Spinal drain for TEVAR

I had a patient come in for a 2 stage endovascular aortic repair. The patient had a 1st stage left carotid to subclavian bypass done about 3 days ago. We did a 2nd stage TEVAR for a descending aortic aneurysm. The patient did really well. Stayed in constant communication with the vascular surgeon as well as endovascular surgeon. A plan was in place. Patient was maximally beta blocked. I found dexmetetomidine to be a great drug for sedation pre-induction as well as blunting any responses to laryngoscopy during induction. Cordis for volume. Used the side port of the cordis for drips (nicardipine, phenylephrine). There were various times during the surgery where the surgeon wanted hypotension vs. hypertension. During deployment of the stent, SBP < 90. Once the stent was deployed, goal SBP 140 (MAP>90). Overall great case and great outcome for the patient.

What is a TEVAR (Thoracic EndoVascular Aortic Repair)?

Why place a spinal drain?

Management of spinal drain:

Potential complications


Key Points:

  • Pre-op planning: chat with the surgeon before hand regarding a plan. Make sure the OR team understands the plan.
  • Communication: before, during, after the case.
  • Be vigilant about tight BP control

Erector Spinae Plane Block

After speaking to a colleague of mine regarding regional anesthesia for thoracotomy and mastectomy, I am reading up on Erector Spinae Plane (ESP) block.

 

Indications:

 

 

Other regional blocks

Continuous ESP block catheter (my current regimen and what I’m able to get at my institution):

  • Braun Periflex catheter through 17g epidural needle
  • Cranial-to-caudal approach @ T5 (mastectomy, vats, rib fractures)
  • 20ml 0.25% bupi + epi prior to catheter
  • Catheter 5cm in space
  • 5 ml 0.25% bupi + epi after catheter placed
  • Mix: 0.125% bupi + fentanyl @ 10 ml/hr
  • If PCEA available, bolus 15ml every 3 hours; continuous as mix above.