracoabdominal aortic aneurysmectomy. Two patients had a type-B dissecting aneurysm while the other 42 patients suffered from degenerative aneurysm. INTERVENTIONS None. METHODS During surgery, samples of cerebrospinal fluid and arterial blood were withdrawn simultaneously to evaluate lactate concentration. Samples were collected at 4 fixed times during and after surgery: T1 (beginning of the intervention), T2 (15 minutes after aortic cross-clamping), T3 (just before unclamping), T4 (end of surgery). MEASUREMENTS AND MAIN RESULTS Mean lactate levels in cerebrospinal fluid rose consistently and steadily from the beginning of the intervention until after surgery (T1 = 1.83 mmol/L), T2 = 2.10 mmol/L, T3 = 2.72 mmol/L, T4 = 3.70 mmol/L). Seven patients developed spinal cord injury; two of them had delayed injury occurring 24 hours after the end of surgery; the remaining 5 had early onset. In this group of 5 patients, preoperative cerebrospinal fluid lactate levels were significantly (p = 0.04) higher than those of the other 37 patients preoperatively (2.12 ± 0.35 v 1.79 ± 0.29 mmol/L). CONCLUSIONS Preoperative cerebrospinal lactate concentration is elevated in patients who will develop early-onset spinal cord injury after thoracoabdominal aortic aneurysmectomy. This may allow a better stratification of these patients, suggesting a more aggressive strategy of spinal cord function preservation, such as systematic reimplanting of intercostal arteries, and possibly obtaining a better outcome.
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Affiliation(s)
- Alberto Zangrillo
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Luca Buratti
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Carozzo
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Giuseppina Casiraghi
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy.
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Laura Pasin
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Enrico Maria Marone
- Department of Vascular Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Germano Melissano
- Department of Vascular Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Roberto Chiesa
- Department of Vascular Surgery, San Raffaele Scientific Institute, Milan, Italy
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