Carotid Endarterectomy

Question 1

So, who gets carotid surgeries?

Answer 1

symptomatic patients with 70-99% stenosis

Asymptomatic patients with 60-99% stenosis can be discussed

Question 2

What are some things that you need to make sure that you ask before going forward?

Answer 2

are they symptomatic or asymptomatic? What neurological deficits do they currently have?

Question 3

Regional technique in CEA-what’s the block, and what are its two parts? Explain the anatomy and when it divides into these two parts? where do you insert the needle? How much local would you use?

Answer 3

Cervical plexus block (CPB) deep or superficial.
Cervical plexus is formed from C1-C4. At transverse processes of C2-C4 divide and form deep and superficial branches.
Deep branches: motor
Superficial branches: sensory.
For superficial block: Needle inserted at midpoint of the posterior border of SCM (Erb’s point)
I would use 3-5 mL per level of local anesthetic (0.5% bupi)

Question 4

Complications from cervical plexus blocks:

Answer 4

Infection, hematoma, phrenic nerve blockade, Spinal anesthesia:his complication may occur with injection of a larger volume of local anesthetic inside the dural sleeve that accompanies the nerves of the cervical plexus

Question 5

3 landmarks for a deep crevical plexus block:

Answer 5

The following three landmarks for a deep cervical plexus block are identified and marked (Figure 4):

Mastoid process
Chassaignac tubercle (the transverse process of the sixth cervical vertebra)
The posterior border of the sternocleidomastoid muscle

Question 6

Deep block process:

Answer 6

. Position the
patient supine with the head turned toward the
nonoperative side. Palpate the transverse process
of C6 (Chassaignac’s tubercle) at the level of the
cricoid cartilage. Palpate the mastoid process
behind the ear. Draw a line between the mastoid
process and Chassaignac’s tubercle. The trans
-
verse processes of the other cervical vertebrae
will lie on or near this line. The first palpable
transverse process below the mastoid process is
C2. Palpate and mark the transverse processes of
C2 to C4 (the C4 transverse process lies approximately at the level of the mandible). Insert the
needle medially and caudally so that the needle
tip is resting on the transverse process.

The needle is advanced slowly until the transverse process is contacted (Figure 7). At this point, the needle is withdrawn 1–2 mm and stabilized for injection of 4 mL of local anesthetic per level after negative aspiration for blood.

Question 7

Anesthetic type for CEA:

Answer 7

You can do: regional, local, or GA. If regional/local-must have thorough discussion with the patient.
You can do TIVA, inhalation (isoflurane)
Do NOT use nitrous to decrease risk of air embolism that could happen during carotid artery cross clamping.

Question 8

What are your anesthetic goals for CEA: (5)

Answer 8

• blunting of noxious stimuli during intubation and incision
• Reliable hemodynamic control
• Maintaining CV stability
• Expeditious emergence from anesthetic-allowing for rapid neurologic assessment
• Anesthetic that does NOT negatively impact the neuromonitoring technique employed