Carotid Endarterectomy

Question 1

CE causes risk of stroke-how?

Answer 1

from plaque at carotid bifurcation

Question 2

Who has a definite benefit?

Answer 2

Symptomatic pt (TIA or CVA) with >70% stenosis.

Question 3

What’s cross clamped in an open carotid endarterectomY?

Answer 3

internal, external and common carotid arteries are cross clamped (hepariniazation)

Question 4

If doing cerebral monitoring, what do you want the stumpr pressure to be? what else can you monitor?

Answer 4

Stump pressure (40-50), SSEPs can be monitored as well as cerebral oximetry

Question 5

What does it mean to do a shunt in CEA? What are the risks?

Answer 5

blood from common carotid goes to internal carotid across cross clamp. Use varies from routine to selective if cerebral iscemia. Risks include: air/plaque emboli, intimal tears, carotid dissection

Question 6

What are the risks of the procedure? which nerves?

Answer 6

stroke, MI, cranial nerve injury, hematoma, airway edema mandibular branch of the facial (Vth) nerve, the laryngeal branches of the vagus (Xth) nerve and the hypoglossal (XIIth) nerve due to their close anatomical relationships to the carotid bifurcation

Question 7

Which type of anesthesia can these patients have? Any difference in death or stroke?

Answer 7

regional or general-no difference in rate of death or stroke

Question 8

What is hyperperfusion syndrome, and when would you see it?

Answer 8

Postop syndrome of hypertension, seizures, and neurologic deficits

Question 9

What kind of Hx would you like to get out of the pt?

Answer 9

Neuro-hx of CVA, TIA, residual symtoms b/c of that?

comorbid conditions-uncontrolled HTN has a higher risk of postoperative stroke,

Question 10

If you choose regional-what should you make sure of?

Answer 10

assess for a communication barrier or hx fo claustrophobia or anxiety

Question 11

What are you looking for on physical exam?

Answer 11

BP, Neuro deficits, cardiopulmonary exam, and ability to tolerate surgical position (supine with shoulder roll and head turned to the side)

Question 12

What kind of labs do you want prior to CEA?

Answer 12

ECG, echo, stress test as required

Question 13

What is a conflict of GA vs regional? What other options are available?

Answer 13

GA provides controlled environment, but local anesthesia or cervical plexus block allows direct neurologic monitoring of the patient. Other options available include: Local anesthesia

Question 14

How can you optimize these patients? What can you maintain?

Answer 14

Control over their BP
Avoid cerebral ischemia-note change in mental status if awake, or change in neurologic monitoring of GA. Maintain oxygenation, and NORMOCARBIA (hypercarbia can cause HTN)

Question 15

Goals in CEA:

Answer 15

hemodynamic stability, monitor neurologic status

Question 16

Can an LMA be used in CEA?

Answer 16

Yes-but I wouldn’t do it

Question 17

Explain your regional anesthesia technique for CEA

Answer 17

Regional Anesthesia-cervical plexus formed from C1-C4

Question 18

Whee do the processes of C2-C4 divide and form deep and superficial branches? what does deep versus motor do?

Answer 18

At transverse processes of C2-C4, is where they divide and form deep and superficial branches. Deep is motor and superficial is sensory.

Question 19

Where exactly would you perform the superficial block?

Answer 19

I would perform the block at the mid point of the posterior border of the SCM muscle (Erb’s point)

Question 20

Do you want blood?

Answer 20

Type and cross yes

Question 21

Room set up:

Answer 21

Arterial line,
Meds-heparin, vasopressors, vasodilators,
cerebral monitor

Question 22

How are you going to maintain this patient? Why would N20 be beneficial?

Answer 22

Balanced technique-volatile agent with short acting narcotics. N20 will preserve the EEG signal copared to propofol or volatile anesthetic.

Question 23

If you’re going to use GA-which infusion may be good to use?

Answer 23

phenylephrine infusion

Question 24

Emergence:

Answer 24

assess airway re: hematoma/airway edema

Question 25

Disposition pain-

Answer 25

Hypotension and hypERtension common
Monitor for wound hematoma
Monitor for hyperperfusion syndrome-treat HTN
postoperative MI (monitor)