Anesthesia for vascular surgery 1

Question 1

Coexisting diseases with vascular disease include

Answer 1

Diabetes
hypertension
renal impairment
pulmonary disease
systemic atherosclerosis
coronary artery disease

Question 2

______ is the leading cause of perioperative mortality at the time of vascular surery

Answer 2

Coronary artery disease*****

Question 3

________ occur in 23% to 28% of vascular patients

Answer 3

Unrecognized or silent MI’s

Question 4

Atherosclerosis potentially compromises blood flow to all the

Answer 4

organs and extremities leading to MI, stroke, & gangrene

Question 5

Atherosclerosis is a generalized, progressive, chronic

Answer 5

inflammatory disorder of the arterial tree with development of plaque

Question 6

Describe atherosclerosis progression

Answer 6

Stage 1: fatty streak- endothelial damage
Stage II: fibrous plaque- blood flow reduction
Stage III: advanced lesion- complete occlusion possible

Question 7

The most common sites for atherosclerotic lesions include

Answer 7

aortoiliac peripheral
coronary
arch branches

Question 8

Three types of atherosclerosis morbidity include:

Answer 8

1. enlarged plaque reduces lumen of blood vessel- supply vs. demand problem, “delayed” peri-op MI
2. plaque rupture/ulceration, embolization, and thrombus formation- acute occlusion, “early” peri-op MI
3. atrophy of media with arterial wall weakening (aneurysm dilation)

Question 9

The goal of the American college of cardiology & american heart association preoperative evaluation guidelines includes:

Answer 9

information obtained should be used for both the peri-operative period and to inform the long-term treatment plan*

Question 10

ACC & AHA preoperative evaluation guidelines include

Answer 10

clinical history- clinical risk factors, exercise tolerance
supplemental evaluation
perioperative therapy
surgical procedure- low risk, intermediate risk, high risk

Question 11

Drug regimens can effect surgical and anesthetic management but

Answer 11

many should be continued**

Question 12

Drug regimens may include

Answer 12

aspirin
plavix
statins
ace inhibitors
diuretics
Ca+ channel blockers
hypoglycemic drugs
beta blockers

Question 13

Concerns with aspirin include

Answer 13

inhibit platelets–> potential for increased bleeding and decreased GFR

Question 14

Concerns with plavix include

Answer 14

inhibits platelets–> potential for increased bleeding

Question 15

Concerns with statins include

Answer 15

effects liver function

Question 16

Concerns with ACE-inhibitors include

Answer 16

induction hypotension, coughing

Question 17

Concerns with diuretics include

Answer 17

hypovolemia, electrolyte imbalance

Question 18

Concerns with Ca+ channel blockers include

Answer 18

hypotension

Question 19

Concerns with hypoglycemic drugs include

Answer 19

hypoglycemia, lactic acidosis with metformin

Question 20

Concerns with beta blockers include

Answer 20

bronchospasm, decreased blood press, & HR

*** if you think pt could benefit from them start them at least 3-4 days prior to surgery

Question 21

Medical management of the patients prior to surgery includes

Answer 21

cessation of smoking
weight loss
exercise

Question 22

After coronary stenting, post stenting _____ is required

Answer 22

dual-antiplatelet therapy with aspirin & plavix

Question 23

The critical period to endothelialize after a coronary stent is

Answer 23

6 weeks***

Question 24

If dual anti-platelet therapy is stopped too soon after coronary stenting, there is a greater risk for

Answer 24

MI

• bare metal stent (do not want to stop antiplatelet therapy <1 month)
• drug eluting stent (do not want to stop antiplatelet therapy <6 months)

Question 25

The risk of stent thrombosis if the dual antiplatelet therapy is discontinued must be balanced with

Answer 25

the risk of increased intraoperative bleeding if DAPT is continued -newer generation drug eluting stents require shorter durations of DAPT (3 to 6 months)***

Question 26

Perioperative MI's are the result of

Answer 26

``` culprit lesions demand ischemia (likely predominant cause of periop MI) ```

Question 27

Culprit lesions are often located in

Answer 27

coronary vessels without critical stenosis (vulnerable plaques with high likelihood of thrombotic complications

Question 28

Assessment of cardiac function includes

Answer 28

exercise/pharmacologic stress test Echo duplex imaging of carotid arteries or angiography assessment of myocardial ischemia, previous MI, valvular dysfunction, and heart failure

Question 29

Advanced cardiac testing is used to determine if coronary intervention is needed prior to

Answer 29

vascular surgery OR to determine if aggressive intraop and postop management is needed

Question 30

The most important pulmonary complications are

Answer 30

atelectasis, pneumonia, respiratory failure, and exacerbation of underlying chronic disease

Question 31

There is a high prevalence of _______ related to pulmonary function in vascular patients

Answer 31

cigarette smoking, COPD, and chronic bronchitis

Question 32

Tests to assess for pulmonary function include

Answer 32

PFTs, ABGs, chest XRs

Question 33

For patients with reduced pulmonary function consider

Answer 33

incentive spirometry, steroids, regional anesthesia, antibiotics, and CPAP

Question 34

Chronic renal disease strongly predicts

Answer 34

long-term mortality* in patents with symptomatic lower extremity arterial occlusive disease -CV disease is independently associated with a decline in renal function and the development of kidney disease

Question 35

Tests for assessment of renal function include

Answer 35

serum creatinine, creatinine clearance

Question 36

For renal function consider the use of

Answer 36

contract dye use, beta-blockers, statins, volume status, & perfusion pressures

Question 37

Lower extremity peripheral artery disease is defined as

Answer 37

insufficiency in lower extremities presenting with acute or chronic limb ischemia with occlusions distal to the inguinal ligament

Question 38

______ is indicated for peripheral artery disease or atherosclerotic occlusive disease of lower extremities

Answer 38

lower extremity revascularization

Question 39

There is a risk for _______ with peripheral artery disease

Answer 39

amputation, stroke, MI, and death probably atherosclerosis in other beds (cardiac, cerebrovascular) DM at extra higher risk

Question 40

Patients presenting for lower extremity revascularization are often taking

Answer 40

anti-platelets and anticoagulants which makes it challenging in the periop period

Question 41

Peripheral revascularization indications include

Answer 41

acute ischemia | chronic ischemia

Question 42

Acute ischemia can be due to

Answer 42

emboli thrombus pseudoaneurysm postop from femoral arterial line

Question 43

Chronic ischemia can be due to

Answer 43

atherosclerotic plaque progressively narrowing vessel- claudication with eventual thrombosis of vessel

Question 44

Peripheral revascularization surgery is indicated when

Answer 44

severe disabling claudication | critical limb ischemia (limb salvage)

Question 45

Irreversible ischemic damage occurs in 4-6 hours and requires

Answer 45

urgent thrombolytic therapy &/or angioplasty arteriography surgical intervention

Question 46

For peripheral occlusions, the traditional surgical approach includes the unobstructed blood flow source (donor)

Answer 46

artery is exposed -typically the common femoral, superficial femoral, or deep femoral target distal artery (recipient) is exposed at or below the knee- typically the dorsalis pedis or posterior tibial arteries

Question 47

After exposure of the donor and recipient arteries for the traditional surgical approach of peripheral revascularization, the following steps occur:

Answer 47

``` a tunnel is created & graft is passed graft may be saphenous vein or prosthesis heparin IV given anastomosis are constructed arteriogram to confirm adequate flow heparin is not likely to be reversed ```

Question 48

Anesthetic management for peripheral revascularization includes

Answer 48

preop beta blockers and/or other chronic medication intraop-arterial line continuous EKG monitoring & ST analysis monitor intravascular volume by foley catheter- +/- CVP or PA catheter minimal blood loss & 3rd space

Question 49

For emergency surgery of peripheral revascularization, anesthetic management includes

Answer 49

carefully watching K+ levels, myoglobinemia, fasciotomy may be required, coagulation status, ECG ischemia, etc.

Question 50

Describe considerations for regional vs. general for peripheral revascularization.

Answer 50

assess for coagulopathy or anticoagulation therapy epidural>spinal most studies have shown no difference between RA & GA in terms of cardiopulmonary*** complications

Question 51

There is a significant difference in complication rate in terms of

Answer 51

GRAFT occlusion with REGIONAL being superior

Question 52

Graft occlusion is significant with GA in the postop period because of

Answer 52

hypercoagulable state with GA as opposed to RA fibrinolysis decreased after GA, therefore, fibrinogen not broken down and clots form Epi, norepi, & cortisol release increased after GA compared to RA patency of graft maintained with RA secondary to increased blood flow with sympathectomy

Question 53

________ drugs should be avoided with revascularization procedures.

Answer 53

VASOPRESSORS****- keep feet warm

Question 54

If performing RA for revascularization, the following dermatomes must be achieved

Answer 54

L1-L4 dermatomes (T10 level adequate) | epidural dosing is usually 9-12 mL

Question 55

General anesthetic implications with revascularization include

Answer 55

balanced anesthetic with opioids, inhalation agent, nitrous oxide, neuromuscular blocker - minimal opioids to facilitate extubation - deepen anesthetic level during the tunneling phase - avoid hemodynamic extremes- Beta blockers intraop often necessary

Question 56

Postoperative anesthetic management for revascularization includes

Answer 56

``` control pain & anxiety- high risk for MI in this period- stress reduction essential! avoid anemia (Hgb <9.0 g/dL) control heart rate & blood pressure frequent checks of peripheral pulses continuous EKG monitoring & ST analysis ```

Question 57

Lower extremity endovascular treatment includes (anesthetic type)

Answer 57

GA, neuraxial, or MAC percutaneous procedures so often MAC open access- e.g. femoral stenosis--> consider GA