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Principles III > Anesthesia for Vascular Surgery > Flashcards

Anesthesia for Vascular Surgery Flashcards

1
Q

What is atherosclerosis and when does it begin?

A

Slow progressive disease that may begin in childhood but doesn’t become a concern until the 5th or 6th decade, involves deposition of lipids, cholesterol, platelets, cellular debris, decreased BF and O2 delivery, primarily affects medium-sized and large arteries

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2
Q

What are some risk factors for atherosclerosis?

A
  • elevated cholesterol/triglycerides
  • smoking
  • HTN
  • diabetes
  • obesity
  • genetics
  • sedentary lifestyle
  • males
  • elevated homocystine and C-reactive protein levels
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3
Q

What are some surgical treatments for atherosclerosis?

A
  • transluminal angioplasty
  • endarterectomy
  • thrombectomies
  • endovascular stenting
  • arterial bypass
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4
Q

What 3 main comorbidites are you evaluating for preoperatively in someone with atherosclerosis?

A
  • existing cardiac abnormalities
  • coexisting pulmonary dysfunction
  • renal dysfunction
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5
Q

What is an aneurysm?

A

dilation of all three layers of an artery that causes a 50% increase in diameter compared to normal

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6
Q

Where can aneurysms occur in the aorta?

A

anywhere

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7
Q

What are some presenting symptoms of someone with a thoracic aortic aneurysm?

A
  • hoarseness due to stretch of the left RLN
  • stridor due to compression of the trachea
  • dysphagia due to compression of the esophagus
  • dyspnea due to compression of the lungs
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8
Q

What law explains the tension generated by an aneurysm?

A

law of laplace

T = P x r

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9
Q

Who is at highest risk for an AAA?

A

elderly men (8%)

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10
Q

What are other risk factors for AAA?

A

age
family hx
smoking
atherosclerosis

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11
Q

What is the primary cause of AAA?

A

atherosclerosis, proteolytic degradation of the extracellular matrix proteins elastin and collagen

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12
Q

What is the process that generates an AAA?

A

remodeling of the aortic wall from oxidative and biochemical wall stress

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13
Q

What comorbidity do 60% of AAA patients have?

A

HTN

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14
Q

What can increase the incidence of AAA by 8-fold?

A

smoking

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15
Q

What age criteria indicates a high risk AAA repair?

A

> 70 years old

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16
Q

What gender indicates a high risk AAA repair?

A

female

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17
Q

What cardiac conditions indicate a high risk AAA repair?

A 
hx of MI
active angina
myocardial disease
Q waves on ECG
ST changes
ventricular ectopy
HTN with LVH
CHF
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18
Q

What endocrine condition indicates a high risk AAA repair?

A

diabetes

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19
Q

What neurologic condition indicates a high risk AAA repair?

A

stroke

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20
Q

What renal condition indicates a high risk AAA repair?

A

chronic or acute renal disease

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21
Q

What pulmonary conditions indicate a high risk AAA repair?

A

COPD
emphysema
dyspnea
previous pulmonary surgery

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22
Q

At what aneurysm size is open repair done?

A

> 5.5 cm in diameter

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23
Q

Where do most AAA repairs require cross clamping?

A

at the infrarenal level

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24
Q

When do smaller AAA’s need open repair?

A

If they become symptomatic or expand >0.5 cm in 6 month period

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25
Q

What is involved in the preoperative preparation of someone having an AAA repair?

A
  • thorough assessment of functional cardiac status
  • full set of labs
  • 4 units PRBC and have in the room prior to induction
  • +/- PFTs
  • 2 large bore PIVs or central line
  • A-line
  • +/- epidural depending on coagulation status
  • adequate anxiolysis
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26
Q

What intraoperative monitoring should you do for a AAA repair?

A
  • 5 lead ECG
  • urinary catheter
  • radial A-line
  • +/- central line (placed in OR prior to induction)
  • +/- pulmonary catheter
  • TEE (sensitive monitor for cardiac function and ischemia)
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27
Q

How should an induction be done for an AAA repair?

A

smooth, slow, and controlled with vasoactive gtts in line prior to induction and multiple syringes with “uppers” and “downers” readily available

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28
Q

What type of anesthetic plan is appropriate for AAA repair?

A

high narcotic technique

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29
Q

What is important to avoid prior to cross-clamp for a AAA repair?

A

HTN, do not overhydrate prior to cross-clamp

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30
Q

What should be included in the maintenance phase of an AAA repair?

A
  • volatile concentrations should be
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31
Q

Where should you maintain PCWP to ensure adequate fluid volume?

A

5-12 mmHg

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32
Q

What is the pathophysiology of aortic cross-clamping dependent on?

A
  • level of the cross-clamp
  • status of the IV
  • degree of the periaortic collateralization
  • blood volume and distribution
  • activation of the SNS
  • anesthetic agents and techniques
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33
Q

Cross clamping above what anatomic structure causes the greatest increase in ABP unless blood is shunted around the level of the clamp or vasodilators are used?

A

diaphragm

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34
Q

What 2 vasodilators are commonly used with AAA repair?

A

SNP

nitroglycerin

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35
Q

How does an open AAA repair affect your mixed venous O2 saturation?

A

increases mixed venous O2

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36
Q

How does an open AAA repair affect epi and norepi release and what are the subsequent effects?

A

increased epi and norepi release which causes increased HR and myocardial O2 demand

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37
Q

How does an open AAA repair affect lactic acid production?

A

increases lactic acid which leads to metabolic acidosis

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38
Q

How does an open AAA repair affect thromboxane A2?

A

increases thromboxane A2 leading to decreased contractility and CO

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39
Q

How does an open AAA repair affect total body O2 consumption?

A

decreases total body O2 consumption

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40
Q

How does an open AAA repair affect total body CO2 production?

A

decreases total body CO2 production

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41
Q

How does an open AAA repair affect cytokines?

A

increases cytokines that trigger an inflammatory response and temperature, leukocytosis, tachycardia, and fluid sequestration

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42
Q

Are renal insufficiency and renal failure common after AAA repair?

A

Yes, regardless of level of clamp

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43
Q

How does infrarenal cross-clamping affect RBF and renal SVR?

A

causes a 38% decrease in RBF and 75% increase in renal SVR

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44
Q

What is the rate of mortality in patients that develop renal failure after aneurysm repair?

A

50-90%

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45
Q

What is the most significant indicator of post-op renal dysfunction?

A

preoperative renal function

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46
Q

Can SNS blockade with epidural at T6 or ACE inhibitors improve renal hemodynamics?

A

No

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47
Q

What is the most effective renal protection mechanism during a AAA repair?

A

Optimal systemic hemodynamics and maintenance of intravascular volume

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48
Q

What are drugs that you can use for renal protection during an AAA repair?

A 
Mannitol (0.25-0.5 mg/kg)
Loop diuretics
Low-dose dopamine (1-3 mcg/kg/min)
Fenoldopam (0.05-0.1 mcg/kg/min)
Statins
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49
Q

What does the hemodynamic response during removal of the cross-clamp dependent on?

A
  • level of clamp
  • total clamp time
  • use of diverting support
  • intravascular volume
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50
Q

What is the most common response following removal of the cross-clamp?

A

hypotension primarily due to reactive hyperemia (transient increase in organ BF) and relative central hypovolemia

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51
Q

What should you do prior to removal of the cross-clamp?

A
  • assess and maximize intravascular volume
  • reduce or discontinue vasodilators
  • decrease volatile agent concentration
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52
Q

When should you administer Protamine?

A

prior to emergence and at the request of the surgeon

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53
Q

What are common side effects of Protamine?

A

hypotension, pulmonary vasoconstriction and pulmonary HTN from release of thromboxane A and serotonin

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54
Q

How does Protamine work?

A

positively charged substance that NEUTRALIZES the negatively charged heparin

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55
Q

What does rapid administration of Protamine cause?

A

histamine release causing flushing, tachycardia, and hypotension

56
Q

Who may be at higher risk of having an allergy to Protamine?

A

patients with chronic exposure to NPH or who are allergic to fish

57
Q

Should you warm the lower body during an emergent AAA repair?

A

NO, may increase ischemic injury to tissues below the cross-clamp due to increased metabolic demands

58
Q

What are some benefits of endovascular AAA repair? TEVAR

A
  • lower short-term mortality rates - no difference in AAA-related deaths at 1 year compared to open repair
  • less hemodynamic instability and blood loss
59
Q

What is an endovascular AAA repair?

A

deployment of graft stent in aortic lumen through the femoral artery, fluoroscopy used to position sheath at the site of the aneurysm

60
Q

What kind of anesthetic technique can you use for an endovascular AAA repair?

A

neuraxial technique +/- GA or GA

61
Q

Who are appropriate candidates for an endovascular AAA repair?

A
  • non-ruptured aneurysm >5 cm

- aneurysm

62
Q

Is anticoagulation still necessary for an endovascular AAA repair?

A

Yes

63
Q

What can happen during stent deployment during an endovascular AAA repair?

A

hypotension and bradycardia

64
Q

What should you always be prepared for during an endovascular AAA repair?

A

conversion to open

65
Q

What are potential complications from endovascular AAA repair?

A
  • failed graft deployment
  • microembolism
  • migration/occlusion of major branch arteries
  • aortic perforation/rupture/dissection
  • hematoma formation
  • endoleak
  • stenosis/kink/thrombosis
  • infection
  • radiation exposure
  • allergy to contrast due/associated renal insufficiency
  • postimplant syndrome
66
Q

What is the mortality rate for a ruptured AA?

A

94%

67
Q

What are the most common symptoms for a ruptured AA?

A
  • abdominal discomfort/back pain
  • pulsatile abdominal mass
  • decreased peripheral pulses
  • hypotension
68
Q

You have a patient in the ER with a ruptured AA, how would you proceed?

A
  • immediate transport to OR, level 1
  • very basic preop evaluation
  • ensure placement of at least 1 functional PIV
  • cardiovascular resuscitation and hemodynamic stability are primary goals
  • greatest concern is gaining control of the proximal aorta!!
69
Q

How much blood and what blood type should you have in the OR for a ruptured AA?

A

10-12 units O negative PRBCs

70
Q

How should you do the induction for someone with a ruptured AA?

A

surgical team will prep while you are preparing for induction, use minimal anesthesia, use midazolam liberally and consider scopolamine

71
Q

When would you place invasive lines for someone with a ruptured AA?

A

AFTER the patient is asleep and hemodynamically stable

72
Q

What must you be adept in to manage a thoracoabdominal aortic surgery?

A
  • one-lung ventilation
  • extracorporeal circulatory support, including circ. arrest
  • renal and spinal cord protection
  • induced hypothermia
  • invasive hemodynamic monitoring including TEE
  • massive transfusion
  • management of coagulopathy
73
Q

How are thoracic aortic aneurysms classified?

A

Based on size, shape, and location

74
Q

What is the primary cause of thoracic aortic aneurysms?

A

atherosclerotic disease (80%)

75
Q

What are other causes for thoracic aortic aneurysms besides atherosclerotic disease?

A

chronic aortic dissection (17%)

trauma or connective tissue disease (3%)

76
Q

What is a type I thoracic aneurysm using the Crawford classification?

A

descending thoracic and upper abdominal aorta

77
Q

What is a type II thoracic aneurysm using the Crawford classification?

A

descending thoracic and most of abdominal aorta

78
Q

What is a type III thoracic aneurysm using the Crawford classification?

A

lower thoracic and most of abdominal aorta

79
Q

What is a type IV thoracic aneurysm using the Crawford classification?

A

most of all of abdominal aorta

80
Q

What is a dissection?

A

blood enters the media layer of the blood vessel via a tear in the intima

81
Q

What symptoms may suggest a thoracic aortic dissection?

A
  • pain in anterior chest, neck, or between shoulder blades
  • may appear to be in shock although the systemic BP is elevated
  • decreased or absent peripheral pulses
  • acute mental status changes/stroke from occlusion of carotid artery
  • pain may also be associated with MI due to compression of coronary arteries
  • paraparesis or paraplegia of lower extremities due to impaired BF to the spinal cord
  • GI and renal ischemia
82
Q

Where are majority of the thoracic aneurysms?

A

ascending aorta (60%)

83
Q

What is involved with an ascending thoracic aneurysm repair?

A

CPB and median sternotomy

84
Q

What are major complications associated with an ascending thoracic aneurysms repair?

A
  • aortic regurg.
  • long aortic cross-clamp times
  • large intraoperative blood loss
85
Q

What drug can be used to help reduce blood loss during am ascending thoracic aneurysm repair?

A

aprotinin (Amicar)

86
Q

What monitoring device is extremely useful during an ascending thoracic aneurysm repair?

A

TEE

87
Q

What is a Bentall procedure?

A

repair of ascending thoracic aneurysm with replacement/repair of aortic valve and coronary reimplantation

88
Q

Where is arterial monitoring done for an ascending thoracic aneurysm repair?

A

left radial artery

89
Q

Will an ascending thoracic aneurysm repair require heparinization?

A

YES, ACT>400

90
Q

What are anesthetic implications for a transverse aortic arch repair?

A
  • median sternotomy and CPB
  • deep hypothermia (15 degrees Celsius) with circulatory arrest
  • pack head in ice
  • maintain flat EEG
  • methylprednisolone or dexamethasone
  • mannitol
  • phenytoin
  • coagulopathies common
91
Q

Where is a descending thoracic aneurysm?

A

between left subclavian artery and aortic hiatus (diaphragm)

92
Q

Where is the incision for a descending thoracic aneurysm repair?

A

left thoracotomy - need one-lung ventilation R DLT or bronchial blocker

93
Q

What are anesthetic implications for a descending thoracic aneurysm repair?

A
  • left thoracotomy so one lung ventilation
  • may use femoral bypass (partial CPB)
  • arterial line on right side***
  • high risk for significant blood loss
  • have current T&C and have blood in room
94
Q

What is the most devastating complication of descending thoracic aneurysm repairs?

A

poor perfusion of spinal cord causing paraplegia

95
Q

What should you keep in mind during a descending thoracic aneurysm repair regarding immediate post-op care?

A

Will need to assess lower extremity movement ASAP so make sure patient fully reversed and watch amount of NDNMB given

96
Q

What is the intrinsic circulation to the spinal cord?

A
  • one anterior spinal artery (75-80% of blood flow to anterior cord)
  • two posterior spinal arteries (20-25% blood flow to posterior cord)
97
Q

What is the extrinsic circulation to the spinal cord?

A

Radicular and medullary arteries

98
Q

What is the artery of adamkieweicz?

A

aka great radicular artery or the arteria radicularis magna, enters intravertebral foramen in thoracolumbar region and provides most of the blood flow to the anterior spinal cords or motor tracts of the spinal cord, major source of blood flow to the lower 2/3 of the spinal cord

99
Q

At which thoracolumbar space do majority of arteries of adamkieweicz enter?

A

T9-T12 (75%)
T5-T8 (15%)
L1-L2 (10%)

100
Q

Occlusion of what artery is the main determinant of paraplegia?

A

artery of adamkieweicz

101
Q

Which patients are at highest risk of spinal cord ischemia?

A
  • aortic dissection or rupture
  • extensive aneurysm size
  • prolonged aortic occlusion time
  • patient age
  • CSF pressure
  • perioperative hypotension
102
Q

What is the most important determinant of paraplegia and acute renal failure following aneurysm repair?

A

location and extent of the aneurysm notwithstanding, the duration of aortic crossclamping

103
Q

About how much time during cross-clamping is there little change of spinal cord injury?

A

first 20-30 mins

104
Q

After about how long during cross-clamp time is there increased risk for spinal cord injury?

A

aka “the vulnerable interval”, 30-60 mins of cross-clamp time = ~10-90% incidence of paraplegia, the likelihood of paraplegia increases with duration

105
Q

What are some strategies used to protect the spinal cord?

A
  • monitoring of evoked potentials
  • operative strategies
  • CSF drainage
  • mild to moderate hypothermia
  • intrathecal papaverine (dilates spinal arteries and oxygen free radical scavenger)
  • retrograde venous spinal cord perfusion
  • neuroprotective pharmacolgoical intervention
106
Q

What is the spinal cord perfusion pressure?

A

spinal cord perfusion pressure (SCPP) = mean aortic pressure - CSF pressure

107
Q

At what distal perfusion pressure is there a higher association with paraplegia?

A
108
Q

What normally happens to CSF pressure and arterial pressure during cross clamp?

A

CSF pressure increases while arterial pressure decreases distal to cross clamp

109
Q

How can SC perfusion pressure be manipulated?

A

altering ABP and draining CSF through an intrathecal catheter

110
Q

What is the primary cause of carotid occlusive disease?

A

atherosclerosis

111
Q

Where are carotid artery occlusions usually found?

A

carotid bifurcation

112
Q

What are clinical manifestations of carotid artery occlusions?

A
  • stroke
  • TIA
  • monocular
  • blindness (amaurosis fugax)
  • asymptomatic bruit
113
Q

What is the degree of cerebral injury with carotid artery occlusions dependent on?

A

cerebral collateral flow due to the integrity of the Circle of Willis, duration of hypoperfusion, cerebrovascular vasoreactivity, plaque morphology

114
Q

What are indications for a carotid endarterectomy (CEA)?

A
  • TIA associated with ipsilateral severe carotid stenosis (>70%)
  • severe ipsilateral stenosis with minor stroke
  • 30-70% stenosis with ipsilateral symptoms
  • asymptomatic but with significantly stenotic lesions (>60%)
115
Q

What does carotid artery occlusion ultimately lead to?

A

ischemia and ultimately loss of cerebral blood flow autoregulation

116
Q

What should a pre-op evaluation involve for someone having a carotid endarterectomy?

A
  • cardiac function
  • EKG, ECHO, TEE, previous cardiac surgeries, etc.
  • pulmonary function
  • previous surgical procedures involving neck
  • vocal cord function/abnormalities
  • pertinent labs - CBC, F&E, coags
117
Q

What is involved with perioperative management of a CEA?

A
  • maintain adequate cerebral and myocardial perfusion and oxygenation
  • minimizing the stress response (avoid HTN & tachycardia, ensure adequate pain control)
  • smooth induction and emergence
  • avoid large swings in BP
  • cerebral protective measures
  • fully awake patient at the end of the procedure to allow for comprehensive neurologic assessment
118
Q

What are benefits of regional anesthesia for a CEA?

A
  • allows continuous assessment of an awake patient
  • avoids use of expensive monitoring equipment
  • reduces need for shunting
  • less hemodynamic instability
  • fewer medications needed for sedation/anesthesia
119
Q

What regional block is used for a CEA and what dermatomes are blocked?

A

superficial and deep cervical block, C2-C4 dermatomes

120
Q

What are potential disadvantages of regional anesthesia for CEA?

A
  • inability to use pharmacologic tx for cerebral protection
  • patient panic and loss of cooperation
  • inadequate airway access
  • phrenic nerve paralysis leading to potential for respiratory compromise
  • LA toxicity with high volumes of LA or intravascular injection
121
Q

What are absolute contraindications for regional anesthesia for CEA?

A
  • patient refusal

- language barriers

122
Q

What are relative contraindications for regional anesthesia for CEA?

A
  • difficult anatomy

- Severe COPD or diaphragmatic dysfunction

123
Q

What is the most sensitive monitor of cerebral perfusion/ischemia during a CEA with regional anesthesia?

A

an awake patient!

124
Q

When do you place an arterial line for a CEA?

A

prior to induction

125
Q

How do you manage BP for a CEA?

A

treat hypotension

126
Q

What monitors can be used during a CEA?

A
  • EEG
  • SSEPs
  • carotid stump pressures
  • transcranial doppler (TCD)
  • cerebral oximetry
127
Q

What is the purpose of using SSEPs during a CEA?

A

measures integrity of dorsal (sensory) portion of spinal cord and deep brain function

128
Q

What is the purpose of monitoring carotid stump pressures during a CEA?

A

assess extent of collateral flow, pressures

129
Q

Is there a correlation between EEG changes and stump pressures?

A

No

130
Q

What is the purpose of transcranial doppler monitoring?

A

measures BF velocity of MCA, measures integrity of the cerebral hemispheres

131
Q

What is the purpose of cerebral oximetry monitoring during a CEA?

A

assess cerebral regional O2 saturation, low positive predictive value

132
Q

What should you do before the release of the cross-clamp during a CEA?

A
  • ABP should be decreased to baseline level or slightly lower (within 20% of baseline value)
  • most surgeons request SBP to be kept 140-160 mmHg to ensure adequate but not excessive cerebral perfusion
  • DC phenylephrine and reduce volatile agent (if necessary) prior to unclamping
  • be prepared to administer small boluses doses (20-40 mcg) of SNP or NTG
  • surgeon may or may not ask to reverse heparin with protamine
133
Q

What are post-op complications of CEA?

A
  • denervation of ipsilateral carotid baroreceptor
  • postoperative hoarseness, ipsilateral deviation of the tongue, and/or Horner’s syndrome
  • surgical retraction of RLN and hypoglossal nerves, respectively
  • hematoma formation at surgical site may compromise ventilation–maintain normal BP
  • postoperative cerebral hyperperfusion syndrome
134
Q

What results from denervation of ipsilateral carotid baroreceptor as a complication from CEA?

A

HTN, blunted ventilatory response to hypoxemia by CAROTID CHEMORECEPTORS (primarily decreases in PaO2) –NOT CENTRAL

135
Q

What is postoperative cerebral hyperperfusion syndrome?

A

Complicaiton from CEA:

  • increase in cerebral BF with loss of autoregulation in reperfused brain leading to a h/a, seizures, focal neurologic signs, edema, hemorrhage
  • typically occurs several days following CEA
  • patients with severe preop carotid stenosis and postop HTN are at increased risk
136
Q

What can cause acute respiratory compromise following CEA?

A
  • hematoma
  • bilateral RLN
  • deficient carotid body functon
  • vocal cord paralysis
  • tension pneumo
  • stroke or loss of consciousness

Principles III (12 decks)

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