Emergency repair

The principles of management are similar to those discussed above. However, the patient may be grossly hypovolaemic and often arterial pressure is maintained only by marked systemic vasoconstriction and the action of abdominal muscle tone acting on intra-abdominal capacitance vessels. Resuscitation with intravenous fluids before the patient reaches the operating theatre should be judicious, as hypertension may increase the extent of haemorrhage. The patient is prepared and anaesthetized on the operating table. While 100% oxygen is administered by mask, all monitoring catheters and two large-gauge i.v. cannulae are inserted under local anaesthesia. The surgeon then prepares and towels the patient ready for surgery and it is only at this point that anaesthesia is induced using a rapid-sequence technique. When muscle relaxation occurs, systemic arterial pressure may decrease precipitously and immediate laparotomy and aortic clamping may be required. Thereafter, the procedure is similar to that for elective repair.

The prognosis is poor for several reasons. There has been no preoperative preparation and most patients have concurrent disease. There may have been a period of severe hypotension, resulting in impairment of renal, cerebral or myocardial function. Massive blood transfusion, with its own attendant risks, is usually required. Postoperative jaundice is common because of haemolysis of damaged red cells in the circulation and in the large retroperitoneal haematoma which usually develops after aortic rupture. In addition, postoperative renal impairment and prolonged ileus often occur, frequently prolonging artificial ventilation for several days.

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