The nurse is providing postoperative care to a patient who underwent aortic graft surgery

Open repair of AAAs and thoracic aortic aneurysms (TAAs) has a mortality of about 4%, with myocardial infarction (MI) being a frequent cause of death. [14]  Preoperative reduction of cardiac risk by means of cardiac investigations and beta blockade may lower mortality. Autologous transfusion techniques (eg, acute normovolemic hemodilution and intraoperative cell salvage) reduce the need for allogeneic blood and the complications associated with open surgery.

Before the procedure, it is important to obtain a careful history and perform a physical examination and laboratory assessment. These basic evaluations provide the information that allows the treating physician to estimate perioperative risk and life expectancy after the proposed procedure.

Careful consideration should be given to the issue of whether the patient’s current quality of life is sufficient to justify the operative intervention. In the case of elderly persons who may be debilitated or may have mental deterioration, this decision is made in conjunction with the patient and family.

Once the decision in favor of surgical treatment is made, the next step is to identify any comorbid conditions or risk factors that may increase operative risk or decrease the chances of survival. To this end, the patient’s activity level, stamina, and stability of health are evaluated, and a thorough cardiac assessment is performed that is tailored to the patient’s history, symptoms, and results from preliminary screening tests (eg, ECG and stress testing).

Because COPD is an independent predictor of operative mortality, lung function should be assessed by performing room-air arterial blood gas measurement and pulmonary function tests. In patients with abnormal test results, preoperative intervention in the form of bronchodilators and pulmonary toilet often can reduce operative risks and postoperative complications.

Antibiotics (usually a cephalosporin, such as cefazolin, 1 g IV piggyback) are administered to reduce the risk of infection. Arranging for appropriate IV access to accommodate blood loss, arterial pressure monitoring through an arterial line, and Foley catheter placement to monitor urine output are routine preparations for surgery.

For patients at high risk because of cardiac compromise, a Swan-Ganz catheter is placed to assist with cardiac monitoring and volume assessment. Transesophageal echocardiography (TEE) can be useful for monitoring ventricular volume and cardiac wall motion and for helping guide fluid replacement and pressor use.

Preparations are made for blood replacement. The patient should have blood available for transfusion. Intraoperative use of a cell salvage machine and preoperative autologous blood donation have become popular.

The patient’s body temperature should be kept at a normal level during the operative intervention to prevent coagulopathy and maintain normal metabolic function. To prevent hypothermia, a recirculating, warm forced-air blanket should be placed on the patient, and any IV fluids and blood should be warmed before being administered.

The skin is prepared from the nipples to the midthigh. General anesthesia is administered, with or without epidural anesthesia.

The aorta may be approached either transabdominally or through the retroperitoneal space. Juxtarenal and suprarenal aortic aneurysms are approached from the left retroperitoneal space. Self-retaining retractors are used. The bowel is kept warm and, if possible, is not exteriorized. The abdomen is explored for abnormalities (eg, gallstones or associated intestinal or pancreatic malignancy). Depending on the anatomy, the aorta can be reconstructed with a tube graft, an aortic iliac bifurcation graft, or an aortofemoral bypass.

For proximal infrarenal control, the first step is to identify the left renal vein. Occasionally (< 5% of cases), patients may have a retroaortic vein. In this situation, care must be taken in placing the proximal clamp. Division of the left renal vein is usually required for clamping above the renal arteries.

Before aortic cross-clamping, the patient is heparinized (5000 U IV). If significant intraluminal debris, juxtarenal thrombus, or prior peripheral embolization is present, the distal arteries are clamped first, followed by aortic clamping.

With respect to pelvic outflow, the inferior mesenteric artery is sacrificed in most instances. Therefore, to prevent colon ischemia, every attempt must be made to restore perfusion from at least one hypogastric (internal iliac) artery. If the hypogastric arteries are sacrificed (eg, because of associated aneurysms), the inferior mesenteric artery should be reimplanted.

For supraceliac aortic control, the ligaments are first divided to the left lateral section of the liver, which is then retracted. The crura of the diaphragm are separated, and the aorta is bluntly dissected.

Supraceliac control is recommended for inflammatory aneurysms, along with minimal dissection of the duodenum and balloon occlusion of the iliac arteries. In patients with inflammatory aneurysms or large iliac artery aneurysms, the ureters should be identified; occasionally, ureteral stents are recommended in patients with inflammatory aneurysms.

The aorta is reconstructed from within by using a polytetrafluoroethylene (PTFE) or Dacron graft. The aneurysm sac is closed, and the graft is put into the duodenum to prevent erosion. Before restoration of lower-extremity blood flow, both forward flow (aortic) and backflow (iliac) are allowed to remove debris. The graft is also irrigated to flush out debris.

Before closure, the colon is inspected, and the femoral arteries are palpated. Before the patient leaves the operating room, the status of the lower-extremity circulation must be determined. If a clot was dislodged at the time of aortic clamping, it can be removed with a Fogarty embolectomy catheter. Heparin reversal usually is not required.

Fluid shifts are common after aortic surgery. Fluid requirements may be high in the first 12 hours, depending on the amount of blood loss and fluid resuscitation in the operating room. The patient should be monitored in the surgical intensive care unit for hemodynamic stability, bleeding, urine output, and peripheral pulses. Postoperative ECG and chest radiography are indicated. Prophylactic antibiotics (eg, cefazolin 1 g) are administered for 24 hours. The patient is seen in 1-2 weeks for suture or skin staple removal, then yearly thereafter.

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Introduction

Nursing care of the patient following major surgery is a complex task, involving holistic management of patient wellbeing in the light of several challenges to health and homeostatic stability. This essay sets out to discuss the care of one such patient, following surgery to repair an abdominal aortic aneurysm. In order to address the issue and provide the highest possible standards of individualised care, nurses need a considerable knowledge base, gleaned from training, from ongoing updating, from the available evidence, and from their experience as professionals in their field. This essay will also set out to explore how nursing knowledge is applied to practice, always keeping the patient as the focus of care, with reference to the underlying physiology which relates to the patient’s condition.

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Nursing skills are also based on knowledge and experience, both the experience of the nurse themselves and the experience of those who have taught them, who work with them and who collaborate in the provision of care. While this essay focuses on the nurse’s role in relation to the case and the client, it is important to remember that nursing care does not take place within a vacuum, and reference will be made to those with whom the nurse must interact and engage as part of this role.

The care of a patient following surgical abdominal aortic aneurysm repair follows the principles of general postoperative surgical care, along with specific interventions, monitoring and support that are a consequence of the condition and the nature of the surgery. The holistic management of this case must also take into account the psycho-social and emotional factors which may affect the case, given the life-threatening nature of the condition and the potential complications of the surgery.

The Case

David Grainger is a 65 year old man, who is retired and who tries to keep himself fit by playing golf. He had a history of recurrent pain underneath his rib cage for some month, and had been treating himself for indigestion with limited success. His friends became worried about him and his condition when he appeared to be losing weight, and so eventually David plucked up the courage to visit his GP. He was referred to the local hospital for tests, which eventually led to a diagnosis of abominal aortic aneurysm. David was later admitted to the surgical ward for surgery to repair the aneurysm.

On return to the ward David had a blood transfusion running and a wound drain (Redivac) from the abdomen close to the surgical incision site. He had an indwelling Foley catheter with an hourly urine bag, which was changed to free drainage after 12 hours of adequate urine output, and a PCA (patient controlled analgesia) device in situ. He has a mepore dressing to the abdominal wound site.

David has two IVI sites, one in each hand. The blood transfusion was running via the left hand, and normal saline (0.9%) was running in the other, along with the PCA, on a three-way tap. The day following surgery David’s temperature is recorded at 39.6c with an elevated pulse of 90bpm. He repeatedly complains of feeling cold. Discussion with the senior sister and the SHO suggests that David is experiencing a potential pyrexia.

Abdominal Aortic Aneurysm.

Abdominal Aortic Aneurysm (AAA) is a fairly common condition (the 14th leading cause of death in the US (Birkmeyer and Upchurch, 2007). It is a life-threatening condition (Isselbacher et al, 2005). The greatest risk of an AAA is the risk of rupture, which has a significant mortality rate attached to it (Birkmeyer and Upchurch, 2007). It is defined as an abnormal localised arterial dilation or ballooning that is greater than one and half times the artery’s normal circumference, and must involve all three layers of the vessel wall (Irwin, 2007). Abdominal aortic aneurysms are those which are located below the diaphragmatic border, and account for 75% of aortic aneurysms (Irwin, 2007). Men are four to five times more likely to develop the condition, and risk factors include smoking, hypertension and dyslipidemia, cellular changes in the tunica media associated with diseases such as Marfan syndrome, inflammation, and blunt trauma (Irwin, 2007). There is also a family history factor, with increased risk amongst primary relatives of someone with AAA (Irwin, 2007). Another risk factor is atherosceloris, although someone without this condition can develop an aneurysm (Irwin, 2007).

Repair is either through open surgical repair, through a large midline incision (Irwin, 2007). The procedure is major surgery, and the aorta is cross-clamped to allow the insertion of a synthetic graft which is attached to proximally and distally to health aortic tissue (Irwin, 2007). Another procedure is endovascular repair using a percutaneous vascular stent (Irwin, 2007; Beese-Bjustrom, 2004). In this procedure, a woven polyester tube covered by a stent is placed inside the aneurismal section of the abdominal aorta, which keeps normal blood flow away from the aneurysm, greatly reducing the risk of dissection and rupture (Bese-Bjustrom, 2004). In this case David underwent open surgery.

Assessment

Assessment of the patient’s condition is the first stage in nursing care planning and management, forming the basis of nursing decision making (Watson-Miller, 2005). A summary of assessment activities carried out for David can be found in Table 1.

Table 1. Nursing Assessment of David on Day 1 Post-Op.

Assessment during the first 24 hours is usually aimed at establishing physiological equilibrium, managing pain, preventing complications and supporting the patient towards self-care (Watson-Miller, 2005). These are standard post-operative observations, but the care of the person having undergone abdominal aortic aneurysm repair may be somewhat more specific. Some of these areas will be dealt with in more detail below, considering the evidence base and the nature of nursing knowledge applied to the problem. The nursing knowledge applied in the assessment process derives from acquired knowledge (that gleaned during training, and study), and experiential knowledge, from previous experiences of applying theoretical knowledge to practice. If the nurse has previously cared for patients with this condition, she will apply that experience to this case. If not, the application of clinical, theoretical and other knowledge (such as colleagues’ experience) to the scenario, alongside thorough understanding of physiological principles, should result in effective and appropriate care. The evidence base must also be utilised.

Pyrexia

Having identified a potential problem in relation to temperature regulation, it is important to plan for ongoing monitoring, identification of the cause of increased temperature, treatment of the cause and relief of symptoms. The cause of the temperature is most likely to an infection. Nosocomial infection is a concern after surgery, especially when the patient has an incision involving any aspect of the vascular system (Irwin, 2007). In order to prevent wound infection, David will be prescribed IV antibiotics, which will then be changed to oral antibiotics at the appropriate time (Irwin, 2007). Symptomatic relief of the pyrexia can be achieved by fan therapy and the administration of paracetamol, which can be given PR if David remains nil by mouth. However, the nurse would ensure this was prescribed and not contraindicated due to any interactions with David’s other medications. David’s increased temperature may also be due to the development of ischaemic colitis (a complication of abdominal aortic aneurysm repair) and so white cell counts should be checked, as a raised count may be indicative of this (Beese-Bjustrom, 2004). The pyrexia may be in response to the blood transfusion (Jones and Pegram, 2006), although we would expect this to have developed earlier in the treatment.

At this point, David’s pyrexia indicated a potential problem, and may not require paracetamol or fan therapy. Instead, prevention of the development of infection, and reassurance that his feeling of being cold may be due to raised temperature, may suffice.

Blood Pressure Management and Fluid Balance.

Keeping David’s blood pressure within the normal range is critical to maintain end organ perfusion, and so both hypertension and hypotension must be prevented in this case (Irwin, 007). In order to prevent hypertension and the complications described above, David may be given IV beta blockers, and will be monitored for any cardiovascular changes such as chest discomfort, ST-T wave changes, or dysrhythmias (Irwin, 2007). Given his stability 24 hours post-operatively, he may be moved from ITU to a high dependency or standard surgical ward, where telemetry may then be stopped.

Monitoring mean arterial pressure and maintaining a reading of at least 70 mmHg can ensure proper perfusion of major organs, and this can be supported by careful infusion of intravenous fluids as described above (Irwin, 2007). In relation to fluid balance (and continuing organ functioning) a urine output of around 50ml/hour would indicate adequate glomerular filtration rate and renal perfusion (Irwin, 2007). Any deviations from these ‘ideals’ would be recorded and reported promptly to the appropriate members of the multi-disciplinary team (Irwin, 2007).

Pain Management

While David’s pain is being managed effectively with the Patient Controlled Analgesia (PCA) device, the use of a PCA is not a long-term means of pain management. Therefore, the planning stage of management of David’s care for the nurse looking after him should involved a collaborative plan for pain management. This may be in collaboration with the medical team, the anaesthetist, and David himself. A range of medications are available for David to use once he has reached a stage of being able to manage without the PCA, but it is also important that his pain be properly managed during the postoperative period, because good pain management will help David to mobilise properly and reduce the other postoperative risks, such as those of DVT, PE (Irwin, 2007) and pressure sore development.

Another area to address is the prevention of atelectasis. Regardless of the type of surgical procedure, as many as 90% of patients who have a general anaesthetic develop some degree of atlectasis in the postoperative period ( Irwin, 2007; Pruitt, 2006). Pneumonia is another risk (Irwin, 2007). As well as the risks from having an anaesthetic anyway, David is at increased risk because he is more likely to demonstrate postoperative hypoventilation, because pain from abdominal surgery can prevent him from deep breathing and coughing which helps prevent atelectasis (Pruitt, 2006). David can be taught to splint the surgical site with a pillow or roll of blanket, and then carry out these breathing exercises – incentive spirometry, coughing and deep breathing – to help keep his lungs clear (Irwin, 2007). Adopting a good upright position also helps to increase lung capacity and encourage deeper breaths (Pruitt, 2006), and so good pain management is also important in supporting David to do this (Irwin, 2007). Adequate pain control is also essential to graft patency, because uncontrolled pain causes the release or epinephrine, noreinephrine, and other hormones that active the fight or flight response (Bryant et al, 2002). The consequent vasoconstriction can decrease blood flow through the graft and can increase risk of thrombus formation (Bryant et al, 2002).

Alongside a drug therapy plan for pain management, it might also be appropriate to consider nondrug pain management as well (Tracy et al, 2006). Opioids used to manage postoperative pain can cause respiratory depression (Irwin, 2007). Some of the other advantages of nondrug pain management techniques is that they are readily available, inexpensive, and not associated with side effects, but the biggest advantage in this case is that they promote self-care and enhance personal control for one’s own health (Tracy et al, 2006). For David’s case, promoting self-care may have a number of beneficial effects on him holistically, given that he has recently experienced the diagnosis and treatment of a life-threatening condition (Manias, 2003). There is some evidence to suggest that tailored education and support in such therapies can benefit patient outcomes (Tracy et al, 2006), but this would require that the nurse is knowledgeable about the techniques, and that all members of the multidisciplinary team are equally invested and have been prompted to include nondrug pain management in the care plan (Tracy et al, 2006).

Prevention of Problems Associated with Aneurysm Repair.

There are a number of potential complications of surgical abdominal aortic aneurysm repair, which are in addition to the usual postoperative risks. These include graft rupture, haemorrhage, and graft occlusion (Irwin, 2007). This is another reason for close monitoring of David’s haemodynamic status, because a drop in blood pressure or urine output, associated with increased heart rate and perhaps a change in mental status may indicated shock consequent to blood loss (Irwin, 2007). It is also important to carefully and frequently assess the abdomen, for pain, distension or increasing girth (Irwin, 2007). Graft occlusion may manifest as coronary ischaemia, MI, cerebral ischaemia or stroke, ischaemic colitis or even spinal cord ischaemia resulting in paralysis (Irwin, 2007). Similarly, occlusion of an abdominal graft can also compromise renal blood flow, causing acute tubular necrosis and renal failure, or compromise peripheral circulation, which might lead to limb loss (Irwin, 2007). Therefore it might be prudent to calculcate ankle/brachial index regularly to evaluate lower extremity perfusion (Irwin, 2007).

Nursing Issues

In an empirical study of nursing in patients undergoing procedures for abdominal aortic aneurysm repair, Kozon et al (1998) found that patients who undergo the traditional open procedure require more intensive nursing care of lengthier duration, to move them along the illness-wellness spectrum towards self-care and independence. Kozon et al (1998) demonstrate a tailor made model based on the nursing process, which allows nurses to predict the postoperative course for individual patients. They also consider the psychological aspects of care, discussing the state of fear of patients, which is either externally visible to the nursing staff or is expressed by the patients themselves (Kozon et al, 1998). This is important in ensuring the holistic management of David’s care. However, Kozon et al (1998) also recommend further nursing research on this area to fully optimise nursing and enable the recognition of the nursing needs of the individual patient. This says much about the nature of nursing knowledge and the evidence base on this topic, which remains very much focused on the physical and medical aspects of care. Kozon et al (1998) developed a protocol to apply to such cases, but in terms of evidence, larger scale studies are needed to validate this. The high risks of both the procedure and the repair are highlighted in the literature (Bryant et al, 2002), and so a thorough understanding of these is vital in order to underpin nursing practice and ensure rapid and appropriate prioritisation of care needs, recognition of deviations from the norm and prompt, appropriate referral and treatment.

Another issue which the evidence base throws up is the documentation and monitoring of pain management. In a descriptive, retrospective audit of nursing records, Idvall and Ehrenberg (2002) found that there are many shortcomings in content and comprehensiveness of nurses’ monitoring and recording of patients’ pain. This is of particular importance in relation to postoperative care of those patients having undergoing surgical repair of abdominal aortic aneurysm, given that pain can indicate a number of complications of the procedure.

Conclusion

As can be seen, the care of the patient having an AAA repair is a complex undertaking, requiring a thorough knowledge base on the part of the nurse, and the skills necessary to recognise complications, deviations from clinical parameters, and effects of treatments in order to promptly and appropriately treat and refer the patient (Warbinek and Wyness, 1994). In David’s case, he has presented with a potential complication of his surgery, but the complex nature of his condition could mean that his potential pyrexia is due to a number of causes. Understanding the underlying physiology of his condition is vital in ensuring all his care needs are met and that he is kept in the optimal state of health to promote rapid recovery. This involves an holistic approach, with attention paid to his pain management and psychological state as well as his considerable medical and physical needs. The evidence base for care is suggestive of the existence of some useful nursing evidence on which to base care, but also suggests the need for more concrete and comprehensive research to underpin practice. Nursing assessment and intervention can be crucial to the survival of patients with this condition (Myer, 1995). Thus nursing knowledge must draw upon their own and other’s knowledge and experience, and the knowledge and understanding of the patient, and their reported symptoms and feelings, in order to provide the highest standard of care and promote David’s optimal wellbeing and return to health.

References

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Kozon, V., Fortner, N. and Holzenbein, T. (1998) An empirical study of nursing in patients undergoing two different procedures for abdominal aortic aneurysm repair. Journal of Vascular Nursing. 16 (1) (1-5).

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Neacsu, A. (2006) Malignant hyperthermia. Nursing Standard 20 (28) 51-57.

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