NCM 112 (MEDICAL SURGERY)
LECTURE
CHEST AND LOWER RESPIRATORY TRACT DISORDERS
ANEURYSMS
 It’s a localized sac or dilation formed at a weak point
in the wall of the artery.
 It may be classified by its shape or form.
 The most common forms of aneurysms are:
Saccular
Fusiform
 Saccular aneurysms projects from only one side of
the vessel. If an arterial segment becomes dilated, a
fusiform aneurysm develops.
 Very small aneurysms due to localized infection are
called mycotic aneurysms.
 Historically, the cause of abdominal aortic aneurysm,
the most common type of degenerative aneurysm,
has been attributed to atherosclerotic changes in the
aorta.
 Aneurysms are potentially serious; if they are located
in large vessels that rupture, this can lead to
hemorrhage and death.
THORACIC AORTIC ANEURYSM
 Approximately 70% of all cases of thoracic aortic
aneurysm are caused by atherosclerosis.
 Occur most frequently in men between the ages of 50
and 70 years.
 Thoracic area is the most common site for a
dissecting aneurysm.
 Thoracic aortic emergencies are associated with
high morbidity and mortality rates, but with the
emergence of endovascular aortic repair there is an
improvement in the mortality rate; in particular, the
mortality rate for patients treated at high volume aortic
centers can be as low as 4.8%
CLINICAL MANIFESTATIONS
 Symptoms vary and depend on how rapidly the
aneurysm dilates and how the pulsating mass affects
surrounding intrathoracic structures.
 Some patients are asymptomatic
 Pain is usually constant and boring but may occur
only when the person is supine.
 Other conspicuous symptoms are:
Dyspnea, the result of pressure of the
aneurysm sac against the trachea, a main
bronchus,
Cough, frequently paroxysmal and with a
brassy quality,
Hoarseness, stridor, or vocal weakness
or aphonia (complete loss of the voice),
resulting from pressure against the laryngeal
nerve,
Dysphagia (difficulty in swallowing) due
to impingement on the esophagus by the
aneurysm.
ASSESSMENT AND DIAGNOSTIC FINDINGS
 When large veins in the chest are compressed by the
aneurysm, the superficial veins of the chest, neck, or
arms become dilated, and edematous areas on the
chest wall and cyanosis are often evident.
 Pressure against the cervical sympathetic chain can
result in unequal pupils.
 Diagnosis of a thoracic aortic aneurysm is principally
made by:
Chest X-ray
Computed Tomography Angiography
(CTA)
MRA
Transesophageal Echocardiography
(TEE)
 CTA’s are typically performed because they are
widely available, can be completed rapidly, and can
remove cardiac motion artifacts, enhancing their
accuracy.
MEDICAL MANAGEMENT
 Treatment is based on whether the patient is
symptomatic and whether the aneurysm is
expanding in size, caused by an iatrogenic injury,
contains a dissection, or involves branch vessels.
 General measures such as:
Controlling blood pressure and
correcting risk factors are helpful
 Beta-blockers (e.g., atenolol, metoprolol,
carvedilol) have been the mainstay of medical
treatment for aortic aneurysms; however,
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LECTURE
 Angiotensin receptor blockers (ARBs)
(e.g., losartan, valsartan, irbesartan) may also
retard aortic dilation.
 Controlling blood pressure is also important in
patients with dissecting aneurysms.
 Preoperatively, the systolic pressure is maintained
at approximately 90 to 120 mmHg in order to
maintain a mean arterial pressure at 65 to 75 mmHg
with a beta-blocker such as esmolol or metoprolol.
 Occasionally, antihypertensive agents such as
hydralazine are used for this purpose
 Sodium nitroprusside is the most established drug
used for this purpose; it is given by continuous IV drip
to emergently lower the blood pressure, as it has a
rapid onset and short action of duration and is easily
titrated.
 The goal of the surgery is to repair the aneurysm
and restore vascular continuity with a vascular
graft
 Intensive monitoring is required after this type of
surgery, and the patient is cared for in the critical
care unit.
 Repair using endovascular grafts placed
percutaneously in an interventional suite (e.g.,
interventional radiology, cardiac catheterization
laboratory) or combined interventional suite and
operating room (hybrid suite) may decrease
postoperative recovery time and decrease
complications compared with traditional surgical
techniques.
 Thoracic endografts are made of PTFE material
reinforced with nitinol or titanium stents.
 It is inserted into the thoracic aorta via various
vascular access routes, usually the brachial or
femoral artery. Because a large surgical incision is
not necessary to gain vascular access, the overall
patient recovery time tends to be shorter than with
open surgical repair.
 There is still a chance of spinal cord ischemia as a
potential complication, by decreasing the chances
of spinal cord ischemia and paraplegia, lumbar spinal
drains are usually placed in patients undergoing an
endovascular repair of thoracic aortic aneurysms.
 Cerebrospinal fluid drainage is performed to
decrease the arterial to cerebral spinal fluid
gradient, thereby improving spinal perfusion.
ABDOMINAL AORTIC ANEURYSM
 The most common cause is atherosclerosis
 Most of these aneurysms occur below the renal
arteries (infrarenal aneurysms). Untreated, the
eventual outcome may be rupture and death.
CLINICAL MANIFESTATION
 Some patients complain that they can feel their heart
beating in their abdomen when lying down, or they
may say that they feel an abdominal mass or
abdominal throbbing.
 If the abdominal aortic aneurysm is associated with
thrombus, a major vessel may be occluded, or smaller
distal occlusions may result from emboli.
 Small cholesterol, platelet, or fibrin emboli may lodge
in the interosseous or digital arteries, causing
cyanosis and mottling of the toes (also referred to
as trashing or trash toes).
 Signs of impending rupture include severe back or
abdominal pain, which may be persistent or
intermittent.
 Abdominal pain is often localized in the middle or
lower abdomen to the left of the midline.
 Low back pain may be present because of pressure
of the aneurysm on the lumbar nerves.
 Indications that the abdominal aortic aneurysm may
be leaking, or rupturing include constant, intense
back pain; falling blood pressure; and decreasing
hematocrit. Rupture into the peritoneal cavity is
rapidly fatal.
 A retroperitoneal rupture (contained rupture) of an
aneurysm may result in hematomas in the scrotum,
perineum, flank, or penis.
 Signs of heart failure or a loud bruit may suggest a
rupture into the vena cava. If the aneurysm adheres
to the adjacent vena cava, the vena cava may
become damaged when rupture or leak of the
aneurysm occurs.
 Rupture into the vena cava results in higher-
pressure arterial blood entering the lower-pressure
venous system and causing turbulence, which is
heard as a bruit.
 The high blood pressure and increased blood
volume returning to the right side of the heart from
the vena cava may cause heart failure.
ASSESSMENT AND DIAGNOSTIC FINDINGS
 The most important diagnostic indication is pulsatile
mass in the middle and upper abdomen.
 A systolic bruit may be heard over the mass.
Duplex ultrasonography or CTA is used to
determine the size, length, and location of the
aneurysm.
 When the aneurysm is small, ultrasonography is
conducted at 6-month intervals until the aneurysm
reaches a size so that surgery to prevent rupture is of
more benefit than the possible complications of a
surgical procedure.
GERONTOLOGIC CONSIDERATIONS
 Occur in patients between 60 and 90 years of age.
 Rupture is likely with coexisting hypertension and with
aneurysms more than 6 cm wide.
 If the older patient is considered at risk for
complications related to surgery or anesthesia, the
aneurysm is not repaired until it is at least 5.5 cm
(2 inches) wide.
MEDICAL MANAGEMENT
PHARMACOLOGIC THERAPY
 If the aneurysm is stable in size based on serial
duplex ultrasound scans, the blood pressure is
closely monitored over time, because there is an
association between increased blood pressure and
aneurysm rupture.
 Antihypertensive agents, including diuretics, beta-
blockers, ACE inhibitors, ARBs, and calcium
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LECTURE
channel blockers, are frequently
prescribed to maintain the patient’s blood pressure
within acceptable limits.
ENDOVASCULAR AND SURGICAL MANAGEMENT
 When an abdominal aortic aneurysm measured at
least 5.5 cm (2 inches) wide or was enlarging, the
standard treatment had been open surgical repair of
the aneurysm by resecting the vessel and sewing a
bypass graft in place.
 However, endovascular aortic repair has become a
mainstay of therapy for treating an infrarenal
abdominal aortic aneurysm and involves the
transluminal placement and attachment of a suture
less aortic graft across the aneurysm. It is under local
or regional anesthesia.
 Endovascular grafting of abdominal aortic aneurysms
may be performed if the patient’s abdominal aorta and
iliac arteries are not extremely tortuous, small,
calcified, or filled with thrombi.
 Potential complications include bleeding, hematoma,
or wound infection at the arterial insertion site;
distal ischemia or embolization; dissection or
perforation of the aorta; graft thrombosis or
infection; break of the attachment system; graft
migration; proximal or distal graft leaks; delayed
rupture; and bowel ischemia.
NURSING MANAGEMENT
 Nursing assessment is guided by anticipating
rupture and recognizing that the patient may have
cardiovascular, cerebral, pulmonary, and renal
impairment from atherosclerosis.
 Medical therapies designed to stabilize physiologic
function should be promptly implemented.
 Hemorrhage that leads to shock is a serious
adverse consequence that must be treated decisively.
 The patient who has had an endovascular repair must
lie supine for 6 hours; the head of the bed may be
elevated up to 45 degrees after 2 hours.
 Patient needs to use a bedpan or urinal while on
bed rest.
 Vital signs and Doppler assessment of peripheral
pulses are performed initially every 15 minutes and
then at progressively longer intervals if the patient’s
status remains stable.
 Nurse assesses for bleeding and hematoma
formation.
 Skin changes of the lower extremity, lumbar area, or
buttocks that might indicate signs of embolization,
such as extremely tender, irregularly shaped,
cyanotic areas, as well as any changes in vital
signs, pulse quality, bleeding, pulsation, swelling,
pain, or hematoma, are immediately reported to the
primary provider.
 The patient’s temperature should be monitored
every 4 hours, and any signs of post implantation
syndrome should be reported.
 Post implantation syndrome typically begins within
24 hours of stent graft placement and consists of a
spontaneously occurring fever, leukocytosis, and
occasionally, transient thrombocytopenia.
 Because of the increased risk of hemorrhage, the
primary provider is also notified of persistent
coughing, sneezing, vomiting, or systolic blood
pressure greater than 180 mm Hg.
 An IV infusion may be continued until the patient
can drink normally. Fluids are important to
maintain blood flow through the arterial repair site
and to assist the kidneys with excreting IV contrast
agents and other medications used during the
procedure.
 Postoperative care requires frequent monitoring of
pulmonary, cardiovascular, renal, and neurologic
status.
 Possible complications of surgery include arterial
occlusion, hemorrhage, infection, ischemic bowel,
kidney injury, and erectile dysfunction.
TOPIC
SUBTOPIC
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LECTURE
RISK FACTORS

MEDICAL MANAGEMENT

SUBTOPIC 1

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