Anesthesia Considerations 

Aortic Dissection 

 

 

Considerations

 

• Type & urgency:

  • Stanford type A: Surgical management

  • Stanford type B: Medical management or stent only if organ damage or complicated aortic dissection

• End organ damage & ischemia

  • Stanford type A associated with aortic insufficiency, tamponade, MI, CVA

  • Acute renal failure 

  • Spinal cord ischemia

  • Ischemic gut

  • Limb ischemia

  • Hemorrhagic shock 

  • Pleural effusions

  • Retroperitoneal bleeding 

• Underlying cause of aortic dissection

  • Trauma 

  • Hypertension, atherosclerosis

  • Cocaine/amphetamine use

  • Pregnancy

  • Collagen vascular disease (e.g. Marfan's)

 

 

Anesthetic Management 

 

• Medical stabilization:

  • IV access, CVC, arterial line (R arm AND L arm or femoral)

  • Hemodynamic goals 

    • ​Preload: maintain adequate preload; aggressive fluid therapy may worsen dissection 

    • Rate: heart rate <60bpm with beta blockade

    • Rhythm: maintain normal sinus rhythm

    • Contractility: reduce contractility with beta blockade to reduce sheer stress on intima 

    • Afterload: reduce sBP to a target of 100-120 mmHg to reduce sheer stress on intima 

  • Main goal is to ↓ cardiac contractility & BP to ↓ intimal stress 

    • 1st line therapy is beta blockade to achieve hemodynamic goals 

      • Labetalol (bolus 20-80mg then infusion 0.5-2mg/min) 

      • Esmolol (bolus 0.5-1 mg/kg then infusion 50-200 mcg/kg/min)

      • Consider diltiazem (2.5-5mg IV q15min) & verapamil (2.5-5mg IV q15min) in patients intolerant of beta blockers 

      • Consider adding sodium nitroprusside (0.25-0.5mcg/kg/min) to achieve sBP of 100-120mmHg

      • Adequate pain control

• Things to avoid:

  • Inotropes

  • Hydralazine, which can cause aortic wall sheer stress

  • Vasodilation before beta blockade, which can cause reflex sympathetic activation 

  • Pericardiocentesis in tamponade, which can cause exsanguination 

 

 

Pregnancy Considerations 

 

• Aggressive alpha & beta-blockade to ↓ dP/dT as above

• Continuous fetal heart rate monitoring (marker of end organ perfusion)

• Type B:

  • Medical management & expedite delivery

  • Use short acting agents (esmolol, labetalol, phentolamine)

  • Conflicts: 

    • Antihypertensives vs. bleeding risk/post partum hemorrhage (eg. nitroglycerine & ↓ uterine tone)

    • Avoid fetal toxic medications (sodium nitroprusside)

    • Avoid ergotamine for post partum hemorrhage 

• Type A:

  • If diagnosed <28 weeks = surgical repair, then allow pregnancy to continue

  • 28-32 weeks = surgical repair, cesarean section if obstetrical indications

  • >32 weeks = simultaneous repair & cesarean section