Aortik Hastalıklarda Anestezik Yaklaşım ve Preoperatif Değerlendirme

Yasemin Çakır

doi:10.37609/akya.3207

Yazarlar

Yasemin Çakır

https://orcid.org/0009-0009-1674-7815

DOI: https://doi.org/10.37609/akya.3207.c12078

Özet

Aort cerrahisinde preoperatif planlama ve hazırlık, zor ve birçok bileşeni aynı anda düşünmeyi gerektiren bir süreçtir. Yandaş hastalıkların değerlendirilmesi ve koruyucu yaklaşımın planlanması önemlidir. Akut pıhtılaşma bozukluğu yaratabilecek hipotansiyon, dilüsyon, hipotermi ve asidoza karşı dikkatli olunmalıdır. Temel monitörizasyona ek olarak invaziv kan basıncı monitörizasyonu, santral venöz basınç, idrar çıkışı, ısı probu ile vücut sıcaklığı takip edilmeli ve gerekli durumlarda pulmoner arter kataterizasyonu, transözofageal ekokardiyografi (TEE) ve santral nöral monitörizasyon da ilave edilmelidir . Aorta kros klemp konulması, metabolik asidoz, respiratuar alkaloz, katekolaminlerin salınımında artış, toplam vücut oksijen tüketiminde azalma, renal kan akımında azalma, arteryel kan basıncında artış, kardiyak debide artış gibi hemodinamik ve metabolik değişiklikler meydana getirirken; klembin açılması arteryel kan basıncında belirgin azalma, laktat artışı, kardiyak debide azalma, miyokard kontraktilitesinde azalma ve metabolik asidoz gibi hemodinamik ve metabolik değişiklikler meydana getirir. Akut böbrek yetmezliği, abdominal aort cerrahisinde yüksek oranda görülebilecek bir komplikasyondur . Renal koruma için hipotermi, mannitol, dopamin, furosemid, metilprednizolon ve fenoldopam sık kullanılmaktadır; fakat koruyucu etkilerinin kanıtlanması için daha fazla çalışmaya ihtiyaç mevcuttur . Ağrı yönetiminde, lokal anesteziklerle bölgesel blokaj gibi multimodal teknikler de dahil hasta kontrollü sistemik opioid analjezi, bölgesel opioid uygulamaları ve periferik bölgesel teknikler önerilmektedir. Hastalar, ameliyat sonrası gelişebilecek kardiyak komplikasyonların sıklığı, koagülopati, yeniden ısıtma ve hemodinamik stabilizasyon nedeniyle yoğun bakım ünitesinde monitörize takip edilmelidir. Hastanın anamnezi ve kırılganlık seviyesi başarılı bir cerrahi için çok iyi incelenmeli ve planlama yapılmalıdır.

Preoperative planning and preparation in aortic surgery is a difficult process that requires considering many components simultaneously.Evaluation of comorbidities and planning of a preventive approach are important. Care should be taken against hypotension, dilution, hypothermia and acidosis that may cause acute coagulation disorders. In addition to basic monitoring, invasive blood pressure monitoring, central venous pressure, urine output, body temperature with a heat probe should be monitored and, if necessary, pulmonary artery catheterization, transesophageal echocardiography (TEE) and central neural monitoring should be added. While cross-clamping of the aorta causes hemodynamic and metabolic changes such as metabolic acidosis, respiratory alkalosis, increased release of catecholamines, decreased total body oxygen consumption, decreased renal blood flow, increased arterial blood pressure, and increased cardiac output; Opening the clamp causes hemodynamic and metabolic changes such as a significant decrease in arterial blood pressure, increase in lactate, decrease in cardiac output, decrease in myocardial contractility and metabolic acidosis. Acute renal failure is a complication that can be seen at a high rate in abdominal aortic surgery. Hypothermia, mannitol, dopamine, furosemide, methylprednisolone and fenoldopam are frequently used for renal protection; however, further studies are needed to prove their protective effects. In pain management, patient-controlled systemic opioid analgesia, regional opioid applications and peripheral regional techniques are recommended, including multimodal techniques such as regional blockade with local anesthetics. Patients should be monitored in the intensive care unit due to the frequency of cardiac complications that may develop after surgery, coagulopathy, rewarming and hemodynamic stabilization. The patient's history and fragility level should be examined and planned very well for a successful surgery.

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