Delayed volume resuscitation during initial management of ruptured abdominal aortic aneurysm

Dick, Florian; Erdoes, Gabor; Opfermann, Philipp; Eberle, Balthasar; Schmidli, Juerg; Allmen, Regula S. von

doi:10.1016/j.jvs.2012.09.072

Cited by 55 publications

(23 citation statements)

References 28 publications

(32 reference statements)

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“…After adjustment, the higher mortality risk associated with aortouni-iliac endografts was not statistically significant (OR 1·46, 0·54 to 3·94; P = 0·457). This higher mortality rate from use of aortouni-iliac grafts has been confirmed by experienced single centres and a systematic review7,13,14.…”

Section: Discussionmentioning

confidence: 74%

Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm

investigators¹,

Powell

Hinchliffe

et al. 2014

British Journal of Surgery

153

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BackgroundSingle-centre series of the management of patients with ruptured abdominal aortic aneurysm (AAA) are usually too small to identify clinical factors that could improve patient outcomes.MethodsIMPROVE is a pragmatic, multicentre randomized clinical trial in which eligible patients with a clinical diagnosis of ruptured aneurysm were allocated to a strategy of endovascular aneurysm repair (EVAR) or to open repair. The influences of time and manner of hospital presentation, fluid volume status, type of anaesthesia, type of endovascular repair and time to aneurysm repair on 30-day mortality were investigated according to a prespecified plan, for the subgroup of patients with a proven diagnosis of ruptured or symptomatic AAA. Adjustment was made for potential confounding factors.ResultsSome 558 of 613 randomized patients had a symptomatic or ruptured aneurysm: diagnostic accuracy was 91·0 per cent. Patients randomized outside routine working hours had higher operative mortality (adjusted odds ratio (OR) 1·47, 95 per cent confidence interval 1·00 to 2·17). Mortality rates after primary and secondary presentation were similar. Lowest systolic blood pressure was strongly and independently associated with 30-day mortality (51 per cent among those with pressure below 70 mmHg). Patients who received EVAR under local anaesthesia alone had greatly reduced 30-day mortality compared with those who had general anaesthesia (adjusted OR 0·27, 0·10 to 0·70).ConclusionThese findings suggest that the outcome of ruptured AAA might be improved by wider use of local anaesthesia for EVAR and that a minimum blood pressure of 70 mmHg is too low a threshold for permissive hypotension.

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Section: Discussionmentioning

confidence: 74%

Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm

investigators¹,

Powell

Hinchliffe

et al. 2014

British Journal of Surgery

153

View full text Add to dashboard Cite

show abstract

“…Several authors have argued that stable patients, whose hemodynamic and physiological conditions permit CT to confirm the anatomic feasibility for EVAR, are preferentially treated with an endovascular approach compared with cardiovascularly compromised patients presenting in severe shock, who are operated on by OR straightaway. 19 In 2013, Dick et al 88 validated earlier observations by Crawford and Cooley by demonstrating the importance of delayed volume resuscitation during the initial management of rAAA. Preoperative fluid infusion correlated directly with 30-day mortality rates.…”

Section: Limitationsmentioning

confidence: 85%

Risk-Adjusted Meta-analysis of 30-Day Mortality of Endovascular Versus Open Repair for Ruptured Abdominal Aortic Aneurysms

Luebke

Brunkwall

2015

Annals of Vascular Surgery

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“…Important principles of treatment continue to include limited fluid resuscitation until the aortic cross-clamp is applied [26], adequate vascular access, intra-arterial blood pressure monitoring before induction of anaesthesia, some form of non-invasive cardiac output monitoring, and careful induction of anaesthesia in the operating theatre after the patient has been draped for surgery, a urinary catheter has been inserted and the surgeon is ready to start. Twenty-four-hour access to intra-operative cell salvage should be a standard of care in vascular centres.…”

Section: Emergency Abdominal Aortic Aneurysm Repairmentioning

confidence: 99%

Emergency surgery: the big three – abdominal aortic aneurysm, laparotomy and hip fracture

2013

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SummaryNational reports recommended that peri-operative care should be improved for elderly patients undergoing emergency surgery. Postoperative mortality and morbidity rates remain high, and indicate that emergency ruptured aneurysm repair, laparotomy and hip fracture fixation are high-risk procedures undertaken on elderly patients with limited physiological reserve. National audits have reported variations in care quality, data that are increasingly being used to drive quality improvement through professional guidance. Given that the number of elderly patients presenting for emergency surgery is likely to rise as the population ages, this review summarises the evidence on which such guidance is based, and provides information about how anaesthetists might participate in audit and research aimed at improving local and national outcomes for these most vulnerable of patients. More recently, national audits have reported several-fold variations in the care of elderly emergency surgical patients in the UK [4][5][6], and importantly, these data are beginning to be used to drive quality improvement [11] through professional guidance [12][13][14] that advocates early, focused, multidisciplinary 70

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Delayed volume resuscitation during initial management of ruptured abdominal aortic aneurysm

Abstract: Aggressive volume resuscitation of patients with rAAAs before proximal aortic control predicted an increased perioperative risk of death, which was independent of systolic blood pressure. Therefore, volume resuscitation should be delayed until surgical control of bleeding is achieved.

Cited by 55 publications

References 28 publications

Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm

Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm

Risk-Adjusted Meta-analysis of 30-Day Mortality of Endovascular Versus Open Repair for Ruptured Abdominal Aortic Aneurysms

Emergency surgery: the big three – abdominal aortic aneurysm, laparotomy and hip fracture

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