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APA 2 > APA 2 - Vascular surgery > Flashcards

APA 2 - Vascular surgery Flashcards

1
Q

PVD is the most common cause of occlusive disease in the lower extremity. It is a degenerative pathophysiologic process that is characterized by what?

A

Formation of atheromatous plaques/stenosis, thrombosis with acute ischemia, embolism from microthrombi or atheromatous debris, aneurysm formation of weakened arterial wall

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2
Q

Risk factors associated with development of atherosclerotic disease

A

hypercholesterolemia, elevated triglycerides, cigarette smoking, hypertension, diabetes mellitus, obesity, genetic predisposition, gender (male > Female), impaired long term glucose regulation, homocysteine, C-reactive protein

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3
Q

Symptoms of PVD

A

claudication, skin ulceration, gangrene, impotence

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4
Q

Mortality rates of PVD at 5 yrs

A

30%

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5
Q

Mortality rates of PVD at 10 yrs

A

70%

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6
Q

Treatment of PVD is _________ first. If fails that will have surgical therapy. What are the surgical therapy options

A

Pharmacological / transluminal angioplasty, endarterectomy, thrombectomy, endovascular stenting, arterial bypass procedures

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7
Q

If they have PVD in one area, more than likely will have it ___________ else.

A

everywhere

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8
Q

Will you usually be putting in an arterial line with PVD surgery?

A

yes

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9
Q

You will want to assess to see if they have associated systemic ________ disease

A

occlusive

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10
Q

There is a high mortality from adverse ________ events. Therefore, It is important to have aggressive identification and management of associated _______ pathology

A

cardiac / cardiac

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11
Q

These patients can have an MI intraoperatively, so try to optimize their care __________

A

preoperatively

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12
Q

Review slides 9-13

A

algorithm for evaluation and care of noncardiac surgery

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13
Q

When choosing an anesthetic for the case, you want the least _________ and the most optimal for the patient

A

invasive

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14
Q

Is it possible that the surgeon will ask you to manipulate the blood pressure higher or lower during the case?

A

YES

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15
Q

TEE can be placed intraoperatively so you can detect a ______ _______ earlier

A

cardiac event

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16
Q

You do not want the patient to be tachy or hypertensive post-op, so _____ control is an important aspect of care.

A

pain

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17
Q

Is it feasible to place an epidural catheter for post op pain mgmt?

A

Yes

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18
Q

AAA occurrence is 36.2 out of _________ surgical procedures

A

100,000

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19
Q

Who is more likely to have a AAA?

A

Aging population, MEN > Women, African Americans

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20
Q

AAA - contributing factors

A

athersclerosis, proteolysis of elastin and collagen within a vessel wall, HTN, cigarette smoking, genetic predisposition, obesity,

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21
Q

What may mask the S/S of AAA?

A

OBESITY

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22
Q

HTN is found in about _____% of AAA patients

A

60%

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23
Q

Diagnosis of a AAA is sometimes _________ and detected incidentally during routine physical exam or on abdominal CT, MRI, ultrasound

A

asymptomatic

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24
Q

Best method for evaluating suprarenal aneurysms?

A

digital subtraction angiography

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25
Q

AAA Mortality rate is an average of 5%. Why?

A

Early detection, early intervention, extensive preoperative preparation, refined surgical techniques, improved hemodyamic monitoring, improved anesthetic technique, improved postoperative management

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26
Q

If the AAA is < 4cm it will be ________ managed as there is no fear of rupture

A

medically

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27
Q

If the AAA is above _____ cm it is recommended to have surgery

A

5.5 cm

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28
Q

If the AAA is untreated, the mortality rate is ___ to ___%

A

35 to 95%

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29
Q

The first endovascular stent was performed in _____

A

1991

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30
Q

The procedure for endovascular AAA repair is deployment of an endovascular stent graft within the aortic lumen, the graft restricts flow to the _______ where the aneurysm exists, and is appropriate for _____ or _____ _______ _____

A

aorta / AAA / descending thoracic AA

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31
Q

For the endovascualr AAA repair, a guide wire is threaded through the _____ artery to the level of the aneurysm. Sheath is inserted over the guide wire and positioned at the level of the aneurysm using ________, once the sheath is deployed, _________ mechanisms such as hooks or barbs on the stent prevent stent migration.

A

iliac / fluoroscopy / fixation

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32
Q

Endovascular procedural considerations

A

Will be in OR 15, systemic anticoagulation with 50-100 units/kg of heparin, ABX prophylaxis with first gen cephalosporin, GETA, MAC, neuraxial blockade

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33
Q

Anesthetic Goals for EVAR

A

maintain hemodynamic stability, anxiolysis and analgesia, Quiet surgical field, preparation for rapid conversion to open procedure

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34
Q

What are you going to have in the OR with you during the EVAR procedure or any vascular procedure?

A

2 units of blood

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35
Q

What are the advantages of EVAR?

A

Greater hemodynamic stability AND Decreased - emoblic events, blood loss, surgical stress response, renal DYSfunction, post-op pain

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36
Q

Complications of EVAR

A

endograft thrombosis, endograft migration, endograft rupture, graft infection, iliac artery rupture, lower extremity ischemia, ischemic gut

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37
Q

Endoleak is a complication of EVAR characterized by peristent blood flow and pressure (endotension) between the endovascular graft and the _____ _____

A

aortic aneurysm

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38
Q

Which type of endoleak is most common?

A

Type II

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39
Q

In a type I leak it is leaking where?

A

around the graft

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40
Q

Type III leak is a ________ of the graft

A

rupture

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41
Q

Type IV is a increased pressure from the graft to the _______

A

aneurysm

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42
Q

Type V leak, the blood is leakind through ________

A

graft

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43
Q

Who is more likely to have a surgical AAA repair and why?

A

really young because the repair will last longer

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44
Q

Contraindications to elective surgical AAA repair

A

intractable angina, recent MI, severe pulmonary dysfunction, chronic renal insufficency

45
Q

High risk AAA repair (AGE)

A

> 85 years

46
Q

High risk AAA repair (PULMONARY)

A

Home 02, Pa02 <50mmHg, FEV1 < 1 L/Sec

47
Q

High Risk AAA repair (RENAL)

A

serum creatinine > 3mg/dl

48
Q

High Risk AAA repair (cardiac)

A

Class III-IV angina, resting LVEF <30%, recent CHF, complex ventricular ectopy and severe noncorrectable CAD

49
Q

Aneurysmal dimensions correspond to the law of _____

A

Laplace T=P x R

50
Q

Anesthesia concerns for open AAA

A

restoration of intravascular fluid volume, reliable venous access, anticipate massive hemorrhage

51
Q

Required monitors for Open AAA repair

A

EKG (II, V and ST segment), pulse ox, capnography, temp, urinary catheter, nerve stimulator, arterial line, central line/PA cath

52
Q

Pay close attention to ____ _____ when clamping and unclamping the aorta

A

blood pressure

53
Q

Which clamp application site is preferred?

A

infrarenal

54
Q

infrarenal

A

below the renal arteries

55
Q

juxtarenal

A

at the level of the renal arteries

56
Q

suprarenal

A

above the renal arteries

57
Q

With aortic cross-clamping you will see ________ above the cross clamp, ________ below the cross-clamp. The organs proximal to aortic occlusion may experience ________ of blood volume

A

hypertension / hypotension / redistribution

58
Q

There will be an absence of blood flow _______ to the clamp

A

distal

59
Q

With cross-clamping, you will see an increase in _______ which will cause an increase in myocardial wall tension

A

afterload

60
Q

_____ and _____ are increased above the clamp

A

MAP and SVR

61
Q

Organs above the clamp will get an increase in volume of _____ and _______

A

blood and pressure

62
Q

With aortic cross-clamping, cardiac output ______ or remains the same. PAOP may ______ or remain unchanged.

A

decreases / increase

63
Q

Increased ventricular wall stress associated with aortic clamp may decrease global ventricular function or cause overt ____ _____

A

cardiac ischemia

64
Q

Aggressive ______ intervention is required to restore and preserve cardiac function during cross clamp time frame

A

pharmacologic

65
Q

During cross clamping time frame, will more than likely need a VASODILATOR like _________, which works primarily by reducing preload. _______ and _______ may be indicated for a weak heart. Nipride works mostly on _______.

A

nitroglycerin / dopamine and dobutamine / afterload

66
Q

Document the cross clamp time so you can document the ________ time

A

ischemic

67
Q

Review slides 44 and 45

A

aortic cross clamping impacts

68
Q

With aortic cross-clamping you may have _____ of tissues distal to clamo

A

hypoxia

69
Q

With aortic cross clamping may have accumulation of anaerobic metabolites like _______

A

lactate

70
Q

With aortic cross clamping may have significant increase in plasma _______; epi and norepi stimulate ___ receptors that can increase heart rate and myocardial oxygen demand

A

catecholamines / beta-1

71
Q

With aortic cross clamping may have NEUROENDOCRINE response which is mediated by _______ and tumor necrosis factor as well as plasma catecholamines and CORTISOL

A

cytokines

72
Q

The ______ _______ mediators are thought to be responsible for triggering the inflammatory response that results in increased body temp, leukocytosis, tachycardia, tachypnea and fluid sequestration

A

neuroendocrine response

73
Q

Juxta/suprarenal cross clamp may be associated with higher incidence of ______ morbidity

A

renal

74
Q

Preop evaluation of renal function is one of the most significant predictors of ____ _____ renal dysfunction

A

post op

75
Q

To Maintain intraoperative renal and glomerular blood flow some practitioners administer _________ g/kg 20-30 minutes PRIOR to aora cross clamp to maintain vigorous UOP.

A

mannitol 0.25-0.5 g/kg

76
Q

After aorta clamp is removed and when hemodynamically stable, consider furosemide 20-80mg to ensure diuresis and UOP of ____cc/kg/hr

A

1

77
Q

Mortality rate increases by __ to ___ times in the patient who develops acute, post-op renal failure after cross clamp

A

4 to 5

78
Q

Interruption of blood flow to the artery of ________ in the absence of collateral blood flow has caused post operative PARAPLEGIA

A

Adamkiewicz

79
Q

The incidence of neurologic complications increases as the clamp is positioned ______ on the aorta

A

higher

80
Q

The artery of Adamkiewicz is AKA as

A

greater radicular artery

81
Q

Look at the Adamkiewicz artery on slide

A

49

82
Q

Primary blood supply to the left colon is the _____ mesenteric artery, and is often sacrificed during surgery so blood flow to the descending and sigmoid colon is dependent on ______ _____

A

inferior / collateral flow

83
Q

Declamping shock syndrome is characterized by what?

A

liberation of anaerobic metabolites, decreased SVR, decreased venous return, reactive hyperemia, further decrease in preload and afterload, hemodynamic instability

84
Q

When aortic cross clamp is released, the magnitude of the response to unclamping can be manipulated. Although the SVR and MAP decrease, intravascular volume may influence the ____ and _____ of change in cardiac output. SO, restoration of circulating blood volume is pramount in providing circulatory stability _______ release of the aortic clamp

A

magnitude and direction / BEFORE

85
Q

Severe hypotension and reduction in cardiac output can be prevented in severity by volume loading and raising the CVP __ to __mmHg or raising PAOP by __ to ___ mmg just prior to clamp release

A

3 to 5 / 3 to 4

86
Q

Evaporative loss and third spacing is influenced by (3)

A

surgical approach, duration of surgery, experience of surgeon

87
Q

Anesthetic plan for AAA may require “slow-cardiac” induction. What is this?

A

opiods, beta blockers, nudge of propofol ~ etomidate may be suitable for patients with minimal cardiac reserve

88
Q

Art line and pulse ox should be on RIGHT side of body d/t LEFT ________ vein compromise with surgery wif thoracic or distal aortic approach

A

Subclavian

89
Q

With TIAs what are the clincal features?

A

S/S last for seconds to minutes, S/S often recur over a 24 hr period, S/S completely resolve within 24 hrs, the patient DOES NOT experience LOC

90
Q

Vertebral involvement usually leads to confusion, dizziness or affects ______

A

vision

91
Q

Carotidd involvement may cause _______ blindness or weakness

A

unilateal

92
Q

Cardinal stroke risk factors

A

agdominal obesity, HTN, diabetes, heart dz, tobacco smoking

93
Q

Symptomatic patients with low grade carotid stenosis (<50%)

A

medical therapy

94
Q

Symptomatic patients with moderate to severe stenosis (>50%)

A

CEA plus medical therapy OR Carotid stenting

95
Q

Review risk table on slide 67 for symptomatic vs. asymptomatic patients

A

slide 67

96
Q

CEA pre-op assessment. Patients with no significant medical history, normal physical exam, and normal EKG are considered ____ risk

A

low

97
Q

_____-______ imaging is very suggestive of increased risk of adverse cardiac events for CEA

A

dipyridamole-thallium

98
Q

Anesthetic concerns with CEA surgery

A

maintain and optimize perfusion to the brain, maintain myocardial pefusion, minimize stress response, fascilitate a smooth and RAPID emergence so you can do rapid neuro assessment

99
Q

Regional anesthesia for CEA surgery would include local infiltration or _____ and _____cervical plexus block

A

superficial and deep

100
Q

General anesthesia for CEA provides a motionless surgical field and inhalation agents may decrease ________

A

CMR02

101
Q

____% of cerebral blood flow is supplied by the carotid arteries, when artery is clamped, _____ will be compromised

A

80% / CBF

102
Q

CPP =

A

MAP - ICP

103
Q

MAP between __ and ____mmHg, CBF remains constant

A

60 and 160

104
Q

Adverse effects of chronic HTN shifts the cerebral autoregualtory curve to the ____ and _____ than normal MAP may be required to ensure adequate perfusion

A

right and higher

105
Q

On the EEG, loss of _____ wave activity, loss of amplitude and emergence of slow-wave activity indicated NEUROLOGIC DYSFUNCTION

A

beta

106
Q

Carotid artery stump pressures of less than 40-50 mmHg suggests neurologic __________ and is criterion for shunt placement

A

hypoperfusion

107
Q

Cerebral HYPERPERFUSION syndrome

A

severe headache, visual disturbances, altered LOC, seizures

108
Q

Considerations for carotid artery stenting

A

safety and efficacy have been questioned, may be associated with increased risk of stroke, routinely done under local anesthesia, anticoagulation of 50-100 units/kg of heparin to get ACT greater than 250 seconds

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