Sandbox Yaz: Difference between revisions
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==Overview== | ==Overview== | ||
==Algorithm== | |||
{{familytree/start}} | {{familytree/start}} | ||
{{familytree | | | A01 | | | | | | | | | | | | | | | | | | | | | | | |A01=Is cardiac catheterization an emergency?}} | {{familytree | | | A01 | | | | | | | | | | | | | | | | | | | | | | | |A01=Is cardiac catheterization an emergency?}} | ||
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❑ Situs inversus<br> | ❑ Situs inversus<br> | ||
❑ History of renal disease (CrCl < 60 mL/min)<br> | ❑ History of renal disease (CrCl < 60 mL/min)? Does the patient currently have a stable renal function?<br> | ||
❑ History of bleeding tendency<br> | ❑ History of bleeding tendency<br> | ||
Line 205: | Line 205: | ||
❑ Vital signs, including BP, HR, RR, T, room air SpO2<br> | ❑ Vital signs, including BP, HR, RR, T, room air SpO2<br> | ||
❑ Height, weight, and body mass index (BMI)<br> | ❑ Height (in meters), weight (in kilograms), and body mass index (BMI)<br> | ||
❑ Level of consciousness, orientation, and ability to cooperate and communicate<br><br> | ❑ Level of consciousness, orientation, and ability to cooperate and communicate<br><br> | ||
Line 373: | Line 373: | ||
❑ Electrolytes panel<br> | ❑ Electrolytes panel<br> | ||
❑ Baseline serum creatinine and BUN<br> | ❑ Baseline serum creatinine and BUN. Calculate and record estimated creatinine clearance/eGFR (creatinine clearance/eGFR may significantly be different from true GFR in patients with unstable renal function) <br> | ||
❑ Glycemia<br> | ❑ Glycemia<br> | ||
Line 389: | Line 389: | ||
❑ CXR if patient suspected to have pulmonary edema or other diseases}} | ❑ CXR if patient suspected to have pulmonary edema or other diseases}} | ||
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}} | {{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}} | ||
{{familytree | | | | | L01 | | | | | | | | | | | | | | | | | | | | | |}} | {{familytree | | | | | L01 | | | | | | | | | | | | | | | | | | | | | |L01='''Address relevant and significant comorbidities'''<br><br> | ||
❑ Prolonged INR (>1.8) 24 hours prior to procedure<br> | |||
:❑ Administer low-dose vitamin K 1-2 mg PO | |||
:❑ Repeat INR and confirm new INR < 1.8 (preferable INR ≤ 1.4). If INR still > 1.8 | |||
::❑ Administer additional vitamin K 2-4 mg PO if anticipated procedure is > 24 hours later. Administer more doses of low-dose vitamin K (1-2 mg PO) if INR still high | |||
::❑ Cancel transfemoral approach (except if emergency) if INR does not normalize in time of procedure | |||
::❑ Consider transradial approach if radial artery accessible to reduce risk of bleeding | |||
::❑ Consider transfusion of fresh frozen plasma (FFP)<br> | |||
❑ Renal insufficiency (CrCl < 60 ml/min)<br> | |||
:❑ Saline administration | |||
::❑ In patients with no CHF, administer 0.9% or 0.45% normal saline: 1 mL/ kg/ hour (MAX 100 ml/hour) for 12 hours before contrast AND 12 hours after contrast ) in patients with no CHF | |||
::❑ In patients with CHF, administer 0.45% normal saline: 0.5 ml/kg/hr (MAX 50 ml/hr) 12 hrs before contrast AND 12 hours after contrast | |||
:❑ Consider administration of NaHCO3 | |||
::❑ Mix 150 mEq of NaHCO3 in 1 liter of D5W in non-diabetic patients OR mix 150 mEq of NaHCO3 in 1 liter of sterile water in diabetic patients. | |||
::❑ Administer 3 ml/kg bolus (MAX 300 ml) for 1 hour prior to procedure AND 1 mL/kg/hour (MAX 100 ml/hr) during the procedure AND 1 mg/kg/hour for 6 hours post-procedure | |||
:❑ Follow-up serum creatinine 2 to 5 days following catheterization<br> | |||
❑ Contrast allergy<br> | |||
:❑ Administer the following regimen before the procedure (controversial timing) | |||
:❑ Regimen 1 | |||
::❑ Methylprednisolone 60 mg IV once, '''AND''' | |||
::❑ Diphenhydramine 50 mg IV once, '''AND''' | |||
::❑ Cimetidine 300 mg (or alternative H2 blocker) IV once | |||
:❑ Regimen 2 | |||
::❑ Prednisolone 50 mg PO at 13 hours, 7 hours, and 1 hour (total of 3 doses) before procedure}} | |||
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}} | {{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}} | ||
{{familytree | | | | | M01 | | | | | | | | | | | | | | | | | | | | | |}} | {{familytree | | | | | M01 | | | | | | | | | | | | | | | | | | | | | |M01='''Confirm pre-cath checklist on the day of the procedure''' | ||
❑ Confirm patient full name<br> | |||
❑ Identify indication for procedure<br> | |||
❑ Planned procedure<br> | |||
:❑ Diagnostic cardiac catheterization | |||
:❑ Diagnostic cardiac catheterization with possible PCI | |||
:❑ PCI | |||
❑ Appropriate history and physical examination documented in patient record<br> | |||
❑ Informed consent is filled within 30 days, complete, signed, and available in patient record<br> | |||
❑ Candidacy for DES<br> | |||
:❑ Does the patient have significant anemia (Hct < 30%) | |||
:❑ Has the patient had any major surgery in the past month or is anticipating any major surgery in the next year? | |||
:❑ Does the patient have clinically overt bleeding? | |||
:❑ Is the patient receiving chronic anticoagulation (e.g. warfarin or dabigatran) | |||
:❑ Does the patient have a history of medications non-adherence? | |||
:❑ Does the patient have someone available to transport to and from the hospital?<br> | |||
❑ Allergies and adverse drug reactions<br> | |||
:❑ Contrast allergy. If yes, was the patient pre-treated? | |||
:❑ Aspirin allergy. If yes, does the patient need desensitization? | |||
:❑ Latex allergy: If yes, remove all latex products from procedural use | |||
:❑ Heparin induced thrombocytopenia (HIT): If yes, consider alterative antithrombotic agent | |||
:❑ Patient known to have multiple allergies? If yes, did you consider pretreatment?<br> | |||
❑ Medications<br> | |||
:❑ Was the patient administered ANY of the following medications within the last 48 hours prior to catheterization? | |||
::❑ Aspirin | |||
::❑ Clopidogrel | |||
::❑ Metformin | |||
::❑ Phosphodiesterase inhibitors (e.g. Tadalafil, sildenafil, or similar drugs) | |||
::❑ Warfarin. If yes, what the patient’s pre-op (within 48 hours) INR? | |||
::❑ Low molecular weight heparin (LMWH). If yes, when was last dose? | |||
::❑ Other chronic anticoagualants (e.g. dabigatran, NOACs) | |||
❑ ASA physical status available<br> | |||
❑ Modified mallampati score available<br> | |||
❑ Does patient have any contraindication to sedation?<br> | |||
❑ Patient's height (in meter) and weight (in kilograms) recorded? <br> | |||
❑ Pre-procedural work-up available AND reviewed (CBC, electrolytes, glycemia, PT/INR, creatinine, BUN, PT/INR within 24 hours if receiving warfarin, ECG within 24 hours, CXR if applicable) | |||
:❑ Renal function (serum creatinine, BUN, creatinine clearance/eGFR) | |||
:❑ Bleeding risk (anemia, thrombocytopenia, prolonged INR/PT) | |||
:❑ Cardiac assessment (ECG)}} | |||
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}} | {{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}} | ||
{{familytree | | | | | N01 | | | | | | | | | | | | | | | | | | | | | |}} | {{familytree | | | | | N01 | | | | | | | | | | | | | | | | | | | | | |N01='''Administer Preprocedural Drugs'''<br><br> | ||
'''''Dual antiplatelet therapy'''''<br> | |||
❑ Administer aspirin 325 mg PO once at least 2 hours before the procedure, AND<br> | |||
❑ Administer clopidogrel 600 mg PO once at least 2 to 6 hours before the procedure<br><br> | |||
'''''Conscious Sedation'''''<br> | |||
❑ Administer diazepam 5-10 mg PO once<br> | |||
❑ Additional drugs, such as fentanyl 25 to 50 microgram IV AND midazolam 1 to 2 mg IV, may be administered pre-procedure, but are usually administered once patient is inside the cath lab)<br><br> | |||
'''''Consider antihistamine'''''<br> | |||
❑ Consider administration of diphenhydramine (Bendaryl) 25 mg PO once<br><br> | |||
'''''Consider anti-nausea agents'''''<br> | |||
❑ Consider administration of ondansetron (Zofran) 4 mg IV once}} | |||
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}} | {{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}} | ||
{{familytree | | | | | O01 | | | | | | | | | | | | | | | | | | | | | |}} | {{familytree | | | | | O01 | | | | | | | | | | | | | | | | | | | | | |O01=Transfer patient to cath lab}} | ||
{{familytree/end}} | {{familytree/end}} | ||
Revision as of 14:28, 17 April 2015
Coronary Angiography and Revascularization
Overview
Algorithm
Is cardiac catheterization an emergency? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Refer to management of acute coronary syndromes | Confirm that the patient has ANY of the following indications for cardiac catheterization ❑ Canadian cardiovascular society (CCS) class III (i.e. symptoms with everyday living activities) or class IV angina (i.e. inability to perform any activity without angina or angina at rest) despite medical therapy, OR
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Obtain a detailed history History of Present Illness ❑ Age ❑ Chest pain or chest discomfort ❑ Onset of symptoms ❑ Sensation of heaviness, tightness, pressure, or squeezing ❑ Duration of each episode ❑ Radiation to the left arm, jaw, neck, right arm, back or epigastrium ❑ Timing of symptoms (morning vs. evening vs. wake patient at night) ❑ Alleviating factors (e.g. medications or rest) ❑ Exacerbating factors ❑ Association of symptoms to food intake ❑ Palpitations ❑ Nausea or vomiting ❑ Sweating ❑ Dyspnea ❑ Orthopnea ❑ Dizziness ❑ Weakness of extremities ❑ Numbness of tingling of extremities ❑ Lightheadedness ❑ Syncope or presyncope ❑ Increased frequency of symptoms ❑ Worsening of symptom severity ❑ Previous episodes ❑ Recent infections ❑ Fever ❑ Weight or appetite changes ❑ Stress ❑ Fatigue Possible Symptom Triggers ❑ Physical exertion ❑ Air pollution or fine particulate matter ❑ Recent infection ❑ Heavy meal intake ❑ Cocaine ❑ Marijuana Cardiovascular Risk Factors ❑ Known CAD (review available catheterizations or CABG reports) ❑ Smoking history ❑ Baseline blood pressure (Duration, antihypertensive therapy, compliance with medications) ❑ History of diabetes mellitus (Duration, DM control, compliance, antidiabetic medications, recent HbA1c, screening for micro- and macrovascular DM complications) ❑ Dyslipidemia ❑ Obesity (BMI > 30 kg/m2) Past Medical History ❑ Congenital heart disease ❑ Left to right shunts ❑ Dextrocardia ❑ Situs inversus ❑ History of renal disease (CrCl < 60 mL/min)? Does the patient currently have a stable renal function? ❑ History of bleeding tendency ❑ Known significant anemia (Hct < 30%) ❑ History of heparin-induced thrombocytopenia (HIT) ❑ History of pulmonary disease ❑ History of major surgery in the past month ❑ Anticipated major surgery in the next year Medications ❑ Prescribed drug ❑ Home oxygen therapy ❑ Over-the-counter drugs ❑ Herbs and supplements ❑ Administration of ANY of the following medications within the last 48 hours prior to catheterization?
Allergies ❑ List of allergies, including severity and manifestations (pruritus, rash, hives, stridor, or anaphylactic shock) ❑ Known drug allergies
Family History ❑ Family history of premature cardiovascular diseases Social and Sexual History ❑ Healthcare proxy and available family members for patient care ❑ Barrier to tolerate or adhere to dual antiplatelet therapy (DAPT) or follow-up visits ❑ Pregnancy or possible pregnancy Advanced Directives ❑ DNR status | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Examine the patient ❑ Vital signs, including BP, HR, RR, T, room air SpO2 ❑ Height (in meters), weight (in kilograms), and body mass index (BMI) ❑ Level of consciousness, orientation, and ability to cooperate and communicate Skin ❑ Xanthelesma or xanthoma (suggestive of dyslipidemia) ❑ Edema (suggestive of congestive heart failure) ❑ Acral and/or central cyanosis HEENT ❑ Head and neck range of motion ❑ Modified Mallampati score
Cardiothoracic ❑ Auscultation of heart sounds (including number of sounds, pitch, interval, murmurs, gallops, or rubs) over 4 precordial regions in sitting position (stethoscope diaphragm) and auscultation of mitral area while in left lateral decubitus position (stethoscope bell)
❑ Point of maximal impulse (PMI) (normally one, non-sustained, tapping impulse per cardiac cycle located less than 2-3 cm from midclavicular line at 5th intercostal space) ❑ Auscultation of anterior and posterior pulmonary regions bilaterally
Vascular ❑ Pulses of both upper extremities (radial, ulnar, brachial) and lower extremities (dorsalis pedis, posterior tibial, popliteal) ❑ Femoral pulses bilaterally ❑ Femoral auscultation bilaterally for bruits ❑ Modified Allen test bilaterally to evaluate adequacy of radial access ❑ Carotid auscultation bilaterally ❑ Jugular venous pressure Neurological ❑ Upper/lower extremity motor strength ❑ Upper/lower extremity sensory exam ❑ Spasticity or rigidity ❑ Deep tendon reflexes ❑ Bilateral Babinski ❑ CN assessment ❑ Coordination and cerebellar exams (Finger to nose, Romberg, Heel to shin, alternating movement) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Provide appropriate counseling before catheterization ❑ Address individual concerns and questions ❑ Keep patient NPO at least 6 hours before elective coronary angiography Hold Certain Medications Before Procedure Warfarin ❑ Hold warfarin for at least 2 to 6 days before elective coronary angiography (to prevent bleeding) ❑ Confirm INR < 1.8 (preferable INR < 1.4) within 24 hours before arterial puncture ❑ Restart warfarin 12 to 24 hours following catheterization (warfarin requires 2 to 3 days for INR to become therapeutic range) ❑ Consider heparin bridging 3 days before planned catheterization for high risk patients to prevent prolonged subtherapeutic INR
Novel Oral Anticoagulants ❑ Hold NOAC before catheterization as follow ❑ Rivaroxaban: Hold rivaroxaban for 2 days in patients with low bleeding risk OR for 3 days in patients with high bleeding risk ❑ Apixaban: Hold apixaban for 2 days in patients with low bleeding risk OR for 3 days in patients with high bleeding risk ❑ If patient does not develop any hematoma, restart NOAC 1 day after the catheterization for patients with low bleeding risk OR 2-3 days after the catheterization for patients with high bleeding risk Dabigatran ❑ Hold dabigatran based on renal function as shown below
❑ CrCl < 30 ml/min: Hold dabigatran for 2 to 5 days if low/intermediate bleeding risk or > 5 days if high bleeding risk (e.g. major surgery) ❑ If patient does not develop any hematoma, restart dabigatran 1 day after the catheterization for patients with low bleeding risk OR 2-3 days after the catheterization for patients with high bleeding risk LMWH ❑ Hold LMWH for 12 hours before cardiac catheterization ❑ Resume LMWH 12-24 hours following cardiac catheterization Metformin ❑ Hold metformin 2 days before elective coronary angiography ❑ Restart metformin 2 days post-procedure OR until creatinine is stable (to prevent lactic acidosis and contrast-induced renal failure) Phosphodiesterase inhibitors ❑ Hold sildenafil/tadalafil/vardenafil for at least 2 days before elective coronary angiography | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Identify ASA physical status ❑ 1=Healthy individual with no systemic diseases ❑ 2=Mild systemic disease ❑ 3=Severe systemic disease ❑ 4=Severe systemic disease that poses a constant threat to the patient’s life ❑ 5=Moribund patient not expected to survive without the operation/procedure | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
ASA physical status ≥ 4 | ASA physical status < 4 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Consult anesthesia | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Perform pre-procedure routine work-up ❑ Complete blood count (CBC) ❑ Platelet count (Administration of unfractionated heparin, low molecular weight heparinoids, and parenteral glycoprotein 2b3a inhibitors are associated with thrombocytopenia. Thrombocytopenia is a contraindication to the administration of parenteral glycoprotein 2b3a inhibitors) ❑ Electrolytes panel ❑ Baseline serum creatinine and BUN. Calculate and record estimated creatinine clearance/eGFR (creatinine clearance/eGFR may significantly be different from true GFR in patients with unstable renal function) ❑ Glycemia ❑ Beta-HCG within 2 weeks of procedure for women of child-bearing age
❑ Presence of baseline bundle branch block (BBB) (Cardiac catheterization may damage HIS system and induce BBB) ❑ PT/INR within 24 hours, especially if patient is receiving warfarin (INR > 1.8 is a relative contraindication of cardiac catheterization) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Address relevant and significant comorbidities ❑ Prolonged INR (>1.8) 24 hours prior to procedure
❑ Renal insufficiency (CrCl < 60 ml/min)
❑ Contrast allergy
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Confirm pre-cath checklist on the day of the procedure
❑ Confirm patient full name ❑ Planned procedure
❑ Appropriate history and physical examination documented in patient record ❑ Informed consent is filled within 30 days, complete, signed, and available in patient record ❑ Candidacy for DES
❑ Allergies and adverse drug reactions
❑ Medications
❑ ASA physical status available ❑ Modified mallampati score available ❑ Does patient have any contraindication to sedation? ❑ Patient's height (in meter) and weight (in kilograms) recorded?
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Administer Preprocedural Drugs Dual antiplatelet therapy ❑ Administer aspirin 325 mg PO once at least 2 hours before the procedure, AND ❑ Administer clopidogrel 600 mg PO once at least 2 to 6 hours before the procedure Conscious Sedation ❑ Administer diazepam 5-10 mg PO once ❑ Additional drugs, such as fentanyl 25 to 50 microgram IV AND midazolam 1 to 2 mg IV, may be administered pre-procedure, but are usually administered once patient is inside the cath lab) Consider antihistamine ❑ Consider administration of diphenhydramine (Bendaryl) 25 mg PO once Consider anti-nausea agents | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Transfer patient to cath lab | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Do's
Don'ts
Abdominal Aortic Aneurysm
Overview
Classification
Abdominal aortic aneurysms may be classified based on the size of the aneurysm:
- Small aneurysm: Diameter < 4.0 cm
- Medium aneurysm: Diameter between 4.0 and 5.5 cm
- Large aneurysm: Diameter ≥ 5.5 cm
- Very large aneurysm: Diameter ≥ 6.0 cm
Abdominal aortic aneurysms may also be classified based on the rate of aneurysm expansion:
- Non-rapidly expanding aneurysm: Diameter increase of ≤ 0.5 cm within 6 months OR ≤ 1.0 cm within 12 months
- Rapidly expanding aneurysm: Diameter increase of > 0.5 cm within 6 months OR > 1.0 cm within 12 months
Causes
Life Threatening Causes
- Ruptured AAA
- Infected (mycotic) aneurysm
- Inflammatory AAA
- Aortovenous fistula
- Aortoenteric fistula
- Lower extremity thromboembolism
Risk Factors for Development of AAA
- Old age 50 > years
- Greater height
- Male gender
- Caucasian race
- Smoking
- History of CAD and atherosclerotic cardiovascular disease
- History of hypertension
- Dyslipidemia
- Family history of AAA
- Personal history of peripheral artery aneurysms
Risk Factors for Rapid Expansion or Rupture of AAA
- Female gender
- Advanced age > 50 years
- Smoking
- Advanced atherosclerosis
- History of prior stroke
- Hypertension
- Transplantation (cardiac or renal)
- Known reduced FEV1 (obstructive pulmonary disease)
FIRE: Focused Initial Rapid Evaluation
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate surgical intervention. Boxes in red signify that an urgent management is needed.
Identify cardinal findings that increase the pre-test probability of abdominal aortic aneurysm (AAA) rupture and development of complications ❑ Known large AAA > 5.5 cm
❑ Pulsating abdominal mass
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Rule out life threatening alternative diagnoses: (suggestive findings: vomiting, subcutaneous emphysema) | |||||||||||||||||||||||||||||||||||||||
Stabilize and resuscitate the patient ❑ Attend to the patient's ABCs (Airway, Breathing, Circulation)
❑ Obtain 12 lead ECG and place the patient on a cardiac monitor
❑ Withdraw blood for CBC, electrolytes, BUN, serum creatinine, LFTS, PT, PTT, troponin I, CK, CK-MB, CRP or ESR, and multiple blood cultures
❑ Maintain patient in a conscious state | |||||||||||||||||||||||||||||||||||||||
Patient hemodynamically unstable despite resuscitation? ❑ Hypotension (SBP < 90 mm Hg) despite resuscitation ❑ Tachycardia (HR > 100 bpm) despite resuscitation | |||||||||||||||||||||||||||||||||||||||
Yes. Patient is still hemodynamically unstable despite resuscitation. | No. Patient is hemodynamically stable following resuscitation | ||||||||||||||||||||||||||||||||||||||
Is the patient known to have an AAA? | Can patient have CT scan with contrast? | ||||||||||||||||||||||||||||||||||||||
Yes | No | Yes | No | ||||||||||||||||||||||||||||||||||||
❑ Proceed to operating room without further work-up | ❑ Obtain focused bedside ultrasound | ❑ Obtain CT scan with IV contrast of abdominal aorta and iliac arteries | ❑ Obtain CT scan without IV contrast of abdominal aorta and iliac arteries | ||||||||||||||||||||||||||||||||||||
AAA confirmed on imaging? | |||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||
Consider alternative diagnoses | |||||||||||||||||||||||||||||||||||||||
Evaluate need for further management of the following AAA complications | |||||||||||||||||||||||||||||||||||||||
Administer antimicrobial therapy Once diagnosis of complicated AAA is confirmed, all patients require blood cultures and empirical antibiotic therapy for gram-positive and gram-negative coverage (even if afebrile at presentation)
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Proceed to further management | |||||||||||||||||||||||||||||||||||||||
Diagnosis
Treatment
Shown below is an algorithm summarizing the management of abdominal aortic aneurysm.
Confirmed AAA | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Symptoms present? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Perform imaging using ANY of the following imaging modalities for the abdominal aorta and iliac arteries:
| Hemodynamically stable? | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Adequate imaging? | No | Yes | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Stabilize and resuscitate the patient ❑ Attend to the patient's ABCs (Airway, Breathing, Circulation)
❑ Place an indwelling urethral catheter and monitor urine output | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Repeat imaging | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
AAA meets AT LEAST ONE of the following criteria for surgical or endovascular intervention? ❑ AAA > 5.5 cm, OR | Perform pre-operative work-up ❑ Obtain 12 lead ECG and place the patient on a cardiac monitor
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No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Pain management ❑ Assess pain severity (self-report NRS scale 0 to 10; unconscious BPS 3-12 or CPOT 0-8). Pain considered significant if NRS≥4, BPS<5, or CPOT≥3
❑ Maintain patient in a conscious state | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Manage modifiable risk factors of asymptomatic AAA ❑ Administer aspirin 80 to 100 mg once daily if patient has no contraindication to aspirin therapy ❑ Administer statin therapy (e.g. simvastatin 40 mg once daily) if patient has no contraindication to statin therapy ❑ Manage hypertension based on guidelines for the management of hypertension (There are currently no recommended antihypertensive pharmacologic therapies for the management of AAA) ❑ Recommend smoking cessation ❑ Recommend moderate physical activity at least 4 times per week (e.g. running, swimming, golfing) ❑ Do NOT recommend intense physical activity (e.g. heavy lifting) due to increased risk of AAA rupture | Administer antimicrobial therapy Once diagnosis of complicated AAA is confirmed, all patients require blood cultures and empirical antibiotic therapy for gram-positive and gram-negative coverage (even if afebrile at presentation)
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Follow-Up ❑ Schedule routine follow-up visits with abdominal ultrasound imaging at regular time intervals to monitor patients who are candidates for surgical or endovascular repair. | Evaluate need for further management of the following AAA complications For patients suspected to have thromboembolism | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Aneurysm size between 5 and 5.5 cm ❑ Consider routine ultrasound every 3 months | Aneurysm size between 4.5 and 4.9 cm ❑ Consider routine ultrasound every 12 months (1 year) | Aneurysm size between 4.0 and 4.4 cm ❑ Consider routine ultrasound every 24 months (2 years) | Aneurysm size between 3.5 to 3.8 cm ❑ Consider routine ultrasound every 36 months (3 years) | Aneurysm size between 2.6 to 2.9 cm ❑ Consider routine ultrasound every 60 months (5 years) | Evaluate patient's surgical risk | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
High surgical risk | Low to moderate surgical risk | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Patient performed CT scan of the abdominal aorta and iliac arteries WITH contrast? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
CT scan demonstrated adequate aortic anatomy and integrity suitable for endovascular procedure? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Consider any of the following: ❑ Endovascular repair, OR ❑ Open AAA repair | Open AAA Repair | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Screening
Screening for AAA is currently recommended only once in the following patient groups:
- Men between the age of 65 and 75 years and who have ever smoked
- Men aged 60 years or older with a sibling or a parent with abdominal aortic aneurysm
There are currently no recommendations to screen AAA in women, but women are at increased risk of AAA expansion or rupture. Some experts recommend one-time screening in women with risk factors of developing AAA (such as smoking or positive family history)
Do's
Don'ts
- ↑ Marso SP, Teirstein PS, Kereiakes DJ, Moses J, Lasala J, Grantham JA (2012). "Percutaneous coronary intervention use in the United States: defining measures of appropriateness". JACC Cardiovasc Interv. 5 (2): 229–35. doi:10.1016/j.jcin.2011.12.004. PMID 22326193.