Vascular / IR Flashcards
Cross clamping
What is your strategy for managing an aortic cross clamp at the following levels – infrarenal; suprarenal; thoracic? What are the implications of cross-clamping at these levels?
SS_VS 1.9
[06B03] Describe the cardiovascular changes which occur during clamping and unclamping of the supra-renal aorta during repair of a AAA in a patient with normal ventricular function and outline your strategies to maintain critical organ perfusion during these times
Changes
1. Haemodynamics
a) cardiac
b) post clamp
c) end organ
- Neurohumoral
a) RAAS
b) SNS act
c) ischaemia-reperfusion inj
HD
a) cardiac
- inc AL –> inc LV EDP/EDV –> ANREP –> inc CO
- inc cor ostia pressure
- CorPP
b) post clamp
- inc VR/PL –> inc SV –> inc LVEDP/LAP
c) end organ
- supply INTERRUPTED
- Kidney –> dec RBF –> RAAS act
- GIT –> dec spl BF
- SC –> CC (cord compression?)
NH
- RAAS
- SNS –> inc circ catechol
- ISCHAEMIA REPERFUSION INJURY
- rel cytokines –> dec contract / vasodil / arrhythmias
Strategies
1. Fluids
2. Not warm legs
3. Spinal drain
4. Minimise cross clamp time
5. Clamp DISTAL
6. GTN for vasodilation
Suprarenal»_space; infrarenal
More proximal = more profound
What recovery room complications might you expect to manage in a patient who has undergone a carotid endarterectomy and why might these occur? How would you manage them?
[15B11] Describe the complications that can occur post carotid endarterectomy and how these may present in the post anaesthesia care unit (PACU).
What monitoring do you think is necessary for carotid artery surgery and why? Do the surgical and anaesthetic techniques make a difference?
SS_VS 1.13-1.15
GA
IAL
Reinforced tube
Cerebral oximetry (O2 consumption)
+/-
Shunt - risk - emboli, thrombosis
GALA trial - no definite benefit o either technique
Outcomes
1. Stroke
2. MI
3. Mortality
at 30 days
COMPLICATIONS
Surgical
1. Neuro
- CVA embolic
- Hypoperf
- Haemorrhagic
- CVS
- CN
Anaes
1. Non spec
HYPOPERFUSION CVA
- GA
A:
B:
C:
D:
E: - Regional
- GEN: infection, bleed, LAST
- SPECIFIC: phrenic n palsy, SAH/epi injection
PATIENT
- Obesity hypovent and atelectasis
- Pre-existing CVS/RESP
(xxx%) Examiner’s report – the borderline standard sought was as below:
* - Recognises common presentations according to patient and anaesthesia/procedural factors:
* - Specific to CEA – bleeding, airway compromise, stroke, CVS instability
* - General factors – Patient, anaesthesia
What are the indications for a thoracoscopic sympathectomy, and what would be your anaesthetic and pain management plans?
SS_VS 1.4
The Society of Thoracic Surgeons Task Force reviewed the current literature and reached a consensus that
*primary hyperhidrosis of the palms, plantars, axillae, or face is best treated with endoscopic thoracic sympathectomy
Anaes:
Preop - young
Intraop
Standard monitoring
Large bore IV
AW
- DLT
- SLT
- SLT+BB
- LMA
What are your anaesthetic goals for a patient undergoing an elective open repair of an AAA and how might you achieve them? What changes would you make if the surgeon performed an endoluminal procedure instead of an open one?
SS_VS 1.4
VASCULAR – EVAR complications
[20B02]
What potential complications may occur during an interventional radiological procedure in the angiography suite and how would you manage these?
SS_VS 1.18
Equipment - unfam
Assistance - trained, expe
Monitoring - Full
Geography - familiarise
Resus facilities - know
- Reaction to intravenous contrast
- Aortic occlusion
- Acute renal impairment
- Spinal cord ischaemia
- High radiation dose
- Haemorrhage
PS55
What are the implications for patient safety when undertaking procedures in the interventional radiology suite?
SS_VS 1.16
CT
- ionising radiation - protection/distance
- Lines
- contrast
- breath holds
MRI
- claustrophobic
- 15mins+
- Ferromagnetic
- Noise
- Helium escape -
- Gad contrast - anaphylaxis ~1:100k
- screening
Cardiac arrest
-remove pt on non-magnetic trolley
- ALS OUTSIDE scan room
What are the procedural requirements and anaesthetic management goals for patients undergoing vascular stenting or embolisation?
SS_VS 1.17
Procedural requirements:
1. Very still pt
2. Painful
3. Paeds
4. Supine post
5. Vagal - balloon dilatation
VASCULAR – Policy for endovascular stroke intervention
[18A05] You are developing an anaesthetic department policy for acute endovascular stroke intervention.
Outline the issues to be considered in your policy.
(41.8%) This question had a low pass rate. Successful candidates demonstrated a structured approach and mentioned communication lines between anaesthesia and other multidisciplinary teams. They recognised the time sensitive nature of treatment and prioritised tasks.
- RAPID ID of potential pts
- rapid ED –> stroke call + MDT (neuro/IR/ICU/anaes) - Prev 2nd BI
sBP
dBP
CPP
Glycaemia - normal
Hb > 70
Plt > 100
Head up - Reperfusion Rx w/in 60 mins
VASCULAR – EVAR complications
[20B02] A 75-year-old man is scheduled for elective endovascular repair of a thoraco-abdominal aortic aneurysm. List the potential complications of this procedure in this patient and discuss your strategies to mitigate these complications
SCI/renal/haem/MI/stroke/remote location
2 column
SYSTEMIC compl
1. SCI - SCPP - lumbar drain
2. AKI - preop/optimise
3. Haemorhh - G+H, fluids, bloods
4. Stroke - ~ SCI
STENT compl
- clot
- infection
- endoleak - type
- 1. failure to seal
- 2. back bleeding
- 3. dislocation
- 4. porosity / endodistension
VASCULAR – EVAR risk of SCI
[16A06]
Outline risk factors for spinal cord ischaemia in a patient undergoing endovascular repair of a thoraco-abdominal aortic aneurysm. (50%)
Discuss your approach to minimising spinal cord ischaemia in this setting. (50%)
RF: pt/ana/surg
Pt
1. smoking
2. CAD
3. HTN
Anaes
1. low O2
2. Low BP
3. Low vol
Surg
1. Complex suPRA renal EVAR
2. long stent graft
3. poor alignment
b) protection
1. inc cord tol to ischaemia
2. min duration of cord ischaemia
3. early detection of ischaemia
4. augment SC perf
VASCULAR – Open AAA considerations
[Made up question] Anaesthetic considerations for elective open AAA repair
VASCULAR – Ruptured AAA considerations
[Made up question] Anaesthetic considerations for emergency ruptured AAA repair
- Maintain adequate PP
- Close HD monitoring
- Line
- Coagulopathy
- Monitor GE and O2
Deep breaths
CEACCP
VASCULAR – CEA changes in BP
[17B02] Discuss the significance of anticipated changes in blood pressure during anaesthesia and in the post anaesthesia care unit in a patient undergoing carotid endarterectomy. (50%) Outline strategies to manage these changes. (50%)
Preop
Intraop
1. induction
2. Clamp -
Post op
1. Neck haematoma
2.
Bleed/stroke/MI
