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
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
3
Q
Symptoms of PVD
A
claudication, skin ulceration, gangrene, impotence
4
Q
Mortality rates of PVD at 5 yrs
A
30%
5
Q
Mortality rates of PVD at 10 yrs
A
70%
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
7
Q
If they have PVD in one area, more than likely will have it ___________ else.
A
everywhere
8
Q
Will you usually be putting in an arterial line with PVD surgery?
A
yes
9
Q
You will want to assess to see if they have associated systemic ________ disease
A
occlusive
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
11
Q
These patients can have an MI intraoperatively, so try to optimize their care __________
A
preoperatively
12
Q
Review slides 9-13
A
algorithm for evaluation and care of noncardiac surgery
13
Q
When choosing an anesthetic for the case, you want the least _________ and the most optimal for the patient
A
invasive
14
Q
Is it possible that the surgeon will ask you to manipulate the blood pressure higher or lower during the case?
A
YES
15
Q
TEE can be placed intraoperatively so you can detect a ______ _______ earlier
A
cardiac event
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
17
Q
Is it feasible to place an epidural catheter for post op pain mgmt?
A
Yes
18
Q
AAA occurrence is 36.2 out of _________ surgical procedures
A
100,000
19
Q
Who is more likely to have a AAA?
A
Aging population, MEN > Women, African Americans
20
Q
AAA - contributing factors
A
athersclerosis, proteolysis of elastin and collagen within a vessel wall, HTN, cigarette smoking, genetic predisposition, obesity,
21
Q
What may mask the S/S of AAA?
A
OBESITY
22
Q
HTN is found in about _____% of AAA patients
A
60%
23
Q
Diagnosis of a AAA is sometimes _________ and detected incidentally during routine physical exam or on abdominal CT, MRI, ultrasound
A
asymptomatic
24
Q
Best method for evaluating suprarenal aneurysms?
A
digital subtraction angiography
25
AAA Mortality rate is an average of 5%. Why?
Early detection, early intervention, extensive preoperative preparation, refined surgical techniques, improved hemodyamic monitoring, improved anesthetic technique, improved postoperative management
26
If the AAA is < 4cm it will be ________ managed as there is no fear of rupture
medically
27
If the AAA is above _____ cm it is recommended to have surgery
5.5 cm
28
If the AAA is untreated, the mortality rate is ___ to ___%
35 to 95%
29
The first endovascular stent was performed in _____
1991
30
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 _____ _______ _____
aorta / AAA / descending thoracic AA
31
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.
iliac / fluoroscopy / fixation
32
Endovascular procedural considerations
Will be in OR 15, systemic anticoagulation with 50-100 units/kg of heparin, ABX prophylaxis with first gen cephalosporin, GETA, MAC, neuraxial blockade
33
Anesthetic Goals for EVAR
maintain hemodynamic stability, anxiolysis and analgesia, Quiet surgical field, preparation for rapid conversion to open procedure
34
What are you going to have in the OR with you during the EVAR procedure or any vascular procedure?
2 units of blood
35
What are the advantages of EVAR?
Greater hemodynamic stability AND Decreased - emoblic events, blood loss, surgical stress response, renal DYSfunction, post-op pain
36
Complications of EVAR
endograft thrombosis, endograft migration, endograft rupture, graft infection, iliac artery rupture, lower extremity ischemia, ischemic gut
37
Endoleak is a complication of EVAR characterized by peristent blood flow and pressure (endotension) between the endovascular graft and the _____ _____
aortic aneurysm
38
Which type of endoleak is most common?
Type II
39
In a type I leak it is leaking where?
around the graft
40
Type III leak is a ________ of the graft
rupture
41
Type IV is a increased pressure from the graft to the _______
aneurysm
42
Type V leak, the blood is leakind through ________
graft
43
Who is more likely to have a surgical AAA repair and why?
really young because the repair will last longer
44
Contraindications to elective surgical AAA repair
intractable angina, recent MI, severe pulmonary dysfunction, chronic renal insufficency
45
High risk AAA repair (AGE)
> 85 years
46
High risk AAA repair (PULMONARY)
Home 02, Pa02 <50mmHg, FEV1 < 1 L/Sec
47
High Risk AAA repair (RENAL)
serum creatinine > 3mg/dl
48
High Risk AAA repair (cardiac)
Class III-IV angina, resting LVEF <30%, recent CHF, complex ventricular ectopy and severe noncorrectable CAD
49
Aneurysmal dimensions correspond to the law of _____
Laplace T=P x R
50
Anesthesia concerns for open AAA
restoration of intravascular fluid volume, reliable venous access, anticipate massive hemorrhage
51
Required monitors for Open AAA repair
EKG (II, V and ST segment), pulse ox, capnography, temp, urinary catheter, nerve stimulator, arterial line, central line/PA cath
52
Pay close attention to ____ _____ when clamping and unclamping the aorta
blood pressure
53
Which clamp application site is preferred?
infrarenal
54
infrarenal
below the renal arteries
55
juxtarenal
at the level of the renal arteries
56
suprarenal
above the renal arteries
57
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
hypertension / hypotension / redistribution
58
There will be an absence of blood flow _______ to the clamp
distal
59
With cross-clamping, you will see an increase in _______ which will cause an increase in myocardial wall tension
afterload
60
_____ and _____ are increased above the clamp
MAP and SVR
61
Organs above the clamp will get an increase in volume of _____ and _______
blood and pressure
62
With aortic cross-clamping, cardiac output ______ or remains the same. PAOP may ______ or remain unchanged.
decreases / increase
63
Increased ventricular wall stress associated with aortic clamp may decrease global ventricular function or cause overt ____ _____
cardiac ischemia
64
Aggressive ______ intervention is required to restore and preserve cardiac function during cross clamp time frame
pharmacologic
65
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 _______.
nitroglycerin / dopamine and dobutamine / afterload
66
Document the cross clamp time so you can document the ________ time
ischemic
67
Review slides 44 and 45
aortic cross clamping impacts
68
With aortic cross-clamping you may have _____ of tissues distal to clamo
hypoxia
69
With aortic cross clamping may have accumulation of anaerobic metabolites like _______
lactate
70
With aortic cross clamping may have significant increase in plasma _______; epi and norepi stimulate ___ receptors that can increase heart rate and myocardial oxygen demand
catecholamines / beta-1
71
With aortic cross clamping may have NEUROENDOCRINE response which is mediated by _______ and tumor necrosis factor as well as plasma catecholamines and CORTISOL
cytokines
72
The ______ _______ mediators are thought to be responsible for triggering the inflammatory response that results in increased body temp, leukocytosis, tachycardia, tachypnea and fluid sequestration
neuroendocrine response
73
Juxta/suprarenal cross clamp may be associated with higher incidence of ______ morbidity
renal
74
Preop evaluation of renal function is one of the most significant predictors of ____ _____ renal dysfunction
post op
75
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.
mannitol 0.25-0.5 g/kg
76
After aorta clamp is removed and when hemodynamically stable, consider furosemide 20-80mg to ensure diuresis and UOP of ____cc/kg/hr
1
77
Mortality rate increases by __ to ___ times in the patient who develops acute, post-op renal failure after cross clamp
4 to 5
78
Interruption of blood flow to the artery of ________ in the absence of collateral blood flow has caused post operative PARAPLEGIA
Adamkiewicz
79
The incidence of neurologic complications increases as the clamp is positioned ______ on the aorta
higher
80
The artery of Adamkiewicz is AKA as
greater radicular artery
81
Look at the Adamkiewicz artery on slide
49
82
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 ______ _____
inferior / collateral flow
83
Declamping shock syndrome is characterized by what?
liberation of anaerobic metabolites, decreased SVR, decreased venous return, reactive hyperemia, further decrease in preload and afterload, hemodynamic instability
84
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
magnitude and direction / BEFORE
85
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
3 to 5 / 3 to 4
86
Evaporative loss and third spacing is influenced by (3)
surgical approach, duration of surgery, experience of surgeon
87
Anesthetic plan for AAA may require "slow-cardiac" induction. What is this?
opiods, beta blockers, nudge of propofol ~ etomidate may be suitable for patients with minimal cardiac reserve
88
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
Subclavian
89
With TIAs what are the clincal features?
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
Vertebral involvement usually leads to confusion, dizziness or affects ______
vision
91
Carotidd involvement may cause _______ blindness or weakness
unilateal
92
Cardinal stroke risk factors
agdominal obesity, HTN, diabetes, heart dz, tobacco smoking
93
Symptomatic patients with low grade carotid stenosis (<50%)
medical therapy
94
Symptomatic patients with moderate to severe stenosis (>50%)
CEA plus medical therapy OR Carotid stenting
95
Review risk table on slide 67 for symptomatic vs. asymptomatic patients
slide 67
96
CEA pre-op assessment. Patients with no significant medical history, normal physical exam, and normal EKG are considered ____ risk
low
97
_____-______ imaging is very suggestive of increased risk of adverse cardiac events for CEA
dipyridamole-thallium
98
Anesthetic concerns with CEA surgery
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
Regional anesthesia for CEA surgery would include local infiltration or _____ and _____cervical plexus block
superficial and deep
100
General anesthesia for CEA provides a motionless surgical field and inhalation agents may decrease ________
CMR02
101
____% of cerebral blood flow is supplied by the carotid arteries, when artery is clamped, _____ will be compromised
80% / CBF
102
CPP =
MAP - ICP
103
MAP between __ and ____mmHg, CBF remains constant
60 and 160
104
Adverse effects of chronic HTN shifts the cerebral autoregualtory curve to the ____ and _____ than normal MAP may be required to ensure adequate perfusion
right and higher
105
On the EEG, loss of _____ wave activity, loss of amplitude and emergence of slow-wave activity indicated NEUROLOGIC DYSFUNCTION
beta
106
Carotid artery stump pressures of less than 40-50 mmHg suggests neurologic __________ and is criterion for shunt placement
hypoperfusion
107
Cerebral HYPERPERFUSION syndrome
severe headache, visual disturbances, altered LOC, seizures
108
Considerations for carotid artery stenting
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
