Anesthetic Management for Vascular Surgery

Question 2

What are 6 significant risk factors for post-op cardiac events?

Answer 2

high risk surgery

ischemic heart disease

creatinine > 2.0

Hx of TIA, CVA

Type I diabetes

Hx of CHF

Question 3

What are 3 noninvasive cardiac evaluations we can perform?

Answer 3

Stress test

Dipyridamole-Thallium Stress test

Dobutamine Stress Echo

Question 4

What are severe cardiac risk factors? (4)

Answer 4

Recent MI
Decompensated heart failure
Significant arrhythmias
Severe valvular disease

Question 5

What are moderate cardiac risk factors? (5)

Answer 5

Ischemic heart disease
Compensated CHF
DM
Renal insufficiency
Cerebrovascular disease

Question 6

What are high risk surgeries? (4)

Answer 6

Emergent surgery
Aortic/major vascular surgery
Peripheral vascular surgery (leg amputation)
Prolonged surgery with large fluid shifts/blood loss

Question 7

What are considered intermediate risk surgeries? (5)

Answer 7

Carotid endarterectomy
Head/neck
Thoracic/Abdominal
Orthopedic
Prostate

Question 8

If functional capacity is < 4 mets and >3 risk factors, do you proceed with intermediate risk surgery?

Answer 8

Yes, with HR control or consider testing if it will change management.

Question 9

When is CABG indicated? (4)

Answer 9

Stable angina w/ left main stenosis
Stable angina and 3-vessel CAD
Stable angina and 2-vessel CAD with LAD
Unstable angina or acute MI

Question 10

What type of monitoring is required for AAR (abdominal aortic reconstruction)? (6)

Answer 10

All cases need:

ASA standard monitors
2 Large bore IVs
Art line

Good LV, need central line

Poor LV, need PA line and TEE

Question 11

Renal effects significant even infrarenally!

What are the renal effects of infrarenal aortic cross clamping?

Answer 11

decreased renal blood flow

increased renal vascular resistance

reduced GFR

Note: Changes persis for at least 1 hour after unclamping.

Question 12

During thoracic aorta repair, what is at risk of ischemia? why?

Answer 12

spinal cord, so drain prior to surgery

ischemia result of thoracic cross clamping

Question 13

Asymptomatic bruit/stenosis does not increase the stroke risk for general surgery. True or false?

Answer 13

True

Question 14

What are the neurological risks for carotid endarterectomies? (6)

Answer 14

irregular/ulcerated ipsilateral plaque
thrombus
poor colllaterals
contralateral occlusion
STATINS
history of stroke

Question 15

When is the highest risk of embolism during a carotid endarterectomy? (4)

Answer 15

dissection

shunt insertion

clamp release

12 hours post op

Question 16

What issues can arise after a carotid endarterectomy? (7)

Answer 16

Hyper, hypotension
Carotid body damage
MI **
Stroke
Hyperperfusion **
Neck hematoma
Cranial nerve injury

Question 17

what is MET?

Answer 17

Metabolic Equivalent = estimates energy requirements

1 = basic low level activities

10 = strenuous exercise

Question 18

coronary stent placement has what effect on coagulopathy increasing the risk for this adverse event?

Answer 18

hypercoagulable

increased risk for MI

Question 19

what drug must be given prior to aortic cross-clamping and why?

Answer 19

heparin (100 U/kg), repeated hourly to prevent thrombosis

Question 20

in order to alter CO2 levels, what must be done when the clamp goes up and then comes back down?

Answer 20

Clamp up = decrease RR

Clamp Down = increase RR

Question 21

What are some differences between Open and Endovascular approaches to AAA repair?

Answer 21

Endo = lower 30 day mortality, less invasive, higher rate of reintervention

Question 22

How do anterior and posterior spinal cord ischemia present differently?

Answer 22

Anterior = impaired motor fxn and temp

Posterior = proprioception & fine motor skills altered

Question 23

aTAA is at an increased risk of rupture when is is what size?

Answer 23

>6 cm

Question 24

what is the main difference between the carotid sinus and carotid bodies?

Answer 24

carotid sinus = baroreceptor

carotid body = chemoreceptor

Question 25

List some types of cerebral monitoring that can be used during CEA

Answer 25

Awake - monitor fxn

EEG - monitor ischemia

SSEP -somatosensory evoked potentials

Oximeter

JvO2

Stump Pressure - pressure above shunt/clamp

TCD - transcranial doppler

Question 26

list 5 physiologic ways to enable cerebral protection

Answer 26

hypertension

hemodilution

hypothermia

normoglycemia

normocarbia

Question 27

what is hyperperfusion syndrome?

Answer 27

vessels maximally dilate distal to stenosis leading to brain edema and hemorrhage

Question 28

what are the risks and symptoms of hyperperfusion syndrome?

Answer 28

Risks:

severe ICA stenosis

uncontrolled HTN

contralateral stenosis

Symptoms:

unilateral headache

seizures

focal signs