May 2019

Article: Abdominal aortic aneurysm repair in the United Kingdom: an exemplar for the role of anaesthetists in perioperative medicine

URL: https://bjanaesthesia.org/article/S0007-0912(17)54111-2/pdf

DOI: 10.1093/bja/aex360

Published: British Journal of Anaesthesia 2017; 119 (S1):i15–i22.

Authors:  S. J. Howell

Article Description: ­­

Data from the 2008 report of the VASCUNET vascular registry suggested that the UK had the highest mortality for elective open abdominal aortic aneurysm (AAA) repair in Europe (7.9%). [Infographic Slide]

In response, a national quality improvement programme (AAAQIP) spanning the disciplines of surgery, anaesthesia, radiology and nursing was put in place. This led to significant changes in all aspects of AAA repair including the role of the anaesthetist. Preoperative assessment by an anaesthetist with a vascular practice was mandated and the role of the anaesthetist in the vascular multidisciplinary team meeting (MDT) established. Anaesthetic data were included in the national data collection system for vascular surgery, the National Vascular Registry.

You can read the Findings and Recommendations of the AAAQIP at the following link (https://www.vsqip.org.uk/content/uploads/2017/06/AAAQIP-Public-Report-_VSGBI-August-2012.pdf).

These changes were associated with decreased mortality from infrarenal AAA repair in the UK to 2.4% by 2012. This improvement reflects changes in perioperative care supported and, in some cases, led by anaesthetists.

Summary:

The wider evolution of the roles of the anaesthetist in perioperative medicine include

  1. The formal initial risk assessment and preoperative assessment.
  2. Risk stratification to predict long-term survival in AAA patients with and without elective AAA repair.
  3. Preoperative identification of patients most at risk of suffering significant adverse long-term outcomes.
  4. There are no sound cardioprotective benefits from the use of beta blockers or aspirin in patients who undergo vascular and endovascular surgery.
  5. The survival rates are comparable between the general and locoregional anaesthetic techniques for open and endovascular AAA repair. However, secondary analyses suggested a substantial survival benefit from regional anaesthesia (https://www.bmj.com/content/bmj/348/bmj.f7661.full.pdf).
  6. Intraoperative care delivered by a specialised vascular anaesthesiologist is associated with better outcomes.
  7. Centres with higher volumes of AAA repair might have better outcomes.

Conclusion:

The role of the anaesthetist in the care of AAA patients has shifted from intraoperative service provider to being integral to the operative decision-making process. The high incidence of cardiac disease and the risk of cardiac complications in this group has made them central to the evolution of the management of cardiac risk in non-cardiac surgery.

Infographic slide

Do you think that involvement of the vascular anaesthesiologist in the perioperative care of patients who undergo AAA could impact the long-term outcome in terms of the quality of life?

Pool 1

Do you think that involvement of the vascular anaesthesiologist in the perioperative care of patients who undergo AAA could impact the long-term outcome in terms of the quality of life?

1- YES
2- NO

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