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Advanced Principles 2 > Anesthesia for vascular surgery 2 > Flashcards

Anesthesia for vascular surgery 2 Flashcards

1
Q

The principal cause of carotid artery disease is

A

atherosclerosis****

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2
Q

Atherosclerosis commonly occurs at the bifurcation of the

A

common carotid artery and the internal & external carotid arteries

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3
Q

Signs & symptoms of atherosclerosis in the carotid artery include

A 
fatal or debilitating stroke
TIA
asymptomatic bruit
transient attack of monocular blindness- amaurosis fugax
******
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4
Q

The risk of having a first stroke is nearly ______as high for Blacks as it is for Whites

A

twice

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5
Q

The leading risk factors for strokes include

A

HTN, smoking, obesity, & DM

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6
Q

87% of strokes are

A

ischemic

extracranial atherosclerotic disease accounts for up to 20% of all ischemic strokes

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7
Q

For symptomatic patients with high-grade carotid stenosis, the definitive treatment is

A

carotid endarterectomy*****

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8
Q

For patients who are asymptomatic and have

A 
medical therapy (ASA)
percutaneous angioplasty/stenting
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9
Q

Preop assessment for carotid endarterectomy includes

A

recent symptoms- surgical intervention timing
optimize medical management
CAD is common- which to treat first

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10
Q

Optimizing medical management for carotid endarterectomy includes

A

beta-blockers, statins, antiplatelet therapy
HTN control, restore intravascular volume, reset cerebral autoregulation
diabetes control

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11
Q

Bad signs of CAD when performing a preop assessment for CEA includes

A

unstable angina, decompensated HF, significant valve disease

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12
Q

Carotid revascularization is recommended before _________ in patients with

A

CABG in patients with symptomatic carotid disease & bilateral severe asymptomatic carotid stenosis

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13
Q

Anesthesia for carotid endarterectomy includes

A 
awake (best monitor of function) vs. GA/ETT
continue ASA throughout preop period
continue cardiac medications
aline (rarely CVC)
PIV x2, large bore, arms tucked
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14
Q

When monitoring EKG for carotid endarterectomy, leads _______ & _________ should be monitored

A

II & V5 for detection of rhythm disturbances & ST segment changes

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15
Q

Inferior MIs can be seen in leads

A

II, III, AvF

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16
Q

Septal MIs can be seen in leads

A

V1, V2

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17
Q

Anterior MIs can be seen in

A

V3 & V4

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18
Q

Lateral MIs can be seen in

A

I, AVL, V5 & V6

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19
Q

Case setup for CEA includes

A

T&S
aline, ACT machine, fluid warmer, lower body forced air warming blanket
phenylephrine & remifentanil infusions inline
clevidipine & NTG infusions available
beta blockers & ephedrine available
heparin & protamine

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20
Q

Monitoring for CEAs includes

A

routine with V5 lead & ST segment analysis plus A-line
consider cerebral oximeter especially if the surgeons are not placing a shunt during cross-clamp
occasionally surgeons want to measure “stump” pressures (have extra pressure tubing and blue male to male adapter) to connect to a-line transducer

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21
Q

Arterial blood pressure should be maintained in the

A

high-normal range throughout the procedure and particularly during the period of carotid clamping to increase collateral flow & prevent cerebral ischemia

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22
Q

In patients with contralateral internal carotid artery occlusion or severe stenosis, induced

A

hypertension to approximately 10-20% above baseline is advocated during the period of carotid clamping

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23
Q

Surgical manipulation of carotid sinus leads to

A

baroreceptor reflexes
HR will- decrease
blood pressure will decrease
cessation of surgical manipulation propmtly restores the hemodynamics

24
Q

_________ on emergence requires immediate discussion with the surgeon about the need for angiography, reoperation, or both

A

Neurologic deficits

25
Q

The period of emergence and extubation may be associated with________ which may require aggressive pharmacologic intervention

A

marked hypertension & tachycardia

-systolic blood pressures as high as 200 mmHg- risk for MI

26
Q

Regional anesthesia for CEA includes blocking the

A

c2 to C4 dermatomes by use of a superficial, intermediate, deep, or combined cervical plexus block

27
Q

Regional & local anesthesia allows ________ of the awake patient

A

continuous neurologic assessment

28
Q

Regional anesthesia provides for

A

greater hemodynamic stability
reduced costs
reduces the need for shunts
requires patient cooperation

29
Q

The superficial cervical plexus block is performed using the

A

midpoint of the posterior border of the sternocleidomastoid muscle
injection along the posterior border of the medial surface of the muscle
-can block accessory nerve causing trapezius muscle paralysis

30
Q

The GALA trial identified that the anesthetic technique was

A

not associated with a significant difference in the composite end point

31
Q

Describe the effects of hypocapnia & hypercapnia on cerebral autoregulation.

A

hypocapnia- decreased cerebral blood flow (i.e. vasoconstriction)
hypercapnia- increased cerebral blood flow (i.e. vasodilation)

32
Q

In the setting of poor collateralization and resultant cerebral hypoperfusion, cerebral resistance vessels in the

A

hypo-perfused territories will dilate to maintain cerebral blood flow

33
Q

Impaired cerebrovascular reactivity to hypercapnia may play a role in the development of

A

stroke ipsilateral to carotid stenosis or occlusion

-impaired CO2 reactivity would increase the risk for cerebral ischemia after carotid artery clamping

34
Q

Carotid stump pressures should be

A

> 50*** (45 at the very minimum)

35
Q

The internal carotid artery stump pressure represents the back-pressure resulting from

A

collateral flow through the circle of Willis via the contralateral carotid artery & the vertebrobasilar system

36
Q

Cerebral oximeters measure the

A

O2 saturation of hemoglobin in the entire tissue bed which is predominantly venous blood and therefore approximates venous blood O2 saturation**

37
Q

Postoperative CEA complications include

A 
thromboembolic & hemorrhage intracerebral events
hypertension
hypotension
cerebral hyper-perfusion syndrome
cranial & cervical nerve dysfunction 
carotid body denervation 
wound hematoma
38
Q

The CEA postop complication of hypertension results from

A

surgical denervation of the carotid sinus baroreceptors

39
Q

The CEA postop complication of hypotension results from

A

baroreceptor hypersensitivity or reactivation

40
Q

Cerebral hyper-perfusion syndrome is the

A

abrupt increase in blood flow with loss of autoregulation

manifested as HA, seizure, focal neurologic signs, brain edema, & possibly intracerebral hemorrhage

41
Q

Carotid body denervation is the result of

A

impaired ventilatory response to mild hypoxemia, central chemoreceptors impaired, worsened with opioid administration

42
Q

Cranial & cervical nerve dysfunction post CEA includes

A

RLN, SLN, hypoglossal, mandibular

-bilateral recurrent laryngeal nerve injury can result in life-threatening upper airway obstruction

43
Q

Endovascular carotid artery stenting may include

A

percutaneous transluminal angioplasty & stenting
dual antiplatelet therapy
self-expanding stents
emboli protection devices

44
Q

Diseases of the aorta include

A

peripheral arteries- occlusive disease

aorta & major branches- aneurysms, dissections

45
Q

Aneurysms are often

A

medically managed
-dilation of all 3 layers of an artery
occasionally produce symptoms of compression on surrounding areas

46
Q

Dissections require

A

emergent surgery (high mortality)

  • occurs when blood enters the medial layer
  • initiation occurs with a tear in the intima
  • can occur over minutes to hours
47
Q

Describe the key symptom differences between aneurysms & dissections

A

aneurysms- asymptomatic or pain due to compression of adjacent structures or vessels
dissections- severe sharp pain in the posterior chest or back pain

48
Q

Risk factors for abdominal aortic aneurysm include

A

elderly, male, smoking, family history of AAA, atherosclerotic disease & HTN***

49
Q

Rare causes of AAA disease include

A

trauma, mycotic infection, syphilis, and Marfan syndrome

50
Q

Advential elastin degradation results in AAA and may be due to

A

genetic, biochemical, metabolic, infectious, mechanical, and hemodynamic factors

51
Q

AAA is typically electively repaired for

A

6cm or larger*******
controversial 5.5-5.9 cm
surgical repair is often considered if small aneurysms become symptomatic or expand more than 0.5 cm in a 6 month period

52
Q

Aneurysms less than _____ in diameter are thought to be relatively benign in terms of rupture & expansion

A

4.0 cm

53
Q

The frequent incidence of associated ______ enhances aneurysm enlargement

A

systemic hypertension

54
Q

Increasing diameter is associated with increased ______ even when arterial pressure is constant

A

wall tension

Law of Laplace

55
Q

The classic triad for ruptured AAA is

A

hypotension, back pain, and pulsatile abdominal mass

-ruptured AAA who die before reaching the hospital may exceed >90%

Advanced Principles 2 (42 decks)

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