Anesthesia for vascular surgery 2

Question 1

The principal cause of carotid artery disease is

Answer 1

atherosclerosis****

Question 2

Atherosclerosis commonly occurs at the bifurcation of the

Answer 2

common carotid artery and the internal & external carotid arteries

Question 3

Signs & symptoms of atherosclerosis in the carotid artery include

Answer 3

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

Question 4

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

Answer 4

twice

Question 5

The leading risk factors for strokes include

Answer 5

HTN, smoking, obesity, & DM

Question 6

87% of strokes are

Answer 6

ischemic

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

Question 7

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

Answer 7

carotid endarterectomy*****

Question 8

For patients who are asymptomatic and have

Answer 8

medical therapy (ASA)
percutaneous angioplasty/stenting

Question 9

Preop assessment for carotid endarterectomy includes

Answer 9

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

Question 10

Optimizing medical management for carotid endarterectomy includes

Answer 10

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

Question 11

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

Answer 11

unstable angina, decompensated HF, significant valve disease

Question 12

Carotid revascularization is recommended before _________ in patients with

Answer 12

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

Question 13

Anesthesia for carotid endarterectomy includes

Answer 13

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

Question 14

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

Answer 14

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

Question 15

Inferior MIs can be seen in leads

Answer 15

II, III, AvF

Question 16

Septal MIs can be seen in leads

Answer 16

V1, V2

Question 17

Anterior MIs can be seen in

Answer 17

V3 & V4

Question 18

Lateral MIs can be seen in

Answer 18

I, AVL, V5 & V6

Question 19

Case setup for CEA includes

Answer 19

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

Question 20

Monitoring for CEAs includes

Answer 20

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

Question 21

Arterial blood pressure should be maintained in the

Answer 21

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

Question 22

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

Answer 22

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

Question 23

Surgical manipulation of carotid sinus leads to

Answer 23

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

Question 24

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

Answer 24

Neurologic deficits

Question 25

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

Answer 25

marked hypertension & tachycardia | -systolic blood pressures as high as 200 mmHg- risk for MI

Question 26

Regional anesthesia for CEA includes blocking the

Answer 26

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

Question 27

Regional & local anesthesia allows ________ of the awake patient

Answer 27

continuous neurologic assessment

Question 28

Regional anesthesia provides for

Answer 28

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

Question 29

The superficial cervical plexus block is performed using the

Answer 29

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

Question 30

The GALA trial identified that the anesthetic technique was

Answer 30

not associated with a significant difference in the composite end point

Question 31

Describe the effects of hypocapnia & hypercapnia on cerebral autoregulation.

Answer 31

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

Question 32

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

Answer 32

hypo-perfused territories will dilate to maintain cerebral blood flow

Question 33

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

Answer 33

stroke ipsilateral to carotid stenosis or occlusion | -impaired CO2 reactivity would increase the risk for cerebral ischemia after carotid artery clamping

Question 34

Carotid stump pressures should be

Answer 34

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

Question 35

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

Answer 35

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

Question 36

Cerebral oximeters measure the

Answer 36

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

Question 37

Postoperative CEA complications include

Answer 37

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

Question 38

The CEA postop complication of hypertension results from

Answer 38

surgical denervation of the carotid sinus baroreceptors

Question 39

The CEA postop complication of hypotension results from

Answer 39

baroreceptor hypersensitivity or reactivation

Question 40

Cerebral hyper-perfusion syndrome is the

Answer 40

abrupt increase in blood flow with loss of autoregulation | manifested as HA, seizure, focal neurologic signs, brain edema, & possibly intracerebral hemorrhage

Question 41

Carotid body denervation is the result of

Answer 41

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

Question 42

Cranial & cervical nerve dysfunction post CEA includes

Answer 42

RLN, SLN, hypoglossal, mandibular | -bilateral recurrent laryngeal nerve injury can result in life-threatening upper airway obstruction

Question 43

Endovascular carotid artery stenting may include

Answer 43

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

Question 44

Diseases of the aorta include

Answer 44

peripheral arteries- occlusive disease | aorta & major branches- aneurysms, dissections

Question 45

Aneurysms are often

Answer 45

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

Question 46

Dissections require

Answer 46

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

Question 47

Describe the key symptom differences between aneurysms & dissections

Answer 47

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

Question 48

Risk factors for abdominal aortic aneurysm include

Answer 48

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

Question 49

Rare causes of AAA disease include

Answer 49

trauma, mycotic infection, syphilis, and Marfan syndrome

Question 50

Advential elastin degradation results in AAA and may be due to

Answer 50

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

Question 51

AAA is typically electively repaired for

Answer 51

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

Question 52

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

Answer 52

4.0 cm

Question 53

The frequent incidence of associated ______ enhances aneurysm enlargement

Answer 53

systemic hypertension

Question 54

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

Answer 54

wall tension | Law of Laplace

Question 55

The classic triad for ruptured AAA is

Answer 55

hypotension, back pain, and pulsatile abdominal mass | -ruptured AAA who die before reaching the hospital may exceed >90%