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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
Q

AAA repair contraindications include:

A
  1. Intractable angina pectoris
  2. Recent MI
  3. Severe pulmonary obstruction
  4. Chronic renal insufficiency
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26
Q

Law of Palace

An Increase wall tension:

A

Increase vessel radius and intramural pressure

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27
Q

Ruptur risk for AAA 4-5 cm?

A

0.5-5 %/year

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28
Q

Rupture risk for AAA < 4cm

A

0%/year

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29
Q

Rupture risk for AAA 5-6 cm?

A

3-15%/year

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30
Q

Rupture risk for AAA 6-7 cm?

A

10-20%/year

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31
Q

Rupture risk for AAA 7-8 cm?

A

20-40%/year

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32
Q

Rupture risk for AAA > 8 cm?

A

30-50%/year

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33
Q

ECG lead to monitor during Aneurism rupture

A
  • Lead II (dysrhythmias)
  • Lead V (ST changes)
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34
Q

Most dramatic physicological change during Aneurysm rupture occurs:

A

During Aortic Cross-Clamping

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35
Q

Hypertension occurs

Proximal

A

Above clamping

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36
Q

Hypotension occurrs

A

Below clamping

Distal

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37
Q

Hormones increase during Aortic cross-clamping:

A
  • Catecholamines
  • Aldosterone
  • Cortisol levels
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38
Q

Which patient are unable to compensate hemodynamic alterations duirng Aortic cross-clamping?

A
  • Ischemic heart disease (IHD)
  • Ventricular dysfunction
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39
Q

Tissue Ischemia during aortic cross clamping forms and release the following into circulation:

A
  • Arachidonic acid
  • nitric oxide
  • Cytokine
  • Prostaglandins
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40
Q

Anaerobic metabolism leads to the accumulation of:

A

Serum lactate

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41
Q

Mesenteric traction syndrome:

A
  • Surgical maneuver to expose the aorta
  • Decrease BP and SVR
  • Tachycardia
  • Increase CO
  • Facial flushing
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42
Q

Suprarenal cross-clamp > 30 min leads to:

A

PostOp Renal failure

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43
Q

Clamp above renal arteries leads to:

A

Severe AKI

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44
Q

What decreases the incidence of AKI?

A
  • Balanced crystalloid
  • Hyperchloremic solutions
  • Avoid Nephrotoxic drugs
  • Avoid NSAIDs
  • Avoid Aminoglycoside
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45
Q

Longitudinal blood supply:

A
  • One anterior spinal artery 80%
  • Two posterior & two post-lateral spinal arterial 20%
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46
Q

Transversed blood supply:

A
  • Greater radicular artery (Adamkiewics)
  • Originates between T8-T12
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47
Q

Spinal cord ischemia complications increase when:

A

Aortic cross-clamp is positioned higher

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48
Q

Spinal coard function is monitor with:

A
  • SSEP
  • MEP
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49
Q

Spinal caord protection strategies:

A
  • CSF drainage
  • Mild hypothermia
  • Normotension SBP > 120 mmHg
  • Distal aortic perfusion
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50
Q

Ischemic colon injury is attributed to:

A

Manipulation of the Inferior Messenteric Artery

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51
Q

Messentaric Artery supplies the:

A

Left colon

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52
Q

Non-Reflow Phenomenon occures when microvasculature is occlude by:

A
  • Platelets
  • Neutrophils
  • Thrombi
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53
Q

Most blood loss aneurysm repair is due to:

A

Back bleeding from lumbar and inferior messenteric arteries

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54
Q

3 options for Autologous transfusion:

A
  1. Preoperative deposit
  2. Intraoperative phlebotomy and Hemodilution
  3. Intraoperative blood salvage
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55
Q

Autologous via cell saver system is:

A

Standard procedure

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56
Q

Opioids in vascular surgery provide

A

Cardiovascular stability

57
Q

Epidural disadvantages

A

Epidural hematoma
Severe hypotension during blood loss

58
Q

Aneurysm repair fluid management:

A
  • Crystalloid at 10mL/kg/hr
  • Initial blood ratio is 3:1
  • Keep UOP at 1mL/kg/hr
59
Q

Patienst with adequate LV functio, hemodynamic are preserve with a”slow” and “controlled” induction using:

A
  • Higher doses of opioids
  • sympathomimetics (if hypotension)
60
Q

Identify Suprarenal and Juxtarenal AAA on the image

A
  • A = Suprarenal
  • B = Pararenal
  • C = Juxtarenal
  • D = Infrarenal
61
Q

Which diuretic class decreases Renal ischemia and dysfunction?

A
  • Osmotic Diuretics
  • Loop Diuretics
62
Q

Most common symptom of ruptered AAA?

A

Severe abdominal discomfort or back pain

63
Q

If Hypocalcemia occur replacement is based on:

A

Calcium Ionized level

Treat with Calcium chloride

64
Q

What helps maximize venous return and Keep O2 sat in AAA patients?

A
  • Minimal PIP
  • Higher FiO2 concentration
65
Q

What improves alveolar recruitment and distention during AAA repair?

A

Manual positive pressure

66
Q

Aortic dissection survival rate without surgery?

67
Q

Aortic dissection is a tear within the

A
  • Intima layer
  • Allows blood flow
68
Q

What layer is involved with a False Aneurysm?

A

Adventitia only

69
Q

How many layers are involved in a True Aneurysm?

70
Q

Aortic dissection shapes:

A
  • Fusiform (most common)
  • Saccular
71
Q

DeBakey AAA Classification

A
  • 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
Q

Standford AAA classifications:

A
  • Type A: involve ascending aorta
  • Type B: does not
73
Q

Crawford Classification

Identify the Crawford Classification Type III and IV

A
  • Type III = E
  • Type IV = C

Thoracoabdominal Aortic Aneurysm

74
Q

Thoracoabdominal Aortic Aneurysm Etiology:

A
  • Atherosclerosis(most common)
  • Marfan syndrome
75
Q

Thoracoabdominal Aortic Aneurysm is most often classified as:

76
Q

Hoarseness is due to:

A

Impingement on LRLN

Intrussion

77
Q

Heparin dose required prior to aortic cross-clamping?

A

50-100 units/kg

78
Q

Sytemic Heparinization dose on Vascular surgery

A

400 units/kg

79
Q

Placement of Arterial line and pulse oxymeter during vascular surgery?

A

Right side

Due to intrussion of left subclavian artery

80
Q

Thoracoabdominal Aortic Aneurysm patient position

A

Right lateral decubitus
Left-sided thoracotomy

81
Q

Extend of thoracotomy is determined by:

A

Extent of aneurysm

82
Q

Lower thoracic incision is associated with:

A

PostOp Pulmonary Dysfunction

83
Q

Which aortic dissection type needs surgical intervention

A

Type A (higher incidence of rupture)

84
Q

Which aortic dissection type is medically managed?

A
  • Type B
  • Arterial dilators and B-blockers
85
Q

Anesthesia for ascending and transversed aortic dissection requires:

86
Q

Descending Thoracic and Thoraco-Abdominal Aneurysm

When is surgery recommended for Patients with degenerative aortic disease

A

Size > 6cm

87
Q

Connective tissue etiology for Thoracoabdominal AA:

A
  • Elhers-Danlol syndrome
  • Marfan syndrome
88
Q

Infectious etiology for Thoracoabdominal AA:

A
  • Spirochetal (Syphilis)
  • TB
  • Bacterial
  • Fungal
89
Q

Most common devastating consequence of Thoracic surgery

90
Q

Which nerve is most succeptible to hoarseness?

A

LRLN

Due to proximity to aortic arch

91
Q

The use of Intraop TEE is recommended for

A

Patients with myocardial dysfunction

92
Q

Indwelling catheter assess:

A

Renal function

93
Q

How is CSF pressure monitor?

A

Lumbar intrathecal catheter

94
Q

Paraplegia incidence of 0-3% occur if surgery clamp is

95
Q

Delayed paraplegia risk factors

A
  • Type 2 aneurysm
  • Renal failure
  • Number of sacrified segments
96
Q

Postop Risk factors for Delayed Paraplegia

A
  • Hemodynamic instability by A-Fib
  • Bleeding
  • Multiorgan failure
  • Spesis
97
Q

Intervention to protect spinal cord during thoracic aortic cross-clamping:

A
  • Routine CSF drainage pressure < 10 mmHg
  • Moderate intraop hypothermia
  • Avoid hypotension MAP > 90 mmHg
  • Avoid SNP (steal phenomenon)
98
Q

Breathing difficulties post extuabation are due to:

A

RLN dysfunction

99
Q

EVAR is associated with:

A

30 day outcome vs OSR

100
Q

Majority of Endoleaks are:

A

Type II (branch leaks)

It was a hotspot on selecting type II

101
Q

In EVAR Endovascular graft migration can occur and lead to:

A
  • Renal artery occlusion
  • Postop Renal failure
102
Q

Fenestrated EVSG is safe for patients with:

A
  • Juxtarenal Aortic Aneurysm
  • Suprarenal Aortic Aneurysm
103
Q

Major EVAR advantages:

A
  • Absence of aortic cross-clamping
  • No incision from xyphoid process to the pubis
104
Q

EVAR procedure use sytemic anticoagulation with

A

Heparin 50-100 units/kg

There is like 2 math questions on the exam

106
Q

Second most common vascualar operation in the USA?

A

Carotid Endarterectomy (CEA)

107
Q

Most CVA are due to

A

Ischemia > Hemorrhage

50% of strokes are preceed by a TIA

108
Q

CEA benefits patients with:

A
  • Recent ipslateral carotid territory symptoms
  • Moderate to severe symptoms than asymptomatic patients
  • Stenosis > 70%
109
Q

CEA is less beneficail in patients with

A

50-69% stenosis

110
Q

CEA surgical interventions are most beneficial in men:

A
  • Older than 75 years
  • Within two weeks of the event
111
Q

Factors contributing to morbidity during CEA:

A
  • Age
  • Operative timing
  • Hyperglycemia
  • Mulitple comorbidities
  • Contralateral carotid disease
  • Progressing stroke
  • Ulcerative lession
  • Surgery with/whithout shunt
112
Q

CEA variables affecting patient outcomes:

A
  • 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
Q

CEA common symptoms:

A
  • Amaurosis fugax
  • ALOC
  • Aphasia
  • Acute motor deficit
  • Carotid bruit
114
Q

CEA CV comorbidity risk include:

A
  1. DM
  2. PVD
  3. COPD
  4. Obesity
115
Q

Normal cerebral flow

A

50 mL/100G/min

116
Q

Cerebral cell death occurs at a flow of:

A

< 6 mL/100G/min

117
Q

ALL anesthetic agents decrease metabolic rate, except:

118
Q

Cerebral flow becomes pressure dependent due to:

A

Ischemia

Autoregulation and compensatory vasodilation

119
Q

Cerebral monitoring standard tool include:

A
  • EEG (Goldstandard)
  • Carotid Stump pressure
120
Q

Most sensitive and specific measure of CBF responsiviness in awake patient tool is:

121
Q

Gross measure of pressure in the circle of willis:

A

Carotid stump pressure

122
Q

A carotid stump pressure indicating neurologic hypoperfusion

A
  • < 40-50 mmHg
  • Criteria for shunt placement
123
Q

Symptoms of inadequate cerebral perfusion include:

A
  • Dizziness
  • Contralateral cerebral perfusion
  • LOC
124
Q

CEA Blood pressure control

A

Maintain MAP at 20% or greater than preop MAP value

125
Q

Drugs to decrease BP during CEA

A
  • Nitroglycerine IV infusion
  • Sodium Nitroprusside
126
Q

Which nerve provokes hypotension and bradycardia during CEA

A

Carotid sinus Baroreceptor Nerve manipulation

127
Q

Hypotension and Bradycardia Tx 2/2 Baroceptor stimulation:

A
  • Stop surgical stimulation
  • Infiltrate region with LA
  • Give an antichollinergic
128
Q

CEA Regional anesthesia Requires a deep and superficial pluxus block at:

A

CN II, III, and IV

129
Q

GETA provides preconditioning in CEA by:

A

Decreases Cerebral and Metabolic Metabolism

130
Q

CEA PostOp considerations

A
  • BP 140/80 mmHg recommended
131
Q

Chronic HTN leads to:

A

Cerebral hypoperfusion syndrome (CHPS)

132
Q

Cerebral hypoperfusion syndrome (CHPS) symptoms:

A
  • Headache
  • Visual disturbances
  • ALOC
  • Seizures
133
Q

What’s the initial manifestion of hemorrhage post CEA?

A

Airway obstruction

134
Q

Emergency Tx for Hemorrhage post CEA include:

A

Hematoma evacuation

135
Q

Recurrent Laryngeal Nerve damage leads to:

A

Inspiratory stridor

136
Q

Identify vagal nerve on the image

137
Q

Cranial nerve to assess for CEA:

A
  • CN VII (facial)
  • CN IX (glossopharyngeal)
  • CN X (Vagus)
  • CN XI (spinal accesory)
  • CN XII (hypoglossal)
138
Q

CEA Anesthesia considerations:

A
  • 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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