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8361 Exam 4 > Mod X: Anesthesia for CAROTID ARTERY DISEASE > Flashcards

Mod X: Anesthesia for CAROTID ARTERY DISEASE Flashcards

1
Q

Anesthesia for CAROTID ARTERY DISEASE

OBJECTIVES

A
  1. State the indications for carotid endarterectomy
  2. State several frequent co-existing diseases in patients with carotid artery disease
  3. Describe the anesthetic management of patients undergoing carotid endarterectomy
  4. Discus intraoperative maneuvers that are utilized to preserve cerebral blood flow
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2
Q

BACKGROUND CVA AND CAROTID ARTERY DISEASE

What’sthe 4th leading cause of death in the U.S. and the leading cause of long-term disability?

A

Stroke

Stroke is the 4th leading cause of death in the U.S.

Leading cause of long-term disability

Also a Major contributor to increased health care costs

(estimated at $65.8 billion in 2008)

With aging population, an increasing amount of patients will present to the OR with cerebral vascular disease

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3
Q

BACKGROUND CVA AND CAROTID ARTERY DISEASE

There is a strong correlation between strokes and

A

Carotid artery disease

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4
Q

BACKGROUND CVA AND CAROTID ARTERY DISEASE

CVA may occur from

A

Embolization of a thrombus or

Plaque debris that cause a reduction in flow

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5
Q

BACKGROUND CVA AND CAROTID ARTERY DISEASE

Regardless of the cause of injury the degree of cerebral injury depends on:

A

Plaque morphology

Characteristics of the embolus

Duration of hypoperfusion

Integrity of the circle of Willis

Degree cerebral collateral circulation present

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6
Q

CEREBRAL BLOOD FLOW (CBF)

Brain is 2% of body weight, but receives what % of CO?

A

12-15% of cardiac output

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7
Q

CEREBRAL BLOOD FLOW (CBF)

Total CBF averages

A

50 ml/100g/min

(750 ml/min)

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8
Q

CEREBRAL BLOOD FLOW (CBF)

Which CBF levels constitute adequate blood flow?

A

CBF levels >50 ml/100g/min

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9
Q

CEREBRAL BLOOD FLOW (CBF)

Which CBF levels are inadequate? are these a/w permanent injury?

A

20-50 ml/100g/min CBF is inadequate, but

No permanent injury occurs if blood flow restored

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10
Q

CEREBRAL BLOOD FLOW (CBF)

Which CBF levels may lead to permanent injury?

A

CBF <20 ml/100g/min => injury will occur

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11
Q

CBF AUTOREGULATION

The phenomenom whereby cerebral blood flow adapts appropriately to changes in mean arterial pressure (MAP) is known as:

A

Autoregulation

Cerebral blood vessels will constrict when MAP increases and dilate when MAP decreases

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12
Q

CBF AUTOREGULATION

What’s the purpose of Autoregulation?

A

Serves to maintain a constant CBF despite swings in MAP

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13
Q

CBF AUTOREGULATION

CBF is autoregulated in humans between which MAP values?

A

60-160 mmHg

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14
Q

CBF AUTOREGULATION

What is CBF regulated by for MAP values >60 or >160?

A

CBP will be passively regulated by MAP

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15
Q

AUTOREGULATION CURVE

With chronic hypertension the Autoregulation curve shifts to:

A

The Right

Autoregulation curve shifts to the right with chronic hypertension

This causes the lower and higher ends of the autoregulation range to be higher than in a normotensive pt

This could potentially protect the brain from transient high MAPs

But it occurs at the expense of raising lower limits, which causes an increase risk of ischemia at lower MAPs that would be otherwise tolerated well in a normotensive pt

This is why Hypertensive patients may develop cerebral ischemia at MAPs easily tolerated by normotensive patients

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16
Q

AUTOREGULATION CURVE

With chronic hypotension the Autoregulation curve shifts to:

A

The Left

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17
Q

CBF AND CHEMICAL CONTROL

What type of relationship exist between CBF and PaCO2 between arterial CO2 25-75 mmHg?

A

Linear relationship

Linear relationship between CBF and PaCO2 between arterial CO2 25-75 mmHg

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18
Q

CBF AND CHEMICAL CONTROL

How does CO2 causes cerebral vasodilation?

A

B/c CO2 diffuses freely into the CNS, causing increased concentration of H+ and dilation of the cerebral vessels

This is how Hypoventilation => cerebral vasodilation and inc CBF

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19
Q

CBF AND CHEMICAL CONTROL

Oxygen tension has an inverse relation with CBF?

A

Hyperventilation => cerebral vasoconstriction and dec CBF

However, Low arterial oxygen tension increases CBF

When PaO2 fall bellow 50mmHg, there is a rapid inc in CBF

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20
Q

CAROTID ARTERY ENDARTERECTOMY

Most common peripheral vascular surgical procedure

A

CAROTID ARTERY ENDARTERECTOMY

Estimated 130K procedures performed annually

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21
Q

CAROTID ARTERY ENDARTERECTOMY ​

Stenosis most commonly at

A

the bifurcation of the common carotid artery

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22
Q

CAROTID ARTERY ENDARTERECTOMY ​

Endarterectomy used to reduce symptoms and prevent stroke for over 50 years - why?

A

Low risk procedure with excellent long-term durability

Many trials have been completed in an effort to recommend the best treatment for pts w/ carotid artery dz, which over the years has actually cause an increase in the number of carotid endarterectomy performed

While carotid surgery has demonstrated postive effects, the terminative benefit must be determined for each pt in order to keep peri-operative strokes and death rates low

Perioperative stroke and death rates must stay low in order to maintain the beneficial effects of surgery over medical therapy

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23
Q

AHA GUIDELINES FOR CAROTID ENDARTERECTOMY

Based on AHA practice recommendations regarding carotid endarterectomies, which Factors are r/t increased risk of stroke?

A

Age, HTN, ischemic heart disease, diabetes, hyperlipidemia, diabetes, cigarette smoking, & high HCT.

HTN and smoking = two most powerful and treatable risk factors for stroke

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24
Q

AHA GUIDELINES FOR CAROTID ENDARTERECTOMY

Based on AHA practice Recommendations for symptomatic and asymptomatic patients regarding carotid endarterectomies, CAE recommended for symptomatic patients with Carotid Artery Dz of what % stenosis?

A

>70% stenois

Must also consider operative stroke and death rate along with life expectancy

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25
Q

AHA GUIDELINES FOR CAROTID ENDARTERECTOMY

Based on AHA practice Recommendations for symptomatic and asymptomatic patients regarding carotid endarterectomies, CAE recommended for asymptomatic patients with Carotid Artery Dz of what % stenosis?

A

>60 stenosis

Must also consider operative stroke and death rate along with life expectancy

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26
Q

PREOPERATIVE ANESTHETIC EVALUATION

Pre-op considerations for carotid artery dz include

A

Carotid artery dz does not occur in isolation

Evaluate for Systemic arterial dz

Perform a detailed system assessment

Evaluate and Optimize clinical status regarding coexisting diseases

Defining pre-existing neurological deficits

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27
Q

PREOPERATIVE ANESTHETIC EVALUATION

Pre-op Manegment Poorly controlled HTN

A

Gradual decrease of BP over several weeks prior to surgery

May help reset autoregulation prior to surgery

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28
Q

PREOPERATIVE ANESTHETIC EVALUATION

Pre-op Manegment Poorly controlled diabetes

A

Manage BG levels prior to surgery

Hyperglyvemia during surgery may enhance cerebral ischemia intra-op

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29
Q

PREOPERATIVE ANESTHETIC EVALUATION

CAD is common in pts w/ Carotid artery dz - How should these two be managed when both are present?

A

Difficult sometimes to determine which dz to treat first

Evaluation of severity of coronary artery disease and of carotid artery dz must be performed

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30
Q

PREOPERATIVE ANESTHETIC EVALUATION

For which pts is carotid revascularization recommended before CABG?

A

Pts w/ symptomatic carotid dz

Pts w/ bilateral severe asymptomatic carotid stenosis

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31
Q

PREOPERATIVE ANESTHETIC EVALUATION

Which pre-op medications must be continued?

A

Beta-blockers

Statins

Antiplatelets

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32
Q

PREOPERATIVE ANESTHETIC EVALUATION

Which pre-op medications must be held?

A

Diuretics

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33
Q

PREOPERATIVE ANESTHETIC EVALUATION

General anesthesia versus Regional anesthesia

A

A choice must be made

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34
Q

MONITORING DURING CAROTID ENDARTERECTOMY

Basic monitors

A

EKG, pulse ox, arterial blood pressure monitoring on contralateral side of surgery and leveled at the head to measure CPP

CPP = MAP - ICP, normal 60-70 mmHg

Anticipate BP fluctuations

Have vasoactive drugs available (constrictors and dilators)

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35
Q

MONITORING DURING CAROTID ENDARTERECTOMY

Cerebral perfusion monitors

A

EEG

Stump pressure

Somatosensory Monitoring

Transcranial Doppler

Cerebral oximetry

Jugular venous bulb monitoring

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36
Q

MONITORING DURING CAROTID ENDARTERECTOMY- Cerebral Perfusion Monitors

”gold standard” for monitoring the adequacy of cerebral perfusion

A

16-channel EEG

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37
Q

MONITORING DURING CAROTID ENDARTERECTOMY- Cerebral Perfusion Monitors

Limitations of the 16-channel EEG monitoring include:

A

High false positive rate

False negative rate (esp. w/ previous strokes)

Does not detect subcortical or small cortical infarct

May impact readings in patients with previous stroke hx

EEG monitoring can be affected by changes in temperature, blood pressure, and anesthesia dept

(In fact, when using GETA, a stable physiologic and anesthetic depth are mandatory to ensure adequacy of EEG monitoring)

May not be sensitive or specific enough to predict need for shunting

38
Q

MONITORING DURING CAROTID ENDARTERECTOMY- Cerebral Perfusion Monitors

What’s the most effective means of assessing cerebral blood flow during carotid endarterectomy under “regional anesthesia” ?

A

Keeping the patient awake!!!

Under “regional anesthesia” it states that keeping the patient awake allows for continuous neurological monitoring of the awake patient, which is considered to be the most sensitive method for detecting inadequate cerebral perfusion and function.

39
Q

MONITORING DURING CAROTID ENDARTERECTOMY- Cerebral Perfusion Monitors

What do recent evidence show regarding EEG vs other methods to monitor Cerebral Perfusion Monitors?

A

No consistent data showing that EEG are superior to other methods

40
Q

MONITORING DURING CAROTID ENDARTERECTOMY

The ipsilateral retrograde perfusion pressure that results from collateral flow through circle of Willis from the contralateral carotid artery is also known as:

A

Stump Pressure

Carotid stump pressure estimates hemispheric blood flow by measuring pressure in the carotid stump distal to the clamp. Stump pressure is more often used to determine whether or not a shunt should be placed intraoperatively.

41
Q

MONITORING DURING CAROTID ENDARTERECTOMY

What’s the utility of Stump Pressure montitoring?

A

Used to evaluate the adequacy of CPP during carotid clamping, and whether collateral circulation is adequate enough to maintain CBF

Used to determine whether a shunt will be needed to maintain cerebral perfusion

42
Q

MONITORING DURING CAROTID ENDARTERECTOMY

Which the Stump Pressure values are considered adequate?

A

Stump pressure should be >45 mmHg,

otherwise shunt is needed

43
Q

MONITORING DURING CAROTID ENDARTERECTOMY

What’s a possible negative consequence of false negative values on Stump Pressure reading?

A

Can result in false negative values, which lead to unnecessary shunt placement

Inexpensive and simple, so still used

44
Q

MONITORING DURING CAROTID ENDARTERECTOMY

What is Somatosensory monitoring (SSEP) based on?

A

Response of the sensory cortex to electrical impulses form peripheral sensory nerve stimulation

Sensory cortex= risk of ischemia during carotid artery clamping

45
Q

MONITORING DURING CAROTID ENDARTERECTOMY

unlike EEG, SSEP are able to detect which type of ischemia?

A

Subcortical sensory pathway ischemia

Able to detect subcortical sensory pathway ischemia unlike EEG

46
Q

MONITORING DURING CAROTID ENDARTERECTOMY

Which characteristic changes of SSEP occur with reduced CBF and ischemia?

A

Decreased amplitude

Increased latency

47
Q

MONITORING DURING CAROTID ENDARTERECTOMY

Which may affect SSEP monitoring?

A

Anesthetic depth

Temperature

Blood pressure

48
Q

MONITORING DURING CAROTID ENDARTERECTOMY

T/F: SSEP monitoring may not be sensitive or specific enough to predict need for shunting

A

True

False positives and negatives do occur

49
Q

MONITORING DURING CAROTID ENDARTERECTOMY

Which monitoring technique offers Continuous measurement of mean blood flow velocity and detection of microemboli (air or particulate matter) in the middle cerebral artery

A

Transcranial doppler (TCD)

Most peri-op neuro deficits are thought to be thrombolic in origin, TCD has been shown to detect embolization in more than 90% of pts

TCD can be difficult to impliment d/t high rates of technical failures, it has limited use in clinical settings

TCD Can also be used post-operatively to monitor for cerebral hyperperfusion

Technically difficult to implement d/t high rate of technical failures

50
Q

MONITORING DURING CAROTID ENDARTERECTOMY

Jugular Venous Bulb Monitoring

A

Refer to Module I and chapter reading

51
Q

MONITORING DURING CAROTID ENDARTERECTOMY

Cerebral Oximetry

A

Refer to Module I and chapter reading

52
Q

CAROTID ENDARTERECTOMY: GENERAL VS. REGIONAL

Regardless of the technique chosen, the ultimate anesthetic goals are

A

Maintain adequate cerebral perfusion of the brain

Awake patient following surgery, so that a neuro exam can be immediately performed

53
Q

CAROTID ENDARTERECTOMY: GENERAL VS. REGIONAL

Common historical anesthetic technique for CEA was:

A

Cervical plexus block

Historically, regional anesthesia, in the form of a cervical plexus block most commonly used

Patients can be examined intraoperatively, more cost effective, shorter length of stay

54
Q

CAROTID ENDARTERECTOMY: GENERAL VS. REGIONAL

T/F: There is no statistical difference in perioperative death, MI, and stroke with regional anesthesia when compared to general anesthesia

A

True

GALA trial showed no statistical difference in perioperative death, MI, and stroke when compared to general anesthesia

The decision between regional vs general anesthesia for CEA varies by institution

55
Q

CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA

Advantages of using General Anesthesia for CEA include:

A

General reduces cerebral metabolic oxygen demands

Better regulation of PaO2, PaCO2, and MAP under GA

No specific technique is more superior than the other

56
Q

CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA

BP consideration when using General Anesthesia for CEA

A

Must anticipate swings in blood pressure and be prepared to treat accordingly

Have Short acting vasoactive and vasodilating drugs available

(Phenylepherine, NTG, Nicardipine)

Specially important w/ Patients with poorly controlled HTN

Have IV fluid for volume depletion

Ready for meticulous titration of anesthetic gases

Prompt treatment of hypotension is very important

57
Q

CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - Induction

Limit benzodiazepine use - Why?

A

May prolong wake up time at the end

Consider opioids for anxiety

58
Q

CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - Induction

Typical hypnotic agent is

A

Propofol

(Unless limited cardiac reserves, in which case use Etomidate)

Etomidate

(for patients with limited cardiac reserve)

59
Q

CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - Induction

Which drugs can be used at induction (as adjuntc) to blunt hypertensive reaction to laryngoscopy?

A

Small dose Opioids or Beta-blockers

60
Q

CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA

Which inhalation agents have been shown to provides greatest protection against ischemia

A

Isoflurane

(provides greatest protection against ischemia)

Sevoflurane

(similar protection against ischemia as Isoflurane)

61
Q

CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA

Which inhalation agent is appropriate in accelerating wakeup and allowing for more immediate neurological assessment?

A

Desflurane

accelerates wakeup, allowing for more immediate neurological assessment

62
Q

CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA

Both N2O or Remifentanil appropriate - If N2O is used, it should be d/cd befored the carotid artery is openned. Why?

A

A small amount of air present in the artery could potentially expend and cause an arterial air embolism

63
Q

CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - MAINTENANCE

Consider low dose Opioids, especially if

A

surgeon using local anesthetic in field

Not much pain experienced in such case

64
Q

CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - MAINTENANCE

BP and HR management

A

MAP maintained at or slightly above baseline

Avoid tachycardia

(Beta-blockers if needed in small increments/consider shorter acting)

65
Q

CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - Other Considerations

What dose of Heparin would the surgeon request prior to clamping of the carotid artery?

A

Heparin 100 units/kg

prior to clamping of the carotid artery

Reversal of Heparin with Protamine after procedure

66
Q

CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - Other Considerations

Where should MAP be maintained during carotid clamping?

A

During carotid clamping, maintain MAP within 20%(+/-) of patient’s baseline

67
Q

CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - Other Considerations

Watch for reflex bradycardia - why?

A

Surgical manipulation of the carotid sinus could cause reflex bradycardia

Have Atropine available for treatment

Surgeon main inflitrate the surgical site w/ lidcaine to prevent this from hapenning

68
Q

CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - Other Considerations​

Maintain normocapnia (normal EtCO2) or mild hypocapnia during the procedure - why?

A

Hypercapnia can cause Steal phenomenon

This shunts blood avay from the ischemic areas af the brain

Theoretically, hypocapnia will vasoconstrict and has been advocated for as a reversal for the Steal phenomenon, however its benefits have not been proven clinically

69
Q

CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - Other Considerations​

Keep glucose levels < 180 mg/dl for diabetic pts - Why?

A

Studies show that BG levels > 200 mg/dL on post op Day 1 corellate w/ increased risks for strokes, TIAs, MI, and Death

70
Q

CAROTID ENDARTERECTOMY: GENERAL ANESTHESIA - Other Considerations​

Watch opioid administration, especially if surgeon injects local anesthetic - Why?

A

Not much pain associated with procedure,

71
Q

CAROTID ENDARTERECTOMY: REGIONAL ANESTHESIA

Historically done in the form of

A

Deep and superficial cervical plexus block

C2 - C4 nerve roots

This technique has been around for > 40 yrs and many providers still prefer it

72
Q

CAROTID ENDARTERECTOMY: REGIONAL ANESTHESIA

Advantages of Deep and superficial cervical plexus block for CEA

A

Minimal sedation required

Awake patient allows for continual neurological assessment, which is especially important during trial occlusion of the carotid artery

–No adverse effect –> continued procedure with RA

–Adverse effect –> shunt inserted &/or GA with ETT

Less intraoperative hypotension

Faster postoperative recovery and provides postop analgesia

Lower cost

73
Q

CAROTID ENDARTERECTOMY: REGIONAL ANESTHESIA

What must be done if adverse effect occur with Deep and superficial cervical plexus block for CEA?

A

Shunt inserted &/or GA with ETT

74
Q

CAROTID ENDARTERECTOMY: REGIONAL ANESTHESIA

Disadvantages of using regional anesthesia for CEA include:

A

More intraoperative hypertension (a/w a higher release of catecholamines)

Awkward airway control if need to convert to GA

Sedation may obscure neurological monitoring (and cause hypercapnia and hypoxia)

Patient discomfort (if the procedure is long of if ischemia develops)

Sedation causing hypercapnia or hypoxia

75
Q

CAROTID ENDARTERECTOMY: POSTOPERATIVE CONCERNS

Post-operative Hypertension r/t

A

Surgical denervation of ipsilateral carotid baroreceptor

Especially in pts w/ poorly control HTN prior to surgery

Regional anesthesia is a/w less hypertension

May need Labetalol or Nicardipine or Sodium Nitroprusside post-operatively

76
Q

CAROTID ENDARTERECTOMY: POSTOPERATIVE CONCERNS

Carotid body denervation can also occur - What causes it? what could it lead to?

A

Caused by surgical manipulation

May lead to impaired ventilatory response to mild hypoxemia

77
Q

CAROTID ENDARTERECTOMY: POSTOPERATIVE CONCERNS

Postoperative hoarseness and ipsilateral tongue deviation may occur - How does this happen?

A

Retractors use during the procedure to visualize the surgical field

These retractors can put pressure on the recurrent laryngeal nerve or the hypoglossal nerve

Careful in patients with hx of contralateral CEA or neck surgery

Should subside shortly after surgery

78
Q

CAROTID ENDARTERECTOMY: POSTOPERATIVE CONCERNS

Monitor for postoperative wound hematoma - why?

A

Airway compromise is possible

79
Q

CAROTID ENDARTERECTOMY: POSTOPERATIVE CONCERNS

Postoperative Cerebral Hyperperfusion Syndrome may occur - What causes it?

A

Abrupt increase in amount of blood flow and loss of autoregulation to the reperfused brain

Typically doesn’t occur until several days after the procedure

80
Q

CAROTID ENDARTERECTOMY: POSTOPERATIVE CONCERNS

S/S of Postoperative Cerebral Hyperperfusion Syndrome include:

A

Headache, seizures, focal neurologic signs, brain edema, intracerebral hemorrhage

81
Q

CAROTID ENDARTERECTOMY: POSTOPERATIVE CONCERNS

Which pts are at increased risk for Postoperative Cerebral Hyperperfusion Syndrome?

A

Patients with severe postoperative HTN

Patients with severe preoperative internal carotid artery stenosis

82
Q

CAROTID ENDARTERECTOMY: POSTOPERATIVE CONCERNS

Other post-op concerns following CEA include:

A

Postoperative hypotension

Loss of carotid body function

CEAs not associated with large blood loss of fluid shifts

83
Q

ENDOVASCULAR TREATMEBNT: CAROTID ARTERY STENTING

Endovascular treatment of carotid artery disease includes:

A

Percutaneous angioplasty & stenting

84
Q

ENDOVASCULAR TREATMEBNT: CAROTID ARTERY STENTING

Where are Percutaneous angioplasty & stenting procedures typically performed? which anesthetic technique is typically used?

A

Specialized endovascular suites under

Local anesthesia with light sedation (to facilitate pt’s comfort and the need for frequent neuro monitoring)

85
Q

ENDOVASCULAR TREATMEBNT: CAROTID ARTERY STENTING

Monitors used:

A

Routine monitors and arterial line

86
Q

ENDOVASCULAR TREATMENT: CAROTID ARTERY STENTING

Procedural approach

A

Femoral approach is standard

Brachial and high radial arteries are alternative sites

87
Q

ENDOVASCULAR TREATMEBNT: CAROTID ARTERY STENTING​

Embolic protection devices are mandatory - why?

A

Provide protection in the form of a filter or an occlusive balloon

88
Q

ENDOVASCULAR TREATMEBNT: CAROTID ARTERY STENTING​

Antiplatelet therapy:

A

Dual Antiplatelet therapy​ is used along w/ self-expanding stent

89
Q

ENDOVASCULAR TREATMEBNT: CAROTID ARTERY STENTING​

How does endovascular tx compares to traditional CEA?

A

Unfortunately, endovascular tx has been shown to be inferior to the traditional CEA in outcome studies related to stroke and death rates

Especially in pt > 70 yo

90
Q

ENDOVASCULAR TREATMEBNT: CAROTID ARTERY STENTING​

In which outcome areas is endovascular tx superior to traditional CEA?

A

Reduced rates of myocardial infarction, cranial nerve palsy, and access site hematomas

8361 Exam 4 (16 decks)

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