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Advance Anesthesia II > FINAL EXAM Review Vascular surgery ONLY > Flashcards

FINAL EXAM Review Vascular surgery ONLY Flashcards

1
Q

PVD Preop Pharmacological mangement

A
  • Beta-blockers
  • Statins
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2
Q

Drug class that provides a cardioprotective effect in PVD:

A

Statins

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3
Q

PVD Preop Management

Metoprolol

A
  • Tenfold decrease in cardiac mortality
  • instituted days to weeks prior surgery
  • Titrate dose to HR of 50-60 bpm
  • Continue up to day of surgery and postop period
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4
Q

Cardioprotective effects provided by Statin drugs include:

A
  • Decrease vascular inflammation
  • Decrease incidence of thrombogenesis
  • Enhance nitric oxide bioavialability
  • Stabilize atherosclerosis plauques
  • Decrease lipid concentration
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5
Q

Benefit of A-line in PVD Sx patients:

A
  • Allows near-real time BP values
  • Guides treatment options
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6
Q

Benefit of General Anesthesia in PVD sx patient:

A

Protects neurologic and cardiac tissue

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7
Q

Epidural anesthesia risk in PVD Sx patients:

A

High risk for epidural hematoma

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8
Q

Epidural CV benefits for vascular surgery:

A
  • Increases hemodynamic stability
  • Increases endocardial persuion at ischemic zone
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9
Q

Epidural Pulmonary benefits for vascular surgery:

A

Improves atrioventricular oxygen differentiation

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10
Q

PostOp PVD conditions include:

A
  • Pain (SNS stimuation)
  • Venous Thromboembolism (VTE)
  • Deep Vein Thrombosis (DVT)
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11
Q

Inflammatory mediators increased in Acute Pain:

A
  • Creatine kinase
  • C-Reactive protein
  • Interlukin (IL) 6
  • Tumor necrosis factor (TNF)
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12
Q

Inflammatory Mediators lead to:

A
  • Blood flow alteratios
  • Organ dysfunction
  • Cell death
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13
Q

VTE and DVT risk is increase during:

A

PostOp period

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14
Q

VTE and DVT prevention:

A
  • LMWH (bridge)
  • Restart oral anticoagulant postop when risk of bleeding is decrease
  • Low HTC concentration
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15
Q

AAA mortality in men is:

A

2-3 times white > black

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16
Q

AAA surgery is recommended if:

A

AAA is > 5.5 cm or greater in diameter

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17
Q

Elective AAA surgery mortality

A

< 5%

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18
Q

5 year mortality of untreated AAA

A

81%

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19
Q

10 year mortality of untreated AAA

A

100%

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20
Q

Mortality rate of undetected AAA

A

35-94%

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21
Q

AAA risk factors

A
  • Atherosclerosis (most common)
  • Smoking
  • Male
  • White > Black
  • Hypertension
  • Advanced age
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22
Q

AAA physical examination will find:

A

Pulsatile abdominal mass

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23
Q

< 30 % of AAA are identified during:

A

Routine physical examination with PCP

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24
Q

Additional AAA risk factors:

A
  • Presence of carotid artery disese
  • PVD
  • Obesity
  • Diabetes

All these factors increase rate detection to 90%

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25
AAA repair contraindications include:
1. Intractable angina pectoris 2. Recent MI 3. Severe pulmonary obstruction 4. Chronic renal insufficiency
26
# Law of Palace An Increase wall tension:
Increase vessel radius and intramural pressure
27
Ruptur risk for AAA 4-5 cm?
0.5-5 %/year
28
Rupture risk for AAA < 4cm
0%/year
29
Rupture risk for AAA 5-6 cm?
3-15%/year
30
Rupture risk for AAA 6-7 cm?
10-20%/year
31
Rupture risk for AAA 7-8 cm?
20-40%/year
32
Rupture risk for AAA > 8 cm?
30-50%/year
33
ECG lead to monitor during Aneurism rupture
* Lead II (dysrhythmias) * Lead V (ST changes)
34
Most dramatic physicological change during Aneurysm rupture occurs:
During Aortic Cross-Clamping
35
Hypertension occurs | Proximal
Above clamping
36
Hypotension occurrs
Below clamping | Distal
37
Hormones increase during Aortic cross-clamping:
* Catecholamines * Aldosterone * Cortisol levels
38
Which patient are unable to compensate hemodynamic alterations duirng Aortic cross-clamping?
* Ischemic heart disease (IHD) * Ventricular dysfunction
39
Tissue Ischemia during aortic cross clamping forms and release the following into circulation:
* Arachidonic acid * nitric oxide * Cytokine * Prostaglandins
40
Anaerobic metabolism leads to the accumulation of:
Serum lactate
41
Mesenteric traction syndrome:
* Surgical maneuver to expose the aorta * Decrease BP and SVR * Tachycardia * Increase CO * Facial flushing
42
Suprarenal cross-clamp > 30 min leads to:
PostOp Renal failure
43
Clamp above renal arteries leads to:
Severe AKI
44
What decreases the incidence of AKI?
* Balanced crystalloid * Hyperchloremic solutions * Avoid Nephrotoxic drugs * Avoid NSAIDs * Avoid Aminoglycoside
45
Longitudinal blood supply:
* One anterior spinal artery 80% * Two posterior & two post-lateral spinal arterial 20%
46
Transversed blood supply:
* Greater radicular artery (Adamkiewics) * Originates between T8-T12
47
Spinal cord ischemia complications increase when:
Aortic cross-clamp is positioned higher
48
Spinal coard function is monitor with:
* SSEP * MEP
49
Spinal caord protection strategies:
* CSF drainage * Mild hypothermia * Normotension SBP > 120 mmHg * Distal aortic perfusion
50
Ischemic colon injury is attributed to:
Manipulation of the Inferior Messenteric Artery
51
Messentaric Artery supplies the:
Left colon
52
Non-Reflow Phenomenon occures when microvasculature is occlude by:
* Platelets * Neutrophils * Thrombi
53
Most blood loss aneurysm repair is due to:
Back bleeding from lumbar and inferior messenteric arteries
54
3 options for Autologous transfusion:
1. Preoperative deposit 2. Intraoperative phlebotomy and Hemodilution 3. Intraoperative blood salvage
55
Autologous via cell saver system is:
Standard procedure
56
Opioids in vascular surgery provide
Cardiovascular stability
57
Epidural disadvantages
Epidural hematoma Severe hypotension during blood loss
58
Aneurysm repair fluid management:
* Crystalloid at 10mL/kg/hr * Initial blood ratio is 3:1 * Keep UOP at 1mL/kg/hr
59
Patienst with adequate LV functio, hemodynamic are preserve with a"slow" and "controlled" induction using:
* Higher doses of opioids * sympathomimetics (if hypotension)
60
Identify Suprarenal and Juxtarenal AAA on the image
* **A = Suprarenal** * B = Pararenal * **C = Juxtarenal** * D = Infrarenal
61
Which diuretic class decreases Renal ischemia and dysfunction?
* Osmotic Diuretics * Loop Diuretics
62
Most common symptom of ruptered AAA?
Severe abdominal discomfort or back pain
63
If Hypocalcemia occur replacement is based on:
Calcium Ionized level | Treat with Calcium chloride
64
What helps maximize venous return and Keep O2 sat in AAA patients?
* Minimal PIP * Higher FiO2 concentration
65
What improves alveolar recruitment and distention during AAA repair?
Manual positive pressure
66
Aortic dissection survival rate without surgery?
3 months
67
**Aortic dissection** is a tear within the
* Intima layer * Allows blood flow
68
What layer is involved with a **False Aneurysm**?
Adventitia only
69
How many layers are involved in a **True Aneurysm**?
3 layers
70
Aortic dissection shapes:
* Fusiform (most common) * Saccular
71
DeBakey AAA Classification
* **Type I**: Originates in the asceding aorta to aortic arch * **Type II**: Originates in ascendig aorta. Confined * **Type III**: Originates in descending oarta, extend distally
72
Standford AAA classifications:
* **Type A**: involve ascending aorta * **Type B**: does not
73
# Crawford Classification Identify the Crawford Classification Type III and IV
* Type III = E * Type IV = C | Thoracoabdominal Aortic Aneurysm
74
Thoracoabdominal Aortic Aneurysm Etiology:
* Atherosclerosis(most common) * Marfan syndrome
75
Thoracoabdominal Aortic Aneurysm is most often classified as:
Fusiform
76
Hoarseness is due to:
Impingement on LRLN | Intrussion
77
Heparin dose required prior to aortic cross-clamping?
50-100 units/kg
78
Sytemic Heparinization dose on Vascular surgery
400 units/kg
79
Placement of Arterial line and pulse oxymeter during vascular surgery?
Right side | Due to intrussion of left subclavian artery
80
Thoracoabdominal Aortic Aneurysm patient position
Right lateral decubitus Left-sided thoracotomy
81
Extend of thoracotomy is determined by:
Extent of aneurysm
82
Lower thoracic incision is associated with:
PostOp Pulmonary Dysfunction
83
Which aortic dissection type needs surgical intervention
Type A (higher incidence of rupture)
84
Which aortic dissection type is medically managed?
* Type B * Arterial dilators and B-blockers
85
Anesthesia for ascending and transversed aortic dissection requires:
CPB
86
# Descending Thoracic and Thoraco-Abdominal Aneurysm When is surgery recommended for Patients with degenerative aortic disease
Size > 6cm
87
Connective tissue etiology for Thoracoabdominal AA:
* Elhers-Danlol syndrome * Marfan syndrome
88
Infectious etiology for Thoracoabdominal AA:
* **Spirochetal (Syphilis)** * TB * Bacterial * Fungal
89
Most common devastating consequence of Thoracic surgery
Praplegia
90
Which nerve is most succeptible to hoarseness?
LRLN | Due to proximity to aortic arch
91
The use of Intraop TEE is recommended for
Patients with myocardial dysfunction
92
Indwelling catheter assess:
Renal function
93
How is CSF pressure monitor?
Lumbar intrathecal catheter
94
Paraplegia incidence of 0-3% occur if surgery clamp is
< 10 min
95
Delayed paraplegia risk factors
* Type 2 aneurysm * Renal failure * Number of sacrified segments
96
Postop Risk factors for Delayed Paraplegia
* **Hemodynamic instability by A-Fib** * **Bleeding** * Multiorgan failure * Spesis
97
Intervention to protect spinal cord during thoracic aortic cross-clamping:
* Routine CSF drainage pressure < 10 mmHg * Moderate intraop hypothermia * Avoid hypotension MAP > 90 mmHg * Avoid SNP (steal phenomenon)
98
Breathing difficulties post extuabation are due to:
RLN dysfunction
99
EVAR is associated with:
30 day outcome vs OSR
100
Majority of Endoleaks are:
Type II (branch leaks) ## Footnote It was a hotspot on selecting type II
101
In EVAR Endovascular graft migration can occur and lead to:
* Renal artery occlusion * Postop Renal failure
102
Fenestrated EVSG is safe for patients with:
* Juxtarenal Aortic Aneurysm * Suprarenal Aortic Aneurysm
103
Major EVAR advantages:
* Absence of aortic cross-clamping * No incision from xyphoid process to the pubis
104
EVAR procedure use sytemic anticoagulation with
Heparin 50-100 units/kg | There is like 2 math questions on the exam
105
106
Second most common vascualar operation in the USA?
Carotid Endarterectomy (CEA)
107
Most CVA are due to
Ischemia > Hemorrhage | 50% of strokes are preceed by a TIA
108
CEA benefits patients with:
* Recent ipslateral carotid territory symptoms * Moderate to severe symptoms than asymptomatic patients * Stenosis > 70%
109
CEA is less beneficail in patients with
50-69% stenosis
110
CEA surgical interventions are most beneficial in men:
* Older than 75 years * Within two weeks of the event
111
Factors contributing to morbidity during CEA:
* Age * Operative timing * Hyperglycemia * Mulitple comorbidities * Contralateral carotid disease * Progressing stroke * Ulcerative lession * Surgery with/whithout shunt
112
CEA variables affecting patient outcomes:
* **State of collateral flow through circle of willis** * Presence of concurrent atherosclerotic disease * Size and morphology of the offending plaque * **Specific symptoms** * **Concurrent CV diseases**
113
CEA common symptoms:
* **Amaurosis fugax** * ALOC * Aphasia * **Acute motor deficit** * **Carotid bruit**
114
CEA CV comorbidity risk include:
1. DM 2. PVD 3. COPD 4. Obesity
115
Normal cerebral flow
50 mL/100G/min
116
Cerebral cell death occurs at a flow of:
< 6 mL/100G/min
117
ALL anesthetic agents decrease metabolic rate, except:
**KETAMINE!**
118
Cerebral flow becomes pressure dependent due to:
Ischemia | Autoregulation and compensatory vasodilation
119
Cerebral monitoring standard tool include:
* EEG (Goldstandard) * Carotid Stump pressure
120
Most sensitive and specific measure of CBF responsiviness in awake patient tool is:
EEG
121
Gross measure of pressure in the circle of willis:
Carotid stump pressure
122
A carotid stump pressure indicating neurologic hypoperfusion
* < 40-50 mmHg * Criteria for shunt placement
123
Symptoms of inadequate cerebral perfusion include:
* Dizziness * Contralateral cerebral perfusion * LOC
124
CEA Blood pressure control
Maintain MAP at 20% or greater than preop MAP value
125
Drugs to decrease BP during CEA
* Nitroglycerine IV infusion * Sodium Nitroprusside
126
Which nerve provokes hypotension and bradycardia during CEA
Carotid sinus Baroreceptor Nerve manipulation
127
Hypotension and Bradycardia Tx 2/2 Baroceptor stimulation:
* Stop surgical stimulation * Infiltrate region with LA * Give an antichollinergic
128
CEA Regional anesthesia Requires a deep and superficial pluxus block at:
CN II, III, and IV
129
GETA provides preconditioning in CEA by:
Decreases Cerebral and Metabolic Metabolism
130
CEA PostOp considerations
* BP 140/80 mmHg recommended
131
Chronic HTN leads to:
Cerebral hypoperfusion syndrome (CHPS)
132
Cerebral hypoperfusion syndrome (CHPS) symptoms:
* Headache * Visual disturbances * ALOC * Seizures
133
What's the initial manifestion of hemorrhage post CEA?
Airway obstruction
134
Emergency Tx for Hemorrhage post CEA include:
Hematoma evacuation
135
Recurrent Laryngeal Nerve damage leads to:
Inspiratory stridor
136
Identify vagal nerve on the image
137
Cranial nerve to assess for CEA:
* CN VII (facial) * CN IX (glossopharyngeal) * CN X (Vagus) * CN XI (spinal accesory) * CN XII (hypoglossal)
138
CEA Anesthesia considerations:
* ACT > 250 sec * Atropine & Robinul prior inflation to offset vagal response * Carotid duplex scan prior discharge * ASA treatment for life

Advance Anesthesia II (7 decks)

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