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88 Abdominal aortic aneurysm
occurs even in critically ill and injured patients (some of whom had ruptured
AAA). 5–10 These studies and expert reviews consistently indicate that
fentanyl can be safely titrated in doses of 25–50 μg. 11–13 Respiratory depression
is dose related and extremely rare, probably because of the titrated
dosing of the drug. 14 The acute care findings of fentanyl’s safety and efficacy
are mirrored by recommendations favoring fentanyl’s employment for inpatient
critical care use in potentially unstable patients. 7,15,16
In patients with normal renal function, NSAIDs (e.g. ketorolac) have been
used perioperatively, without sequelae, in patients undergoing abdominal
and retroperitoneal procedures. 17 However, patients with symptomatic AAA
are at particular risk for perioperative renal hypoperfusion. The risk of
compromised renal function, in addition to the potential for increased perioperative
blood loss (in a population with limited fluid-status reserves),
renders NSAIDs a poor analgesic choice in symptomatic AAA. 17–22
n Summary and recommendations
First line: fentanyl (initial dose 50–100 μg IV, then titrate)
Pregnancy: fentanyl (initial dose 50–100 μg IV, then titrate)
Pediatric: fentanyl (initial dose 1–2 μg/kg IV, then titrate)
Special case:
n no concern about hemodynamic instability: morphine (initial dose 4–6mg
IV, then titrate) or hydromorphone (initial dose 1 mg IV, then titrate)
References
1. Marret E, Lembert N, Bonnet F. [Anaesthesia and critical care for scheduled
infrarenal abdominal aortic aneurysm surgery.] Ann Fr Anesth Reanim.
2006;25:158–179.
2. Brimacombe J, Berry A. A review of anaesthesia for ruptured abdominal aortic
aneurysm with special emphasis on preclamping fluid resuscitation. Anaesth
Intensive Care. 1993;21:311–323.