endovascular repair question

SubSippi · Mar 8, 2015

Use your critical thinking skills...

The patient has a history of AAA repair. This means that a graft is placed in the patient's aorta to shunt blood flow past the aneurysm, and that there will always be a risk for something going wrong with the graft, such as the graft getting a kink or migrating out of place. Depending on the type of surgery, the aorta is still at risk for rupturing. There is also a risk for thrombus formation.

Knowing that, how could a history of AAA repair be significant when a patient is complaining of weakness and back pain? Give it some thought, I'm sure you know the answer.

I'm not super experienced, but once I found out the patient's history, my first move would have been to tell the doc and get an abdominal CT, because this is really the only way to see what's going on in the aorta. Even if vital signs are stable and labs are good, since this patient is new to you, you don't know what their real baseline is, so when a patient has these sorts of risks, you can't blow it off. It doesn't sound like anything really bad ended up happening to the patient from your post, but it definitely could have, and I agree with the doctor that it was a pretty big miss, whether you're new or not.

Lastly, from this point on, you should keep in mind that a current AAA or even a history of a repair is something that is always going to be worth telling the doctor about, even if you're not sure it is relevant to the chief complaint.

That's pretty much all I have to say, I would love to hear from someone who has lots of experience with this.

What ended up happening with the patient? What did your colleagues say?

rearviewmirror, BSN, RN · Mar 8, 2015

Use your critical thinking skills...
The patient has a history of AAA repair. This means that a graft is placed in the patient's aorta to shunt blood flow past the aneurysm, and that there will always be a risk for something going wrong with the graft, such as the graft getting a kink or migrating out of place. Depending on the type of surgery, the aorta is still at risk for rupturing. There is also a risk for thrombus formation.
Knowing that, how could a history of AAA repair be significant when a patient is complaining of weakness and back pain? Give it some thought, I'm sure you know the answer.
I'm not super experienced, but once I found out the patient's history, my first move would have been to tell the doc and get an abdominal CT, because this is really the only way to see what's going on in the aorta. Even if vital signs are stable and labs are good, since this patient is new to you, you don't know what their real baseline is, so when a patient has these sorts of risks, you can't blow it off. It doesn't sound like anything really bad ended up happening to the patient from your post, but it definitely could have, and I agree with the doctor that it was a pretty big miss, whether you're new or not.
Lastly, from this point on, you should keep in mind that a current AAA or even a history of a repair is something that is always going to be worth telling the doctor about, even if you're not sure it is relevant to the chief complaint.
That's pretty much all I have to say, I would love to hear from someone who has lots of experience with this.
What ended up happening with the patient? What did your colleagues say?

ct showed endoleak, so it was no full blown dissection or another rupture, but pretty bad leak. he was stable for the whole time until i took him upto icu. he will need surgery pretty quick though. but all in all in all, I will not forget from this exp and definitely will be on alert when AAA pt rolls in, I guess you learn from knowing nothing to something :) thank you for your post!

Anna Flaxis, BSN, RN · Mar 8, 2015

Weakness+back pain can be signs of AAA, and with the history of AAA repair, this suggests continued bleeding, which should get your Spidey senses tingling, and at least get you to track down the doc and mention "Hey, I just put this guy in room X- he has a history of AAA repair and he's here for back pain and weakness- his BP is XXX/XX with a HR of XX, just thought I'd let you know, is there anything you want me to do right now?".

Does this mean that every patient with a complaint of weakness/back pain should put you on high alert? No, of course not- more often than not, it's a little old lady/man with a UTI or pneumonia and chronic back pain. But, you should be doing a careful assessment to look at possible cardiac etiology, AAA, stroke, cauda equina syndrome, etc. Watch them carefully, put them on a monitor, do frequent VS, start whatever nurse initiated protocols you have at your disposal (EKG, line and labs, UA, etc), and keep your eyes open for anything concerning and communicate any concerns to the doc.

At least you know now, and this is part of becoming an experienced ED RN. Learn from it and move on.

Home Health Columnist / Guide · Mar 9, 2015

My 86yo Dad had endovascular stent graft repair 10 yrs ago.

He threw within 12 hrs a 12" clot in L leg- side of graft repair needing immediate surgery to declot. Sent home on baby ASA, Plavix and post heparin in hospital so developed GI Bleed within a week..

Recomemnded f/u is CAT ABD q 6months x 2 yrs then yearly thereafter to monitor for complications.

Great info:

[h=3]Endovascular Stent Graft - VascularWeb[/h]Medline Plus: Aortic aneurysm repair - endovascular

sockov, ADN, ASN, BSN, CNA, LVN · May 26, 2015

Curious.. If you forgot to tell the Doc. About the history of AAA, wouldn't the doc see it in the history or when they go into assess and get a history? Or is this heavily relied on the triage? I'm new to ED.

NurseOnAMotorcycle, ASN, RN · May 27, 2015

It's the fact that the provider would have made the pt a top priority instead of waiting to be seen. This is a High risk pt.