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Advanced Principles 2 > Anesthesia for vascular surgery 1 > Flashcards

Anesthesia for vascular surgery 1 Flashcards

1
Q

Coexisting diseases with vascular disease include

A 
Diabetes
hypertension
renal impairment
pulmonary disease
systemic atherosclerosis
coronary artery disease
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2
Q

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

A

Coronary artery disease*****

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3
Q

________ occur in 23% to 28% of vascular patients

A

Unrecognized or silent MI’s

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4
Q

Atherosclerosis potentially compromises blood flow to all the

A

organs and extremities leading to MI, stroke, & gangrene

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5
Q

Atherosclerosis is a generalized, progressive, chronic

A

inflammatory disorder of the arterial tree with development of plaque

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6
Q

Describe atherosclerosis progression

A

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

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7
Q

The most common sites for atherosclerotic lesions include

A

aortoiliac peripheral
coronary
arch branches

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8
Q

Three types of atherosclerosis morbidity include:

A
  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)
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9
Q

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

A

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

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10
Q

ACC & AHA preoperative evaluation guidelines include

A

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

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11
Q

Drug regimens can effect surgical and anesthetic management but

A

many should be continued**

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12
Q

Drug regimens may include

A 
aspirin
plavix
statins
ace inhibitors
diuretics
Ca+ channel blockers
hypoglycemic drugs
beta blockers
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13
Q

Concerns with aspirin include

A

inhibit platelets–> potential for increased bleeding and decreased GFR

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14
Q

Concerns with plavix include

A

inhibits platelets–> potential for increased bleeding

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15
Q

Concerns with statins include

A

effects liver function

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16
Q

Concerns with ACE-inhibitors include

A

induction hypotension, coughing

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17
Q

Concerns with diuretics include

A

hypovolemia, electrolyte imbalance

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18
Q

Concerns with Ca+ channel blockers include

A

hypotension

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19
Q

Concerns with hypoglycemic drugs include

A

hypoglycemia, lactic acidosis with metformin

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20
Q

Concerns with beta blockers include

A

bronchospasm, decreased blood press, & HR

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

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21
Q

Medical management of the patients prior to surgery includes

A

cessation of smoking
weight loss
exercise

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22
Q

After coronary stenting, post stenting _____ is required

A

dual-antiplatelet therapy with aspirin & plavix

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23
Q

The critical period to endothelialize after a coronary stent is

A

6 weeks***

24
Q

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

A

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)
25
Q

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

A

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

26
Q

Perioperative MI’s are the result of

A 
culprit lesions
demand ischemia (likely predominant cause of periop MI)
27
Q

Culprit lesions are often located in

A

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

28
Q

Assessment of cardiac function includes

A

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

29
Q

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

A

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

30
Q

The most important pulmonary complications are

A

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

31
Q

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

A

cigarette smoking, COPD, and chronic bronchitis

32
Q

Tests to assess for pulmonary function include

A

PFTs, ABGs, chest XRs

33
Q

For patients with reduced pulmonary function consider

A

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

34
Q

Chronic renal disease strongly predicts

A

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

35
Q

Tests for assessment of renal function include

A

serum creatinine, creatinine clearance

36
Q

For renal function consider the use of

A

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

37
Q

Lower extremity peripheral artery disease is defined as

A

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

38
Q

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

A

lower extremity revascularization

39
Q

There is a risk for _______ with peripheral artery disease

A

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

40
Q

Patients presenting for lower extremity revascularization are often taking

A

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

41
Q

Peripheral revascularization indications include

A

acute ischemia

chronic ischemia

42
Q

Acute ischemia can be due to

A

emboli
thrombus
pseudoaneurysm postop from femoral arterial line

43
Q

Chronic ischemia can be due to

A

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

44
Q

Peripheral revascularization surgery is indicated when

A

severe disabling claudication

critical limb ischemia (limb salvage)

45
Q

Irreversible ischemic damage occurs in 4-6 hours and requires

A

urgent thrombolytic therapy &/or angioplasty
arteriography
surgical intervention

46
Q

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

A

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

47
Q

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

A 
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
48
Q

Anesthetic management for peripheral revascularization includes

A

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

49
Q

For emergency surgery of peripheral revascularization, anesthetic management includes

A

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

50
Q

Describe considerations for regional vs. general for peripheral revascularization.

A

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

51
Q

There is a significant difference in complication rate in terms of

A

GRAFT occlusion with REGIONAL being superior

52
Q

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

A

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

53
Q

________ drugs should be avoided with revascularization procedures.

A

VASOPRESSORS**- keep feet warm

54
Q

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

A

L1-L4 dermatomes (T10 level adequate)

epidural dosing is usually 9-12 mL

55
Q

General anesthetic implications with revascularization include

A

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
56
Q

Postoperative anesthetic management for revascularization includes

A 
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
57
Q

Lower extremity endovascular treatment includes (anesthetic type)

A

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

Advanced Principles 2 (42 decks)

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