SECTION 1.00 WORK UP

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1.01 FOR AN ELECTIVE PATIENT

A full clinical work up is needed. ie

History.
Examination.
Ultrasound or CT scan to exclude a suprarenal aneurysm.
ECG.
Hb + Full blood count.
Clotting screen.
Urea and electrolytes.
Chest X-ray.
Blood glucose.
Cross match 6 units of blood.

1.02 FOR AN URGENT PATIENT -i.e. need to operate within the next 3 hours.

Assess in the Emergency Area, where there is access to resuscitation and imaging.
Do not admit the ward. This will cause unnecessary delays.
Take a history and examine the patient.
Inform the consultant surgeon or the surgeon who will be doing the operation.
Warn the anaesthetic team.
Warn the operating theatre team.
The patient has some pain and an expansile selling.
The diagnosis is in doubt.
About 25% of patients with aneurysms have other causes for abdominal pain e.g. peptic ulcer, ischaemic bowel.
There have been no hypotensive episodes.
The systolic blood pressure is above 100mm of mercury.
The pulse rate is less than 100 per minute.
The same investigations should be done.
Cross match 10 units of blood instead of 6.
The ultrasound or CT scan will indicate whether there is any leakage around the aneurysm or into the peritoneal cavity.

1.02 WORK UP

Some dilatation of the suprarenal aorta up to 25mm is acceptable for grafting.
Dilatation greater than 25mm or thrombus in a suprarenal aneurysm makes a successful operation unlikely.
** NB There is a danger of underestimating the urgency of operation. Patients can deteriorate within minutes. Aneurysm wait for nobody.

1.03 FOR A RAPIDLY DETERIORATING PATIENT - i.e. need to operate as soon as possible.

The patient has pain and an expansile selling.
The diagnosis is clear.
There is no serious intercurrent disease.
Patients over 80 years have less than 20% chance of surviving emergency surgery for aneurysms.
There have been hypotensive episodes.
The systolic blood pressure is below 100mm of mercury.
The pulse rate is more than 100 per minute.
Take blood for:
   Cross matching 10 units of blood.
   Hb + full blood count + clotting screen.
   Urea and electrolytes.
Use a femoral vein stab if the arm veins are not accessible.
Do ECG.
Insert two intravenous lines in the upper limbs. Use 14 swg. diameter cannulas eg Venflon. Use the most peripheral sites possible in the upper limbs.
Scan if immediately available.
Do not shave.

SECTION 1.03 WORK UP

Obtain written consent the patient if there is time.
Do not hesitate.
Call the anaesthetic and scrub team.
***Transfer the patient to the anaesthetic room for resuscitation.