Case Study Abdominal Aortic Aneurysm Health And Social Care Essay

A 72 year old male patient, smoker and family history of AAA, was referred by his GP to x-ray department. With clinical indication of fall at stairs 2 weeks ago and pain in lower back and right hip, to have an x-ray of lumbar spine and pelvis. After justifying the request card and check his details, they did AP and Lateral of his lumbar an AP examination of pelvis. And they send him back to have a result by his GP after 10 days. Radiologist reported on his x-rays and sends it back to the GP. There was an evaluation of the classification in the abdomen and suspected abdominal aortic aneurysm. So GP asked him to attend the surgery to discuss the x-ray result, and request an ultrasound of abdomen to have a better result and rough indication of the internal diameter and accurate assessment .Gp asked him to wait until he received appointment letter from hospital.

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After 4 weeks he had his appointment. Clinical indication was classification on lumbar x-ray, query abdominal aneurysm. Before he goes to do the screening he was fast for eight hours because food and liquid in the stomach and urine in the bladder can make it difficult to a get clear picture of the aorta for the ultrasound technician. He changed into a gown. Radiologist asked him to lie on his back and then he applied small amount of cold gel in his abdomen because the air between the skin and aorta will help to reduce by using the gel, by pressing the transducer against the skin over the abdomen. Radiologist monitored blood flow through the abdominal aorta to check for an aneurysm (Myo clinical staff 2010 and NHS website 2010). After procedure he discussed the result with patient. And reported the scan to his GP. The evaluation of ultrasound scan was an abdominal aortic aneurysm which was 4.5 cm. Heart was in normal size. No evidence of any significant mediastinal mass or lymph node enlargement. Kidneys were in normal sizes.

The routine measurements and protocol are:

Longitudinally, will examine the aorta from diaphragm to bifurcation, and will Document the length of the aneurysm and measure the anteroposterior (AP) diameter from outer wall to outer wall, and also will examine the iliac arteries to the iliac bifurcation and measure aneurysm from outer wall to outer wall.

Transversically will Document the maximum diameter of the aorta at the diaphragm, superior mesenteric artery (SMA), and distally, and Measure AP and transverse diameters from outer wall to outer wall, also will Visualize the iliac arteries and measure aneurysms (Vikram and Deborah 2004).

GP reoffered him to vascular surgeon, after 3 weeks he met the surgeon, He reviewed his medical history and discussed the x-ray and ultrasound result with him And rerecommend him watchful waiting, it means that the if aneurysm was smaller than 2 inches (5 centimetres) in diameter, it is not serious enough to require surgery. In this case, his doctor will check his condition every six months using additional ultrasound exams or other imaging tests until aneurysm reaches to 5.5cm (Medline Plus 2004). He also asked him to quit smoking, because Smokers are approximately 5times as likely as non-smokers to develop AAA (Hafez 2008).

Six month after In Dec 2007 he received his second appointment for scan of his abdomen. He attends his appointment with same procedure. There was a small amount of increase in his aneurysm. Therefore report was send to Gp. Evaluation was 4.7cm aortic aneurysm.

In April 2008 he had another scan with aneurysm with 5.2cm aneurysm. He could not stop smoking, but his GP strongly advised him to stop smoking. In March 2009, it was 5.6cm aneurysm and if the abdominal aortic aneurysm expands by more than 0.6 to 0.8cm per year, repair is usually recommended (Robert et al 2008).

http://www.e-radiography.net/radrep/Vascular/Vascular_AAA_US_55mm/Vascular_AAA_US_55_long.jpg

Radiological Report : US Abdominal Aorta :

The maximum A.P. internal diameter of the abdominal aorta is 5.6 cms. Mural thrombus reduces the internal diameter to 2.0cms (x-ray 2000). 

Vascular surgeon discussed with patient that he need a surgery as soon as possible, also explained the existence of two possible methods of repair and to outline the major risks and benefits of each. The traditional (open) surgical approach involves direct exposure of the aneurysm followed by replacing the aneurismal part of the aorta with a synthetic graft.

Endovascular aneurysm repair (EVAR) is a more modern and less invasive technique which is becoming widely used (Hafez 2008).

Patient preffered to have EVAR operation, but everybody is not suitable for EVAR, because of the shape of their aneurysm. So he was asked to have a CT angiogram to check if he is suitable for EVAR, otherwise he should have open surgery (NICE 2006). Surgeon request CT angiogram for him with clinical indication of EVAR 5.6cm in ultrasound scan.

The week after he had a CT angiogram aorta. The technologist asked him if he has allergy to any contrast media, then positioned him on the CT examination table, lying flat on his back. He inserted an intravenous (IV) line into a small vein in his arm. A small dose of contrast material injected through the IV to determine how long it takes to reach the area under study.

Week after the surgeon received the report from Radiologist. Evaluation of CT scan was a 6.2cm infrarenal AAA with a satisfactory neck and

good potential common iliac landing zones suitable for EVAR ( Bhattacharya ).

He asked to attend a pre-operative assessment clinic to meet his surgeon and other members of clinical team.

They took his medical history and carried out a physical examination. The surgical team carried out a number of tests to make sure that he is healthy enough to have an anaesthetic and surgery.

The tests were included:

Arterial Blood Gas (ABG) levels, to monitor oxygenation, ventilation, and acid base status.

Complete blood count to monitor Red blood cell, White blood cell(WBC), and platelet counts altered haemoglobin levels and hematocrit reflect any blood loss and the oxygen carrying ability of the blood. An elevated WBC count reflects an inflammatory response.

Serum electrolyte panel-monitors fluid ,electrolyte, and acid base status

Serum creatinine and blood urea nitrogen (BUN) levels, to monitor renal function.

Blood coagulation studies to monitor clotting.

Urinalysis to monitor renal status including secretion and concentration

Blood crossmatching necessary for blood replacement

Electrocardiography (ECG) may reveal cardiac changes associated with ischemia

Chest X-ray may reveal abnormalities of the chest, heart and lungs (Holloway 2004).

his RWS was 4.6 M/mcL, WBC: 6 K/mm^, haemoglobin levels: 11 g/dL, Hematocrit 44%, Blood urea nitrogen 13 mg/dL, Bilirubin, direct 0.2 mg/dL, Bilirubin, total 0.2 mg, Creatinine 0.8 mg/dL,( GAIL HOOD 2007).

The surgical team gave him advice about what he can do to prepare for surgery, and they also asked him about his home circumstances so that his discharge from hospital can be planned. If he still smoker, he strongly advised to stop smoking as soon as surgery is required. Research has found that people who stop smoking for at least two months before having surgery are four times less likely to experience complications following surgery compared with those who smoke. He already stopped smoking. Surgeon discussed him what will happen before, during and after his procedure, and any pain he might have.

On admission day which was the week after, he was seen by one of the junior doctors who was obtained a detailed medical history and did a full physical examination. Blood tests were repeated and any pending investigations (for example heart scan) performed. One of the more senior doctors took through the consent form which you was required to sign before they can proceed with surgery. He was fasting from midnight before the procedure. Nursing care was focused on restoring and maintaining hemodynamic stability. Administer supplemental oxygen, monitor the patient’s cardiovascular status, insert two large-bore I.V. devices, and fluid resuscitate with 0.9% sodium chloride or lactated Ringer’s solution if he’s hypotensive (Raymond 2006).

He was taken to the theatre complex in his bed, In the anaesthetic room. the anaesthetist gave him an epidural and involves a needle puncture into his back. He also had a tube in his bladder, so that they could monitor the function of his kidneys; a tube in his hand, so that they could monitor his blood pressure. Then he transferred to the recovery area in the theatre complex, where he was taken care of by one of the recovery nurses pending transfer to the High Dependency Unit or the Vascular Ward. All the above mentioned tubes stayed in till the next morning, when all the tubes are removed and was encouraged to start walking and moving around. They gave him aspirin and cholesterol-lowering medication. He strongly advised to stay on these for life to reduce the risk of developing heart problems or having a stroke as he grow older. During his hospital stay, he was getting a mini-injection of heparin (Fragmin). This will thin his blood and prevent him from getting clots whilst he is in hospital (Inglott 2007).

So surgeon start elective surgery to repair an aorta. He made small cut in his groin and passed up a catather inside an artery in his leg until it reached the area of the aneurysm. A compressed stent graft was fed to the site of the aneurysm. The procedure was guided using intensifier x-ray machine and radiographer took images step by step. The stent graft is made of a tube supported by a metal mesh. The stent graft was placed across the aneurysm. The stent kept the aorta open and aneurysm was protected from further pressure. The stent graft is slowly released from the delivery system into the aorta. As the stent graft is released, it was expanded to its proper size so that it snugly fits into aorta both above and below the aneurysm The guide wire is then removed from the

Body. The stent graft remained inside the aorta permanently. Imaging procedures was

Performed to check whether the stent graft is properly placed. the cut was closed with stitches and a dressing was placed over the stitches. (Bupa’s Health Information Team 2010).

After the procedure, his breathing tube removed and he was taken to the intensive care unit for recovery. He received fluids and nutrition through his IV. The catheter in his bladder was remained in place for several days. The hospital stay was 5 days. During this time he was encouraged to get up and out of bed. Complete recovery was 3 months.

In order to detect any complication he had need to follow-up carefully, particularly in the early stages. CT angiography was performed at day 2 after placement. No evidence of endoleak was detected during arterial phase scanning or after a 2-min delay. The patient was discharged without complication.Follow-up CT angiography was performed at 1 month and five month. Then every year after that, to make sure there are not any problems.

Discussion:

Aorta is the main blood vessel in body. This carries blood from heart to the rest of the body. The part of the aorta in the abdomen is called the abdominal aorta. It supplies blood to the stomach, pelvis and legs.

An aneurysm is a weak area in a blood vessel. If a blood vessel weakens, it starts to bloat like a balloon and becomes unusually big. If an aneurysm forms on the abdominal aorta and grows too big, the aorta might tear or rupture (Upchurch and Schaub April 1, 2006, Heather 2008).

The most common of these aneurysms known as abdominal aortic aneurysms AAA, is below the origin of the arteries to the kidneys. A more anatomically correct description would be infrarenal aortic aneurysms.

In men, the maximum normal aortic diameter at this level should not exceed 2.5 cm. An aorta that is 3 cm or more in diameter at this level qualifies as being aneurismal. The prevalence of AAA varies according to ethnicity, age and gender. Men are six times more likely to be affected by this condition. At the age of 65 years, 3% of men will have an AAA. The popularity then increases with age to reach nearly 8% at the age of 80. AAAs represents nearly 98% of aneurysms of the whole aorta (Hafez 2008).

The rate of growth and the risk of rupture increase exponentially with the diameter of the aneurysm, with a watershed level for serious risk at about 5.5cm. Therefore until the patient is gravely ill from other causes, any aneurysm wider than 5.5 cm should be operated upon electively (Raymond 2006 and Dillon et al 2010).Abdominal aortic aneurysm is usually asymptomatic .smoking and high blood pressure, are most important risk factors (patient booklet 2009 and Hafez 2008)

About 80% of patients who present with a ruptured abdominal aortic aneurysm have no previous diagnosis. When rupture occurs, mortality is very high (Scot et al 2008 and Philip et al 2009).February

On physical examination, AAAs with 3 to 3.9 cm range are palpable 29% of the time, compared with those with an AAA more than 5 cm. which can be palpated 76% of the time (Gilbert et al 2008).

The symptoms associated with AAAs are:

blurred abdominal or back pain, abdominal pulsatile and abdominal mass may be present

in obese patients, Palpation of aneurysm may be difficult

Early satiety, nausea or vomiting may occur due to duodenal compression.

Ruptured or leaking aneurysms may present with severe back, abdominal, or flank pain that may radiate to the groin

Hypertension or tachycardia

Syncope

Abdominal mass on exam

Signs of retroperitoneal hematoma (Scott et al 2004 and Rosalyn 2006 and Louise and Anderson 2001).

Compared with open surgery, EVAR has lower operative mortality, lower morbidity, and shorter length of hospital stay and greater likelihood of discharge to home than open surgery (Schermerhorn 2009)

CT is the next step to help determine which treatment should be used (endovascular or open surgery) .Serial CT scans can be used to

visualise the proximal neck (the transition between the normal and aneurysmal aorta), the extension to the iliac arteries, and the patency of the visceral arteries. They can also measure the thickness of the mural thrombus.

With three-dimensional imaging, helical CT and CT angiography can provide additional anatomical details, especially useful if endovascular procedure is considered.( Akalihasan et al 2011and Macari et al 2001)

Informed consent for any AAA repair must include accurate information about the reason for recommending surgery (i.e. the risk of aneurysm rupture without surgery), the reason for recommending either open or endovascular surgery and about the likely outcomes. Warn about the site and size of the surgical scar, about wound infection and incisional hernia formation, about deep venous thrombosis and particularly about sexual dysfunction which, it appears, may be equally common after open and endovascular repair (Brian 2008).

If the patient is hypertensive, administer beta-blockers and nitroprusside as ordered. Manage pain with morphine sulfate or hydromorphone to keep him comfortable and to combat pain-induced increases in BP, heart rate, and oxygen demand (GAIL HOOD 2007).

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