Arterial dissection refers to the gradual detachment and expansion of the intima due to local tearing and strong blood impact, resulting in the formation of true and false lumens within the artery. This leads to a series of manifestations including tearing like pain. The aorta is the main blood vessel of the body, which bears direct pressure from the beating of the heart and has a huge blood flow. If left untreated, there is a high chance of rupture and a high mortality rate.
The treatment methods for aortic dissection mainly include conservative treatment, interventional treatment, and surgical treatment. Surgical treatment is the most effective and long-term remedial treatment for aortic dissection, which is the fundamental method to completely remove the lesion, prevent its development, and rescue complications such as rupture and organ ischemia. For ascending aortic dissection (type A), although effectively treated with antihypertensive medicine, the risk of fatal complications such as aortic rupture or pericardial tamponade remains quite high. Therefore, it is currently advocated that once diagnosed, timely surgical treatment should be the first choice if conditions permit. Due to the relatively low risk of rupture in type B aortic dissection and the high mortality rate of descending aortic surgery, acute ischemia caused by aortic clamping during surgery can lead to serious complications such as paraplegia and acute renal failure. Therefore, the surgical indications for type B are limited to cases with concurrent aortic rupture, poor distal perfusion, expansion and spread of dissection after drug treatment, uncontrolled hypertension, and severe pain. In recent years, with the development of minimally invasive vascular surgery, interventional vascular therapy techniques have been applied to the treatment of aortic dissection.
General postoperative care for aortic dissection: 1. Electrocardiogram monitoring. Aortic surgery has a wide range of procedures, multiple anastomosis sites, myocardial occlusion, and long extracorporeal circulation time, which may lead to postoperative arrhythmia, myocardial ischemia, low cardiac output, and even cardiac arrest. Postoperative multi parameter physiological monitoring and hemodynamic monitoring are required. Routine electrocardiogram should be performed immediately after surgery, and any abnormal electrocardiogram should be reported and dealt with promptly. 2. Blood pressure monitoring. Preoperative hypertension, surgical hypothermia, postoperative pain, and confusion can all cause an increase in postoperative blood pressure. High blood pressure can easily lead to anastomotic leakage and suture tearing, so postoperative blood pressure must be controlled. Postoperative warmth and sedation can prevent blood pressure elevation caused by vasoconstriction, pain, and tension. Vasodilators can be administered, commonly including nitroglycerin, sodium nitroprusside, and nifedipine, which generally need to be controlled at a systolic blood pressure of around 110mmHg. If there is excessive bleeding during or after surgery, insufficient blood volume leading to hypotension and increased lactate, timely infusion of colloids such as plasma, albumin, or plasma substitutes should be administered. The speed of fluid replacement is controlled based on the patient's cardiac function and central venous pressure. If the blood volume has been replenished and the central venous pressure has exceeded the normal range, but the blood pressure is still at a low level, consider the possibility of low cardiac output or cardiac tamponade. Follow the doctor's advice to administer positive inotropic drugs such as dopamine, norepinephrine, and epinephrine to increase myocardial contractility, or perform chest exploration in a timely manner. 3. Respiratory care. After surgery, the patient needs mechanical assisted breathing, with an initial inhalation oxygen concentration of 80%, and then adjusting the ventilator parameters based on blood gas results. Keep the respiratory tract unobstructed and suction phlegm as needed. Routine daily chest X-ray and symptomatic treatment based on the results. After removing the endotracheal tube, the surgery often causes pain in the lung due to its impact on the wound area. Postoperative fatigue makes it difficult for patients to effectively cough up phlegm. Therefore, pulmonary therapy such as nebulization, physical therapy, and the use of expectorants should be actively applied. If necessary, nasal suctioning can be used to help patients effectively clear their respiratory tract. 4. Observation of Consciousness: During the process of awakening, pay attention to observing the patient's consciousness and pupil condition. After anesthesia, observe whether the patient can perform directive movements and autonomous activities. For patients with delayed awakening, confusion, or agitation, medications that nourish the brain nerves and dehydrating drugs such as Xingnaojing and mannitol can be given. 5. Renal function testing. Routine indwelling catheterization is performed after surgery, and urine volume is recorded once per hour. A urine volume greater than 1ml/(kg · h) indicates good circulation. If oliguria is caused by insufficient blood volume or low blood pressure, blood volume can be replenished in a timely manner. When blood volume is sufficient but oliguria persists, diuretics can be administered intravenously. 6. Observation of drainage fluid. In the early postoperative period, the amount and nature of the drainage fluid in the chest and abdominal cavity should be observed at all times. If the drainage fluid continues to increase and exceeds 4ml/(kg · h), the surgeon should be notified in a timely manner to determine whether a second thoracotomy is needed for hemostasis. Observe whether there are blood clots in the drainage fluid, monitor the coagulation time of whole blood to understand the neutralization of protamine during surgery, and follow the doctor's advice to give protamine, fresh plasma, fibrinogen, or directly inject clotting factors to increase the coagulation factors in the patient's plasma, or give hemostatic drugs to reduce postoperative bleeding. 7. Observation of blood supply to the main branches of the aorta. The obstruction of the connection between the artificial blood vessel and the main branches of the aorta after surgery, the occurrence of dissection, and the formation of thrombosis can cause ischemia, hypoxia, and dysfunction of the branch blood vessel supply organs. Therefore, it is necessary to constantly observe whether the peripheral arterial pulsation of the patient's limbs is good, as well as the temperature and color of the skin on the limbs. Monitor limb blood pressure, record every 6 hours, and compare it with previous blood pressure levels. If there is a significant difference, notify the doctor to identify the cause. 8. Observation of the digestive system. After surgery, a gastric tube is routinely left in place to keep it unobstructed, and intermittent flushing with warm water can be used. Administer intestinal decompression and observe the amount, color, and properties of gastric juice. If the gastric juice is bright red, consider whether there is stress-induced gastrointestinal bleeding. Postoperative routine administration of acid suppressants to prevent the occurrence of stress ulcers. Daily auscultation of bowel sounds and asking if the patient has exhaled. Unventilated individuals should abstain from drinking water. If thirsty, they can drink a small amount of water to make the patient feel more comfortable. The usual amount of drinking water is 10-20ml per session, limited to moistening the mouth. Accurately record the amount of water consumed. Patients who fast from water need oral care to maintain oral hygiene. The occurrence of gastrointestinal bloating can be reduced by gastrointestinal decompression or by administering laxatives to promote intestinal peristalsis and facilitate early expulsion.