Vascular Flashcards
Main focus of anesthesia care in vascular surgery is
maintain organ perfusion
Greatest cause of morbidity after vascular procedures is injury to the
heart
Atherosclerosis compromises
blood supply to organs / extremities
Clinical manifestation of Atherosclerosis- 3
- MI
- Stroke
- Gagrene
Atherosclerosis occurs in ____ sized arteries
- What sides?
- What kind of flow is present in Atherosclerosis?
- medium/large sized arteries
- branch side
- turbulent, disrupts laminar flow
Most common sites for Atherosclerosis- 5
- carotid
- coronary
- femoral
- iliac
- abdominal
Foam cells consist of -2
T- Cells & macrophages
Fibroatheromatous plaque consist of- 2
- calcium accumulation
- endothelial integrity is disrupted
Risk factors for Atherosclerosis
- Age
- Smoking
- low HDL
- high LDL
- HTN
- Obsity
- Family hx of CVD
Prevention of Atherosclerosis- 2
- control HTN
- control HLD- statins/ anti-platelets
Which anti-platelet drugs for Atherosclerosis?
-plavix & ASA
Statins MOA
-inhibit HMG- COa
Most common cause of PVD
Atherosclerosis
Signs of PVD
- claudication
- skin ulceration
- gangrene
- impotence
How to approach vascular procedures for last decade- 2
- less invasive procedures
- mdx mgmt
2014 ACC/AHA pre-op CV evaluation guidelines for non-cardiac surgery recommendations- 3
- evaluation
- mgmt
- risk of cardiac issues
↑ in myocardial 02 demand- 4
-↑ HR, contractility, BP, Diastolic volume
↓ myocardial 02 supply from_____
- ↑HR, diastolic volume
- ↓ coronary blood flow, 02 content, Hct, 02 saturation
Elective surgery should be delayed for ______ after uncomplicated MI
4-6 weeks
Delay surgery after stents
- DES
- BMS
- DES 1 year
- BMS 1 month
V1, V2
- affected myocardial area?
- Which artery(s)?
V1, V2
- affected myocardial area? -septal
- Which artery(s)? -proximal LAD
V3, V4
- affected myocardial area?
- Which artery(s)?
V3, V4
- affected myocardial area? -anterior
- Which artery(s)? -LAD
V5, V6
- affected myocardial area?
- Which artery(s)?
V5, V6
- affected myocardial area?- apical
- Which artery(s)?- distal LAD, LCX, RCA
I, avL
- affected myocardial area?
- Which artery(s)?
I, avL
- affected myocardial area?- lateral
- Which artery(s)?- Lcx
II, III, avF
- affected myocardial area?
- Which artery(s)?
II, III, avF
- affected myocardial area?- inferior
- Which artery(s)?- RCA
high incidence of COPD due to high incidence of_____
smoking
post-op mgmt of patients with pulm. disease- 3
- CPAP
- incentive spirometer
- epidural for post-op pain
what is an independent risk factor for post-op cardiac complications?
Cr > 2 g/dL
These 2 classes of medications ↓ risk of death in patients with renal impairment
- BB
- Statins
Renal ischemia results from (3) during vascular procedures
- cross clamping
- change in intravascular volume
- change in CO
Keep Hbg > ____ or may lead to _____
> 9
-Myocardial Ischemia
Monitoring for MI via these 3 modalities
- TEE
- ECG
- Pulm artery cath
Ischemia > ____ hours can lead to infarction
2
Surgical stress causing sympathetic stimulation, consider giving____
BB
Statin current guidelines- recommended for all patients with_____
PAD
Statins benefit for lower extremity bypass graft?
-Aortic surgery?
- LE bypass– preserve graft patency
- Aortic surgery- preserve renal function
which artery do you release to perform allen test
radial
Take BP in each arm and use the arm with ____ BP
highest
Abdominal Aortic Aneurysm risk factors- 5
- Male
- Age
- smoker
- family hx
- Atherosclerotic disease
Factors contributing to AAA development -6
- trauma
- Chronic inflammation
- Infection
- marfan
- syphillis
- crack/cocaine
4 inherited disorders that can lead to aneurysms
- marfan
- ehlers-danlos
- bicupid aortic valve
- non-syndromic familial aortic dissection & aneurysm
Surgical repair for AAA indicated if size is > ____
6 cm
Repair for AAA is warranted if it grows > ___ in ____ time
> 0.5 cm in 6 months
triad of ruptured AA s/s
- change in LOC
- severe abdominal/back pain
- pulsatile abd mass
-other s/s: syncope, hematuria, groin gernia, flank pain
2 most common sites for chronic atherosclerosis
- iliac
- infrarenal aorta
GOLD STANDARD treatment for aortoiliac occlusive disease
aortobifemoral bypass
factors involved with aortic cross clamping - 6
- level of clamp
- blood volume
- sympathetic NS response
- Anesthesia technique
- Anesthesia drugs
- peri-aortic colaterilazation
Above the clamp you will see __?BP
below?
above the clamp- HTN
below- HYPOT
Physiologic changes with cross-clamping:
- Segmental wall motion abnormalities
- LV wall tension
- EF
- CO
- RBF
- Pulmonary occlusion pressure
- CVP
- CI
- MAP
- Coronary blood flow
- Segmental wall motion abnormalities ↑
- LV wall tension ↑
- EF ↓
- CO ↓
- RBF ↓
- Pulmonary occlusion pressure ↑
- CVP ↑
- CI ↓
- MAP ↑
- Coronary blood flow ↑
Metabolic changes during cross clamping:
- Oxygen consumption
- CO2 production
- mixed venous oxygen saturation
- Total body oxygen extraction
- Epi/Norepi release
- Oxygen consumption ↓
- CO2 production ↓
- mixed venous oxygen saturation ↑
- Total body oxygen extraction ↓
- Epi/Norepi release ↑
You will see
resp _____
metabolic ____
during cross-clamping
resp alkalosis
met. acidosis
Hemodynamic changes with proximal descending thoracic aortic cross-clamping
↑ MAP, CVP, Pulm artery pressure
↓ CI
changes to superceliac aorta with cross-clamping
↓ EF
↑ MAP, Pulm. pressures, left ventricular pressures, wall abnormalities leading to ischemia.
What’s one result of thoracic aortic cross clamping?
50% ↓ 02 consumption
T/F?
-thoracic epidural and adequate urine output can prevent/indicate post-op renal failure?
false
Clamping above renal arteries, blood flow reduced by:
83-90%
clamping below renal arteries, blood flow reduced by:
38%
best indicator for post-op renal failure?
most common cause of post-op renal dysfunction
pre-op renal dysfunction
Acute tubular necrosis
Benefits of Mannitol on kidneys? 4
- improve blood flow
- removes free radicals
- decreases renin release
- decrease endothelial edema
bad effect of dopamine
-Tachycardia- ↑02 consumption
what is released during unclamping?
Cardiodepressants
- lactic acid
- 02 free radicals
- neutrophils
Changes with aortic unclamping:
- contractility
- BP
- Pulm artery pressure
- CVP
- Venous return
- CO
“everything is stuck on left side”
- contractility ↓
- BP ↓
- Pulm artery pressure ↑
- CVP ↓
- Venous return ↓
- CO ↓
Metabolic changes with unclamping
- Total body oxygenation consumption
- lactate
- mixed venous oxygenation saturation
- prostaglandins
- activated complement
- Myocardial depressant factors
- Temp
- Total body oxygenation consumption ↑
- lactate ↑
- mixed venous oxygenation saturation ↓
- prostaglandins ↑
- activated complement ↑
- Myocardial depressant factors ↑
- Temp ↓
clamping of this part of aorta can lead to spinal cord ischemia
thoracic
__#___ anterior spinal artery
____ posterior
1 anterior
2 posterior
Anesthetic plan for induction for patients undergoing aortic surgery
- maintain hemodynamics
- normothermia
- can use thoracic epidurals
Superceliac aortic cross-clamp > 30 mins…..emergence plan?
leave intubated
sign of thoracic aneurysm
back pain
What kind of aneurysm?
- majority descending and upper abdominal
- majority descending and majority abdominal
- lower descending and most abdominal
- mostly abdominal
I
II
III
IV
Debakey I vs II vs III
I- begins in ascending aorta and involes entire aorta
II- ascending aorta
III- after subclavian
most common complication of open surgical repair? other 2?
pulmonary 50%
Gi
Renal
benefits to endovascular approach
- less clamp time
- less blood loss
- faster recovery
- small incision
