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By E. Copper. Immaculata College. 2019.

In contrast to phenoxybenzamine cheap cialis soft 20 mg overnight delivery erectile dysfunction suction pump, the effects of phentolamine are reversible (half-life less than 10 minutes) and new receptor synthesis is not required to restore α-adrenoceptor activity and vascular smooth muscle tone cheap cialis soft 20 mg with mastercard impotence cream. Phentolamine is a potent intravenous vasodilator that rapidly decreases arterial pressure buy cialis soft with mastercard erectile dysfunction 23 years old, but in doing so, also causes baroreceptor reflex-mediated tachycardia. Blockade of cardiac α -2 adrenoceptors by phentolamine may contribute to the development of arrhythmias. Phentolamine also exerts antihistamine and cholinergic activity, the latter of which may produce abdominal cramping and diarrhea. Because the drug causes hypotension and tachycardia, phentolamine is relatively contraindicated and should only be used with extreme caution in patients with flow-limiting coronary artery stenoses. Phentolamine is occasionally used as a local vasodilator to prevent tissue necrosis when iatrogenic extravasation of a vasoconstrictor (e. The α- adrenoceptor antagonist may also be effective when treating refractory hypertension associated with clonidine withdrawal or tyramine exposure in patients receiving a monoamine oxidase inhibitor. Unlike phenoxybenzamine and phentolamine, prazosin is a relatively selective antagonist of α -adrenoceptors (α to α ratio of approximately1 1 2 1,000:1) that causes arterial and venous vasodilation. As a result, baroreceptor reflex-mediated tachycardia is substantially attenuated after administration of prazosin. Nevertheless, orthostatic hypotension is an important clinical side effect of prazosin when the drug is used for the treatment of hypertension. Patients who are treated with these medications occasionally58 present for surgery, and anesthesiologists should be aware that anesthetic- induced vasodilation might be exacerbated in the presence of these urologic α -adrenoceptor antagonists. Clonidine is a partial α -adrenoceptor agonist with relative selectivity for α -2 2 versus α -receptors of approximately 200:1. Because of its sympatholytic1 effects, clonidine was originally used for the treatment of hypertension. Activation of α -adrenoceptors in the vasomotor center, attenuation of2 peripheral norepinephrine release from postganglionic sympathetic neurons, and stimulation of central nervous system imidazoline receptors are postulated mechanisms for the antihypertensive effect of clonidine. In addition, clonidine stimulates parasympathetic nervous system activity, which, when combined with withdrawal of sympathetic tone, produces bradycardia. Unlike other antihypertensive medications, clonidine does not affect baroreceptor- mediated reflex control of heart rate. Nevertheless,1 hypotension and bradycardia may occur when large doses of the drug are administered. Clonidine continues to be used as an antihypertensive medication, but the drug also reduces volatile and intravenous anesthetic requirements, blunts the hemodynamic responses to laryngoscopy and endotracheal intubation, promotes intraoperative cardiovascular stability, partially attenuates the sympathetic stress response associated with surgery, and decreases postoperative tissue oxygen requirements. These anti-ischemic actions were presumably related to the drug’s67 sympatholytic effects, which reduce myocardial oxygen consumption. Clonidine augments the effects of local anesthetics and opioids and increases their duration of action when used for neuraxial and regional anesthesia. As68 831 a result, clonidine decreases the incidence and severity of side effects associated with local anesthetics and opioids because the quantities of these latter drugs required for anesthesia and analgesia are reduced. Clonidine is effective as a postoperative analgesic and also has well-documented utility in the treatment of chronic regional pain syndrome and neuropathic pain. The sedative and anxiolytic effects of clonidine are attributed to activation of α -2 adrenoceptors in the locus coeruleus. Notably, clonidine does not substantially inhibit respiratory drive in the presence or absence of opioids despite the α -2 adrenoceptor agonist’s sedative effect. Thus, clonidine’s sedative–analgesic69 effects may be exploited without undo concern about the potential for respiratory depression. Hyperglycemia may occur in patients treated with clonidine because the α -adrenoceptor agonist inhibits insulin release. This2 side effect may be especially important in patients with poorly controlled diabetes mellitus. Finally, anesthesiologists may occasionally encounter patients who are receiving clonidine to mitigate withdrawal symptoms associated with treatment of a substance abuse disorder. Under these circumstances, invasive monitoring of arterial pressure in an intensive care unit setting and treatment of hypertension with other intravenous medications may be necessary until oral clonidine therapy can be resumed. Alternatively, transdermal clonidine may be used to mitigate or prevent drug withdrawal–induced hypertensive emergency in those patients who are unable to consume the medication. It is important to note that transdermal clonidine requires approximately 48 hours after initial application to achieve therapeutic serum concentrations. Dexmedetomidine is approximately sevenfold more selective for the α -adrenoceptor (α to α ratio of 1,600:1) and has a substantially2 2 1 shorter context-sensitive half-life than clonidine. These characteristics make an intravenous infusion of dexmedetomidine useful for sedation, amnesia, and analgesia in the operating room and intensive care unit. This latter feature is especially beneficial in the setting of elective fiberoptic intubation or weaning from mechanical ventilation. Dexmedetomidine’s relative preservation of respiratory drive and its lack of 832 effects on electrophysiologic monitoring make the α -adrenoceptor agonist2 useful for functional neurosurgery. When used as a sedative in the intensive75 care patients, dexmedetomidine reduced the incidence of delirium, the duration of mechanical ventilation, the length of intensive care unit stay, and mortality compared with midazolam. Dexmedetomidine may be associated76 with hypothermia because the drug lowers the threshold body temperature at which compensatory thermoregulation mechanisms are activated. The peer-reviewed literature describing the actions, uses, and potential limitations of β-blockers is exhaustive. It is not the authors’ intention to review this literature in detail; instead, we wish to highlight the major effects and clinical applications of the most ubiquitous drugs in cardiovascular pharmacology. These medications have been repeatedly shown to reduce morbidity and mortality associated with myocardial infarction in a large number of clinical trials. These combined effects serve to reduce myocardial oxygen demand while simultaneously increasing supply. This latter action is particularly important during acute myocardial ischemia or evolving myocardial infarction because platelet aggregation at the site of an atherosclerotic plaque may worsen a coronary stenosis or produce acute occlusion of the vessel. Perhaps, of most relevance to anesthesiologists, perioperative administration of β-blockers has been shown to reduce the incidence of nonfatal myocardial infarction in patients undergoing noncardiac surgery. Propranolol and other β-blockers are chemically related to isoproterenol and contain an aromatic moiety linked to the ethanolamine group, the latter of which allows interaction with the β-adrenoceptor. Additions to the molecule’s aromatic group determine the degree of β -adrenoceptor specificity. All β-1 blockers have a chiral center; the negative enantiomer of each drug is biologically active. The relative selectivity of β-blockers for β - and β -1 2 adrenoceptors, their lipid solubility, and the presence or absence of intrinsic sympathomimetic ability (e. The ability to prevent isoproterenol- induced increases in heart rate defines each β-blocker’s potency (propranolol is considered the standard in these determinations). Propranolol is a “first- generation” (nonselective) β-blocker that competitively inhibits both β - and1 β -adrenoceptors, whereas metoprolol, atenolol, and esmolol are classified as2 “second-generation” β-blockers because these drugs are selective for the β -1 adrenoceptor. Notably, this β -adrenoceptor selectivity is relative because1 larger doses of second-generation β-blockers inhibit both β - and β -1 2 adrenceptors. For example, labetalol blocks α -adrenoceptors; carvedilol exerts antioxidant and anti-inflammatory actions;1 bucindolol has intrinsic sympathomimetic effects because it is a partial agonist of β -adrenoceptors; and nebivolol produces nitric oxide–mediated1 vasodilation through its actions on vascular endothelium.

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Abdominal wall defect repair with biological prosthesis in transplanted patients: single center retrospective analysis and review of the literature buy cialis soft 20mg free shipping erectile dysfunction causes agent orange. A 5-year clinical experience with single-staged repairs of infected and contaminated abdominal wall defects utilizing biologic mesh buy discount cialis soft 20mg online vascular erectile dysfunction treatment. The role of biologic mesh in abdominal wall reconstruction: a systematic review of the current literature purchase 20mg cialis soft with visa impotence after 60. Repair of incisional hernias with biological prosthesis: a systematic review of current evidence. Management and closure of the open abdomen after damage control laparotomy for trauma. Systematic review and meta-analysis of the repair of potentially contaminated and contaminated abdominal wall defects. Performance of biologic mesh materials in abdominal wall reconstruction - a randomized con- trolled trial. A prospective randomized trial of biologic mesh versus synthetic mesh for the repair of com- plex ventral hernias. A randomized, prospective, double blind clinical trial of non-cross-linked porcine dermis vs. Prospective trial comparing the performance profles of two non-cross-linked porcine dermal matrices in abdominal wall reconstruction. A prospective randomized trial of biologic mesh versus synthetic mesh for the repair of com- plex ventral hernias. Multicentric prospective randomized study comparing technique of tension-free repair with placement of a bovine pericardium bioprosthesis (Tutopatch® and Tutomesh®) to current con- ventional surgical techniques in potentially contaminated hernia repair and abdominal wall reconstruction. Clinical outcomes achieved and the staffng resources required were compared for 30 high-risk open abdominal surgery patients at two metropolitan hospitals. Both hospitals were simi- lar in preoperative morbidity, demographics, and operative characteristics. Development of clinically rele- vant outcome measures such as those described can provide objective data for guid- ing staffng, future service planning, and setting research priorities. Lately, the same group conducted a study aiming to determine if the addition of deep breathing exercises and secretion clearing techniques to a standardized physiotherapist-directed program of early mobilization improved clinical outcomes in patients undergoing open abdominal surgery. This study suggested that, in this clinical setting, the addition of deep breathing and coughing exercises to a physiotherapist-directed program of early mobilization does not signifcantly reduce the incidence of clinically signifcant postoperative pulmonary complications in high-risk open abdominal surgery subjects. This study found that, in this clinical setting, the addition of coached lateral basal expansion and secretion clearance techniques to a targeted program of physiotherapist- directed early mobilization conferred no additional beneft in reducing the incidence of postoperative pulmonary complications after open abdominal surgery in high-risk subjects. This study was signifcant in that, unlike previous randomized trials of physio- therapy after open abdominal surgery, it documented the actual type and dosage of physiotherapy interventions and used a sample of subjects from the population of open abdominal surgery patients who are most likely to beneft from physiotherapy, that is, those identifed as high risk of developing postoperative pulmonary complications. These results were obtained in a clinical setting where patient-controlled epi- dural analgesia was used extensively and the standardized early mobilization pro- gram was implemented and monitored by the physiotherapists. Due to the lack of literature in the rehabilitation after open abdomen procedures in emergency surgery, we can investigate other kinds of abdominal surgery to derive a rationale to apply in rehabilitation programs after and during open abdomen procedures. Many authors talk about surgery interventions that allow patients to conduct some preoperative physical activities in order to undergo surgery in the best physi- cal condition; as far as open abdomen surgery is concerned, this kind of prevention is not possible because it is often an emergency condition. Moreover, after surgery, patients experience tiredness, lethargy, changed emotional state, and a desire to sleep and rest, more commonly known as “postoperative fatigue. These interventions may include lung expansion exercises, secretion clearance techniques, limb exercises, progressive mobilization programs, and other tech- niques [2, 4]. Multiple fac- tors may be involved in diaphragmatic dysfunction, such as irritation and infamma- tion caused by trauma from manipulation close to the diaphragm, refex inhibition of afferent abdominal receptors, and postoperative pain. The incidence of postoperative pulmonary complications has been shown to be lower in open abdominal surgery patients who receive physiotherapy compared to those who receive none [2, 10, 11]. In some cases, such as low blood pressure, severe premorbid debility, patient refusal, pain, atrial fbrillation or other cardiac arrhythmia, nausea and vomiting, motor block from epidural, nurse concern, low hemoglobin, or others [12], physio- therapy should be delayed in order to permit patient’s clinical stabilization. Raised maximal oral temperature >38°C on more than one consecutive postop- erative day 3. Pulse oximetry oxygen saturation (SpO2) <90% on more than one consecutive postoperative day 4. An otherwise unexplained white cell count greater than 11 × 109/l or prescrip- tion of an antibiotic specifc for respiratory infection 7. New abnormal breath sounds on auscultation different to preoperative assessment 8. Since clinical decisions about patient management incorporate a wide range of factors, practical approaches are required to assist clinicians in making the optimal management decisions. Outcome measures most frequently used are temperature, expectoration, subjec- tive experiences and time to chest tube removal, postoperative complications, alveo- lar–arteriolar oxygen difference and cough, dyspnea, mobilization, pain, use of bronchodilators, antibiotics, oxygen, pulse rate, and pulmonary auscultation [13]. Decreased cognition also has been cited as a risk factor for pulmonary complica- tions due to the decreased ability to protect their airway [1, 14]. The primary modifable risk factors are shallow breathing, incision pain, and immo- bility. Breathing exercises and early mobilization are cornerstones of postoperative management. Early mobility following surgery is deemed crucial, since postoperative immobilization is widely held to contribute to cardiovascular instability, thromboem- bolic complications, and catabolism, in addition to pulmonary morbidity. Patients are included in standardized programs of physical therapy treatment which structured the model of patient care, focusing on the use of additional therapeutic resources [4, 15, 16], early sitting position, and ambulation (onset <48 h after surgery) [4, 17]. Physical therapy modalities are generally left to the discretion of the therapists, provided that they correspond with guidelines regarding abdominal strengthening and stabilization, abdominal myofascial release and scar mobilization/massage, core strengthening in neutral only (no crunches), balance training, hip mobilization, gluteus medius strengthening, lumbar strengthening, posture retraining, and upper back strengthening. Physical therapy is recommended—at least two sessions per week for 6 weeks—and encourages a return to independence with regard to mobil- ity and activities of daily living [19]. Sitting out of bed has been shown to be associated with an increase in postoperative func- tional residual capacity [20], and it has been suggested that a program of active enforced progressive mobilization can improve pulmonary function [21]. In the immediate frst period after surgery, it is important to encourage people to move in the right way in order to prevent fear of movement, pain, and lung volume reduction. Changes in body position and physiotherapy aimed to airways clearance are the most necessary interventions. In a second postoperative phase, when the patient has fnally reached stable clinical conditions, it is important to focus on physical activity in order to recover a complete independence in all daily living activities [1, 2, 7, 20, 23–25]. They found out that the sitting and semire- cumbent positions compared with the supine position in six of 12 studies improved postoperative pulmonary function. However, a change from the supine to lateral position in patients in the intensive care unit showed a limited effect on pulmonary function. The duration of the mobilization has not been considered, including repeated measurements over days. The physiologic effects of postoperative immo- bilization have never been thoroughly examined, but are widely supposed to add to thromboembolic and pulmonary complications as well as catabolism and cardiovas- cular instability [27]. Although most agree that postoperative immobilization should be avoided, standard care often includes physiological immobilization for several days [28].

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Advocating policy with patient safety in the balance: The case of cervical spine clearance buy 20mg cialis soft with visa erectile dysfunction high blood pressure. Utility of magnetic resonance imaging in diagnosing cervical spine in children with severe traumatic brain injury cialis soft 20 mg with mastercard erectile dysfunction solutions. Cervical spinal cord discount cialis soft 20 mg without a prescription erectile dysfunction causes cures, root, and bony spine 3835 injuries: A closed claims analysis. Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Cervical spinal motion during intubation: Efficacy of stabilization maneuvers in the setting of complete segmental instability. Motion of cadaver model of cervical injury during endotracheal intubation with a Bullard laryngoscope or a Macintosh blade with and without in-line stabilization. Management of laryngo-tracheal injuries associated with craniomaxillofacial trauma. Management of maxillofacial injuries with severe oronasal hemorrhage: A multicenter perspective. Transcatheter arterial embolization in the treatment of maxillofacial trauma induced life-threatening hemmorrhages. Utilization of tracheostomy in craniomaxillofacial trauma at a level-1 trauma center. Anesthetic management of complete tracheal disruption using percutaneous cardiopulmonary support system. Airway management following repair of cervical tracheal injuries: A retrospective, multicenter study. Acute tracheoesophageal burst injury afteer blunt chest trauma: Case report and review of the literature. Incidence, risk factors, and outcomes for occult pneumpthoraces in victims of major trauma. Pulmonary contusion: An update on recent advances in clinical management World J Surg. Critical evaluation of pulmonary contusion in the early post-traumatic period: Risk of assisted ventilation. Rib score: A novel radiographic score based on fracture pattern that predicts pneumonia, respiratory failure, and tracheostomy. The pathophysiology, diagnosis, and management strategies for flail chest injury and pulmonary contusion. Mechanical ventilation with lower tidal volumes and positive end-expiratory pressure prevents pulmonary inflammation in patients without preexisting lung injury. Use of airway pressure release ventilation is associated witha reduced incidence of ventilator-associated pneumonia in patients with pulmonary contusion. Airway pressure release ventilation in the acute respiratory distress syndrome following traumatic injury. Acute pain management of patients with multipl fractured ribs: A focus on regional techniques. Discrepancy between heart rate and makers of hypoperfusion is a predictor of mortality in trauma patients. In search of the optimal end points of resuscitation in trauma patients: A review. Systolic blood pressure criteria in the national trauma triage protocol for geriatric trauma: 110 is the new 90. Admission hematocrit predicts the need for transfusion secondary to hemorrhage in pediatric blunt trauma patients. Diagnostic performance of serial haematocrit measurements in identifying major injury in adult trauma patients. Early identification of uncontrolled hemorrhage after trauma: Current status and future direction. Identifying life-threatening shock in the older injured patient: An analysis of the National Trauma Data Bank. Correlation of computed tomographic signs of hypoperfusion and clinical hypoperfusion in adult blunt trauma patients. The massive transfusion score as a decision aid for resuscitation: Learning when to turn the massive transfusion protocol on and off. All massive transfusion criteria are not created equal: Defining the predictive value of individual transfusion triggers to better determine who benefits from blood. Impact of common crystalloid solutions on resuscitation markers following Class 1 hemorrhage: A randomized control trial. Crystalloid to packed red cell transfusion ratio in the massively transfused patient: When a little goes a long way. Crystalloid administration during trauma resuscitation: Does less really equal more? Early coagulopathy in multiple injury: An analysis from the German Trauma Registry on 8724 patients. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. Low-volume fluid resuscitation for presumed hemorrhagic shock: Helpful or harmful? A controlled resuscitation strategy is feasible and safe in hypotensive trauma patients: Results of a prospective randomized pilot trial. Impact of age of transfused blood on cerebral oxygenation in male patients with severe traumatic brain injury. Blood transfusion, independent of shock severity, is associated with worse outcome in trauma. Safety of uncrossmatched type-O red cells for resuscitation from hemorrhagic shock. Minimizing dilutional coagulopathy in exsanguinating hemorrhage: A computer simulation. Damage control resuscitation: Directly addressing the early coagulopathy of trauma. Tha ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. Early predictors of massive transfusion in patients sustaining torso gunshot wounds in a civilian level I trauma center. Clearly defining pediatric massive transfusion: Cutting through the fog and the friction with combat data. Goal-directed hemostatic resuscitation for massively bleeding patients: The Copenhagen concept. Evolving beyond the vicious triad: Differential mediation of traumatic coagulopathy by injury, shock, and resuscitation.

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Once the proximal anastomosis is made purchase 20 mg cialis soft amex erectile dysfunction drugs south africa, the clamp is moved from native aorta to graft in order to allow reperfusion of the celiac and renal beds generic cialis soft 20 mg line impotence losartan. This is usually hemodynamically insignificant due to the relatively short duration of ischemia and rapid reapplication of the cross-clamp distal to the visceral vessels until the distal anastomosis (or purchase genuine cialis soft on-line erectile dysfunction treatment duration, in the case of bifurcated graft, anastomoses) are complete. The subsequent release of the distal clamp(s) results in the release of inflammatory mediators, decreased cardiac output, hypoxemia-mediated vasodilation, and a reactive hyperemia that ultimately culminates in profound vasodilation and arterial hypotension (Fig. A relative central hypovolemia develops as blood pools in tissue distal to the cross-clamp. Various therapies have been employed to counteract this response, with no evidence to suggest superiority of one method over another. Most anesthesiologists employ some degree of volume loading during the period of cross-clamp application. Vasoconstrictors such as phenylephrine or norepinephrine, or inotropic agents such as epinephrine or calcium chloride are frequently employed in conjunction with volume loading. It may also be prudent to decrease anesthetic depth and/or discontinue epidural infusions in anticipation of these predictable changes. Preferable to pharmacologic manipulation is a gradual release of the cross- clamp to allow for a slow, controlled release of vasoactive and cardiodepressant mediators. If bilateral iliac clamps are employed, the lower extremities can be reperfused sequentially to allow for a more controlled release and appropriate resuscitation. Clear communication with the vascular surgeon is vital to coordinate appropriate management. For example, bleeding at the anastomosis requires immediate reclamping; if vasopressors and inotropes are administered as boluses and then the clamp is reapplied, profound proximal hypertension can ensue. Passive venous recoil distal the aortic cross-clamp results in a shift in blood volume from distal to the aortic occlusion to proximal to the occlusion. If the aorta is occluded above the level of the celiac axis, the splanchnic reserve is redistributed to the organs and tissues proximal to the clamp. If an infraceliac cross-clamp is placed, the blood volume may shift into the splanchnic system in addition to other organs proximal to the clamp. The ability to shift into or out of the splanchnic vasculature accounts for variability in preload augmentation. Preoperative renal dysfunction is the most powerful predictor of postoperative renal dysfunction. There is no proven renal protective strategy other than minimizing the length of ischemia and avoidance of profound or prolonged hypotension. The incidence of acute renal failure is approximately 5% following infrarenal cross-clamping and approaches 13% after suprarenal cross-clamping. Blood flow is not only reduced but also redistributed, favoring flow to the cortical and juxtamedullary layers over the hypoxia-prone renal medulla. These alterations are predominantly a result of neurohumoral activation rather due to changes in hemodynamics or cardiac output. Physiologic fluctuations do not immediately revert after the release of cross-clamping and may persist for at least 30 minutes beyond systemic cardiovascular return to baseline. Thus, tincture of time may be the best management of decreased urine output in the immediate post–cross-clamping period. Many different pharmacologic methods of renal protection have been advocated, most centering on improving renal blood flow or glomerular flow. In the interim, significant fluid shifting may result in depletion of intravascular volume, adding further renal insult. Diuretics should be reserved only for patients who are demonstrably volume overloaded and then used judiciously to effect. Fenoldopam, a selective dopamine agonist, has shown promise in some clinical trials but results have been conflicting in cardiovascular surgery. In this study, ischemic preconditioning was found to decrease the incidence of postoperative renal insufficiency by 23%. A complex cascade of events, including release of inflammatory mediators, distal vasodilation, increased vascular permeability, and decreased myocardial contractility results in a relative central hypovolemia, decreased cardiac output, and systemic hypotension. The posterior spinal arteries supply approximately 25% of spinal cord blood flow and supply the sensory tracts of the posterior columns. The anterior spinal artery supplies the anterolateral cord, including motor tracts, and supplies 75% of the spinal cord blood flow. The anterior spinal artery is fed by a series of radicular arteries arising from the aorta, although collateralization is variable. This leaves areas of the spinal cord vulnerable to watershed ischemia, particularly with aortic occlusion or prolonged hypotension. The single most important radicular artery supplying the thoracolumbar cord is derived from the artery of Adamkiewicz. The artery of 2804 Adamkiewicz originates between T8 and T12 in 75% of cases and at the level of L1 or L2 in an additional 10% of cases. The singular anterior spinal artery and paired posterior spinal arteries arise from the posterior circulation and provide blood supply to the spinal cord. Variability in collateral flow helps to explain, in part, the unpredictability of paraplegia following aortic surgery. Pertinent risks for spinal cord ischemia include previous aortic surgery (particularly with vascular exclusion of major thoracic radicular collaterals), open surgical repair, aortic cross-clamp location and duration, length of aortic replacement, and intraoperative hypotension/hypoperfusion. The definitive measures to prevent spinal cord ischemia are a short cross-clamp time, maintenance of normal cardiac function, and higher perfusion pressures. Segmental sequential surgical repair may minimize the duration of ischemia to any given vascular bed. Anesthetic Management of Open Aortic Reconstruction Abdominal aortic reconstruction may be approached via a transabdominal or retroperitoneal approach. In the first case, a thoracoabdominal midline incision is performed and the aorta is accessed via the peritoneum. This allows generous exposure and is usually favored for complex aortic reconstruction or replacement. In the retroperitoneal approach, incision is made over the lateral order of the left rectus muscle, from the level of the 12th rib to several centimeters below the umbilicus. This approach allows access to the aorta from the crux of the diaphragm to its bifurcation. Barring contraindication to neuraxial instrumentation, an epidural catheter should be considered. A functional epidural may be used intraoperatively to manage the hemodynamic lability of aortic cross-clamping, decrease postoperative sympathetic stimulation, aid in postoperative pain control, and potentially aid in weaning from mechanical ventilation. Although most ischemic complications are the result of dislodgment of atheromatous material off the disease aorta and not de novo clot formation, most surgeons administer 2806 intravenous heparin to reduce the risk of thromboembolic events before aortic cross-clamping. If neuraxial instrumentation is attempted, heparin dosing should be delayed per current guidelines. Induction of general anesthesia and intubation can be associated with dramatic hemodynamic lability and sympathetic stimulation, which may put the aneurysm at risk of rupture. It is prudent to ensure adequate blood product availability in the operating room and large-bore peripheral intravenous access prior to the induction of general anesthesia.

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