Anaesthesia for vascular emergencies.

Patients presenting with vascular emergencies including acute aortic syndrome, ruptured thoracic or abdominal aortic aneurysms, thoracic aortic trauma and acute lower limb ischaemia have a high risk of peri-operative morbidity and mortality. Although anatomical suitability is not universal, endovascular surgery may improve mortality and the results of ongoing randomised controlled trials are awaited. Permissive hypotension pre-operatively should be the standard of care with the systolic blood pressure kept to 50-100 mmHg as long as consciousness is maintained. The benefit of local anaesthesia over general anaesthesia is not definitive and this decision should be tailored for a given patient and circumstance. Cerebrospinal fluid drainage for prevention of paraplegia is often impractical in the emergency setting and is not backed by strong evidence; however, it should be considered postoperatively if symptoms develop. We discuss the pertinent anaesthetic issues when a patient presents with a vascular emergency and the impact that endovascular repair has on anaesthetic management.

Veno-venous extracorporeal membrane oxygenation and apnoeic oxygenation for tracheo-oesophageal fistula repair in a previously pneumonectomised patient.

The use of extracorporeal membrane oxygenation (ECMO) for elective thoracic surgical procedures has been infrequently reported in the anaesthetic literature. We report the use of intraoperative veno-venous ECMO support for a patient with a previous left pneumonectomy who required a right-sided thoracotomy for repair of a tracheo-oesophageal fistula. To avoid traumatising or pressurising the fistula, a spontaneous ventilation technique was used prior to intubation with a single-lumen endotracheal tube positioned above the level of the fistula. The ECMO cannulas were inserted after induction and ECMO was instituted prior to transfer to the lateral position. Oxygenation during ECMO was augmented with apnoeic oxygen delivery via the breathing circuit. This was associated with an increase in the oxygen saturations from 80% to 99% without compromising surgical access. The use of apnoeic oxygenation via the breathing circuit significantly improved gas exchange in this case and should be considered as an adjunct to veno-venous ECMO.