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6902 - Kronus > Vascular Anesthesia > Flashcards

Vascular Anesthesia Flashcards

1
Q

atherosclerotic process in occlusive disease is not limited to the peripheral arterial beds and should be expected in the …

A

coronary, cerebral and renal arteries

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2
Q

more than half the mortality associated with PVD disease is a result of…

A

adverse cardiac events

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3
Q

Beta blockade therapy

A
  • target between 50-60 bmp
  • instituted weeks prior to surgery
  • decreases cardiac ischemia and troponin values
  • decreased 2 year mortality
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4
Q

Statin therpay

A
  • started 30 days prior to surgery

- beneficial antiinflammatory effects

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5
Q

Risk factors for peripheral vascular disease

A
  • high cholesterol levels
  • elevated triglycerides
  • smoking
  • HTN
  • Diabetes
  • Obesity
  • Genetic predisposition
  • gender (M>F)
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6
Q

Tx for PVD:

medical management

A

stop smoking, weight loss, diabetes control

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7
Q

Tx for PVD:

Pharmacologic therapy

A

ASA, trental, pletal, persantine

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8
Q

Tx for PVD:

Surgical therapy

A

Transluminal angioplasty,
endartectomy
thrombectomies, multiple bypass procedures

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9
Q

Persantine

A

Phsophdiesterase type 5 inhibitor (PDE5) blocks degradative action of phosphodiesterase type 5 on cylcic GMP in the smooth muscle cells lining the blood vessels supplying the corpus cavernosum of the penis. Also used for ED and pHTN (PDE5 also present in the arterial smooth muscle of the lungs)

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10
Q

aortofemoral reroutes…

A

blood from abd aorta to the two femoral arteries in the groin

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11
Q

axillofemoral reroutes…

A

blood from the arm to the groin

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12
Q

femorofemoral reroutes

A

blood from one groin to the other

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13
Q

femoropoliteal reroutes

A

blood from the femoral artery to the popliteal arteries above or below the knee

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14
Q

anesthetic selection in PVD

A
  • depends on the type of surgical procedure and presence of coexisting disease
  • local anesthetic and IV conscious sedation
  • regional anesthesia
  • general anesthesia
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15
Q

Endocrine benefits of a epidural

A

inhibits surgical stress response, inhibits epinephrine and cortisol release, inhibits hyperglycemia, inhibits lymphopenia and granulocytosis, causes nitrogen sparing, blocks sympathetic tone, inhibits inflammatory mediator release

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16
Q

Cardiovascular benefits of epidural

A

decreases myocardial oxygen demand and afterload, increases endocardial perfusion at ischemic zone, increased hemodynamic stability, decreased blood loss, decreases general anesthetic medication requirements, redistributes blood to lower extremities

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17
Q

Pulmonary benefits of an epidural

A

decreased effect of FVC, FEV1 and PEFR (peak expiratory flow rate), decreases ventilation perfusion mismatch, improves atrioventricular oxygen differentiation, decreases pulmonary postoperative complications, decreased incidence of thromboembolism

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18
Q

Renal benefits of an epidural

A

increases blood flow in the renal cortex, decreases renovascular constriction

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19
Q

geriatric and misc benefits of an epidural

A

inhibits physiologic stress, improvese postoperative mental status, allows earlier extubation, amublation and discharge, improves postopeartive pain control

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20
Q

One study suggested a ___% reduction in mortality for those who received combined general anesthetic and an epidural

A

30%

-although no definitive conclusions on a superior anesthetic

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21
Q

Inhalation anesthetic agents induce cardioprotective effects in noncardiac surgery T or F

A

true

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22
Q

neuraxial anesthetic techniques must be used with caution to avoid

A

epidural hematoma

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23
Q

Postoperative considerations with PVD

A
  • Pain management is important for cardiac stability: narcotics, epidural with local ensthetics
  • Postop monitoring: EKG - MI, Respiratory depression - d/t narcs
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24
Q

Risk factors for AAA

A

Smokers, elders, M>F, COPD, CAD, hypercholestermia, HTN, height, PVD

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25
Q

Highest risk factor correlated with AAA

A

smoking increases risk 5 fold

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26
Q

Is age a contraindication to surgery?

A

No, however physiologic age is more indicative of increased surgical risk than chronological age

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27
Q

Contraindications to elective repair

A

-intractable angina pectoris, recent MI, severe pulmonary dysfunction, chronic renal insufficiency

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28
Q

Patients with stable CAD and coronary artery steonissi of > 70% who require non-emergent AAA repair do NOT benefit from __________ if beta-blockade has been established

A

revascularization

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29
Q

High risk patients for AAA

A

Age: > 70
Gender: Female
Cardiac: hx of MI, angina pectoris, myocardial disease, Q waves, ST/T wave changes, ventricular ectopy, HTN with left ventricular hypertrophy, CHF
Endocrine: diabetes
Nuero: stroke
Renal: chronic or acute renal failure
Pulmonary: COPD emphysema, dyspnea, previous pulmonary surgery

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30
Q

AAA aneurysms grow approx _____ per year

A

4mm

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31
Q

aneurysmal vessel dimensions correspond to ______

A 
The law of laplace
T = (P)(r)
T: wall tension
P: transmural pressure
r: vessel radius
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32
Q

Monitoring AAA

A

pulse ox, etco2, EKG (II for rhythm and V5 for ischemia), foley, a-line, TEE, PA/CVP, Neuromuscular blockade monitoring

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33
Q

Earliest indicator of wall motion changes from MI

A

TEE

34
Q

Hemodynamic effects depend upon 3 things

A
  • location of the clamp: below the renal arteries most common, juxtrarenal near or including the renal arteries, suprarenal above the renal arteries
  • cardiac reserve
  • intravascular vol.
35
Q

Structures ____ to the aortic clamp are underperfused during aortic cross clamping

A

distal

36
Q

What type of clamping is associated with a higher incidence of altered renal dynamics

A

Suprarenal and justarenal cross clamping

however reductions in renal blood flow occur even when aortic cross-clamping occurs below the renal arteries

37
Q

Infrarenal aortic cross clamping is associated with a _____% decrease in renal blood flow

A

40%

38
Q

Suprarenal clamp time > _____ min increases the risk of postopeartive renal failure

A

30

39
Q

what is the best method to assess and anticipate patients may devlop postoperative pre

A

preopeartive evaluation of renal function

40
Q

Interruption of blood flow to the ______ in the absence of collateral blood flow has been identified as a factor that causes paraplegia

A

greater radicular artery

artery of adamkiewicz

41
Q

the incidence of neurologic complications increases as the aortic cross-clamped is postition in a more _____ area

A

proximal or higher

42
Q

SSEPs

A

method for identifying spinal cord ischemia, does not provide information of the integrity of the anterior (motor) spinal cord

43
Q

MEP

A

capable of determining anterior cord function, relies on intact neuromuscular functioning and limits its use in AAA d/t need for neuromuscular blockade

44
Q

Complication of AAA: Ischemia of the colon r/t….

A

manipulation of the inferior mesenteric artery (primarily supplies blood to the left colon and is often sacraficed during surgery resulting in the descending and sigmoid colon depending on collateral vessels)

45
Q

what influences cardiac instability during cross-clamp removal

A
  • adequate intravascular vol. resotring circulating blood vol is paramount in providing circulatory stability
  • site and length of cross-clamp time
  • slow release of clamp
  • good communications
46
Q

physiologic dynamics after clamp removal

A

decreased svr, decreased venous return, reactive hyperemia (transient vasodilation secondary to tissue hypoxia release of adenine nucleotides) decreased preload and afterload

47
Q

Hemodynamic instability that may ensue after the release of an aortic cross-clamp is called

A

declamping shock syndrome

48
Q

Endothelin (ET-1) role in hemodynamic alterations after aortic cross clamp is removed

A

venous ET-1 has a positive inotropic effect on the heart and a vasoconstricting and vasodilating action on blood vessels

49
Q

therapeutic measures to prevent spinal cord ischemia

A
  • methyprednisolone
  • mild hypothermia
  • mannitol
  • drainage of CSF - spinal cord perfusion pressure
  • SSEPs
  • temporary Heparin-coated shunt or partial CPB with hypothermia
  • nipride and NTG to control HTN response to cross clamping
50
Q

Classification schemes for thoracic aneurisms

A

Debakey:
Type 1: ascending aorta-@ least to aortic arch often to descending aorta
Type 2: ascending aorta - confined
Type 3: descending aorta & extends distally

Stanford:
Type A: dissection involving the ascending aorta (with or without extension)
Type B: dissection that do not involve the ascending aorta

51
Q

Define aortic dissection

A

spontaneous tear of the vessel wall intima, permitting the passage of blood along a false lumen

52
Q

Potential causes for aortic dissection

A
  • variations in wall integrity

- HTN most common factor contributing to the progression of a lesion

53
Q

Treatemnt of dissecting aortic lesion proximal vs distal

A

Proximal - almost always treated surgically

Distal - dissections may be managed medically

54
Q

Anesthesia of the ascending and transverse aorta require cardiopulmonary bypass T or F

A

True

55
Q

Vocal cord paralysis occurs from injury to what nerve

A

Left recurrent laryngeal nerve

56
Q

Causes of occlusive disease of the aorta

A

Thromboembolic occlusion most commonly athersclerotic in origin, results of atherosclerotic plque and thrombosis, generally present in other parts of the arterial system

57
Q

Monitoring for thoracic aneurisms

A

direct intra-arterial blood pressure (right), PAC, TEE (2-dimensional), UCI, Double-lumen ETT

58
Q

Descending thoracic aorta clamp

A
  • sudden increase in LV afterload may precipitate acute LV failure and myocardial ischemia exacerbating pre-existing aortic regurg
  • CO falls
  • LVEDP and vol rise
  • effects less pronounced if clamp applied more distally
  • Nipride infusion needed
  • excessive intraoperative bleeding
59
Q

Postoperative management for thoracic aneurysm

A
  • remain intubated
  • maintain hemodynamic stability
  • monitor for bleeding
  • maintenance fluids
60
Q

Late complications of thoracic aneurysm repair

A
  • delayed paraplegia
  • graft thrombosis
  • fistula formation
  • false aneurysm
  • graft infection
61
Q

Anethetic selection for EVAR AAA:

EVAR TAA:

A

EVAR AAA: neuraxial blockage or local anesthesia with sedation
EVAR TAA: General

62
Q

List reasons why spinal cord ischemia has lower incidence in EVARs

A
  • no thoracic aortic cross-clamping

- no prolonged periods of extreme hypotension

63
Q

MAP of less than 70 mm Hg was a significant predictor of spinal cord ischemia T or F

A

True

64
Q

_______ cerebrovascular disease accounts for 80% of strokes

A

ischemic

65
Q

______ artery is the most common site of atherosclerosis leading to TIA or storke

A

internal carotid

66
Q

Indication for carotid endartectomy

A

significant stenotic lesions

67
Q

Risk factors for Morbidity in Carotid artery surgery

A 
Neurologic (CVA)
CAD
HTN
Diabetes
Renal disease
Thromboembolism
68
Q

Most common contributor of poor surgical outcomes in a CEA

A

MI, although strokes do have devastating consequences

69
Q

Cerebral monitoring modalities

A

Tight control of BP and PaCO2 is paramount!!
A-line
NTG, SNP phenylephrine

70
Q

Monitoring of CBF during clamping

A

EEG: assess cortical electrical function (gold standard)
SSEP Assess sensory evoked potentials
CSP (Carotid stump pressure): assess perfusion pressure in the operative carotid artery
TCD (Trans cranial doppler): assess blood flow velocity in the middle cerebral artery
Cerebral oximetry: Assess cerbral regional oxygen saturation (near-infrared spectoscopy)

71
Q

Carbon dioxide’s effects on cerebrovascular tone

A

Hypocapnia: decrease CBF

Hypercapnia: increases CBF

Maintenance of normocapnia is paramount

72
Q

Which measurement technique is the most reliable for assessing interior integrity of the cerebral hemispheres

A

transcranial doppler velocity monitoring

73
Q

Cerebral oximetry critical values

A

the reduction of critical 02 sat during clamping of greater than 20-25% persisting for > 4 min indicates potential for deficit

74
Q

Anesthetic management during carotid artery surgery

A 
Provision of analgesia
facilitate the procedure
minimize morbidity
cerebral and myocardial perfusion and oxygenation
minimize stress response
smooth and rapid emergence
75
Q

Anesthetic selection for CAE

A
  • patient’s condition
  • surgeon’s preference
  • preoperative evaluation
76
Q

advantages of regional in CAE

A
  • pt awake and can respond to commands and allow for continuous assessment of neurologic function
  • high patient satisfaction
  • lower shunting requirements
  • less cost
  • minimizes potential postoperative cognitive effects associated with general anesthesia
77
Q

disadvantages of regional in CAE

A
  • pt agitation and inability to remain still
  • minimal airway control
  • seizure or stroke during clamping
  • limited ability to give cerebral neuroprotectants
78
Q

Advantages of GA in CAE

A
  • surgeon able to perfrom more extensive and ifficult surgical procedures
  • better airway control
  • ability to administer cerebral protectancs
  • improved blood pressure control
79
Q

regional during CAE requires anesthesia of what nerves

A

cervical nerves II to IV

accomplished by local infiltration, superfical and deep cervical plexus block or a combination

80
Q

Postoperative considerations for CAE

A

HTN (most common d/t carotid baroreceptor reflex)/Hypotension
carotid hemorrhage (airway obs, prepare for difficult intubation)
RLN damage (inspiratory stridor)
respiratory insufficiency
tension pneumothroax
carotid body damage (poor chemoreceptor function
cerebral hyperperfusion syndrom
acute carotid occlusion

6902 - Kronus (8 decks)

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