Nursing care of patient with aortic dissection

Kanimozhi A¹*, Reena Ignatius², Cesilipriya S³, Sri Ranjani⁴, Sathiya⁵

¹Assistant Manager (Operation Theatre), Kauvery Heartcity, Trichy, India

²Nurse Educator, Kauvery Heartcity, Trichy, India

³Nursing Incharge, Kauvery Heartcity, Trichy, India

⁴Senior staff nurse, Kauvery Heartcity, Trichy, India

⁵Senior staff nurse, Kauvery Heartcity, Trichy, India

*Correspondence: Tel No: 8508698000; [email protected]

Background

An aortic dissection is a medical emergency in which a tear occurs in the inner layer of the body’s main artery (aorta). It’s most common in men in their 60s and 70s. Blood rushes through the tear, causing the inner and middle layers of the aorta to split (dissect). If the blood goes through the outside aortic wall, aortic dissection is often deadly.

The aorta is the main artery which branches off the heart and supplies oxygen-rich blood to the body’s organs and tissues. The wall of the aorta consists of inner, middle and outer layers. Aortic dissection occurs when there is a tear in the inner layer, which allows blood to enter through the tear and fill up between the inner and middle layers, causing these layers to separate or ‘dissect’.

Stanford classification of aortic dissection:

Type A involves the ascending aorta and may progress to involve the arch and thoracoabdominal aorta.
Type B involves the descending thoracic or thoracoabdominal aorta distal to the left subclavian artery without involvement of ascending aorta.

Acute Type-A aortic dissection is a life-threatening emergency that carries a high mortality rate without surgical treatment. Surgical mortality has been estimated to range from 9% to 30% and survival rates of 51% to 82% at 5yrs. Short-term and long-term survival rates after acute type A aortic dissection are unknown. Previous studies have reported survival rates between 52% and 94% at 1 year and between 45% and 88% at 5 years.

Fig 1: Classification of Aortic Dissection.

Case Presentation:

A 29 years old male who was euglycemic and normotensive came to the hospital with the complaints of breathlessness and orthopnea for past 10day for which he went to outside hospital initially. There, he was diagnosed to have severe left ventricular dysfunction and congestive cardiac failure, and referred here for further management.

On admission, His vital signs were;

Temp – 98.6F, Pulse -88bpm, Respiration -22bpm, B.P -130/90 mm of Hg.

Urine Output was found to be adequate.

He underwent ECG, ECHO, X RAY and CT Angiography.

ECHO findings: Type A aortic dissection, severe aortic regurgitation, poor left ventricular function (EF30 %), mild Mitral regurgitation, severe Tricuspid regurgitation and moderate Pulmonary Artery Hypertension. EF-30%.

CT Angiography findings: Aneurysmal dilatation of aortic root and ascending aorta, Stanford Type-A dissection and ground glass opacities with inter lobar septal thickening in bilateral lower lobes.

He was diagnosed to have Type A Aortic Dissection and was planned for emergency Aortic dissection repair and Right atrial thrombectomy on 20-06-2022.

Pre-operative

Consents are obtained
Ensured sterile equipments are used
Blood arrangements are made.
IPSG goals assessed
WHO checklist was done
Counts are checked twice
TransEosophageal echocardiogram was done
Patient was Haemodynamically monitored

Operational Notes

Right axillary artery exposed and 8mm vascular graft sutured end to side
Midline sternotomy done, Heparinised.
Went on Cardio Pulmonary Bypass (CPB) with aortic and bicaval cannulation, aorta cross clamped.
Transverse Aortotomy, heart arrested with ostial cold blood cardioplegia.
Ascending Aorta excised, aortic valve resuspended, aortic dissection repaired with Teflon felt reinforcement,
Ascending aorta replaced with 6 mm vascular graft.
Superior Vena Cava and Inferior Vena Cava snared, Right atrium opened, right atrial thrombus removed.
Right Atrium closed.
Hot shot given, root vented and gross clamp released. Sinus rhythm achieved
Weaning & decannulation done
Chest drain & Right Ventricular pacing wire placed
Chest closed in routine fashion.

Nursing Management

Immediate postoperative care

Patient was stabilised and transferred to post operative ward.
Transferred to specialised cot with sterile equipments & clothes
Placed under Warmer for thermoregulation, according to patient demand at least for intial 4 hrs
Chest X-ray was taken to obtain the baseline lung assessment
Connected to ventilator, All lines are secured. Bundles chart maintained as per HIC protocol.
Vitals are stable, B.P maintained. Patient was extubated after being conscious & oriented.

Late Post operative

After B.P was stabilised, ionotrophic support was weaned as per Doctor’s order.
ICD drain was assessed, when its below 100ml or serous discharge comes out, Drain will be removed.
4 th hourly once ABG was taken, correction was done according to doctors order.
He was managed with necessary supports total ICD drain was 1360ml.patient was extubated.
Fourth hourly once back care was given
B.P maintained between 110 to 70 mm of Hg
Heart rate should be maintained less than 100bpm.
Active and passive mobilization done
Deep breathing & coughing Exercise was encouraged and taught about Spirometry.