Vascular PP1b

Question 1

CEA: considerations

GA vs Regional: pros cons

what to ready

Answer 1

GA: patient stays still. can manipulate gases, RR, Co2. Cons: BP swings

Regional: pt awake. gold standard for neuromonitoring. no BP swings

con: have to stay still, no orthopnea, back pain, anxiety, OA

ready to convert to general if needed

Question 2

CEA: induction and maintainance

discuss plan

Also: ssep, herparin dosing

Answer 2

quick induction. LTA lidocaine. smooth no bucking no HTN or BP swings. propofol ok. ROC x1, but dont redose. opioids and benzo, small doses what good neuro exam on wake up

a line, 2 IV, all standard monitors

maintaince: normothermic, euvolemic, VG depth depends on SSEP or MEP

watch BP closely when clamped baroreceptos (hypotension, bradycardia). give heparin before clamp AVT 200-240

Question 3

CEA emergence considerations

BP changes

neuro exam

coughing

PONV

when do most strokes occur

Answer 3

rapid and quick. HTN and tachycardia common. blunt w LTA, lidocaine, small doses or precedex

want a good neuro exam at wake up

prevent coughing and bucking

zofran, decadron, pherigan to prevent PONV

most stokes occur postop from thrombus

Question 4

CEA and regional placement

how, where

efficecy

best neruo monitoring

considerations if using this method of sedation

Answer 4

regional for CEA

superficial cervical plexus block: C2-C4. SCM, superficial and inferior cervical plexus, scalene muscle

not shown to be more effective than general

awake patient

OA, anxiety, back pain, orthopnea

give mild benzos and opioids, avoid resp depression. want to try and have patient awake, be ready to convert to general

Question 5

what do EEG, SSEP, temporal window look at

Answer 5

EEG looking at corticol structures

SSEP deeper brain structures

transcranial doppler: temporal window (decrease in blood flow and thrombos)

Question 6

EEG changes

normal, ischemia, infarction

latency and amplitude

Answer 6

normal 50mls/100g brain tissue

ischemia <18

infarction <12

decrease in amplitude by 50% and increase in latency by 10%

Question 7

cerebral pulse oxemitry

where specifically in the brain is it looking

Answer 7

like spo2 but for brain

keep within 20% of baseline

tell if there is disruption in blood flow to brain. getting oxygen to the grey matter

Question 8

SSEP

most common nerve monitored

how sensitive

latency and amplitude changes that are important

anesthetic dosing with SSEP or MEP

Answer 8

median

80%, MEPS are more sensitive

50% decrease in amplitude and 10% increase in latency

SSEP less than 1 mac. MEP less than .5 mac

Question 9

transcranial doppler

what does it tell you

where is it looking

Answer 9

looking at the temporal window, reflecting blood flow in MCA

tell you if decrease blood flow and thrombus formation

Question 10

carotid stump pressures

discuss

Answer 10

this is looking at flow during clamping to the contralateral side

clamp on, measure pressure distal to clamp. inserted at common CA

40-50 mmhg is normal

Question 11

angioplasty and stenting

where does this procedure take place

what compensatory function may be disrupted

heparin and ACT goal

Answer 11

IR

baroceptors may be disfunctional. may see hypotension and bradycardia. have pressors ready, glyco ready

Heparin and ACT >300

Question 12

discuss CEA postoperative Considerations A.B.C.C.T.

Answer 12

AIRWAY: RLN and SLN injury. may have respiratory depression, airway compression from bleeding

BLEEDING: most common postop 1-5, leading to aitway compromise

CAROTID BODY DENERVATION: leading to hypertension. rule out bladder distention, pain, hypercapnia,hypoemia (esmolol, NTG, labetolol)

CHS: cerebral hyperperfusion syndrome: HA, seizures, cerebral edema

THROMBUS: formation MI and stroke