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Advanced Principles 2 > Anesthesia for vascular surgery 3 > Flashcards

Anesthesia for vascular surgery 3 Flashcards

1
Q

EVAR technique is used for all types of

A

aortic diseases- traumatic injuries, ruptures, dissections, thoracic, and abdominal aneurysms

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2
Q

The EVAR technique is useful because it is

A

less invasive
reduced M&M
shorter hospital stay

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3
Q

Anesthesia technique for EVARs includes

A

MAC with local/regional vs. GA
-consider pt functional status (can they lay flat?), co-morbidities, aneurysm complexity, and surgical urgency (full stomach?)

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4
Q

Steering guiding sheaths for EVARS may require _________ arm arterial cut down**

A

left

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5
Q

Anesthesia considerations for EVARs includes

A 
spinal cord-extensive collateral network 
hemodynamic management 
preservation of organ perfusion 
blood loss and intravascular volume
temperature
radiation safety
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6
Q

The artery of adamkiewicz is located at

A

T9-T12

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7
Q

The Preserve trial found that the two most important factors that contribute to CIN are the

A

contrast load and the preexisting kidney disease*******

limiting the contrast load & adequate hydration to decrease the viscosity of the iodine-based dyes

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8
Q

Early EVAR complications include

A

paraplegia, stroke, ARI, aneurysm rupture, pelvic hematoma

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9
Q

Late EVAR complication sinclude

A

endoleaks, aneurysm rupture, device migration, limb occlusion, graft infection

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10
Q

Endoleaks are normally treated by

A

balloon angioplasty of the proximal attachment site so that the desired seal is obtained through remodeling of the stent-graft

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11
Q

If endovascular treatment or endoleak fails or is not possible, then

A

open surgical treatment is indicated

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12
Q

Considerations for open abdominal aortic reconstruction includes

A

large incisions & extensive dissections
clamping & unclamping of the aorta or tis major branches
varying duration of organ ischemia- reperfusion
significant fluid shifts
temperature fluctuations
activation of neurohumoral and inflammatory responses

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13
Q

The two most common sites of chronic atherosclerosis include

A

the infrarenal aorta & the iliac arteries

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14
Q

Patients undergo surgery for aortoiliac occlusive disease only if

A

they are symptomatic

-claudication & limb-threatening ischemia

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15
Q

Management of aortoiliac occlusive disease includes

A

direct reconstruction- Gold-standard
extra anatomic or indirect bypass grafts
catheter based endoluminal techniques

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16
Q

The pathophysiology of aortic cross-clamping is complex & depends on the following factors:

A 
level of the cross-clamp
status of the left ventricle
degree of periaortic collateralization 
intravascular blood volume & distribution, activation of the sympathetic nervous system
anesthetic drugs & techniques
heparinization
monitor ACTs
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17
Q

The aortic cross clamp results in arterial __________ above the clamp and arterial ________ below the clamp

A

hypertension****

hypotension***

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18
Q

Common ischemic complications of aortic cross clamp include

A 
renal failure
hepatic ischemia
coagulopathy
bowel infarction 
paraplegia
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19
Q

Thoracic aortic cross clamping leads to an increase in

A

mean arterial pressure
central venous pressure
pulmonary wedge
and mean pulmonary arterial

20
Q

Thoracic aortic cross clamp leads to a decrease in

A

EF
Cardiac index
no change in HR

21
Q

A normal intact heart can withstand large increases in

A

volume without significant ventricular distension or dysfunction

22
Q

An impaired heart with reduced myocardial contractility & coronary reserve may respond to an increase in volume conditions with

A

marked ventricular distension leading to acute left ventricular dysfunction & myocardial ischemia

23
Q

_________ activation resulting from increased aortic pressure should depress the heart rate, contractility, and vascular tone

A

Baroreceptor

24
Q

Cross-clamping of the thoracic aorta decreases ______ by approximately 50%

A

total-body O2

25
Q

Blood flow through tissues & organs below the level of aortic occlusion is dependent on ________ and is independent of ________

A

perfusion pressure***

independent of cardiac output

26
Q

_______ should be used when aortic cross clamp is applied to decrease afterload, wall stress, and myocardial oxygen demand

A

Vasodilators- nitroprusside, nitroglycerine, nicardipine, & clevidipine

27
Q

Perfusion to distal organs is dependent on ________which originate _______ to the clamp or shunts

A

collaterals; proximal

28
Q

Aortic cross clamp management includes

A

acute increase in SVR & decreased CO
avoid long-acting medications
the higher the clamp, the more significant impact on perfusion to vital organs thoracic> supraceliac> infrarenal

29
Q

______ remains the strongest predictor of postoperative renal dysfunction

A

Preoperative renal insufficiency***

30
Q

Renal failure after repair results from

A

preexisting renal dysfunction, ischemia during cross-clamping, thrombotic or embolic interruption of renal blood flow, hypovolemia and hypotension

31
Q

Renal sympathetic blockade with epidural anesthesia to a T6 level does

A

not prevent or modify the severe impairment in renal perfusion and function

32
Q

Renal protection may include

A

mannitol 12.5 g/70 kg
low-dose dopamine (1-3 mcg/kg/min)
can be injected directly into renal artery by surgeon
controversial- mannitol, loop diuretics, methylprednisolone & dopamine

33
Q

Patients with _______ & _______ are most vulnerable to the stress imposed on the cardiovascular system by aortic cross-clamping

A

preexisting impaired ventricular function & reduced coronary reserve

34
Q

Goals during cross clamping include

A 
reduce afterload (nitroprusside or clevidipine)
maintain normal preload (IV fluid)
maintain cardiac output (inotropes, MAP goals)
35
Q

Aortic unclamping may result in

A

hypotension
reactive hyperemia
washout of vasoactive & cardio-depressant mediators
pulmonary hypervolemia

36
Q

The hemodynamic response to unclamping depends on many factors including the

A

level of aortic occlusion, total occlusion time, use of diverting support, and intravascular volume

37
Q

If hypotension persists for more than a few minutes after removal of the cross clamp, consider

A

unrecognized bleeding or inadequate volume replacement

38
Q

Therapeutic interventions for unclamping include

A 
decrease inhaled anesthetics
decrease vasodilators
increase fluid administration
give vasoconstrictors
reapply cross-clamp for severe hypotension 
consider mannitol 
consider sodium bicarbonate
39
Q

Techniques for open AAA include

A

GA/ETT, regional, combined, low volatile
propofol vs. etomidate
fentanyl or sufentanil
esmolol, nitroprusside, nitroglycerin, clevidipine, phenylephrine boluses ready
heparin IV 100-300 units/kg- monitor ACT; protamine

40
Q

Monitors for open AAA include

A

TEE +/-
cerebral oximetry +/-
potential for rapid blood loss- central line, PIVs, a-line (awake?), PAC no longer recommended
cell saver, cross-matched blood

41
Q

Describe temperature management for open AAA

A

forced warming upper body, fluid warmers

lower body should not be warmed during the cross-clamp period because doing so can increase metabolic demands

42
Q

_______ should be avoided because acute stress on the aneurysm can cause rupture

A

HYPERTENSION

43
Q

The heart rate* should be maintained at

A

or below baseline because myocardial ischemia is often related to the heart rate

44
Q

_______ may be deferred until the aortic rupture is surgically controlled in the OR

A

Euvolemic resuscitation**
- the resultant increase in BP without surgical control of bleeding may lead to loss of retroperitoneal tamponade, further bleeding, hypotension, and death

45
Q

Postoperative treatment of AAA include

A

aggressively control hypertension & tachycardia
LOS is variable
pain-epidural vs. PCA

46
Q

__________ (3 things) must be maintained before extubation after AAA

A

hemodynamic, metabolic, and temeprature

47
Q

Complications of AAA include

A

MI, pneumonia, sepsis, renal failure, decreased tissue perfusion, hypothermia

Advanced Principles 2 (42 decks)

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