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N934 Adv Principles Fa 21 > Anesthesia for Vascular Surgery Part 2: Aneurysms > Flashcards

Anesthesia for Vascular Surgery Part 2: Aneurysms Flashcards

1
Q

describe an aortic aneurysm

A

dilation of all 3 layers of artery. occasionally produce symptoms of compression on surrounding areas including possibly pain

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2
Q

describe an aortic dissection

A

occurs when blood enters the medial layer
initiation occurs with a tear in the intima
can occur over minutes to hours
severe sharp pain described in the posterior chest or back

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3
Q

risk factors for abdominal aortic aneurysm (AAA)

A

elderly, male
smoking
family history
atherosclerotic disease

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4
Q

what degradation occurs to create an AAA

A

adventitial elastin degradation (genetic, biochemical, metabolic, infectious, mechanic, and hemodynamic factors may contribute)

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5
Q

how do AAA’s present

A

asymptomatic pulsatile abdominal masses

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6
Q

how do AAA’s present

A

asymptomatic pulsatile abdominal masses

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7
Q

when to repair AAA

A

all patients with AAA 6cm or larger or when small aneurysms become symptomatic/expand >.5cm in 6mo period

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8
Q

aneurysms less than ___cm in diameter are thought to be relatively benign in terms of rupture or expansion

A

4cm

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9
Q

law of laplace in relation to aneurysm

A

increasing diameter is associated with increased wall tension, even when arterial pressure is constant
frequent incidence of associated systemic HTN enhances aneurysm enlargement

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10
Q

law of laplace in relation to aneurysm

A

increasing diameter is associated with increased wall tension, even when arterial pressure is constant
frequent incidence of associated systemic HTN enhances aneurysm enlargement

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11
Q

classic triad of sx for a ruptured AAA

A

HoTN, back pain, pulsatile abdominal mass

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12
Q

what types of aortic diseases is EVAR approach used for

A 
traumatic injuries
ruptures
dissections
TAA and AAA
(all types)
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13
Q

positive aspects of the EVAR approach to aortic aneurysms

A

less invasive
reduced M&M
shorter hospital stay
most common technique for repair

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14
Q

how are femoral arteries accessed during EVAR

A

cutdowns or percutaneous procedures

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15
Q

what are the anesthesia techniques for EVARs

A

MAC with local/regional versus GA
consider patients functional status (can they lay flat), co morbidities, aneurysm complexity, surgery urgency (full stomach)

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16
Q

anesthesia for EVAR’s, steering guiding sheaths may require what?

A

left arm arterial cut down

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17
Q

what is the artery that remains at most risk on spinal cord during EVAR

A

single anterior spinal cord artery that usually originates off descending aorta between T9-12

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18
Q

what are some anesthesia considerations intraoperatively for EVAR procedures

A 
hemodynamic management 
preservation of organ perfusion
blood loss and intravascular volume 
temperature
risk of conversion to open
radiation safety
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19
Q

what are the two most important factors that contribute to contrast induced nephropathy (a possible complication from EVAR)

A

contrast load and preexisting kidney disease

limit the load and adequately hydrate

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20
Q

early EVAR complications (5)

A

paraplegia, stroke, ARI, aneurysm rupture, pelvic hematoma

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21
Q

late EVAR complications (5)

A

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

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22
Q

how are endoleaks usually treated

A

by balloon angioplasty of proximal attachment site so that the desired seal is obtained through remodeling of the stent graft
open surgical treatment remains an option if endovascular treatment of endoleaks fails or is not possible

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23
Q

how are type 2 endoleaks treated

A

transarterial embolization through the iliac arteries or retrograde embolization through the superior mesenteric or inferior mesenteric arteries

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24
Q

describe open abdominal aortic reconstruction considerations and procedure

A

large incision, extensive dissection, clamping and unclamping of aorta or its major branches
varying duration of organ ischemia-reperfusion
significant fluid shifts
temperature fluctuations
activation of neurohumoral and inflammatory responses
think about help and rapid infuser (esp if TAA)

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25
most common sites of chronic atherosclerosis contributing to arotoiliac occlusive disease (2)
infrarenal aorta and iliac arteries
26
when do patients undergo surgery for aortoiliac occlusive disease?
only if they are symptomatic which includes claudication and limb threatening ischemia
27
surgical management of aortoiliac occlusive disease includes (3)
``` direct reconstruction (aortobifemoral bypass, gold standard) extra anatomic orr indirect bypass grafts (ex axillofemoral bypass. for infection or with previous reconstruction) catheter based end-luminal techniques like percutaneous transluminal angioplasty (PTA) with or without tent insertion. relatively local disease. ```
28
what does the pathophysiology of aortic cross clamping depend on (6)
``` level of cross clamp status of left ventricle degree of periarotic collateralization intravascular blood volume and distribution, activation of SNS anesthetic drugs and techniques heparinization (monitor ACT's) ```
29
complications of aortic cross clamp r/t BP management
arterial HTN above cross clamp is common (increase in MAP, CVP, SVR but decrease in EF and CI) arterial HoTN below the clamp will occur
30
aortic cross clamp complications: common ischemic complications
``` renal failure (esp if clamped suprarenal) hepatic ischemia coagulopathy bowel infarction paraplegia ```
31
thoracic aortic cross clamp: what to expect with vital signs
increase in MAP, CVP, pulmonary arterial pressure, pulmonary wedge pressure decrease in CI and EF no change in HR
32
how the aortic cross clamp effects the left ventricle: normal intact heart
can withstand large increases in volume without significant ventricular distention or dysfunction
33
how the aortic cross clamp effects the left ventricle: impaired heart
a heart with reduced contractility and coronary reserve may respond to such increases in volume conditions with marked ventricular distention as a result of acute LV dysfunction and myocardial ischemia
34
aortic cross clamp: baroreceptor activation
results from increased aortic pressure and should depress the HR, contractility, and vascular tone
35
aortic cross clamp: metabolic effects. cross clamping of thoracic aorta decreases total body O2 consumption by
50%
36
aortic cross clamp: blood flow through tissues and organs below the level of aortic occlusion is dependent on _____ and independent of _____
dependent on perfusion pressure and | independent of CO
37
hemodynamic changes associated with aortic cross clamping
increased arterial blood pressure above clamp decreased arterial BP below clamp increased segmental wall motion abnormalities decreased EF, CO, RBF increased pulmonary occlusion pressure increased CVP increased coronary BF (maybe)
38
metabolic changes associated with aortic cross clamping includes
``` decreased total body O2 consumption decreased total body CO2 production increased MVO2 decreased total body oxygen extraction increased epi and NE respiratory alkalosis metabolic acidosis ```
39
significance of impact on perfusion to vital organs in order from most to least detrimental
thoracic>supraceliac>infrarenal
40
management of aortic cross clamp: pharmacologic intervention
use vasodilators to decrease after load, wall stress on LV and myocardial O2 demand ex) nitroprusside, NTG, nicardipine, clevedipine (run these when theyre getting ready to clamp) avoid long acting medications
41
renal effects of cross clamping
while there is a dramatic reduction in RBF when clamped above renal arteries, there is still a reduction in RBF below renal arteries
42
renal failure after repair of aneurysm results from
preexisting renal dysfunction, ischemia during cross clamping, thrombotic or embolic interruption of RBF, hypovolemia and HoTN
43
how does renal sympathetic blockade with epidural anesthesia to a T6 level effect renal perfusion and function
it does not prevent or modify the impairment of perfusion/function plus youre stuck with the vasodilation after unclamping if you've been infusing through the epidural
44
strongest predictor of postoperative renal function
preoperative renal insufficiency
45
how to facilitate renal protection during aortic repair
mannitol 12.5g/70kg (reduces ischemia induced renal vascular endothelial cell edema and vascular congestion, scavenger of free radicals) low dose dopamine 1-3mcg/kg/min loop diuretics methylprednisolone
46
patients with which two preexisting cardiac conditions/dysfunctions are most vulnerable to stress imposed on CV system by aortic cross clamping?
preexisting impaired ventricular funciton | reduced coronary reserve
47
goals during cross clamp for CV patients include
``` reducing after load (nitroprusside or clevidipine) maintain normal preload (IV fluid) maintain CO (inotropes, MAP goals) ```
48
what does the hemodynamic response to unclamping depend on
level of aortic occlusion, total occlusion time, use of diverting support, intravascular volume
49
if HoTN persists for more than a few minutes after removal of cross clamp, consider
unrecognized bleeding or inadequate volume replacement
50
aortic unclamping: expect these symptoms (4)
HoTN, reactive hyperemia, washout of vasoactive and cardio depressant mediators, pulmonary hypervolemia
51
therapeutic interventions to consider during aortic cross clamping
``` decrease inhaled anesthetics decrease vasodilators increase fluid administration administer vasoconstriction reapplication of cross clamp for severe refractory HoTN consider mannitol consider sodium HCO3- ```
52
anesthetic technique for open AAA
GETA most common. regional, combined, low volatile all options but dont do intraop epidural infusion or something. can have it for postop pain N2O okay propofol v thiopental v etomidate fentanyl or sufenta esmolol, nitroprusside, nitroglycerin, clevidipine, phenylephrine boluses ready heparin IV 100-300 units/kg: monitor ACT and have protamine
53
anesthetic managment for open AAA: lines
potential for rapid blood loss so get CVC (more for volume versus monitoring if you think it will be bloody) PIV's aline cell salvage and cross matched blood
54
anesthetic management for open AAA and temperature control
forced warming for upper body, fluid warmers lower part of body should not be warmed during the cross clamp period because doing so can increase injury to ischemic tissue distal to the cross clamp by increasing metabolic demands
55
hemodynamic management of open AAA (3 main considerations)
HTN avoided because acute stress can cause rupture HR should be maintained at or below baseline r/t ischemia risk euvolemic resuscitation deferred until aortic rupture surgically controlled
56
postoperative considerations for open AAA
aggressively control HTN and tachycardia hemodynamic, metabolic, and temperature homeostasis should be achieved before extubations LOS is variable can do epidural versus CVA
57
where is CSF pressure maintained for aortic aneurysm repair (especially TAA)
less than 10cmH2O and in the days immediately after surgery
58
postoperative complications from open AA repair
MI, PNA, sepsis, renal failure, decreased tissue perfusion, hypothermia
59
TAA's are associated with these genetic syndromes
marfans, Ehlers-danlos syndrome, bicuspid aortic valve, non syndromic familial aortic dissection
60
repair approach for TAA: descending aorta
left posterolateral thoracotomy, OLV using left tube (depending on where TAA is) partial versus full bypass
61
repair approach for TAA: ascending aorta
supine, median sternotomy | partial versus full bypass
62
s/sx of TAA
typically reflect impingement of aneurysms on adjacent structures acute, severe, sharp pain in anterior chest, neck, or between shoulder blades with diminution or absence of peripheral pulses is how this usually represents
63
hoarseness as sx of TAA is result of
stretching of RLN
64
stridor or dysphagia sx of TAA is result of
tracheal compression | esophageal compression
65
edema as sx of TAA results from
compression of SVC
66
crawford classification of TAA: type 1
aneurysm involving descending thoracic and upper abdominal aorta
67
crawford classification of TAA: type 2
descending thoracic and most of abdominal aorta (difficult to repair)
68
crawford classification of TAA: type 3
lower thoracic aorta and most abdominal aorta (difficult to repair) renal ischemia worst for this one
69
crawford classification of TAA: type 4
most or all of abdominal aorta
70
debakey classification of dissecting aortic aneurysms aka "how they dissect" type 1
ascending aortic tear with dissection down entire aorta
71
debakey classification of dissecting aortic aneurysms aka "how they dissect" type 2
tear in ascending aorta with dissection limited to ascending aorta
72
debakey classification of dissecting aortic aneurysms aka "how they dissect" type 3
tear in proximal descending thoracic aorta with dissection from thoracic aorta to abdominal aorta
73
the artery that supplies blood to the lower 2/3 of the spinal cord
artery of adamkiewics or great radicular artery | located between T9-12
74
increased risks of paraplegia after aortic surgery includes
duration of cross clamp and anatomic location | not a problem if <30 minutes
75
anterior spinal artery syndrome
flaccid paralysis of lower extremities and bowel and bladder dysfunction sensation and proprioception are spared
76
how to promote spinal cord protection
limit cross clamp to less than 30 minutes distal aortic perfusion via CPB CSF drainage to maintain normal ICP intrathecal papaverine to increase BF to area mild hypothermia barbs, corticosteroids avoid hyperglycemia
77
how much does ICP increase with cross clamping
10-15mmHg
78
SSEP monitoring: what it monitors and considerations
posterior/lateral cord, sensory | cant run increased inhalation, maybe keep under a MAC
79
MEP monitoring: what it monitors and considerations
anterior cord, motor cannot use NMB, do TIVA reduction in amplitude >25%=SCI induction
80
MEP's and inhalationals
inhalational anesthetics depress synaptic condition and significantly decrease amplitude of myogenic MEP's
81
how do fentanyl and ketamine effect MEP's
they have little effect
82
TAA preop considerations
know extent of aneurysm, technique of repair, plans for distal aortic reperfusion have 15U PRBC 15U FFP and platelets in room in a cooler
83
TAA invasive lines to have include
aline (right radial), ability to draw off CSF/measure pressures, IV access, TEE is routine right femoral artery cath placed to monitor BP distal to clamp double limen ETT or bronchial blocker
84
what does right femoral artery monitor during TAA
perfusion to kidneys, SC, and mesenteric circulation
85
how to minimize risk of paraplegia in TAA case (3)
epidural cooling regional hypothermia in line mesenteric shunting
86
contributing factors to coagulopathy during AA surgery (3)
residual heparin, liver ischemia, persistent hypothermia
87
how to treat persistent coagulopathy after AA surgery
FFP, PLT's, cryo PT/PTT, fibrinogen, PLT count, TEG/ROTEM TCA, amicar, desmopressin normothermia
88
emergent ruptured aneurysm considerations
can be repaired open or EVAR awake intubation v RSI .1mg/kg etomidate if open, surgeon will be prepping to clamp aorta at same time as induction PRBC's, normothermia if possible dopa, epi, NE, vasopressin if needed after aorta is clamped and hemodynamics restored, then worry about placing lines TEE recommended for assessment of ventricular function, filling pressure, etc
89
various induction dosages in vascular anesthesia (fent, sufent, etomidate, esmolol, NGT, SNP, lidocaine, rocuronium, scopolamine)
``` fentanyl 10-15mcg/kg sufentanil 1-2mcg/kg etomidate .1-.3mg/kg esmolol 100-500mcg/kg bolus or SNP 25-50mcg bolus or NTG .5-3mcg/kg bolus lidocaine 1.5mg/kg rocuronium 1.2mg/kg if hemodynamically unstable, scopolamine 400mcg provides amnesia ```
90
various medication doses for maintenance of vascular anesthesia (GA and regional)
``` O2/narcotic/benzo low dose volatile des epidural with morphine 2-4mg or hydromorphone .5-.8mg. avoid LA remifent .05-.2mcg/kg/min ```
91
medication dosages of mannitol, lasix, and heparin pre cross clamp in vascular anesthesia
mannitol (.25-.5g/kg) furosemide (20-40mg IV) heparin 100-300 units/kg IV
92
medication dosages of SNP, NTG, esmolol during cross clamp in vascular anesthesia
SNP .5-2mcg/kg/min NGT .5-2mcg/kg/min esmolol 50-300mcg/kg/min bolus NTG is 100mcg
93
medication dosages during uncross clamping in vascular anesthesia
giving volume!

N934 Adv Principles Fa 21 (23 decks)

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