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Vascular > Vascular PP2a > Flashcards

Vascular PP2a Flashcards

1
Q

anatomy of arteries for lower extremity

pathway from the aorta down

A

aorta - iliacs - femoral - popliteal - tibial and peroneal

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2
Q

when your pt has PAD, what other dzs do they probably have

why are they needed bypass sxg (symptoms).

what are they patients at high risk for

what is often a first sign

A

CAD, CVD

intermittment claudication, cold leg ischemia, intermittent pain

at high risk for CV events

first sign is often intermittent claudication

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3
Q

what is the difference between direct reconstruction and extra anatomic reconstruction

A

direct: aorta - fem, fem - pop, fem - tib. these procedures have higher mortality but better long term patency

extra anatomic: fem -fem, ax - fem. these have less mortality but but worse patency long term. sicker patients often get these procedures

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4
Q

what are some risk factors for PAD

A

smoker, dm, HTN, HLD, diabetes, chronic inflammation, renal insufficiency, hypercoaguable, male, nonwhite

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5
Q

what is the cheapest way to test for PAD

A

ankle brachial index. <.9 is abnormal

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6
Q

if the patient has CAD, step to see if they are ready for surgery

A
  1. urgency 2. ACS 3. MACE 4. METS >4 5. Stress test 6. are these tests s going to change whether we do surgery or not
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7
Q

what are some indicators for acute ischemia pathology (3)

timing on surgery

types of procedures

A

thombus or emboli

cold leg ischemia, loss of pulses

best to get surgery within 4-6 hours

angiography, stent, bypass

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8
Q

chronic ischemia indication

why is this occuring

when is surgery indicated

A

gangrene, pain at rest, intermittent claudication, ulcers

patho: progressive narrowing of the vessesl

SBi < .9, severe pain, disabling claudication, critical limb ischemia

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9
Q

how do we run the ankle brachial index

A

ankle SBP/arm SBP

normal is 1.0 - 1.4. <.9 is abnormal

take 2 readings and average

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10
Q

fem-pop procedure

discuss

A

tolerated better than Aox, bc dont need to clamp aorta

expose areas that will be receiving the graph, clamp fem. can use saphenous as graft

fever hemodynamic hcanges when not clamping aorta. give heparin

confirm flow

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11
Q

why are aorta femoral bypasses tolerated better than aneuysm disease

A

bc they have time to build up collaterals which will help devert blood flow during clamping

aneurysm repairs typically wont have collaterals built up yet

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12
Q

extra anatomic bypass: fem-fem or ax-fem

which patients get this surgery

patency of graft after 5 years

do you need to clamp AOX with ax-fem?

when is the most stimulating part, how can we help

where is place the A line: which side and proximal or distal

A

reserved for the higher risk patients

patecy is less at 5 eyars compared to direct repair

ax-fem dont need to cross clamp aorta

tunneling is most stimualting so paralyze

a line is placed opposite side of ax-fem and proximal to clamp

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13
Q

anesthetic management during lower extrm vascular surgery

premeds ti ake

invasive lines

labs to follow

what is an emergency surgery, what (5) things we need to consider

A

BB, statin, aspiring(way the risks for bleeding)

A line yes, +- CVP or PA depending on PHTN and RV failure

bmp, cbc, coags, TEG

fasciotomy, myoglobenimua, hyperK, ekg ischmic changes, coag status

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14
Q

Regional of GA with lower extrem vascular surgery

when its contrainidication

aid with CVD

aid with graft healing

type of regional placement

A

pt refuses or when coagulopathic

no differences show w CV when chossing GA or regional

RA is superior for decerased bleeding and increase in blood flow to surgical area, promoting healing to graft site

lumar epidural

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15
Q

what are reasons (4) that GA is worse for graft healing than regional

A
  1. Regional provides greater blood flow to the site
  2. fibrinolytics are decreased GA
  3. GA is more hypercoagulable
  4. epi and noepi are released higher w GA
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16
Q

when managing the graft intraop what are some considerations

A

T10 block with regional

try not use pressors to perfuse the newly placed graft

maintain blood flow and blood pressure to the anastamotic site.

keep warm

frequent pulse checks with doppler

17
Q

Bypass: postop considerations (5)

A

prevent anemia

prevent hypotension and give adequate fluids to perfuse the site

high risk MI, check for ST elevation changes

control HR and afterload reduction

18
Q

discuss the anatomy of the lower extremity and the spine

A

T12 suprarenal

L1 infrarenal, SMA

L3: IMA inferior mesenteric artery

L5: Iliac

t8-t12 is artery of adomkowit

19
Q

are most aneuysms repairs suprarenal or infrrenal

A

85% are infrarenal

20
Q

for arterial aneurysms, where do most occur thoracic or abdominal

where are most thoracic aneuysms

how are AAA classififed

A

abdominal, 9x more than thoracic

thoracic 40% ascending 35% descending

supra, 85%infra, juxta

21
Q

what is the patho of aneursysm

what is most important predictor of rupture and mortality

what is the law of laplace

A

the connective tissue of the medial layer weakens. from inflammation and immune responses

a weakened wall

law of laplace = wall stress = (pressure x x2radius)/ wall thickness

size of the aneurysm

22
Q

size of aneurysms and when they need to be fixed

AAA

descending AA

A

AAA >5.5cm

DAA > 6.5cm

23
Q

patho of aortic dissection

acute vs chronic

where do most AAA occur

symptoms (3)

DAA death, why?

A

tear in the intimal layer creating a false lumen

acute <14 days

chronic > 14 days

most occur in the asending region

cardiac tampondae, aortic regur, MI

death from acute DAA because not feeding organs: spleen, liver, bowels, stomach

24
Q

changes you will see during clamping, things to worry about OVERVIEW

A

duration, location of clamping. suprarenal above L1 hypertension, decrease of blood flow to spinal cord, bowels, kidneys, spleen. will see hemodyanmic and metabolic changes

if below L1, spleen and visceral organs can take 800cc blood, better tolerated and wont see hypertension. visceral organs get blood flow

25
Q

what are (5) important things to talk about the aortic clamping

A
  1. Location
  2. Duration
  3. volume status
  4. does patient have collarterals
  5. CAD, temp, anesthetics agents used
26
Q

hemodynamic changes with clamping aorta

supra and infrarenral

A

infra: 10% increase MAP
supra: 50% increase MAP, no big changes to HR
supra: will see increase in preload, increase in CVP, increase in CO, may see LV wall abnormalities from the increase in blood flow
infra: splianic organs can take 800 CC of blood, less changes in preload and MAP

27
Q

how to aid in hemodynamic changes with aortic clamping

A

want to keep supply and demand in balance. Esmolol can help keeping HR 60-65

afterload reduction (5): nicardipine 200mg, increase VG, milrinone 50mcg/kg, nitroprusside, .5mcg/kg before clamping, shunt

preload reduction (2): NTG 50mcg, thoracic epidural

make sure we are maintaining cardiac output

28
Q

what metabolic changes are seen with Aortic cross clamping (5)

A

decrease o2 consumption

decrease o2 extraction

decrease C02 production

increase SVO2

with no changes will see respiratory alkylosis

29
Q

changes when unclamping depend on what (4) things

A

duration, level of clamping, coume status, was bypass used

30
Q

hemodynamic changes occur when unclamping

decrease (4) increase (1)

A

SVR will drop 80%, decrease in preload, decrease in CVP, decrease in CO

there is an increase PAP from inflammatory mediators causing an increase in PVR

31
Q

what are the metabolic changes that occur with unclamping

A

increase in o2 consumption

increase in 02 extraction

increase in co2 production

decrease in mixed venous oxygenation

32
Q

what are some therapeutic intervention during unclamping

BP meds: (5)

interventions

what if lots of bleeding

A

help with blood pressure

preload with fluids before unclamping

phenylepherine and levophed ready

can give 500mg CaCl

10mcg epi

release the clamp slowly

clamp needs to be reapplied

33
Q

AAA anesthestic management

where is place the A line, CVP

when to use a PA cath

how much blood

what else for bleeding

help with spinal cord perfusion

BP meds

A

A LINE and CVP need to placed proximal to clamp to work

PA cath if EF less than 30% RV failure or PHTN

4-6 units

colloids, cell save ready

have a thoracic epidural or lumbar drain placed

esmolol, NTG, nicardipine, norepi, epi, CaCl

34
Q

when repairing a AAA, what will determine if the patient goes to the ICU

A

clamp time longer than 30 min

large blood loss and

pulmonary edema from inflammatory mediator release

35
Q

AAA induction goals

regional

emergence

will the patient go to the ICU?

A

smooth, no voughing or bucking, prevent hypotension

can do a thoracic or lumbar block

normal hemocyanamics smooth, keep warm

icuL if clamp time great than 30min, large blood loss, pulm edema

36
Q

what are some potential complications that can occur during aortic surgery

which organs

A

bleeding, hypotension, decreased perfusion to kidney, bowels, spine leading to paraplegia, infection, pulmonary issues, MI from supply demand issues

37
Q

aortic cross clamping and renal function

where does flow preferentially go to, where is most vuneranble

how to prevent renal damage

what is the best predictor of postop renal success

what is not a good indictor of renal postop success

A

injury depends on clamp time and location of clamp

flow goes to cortical structures and juxtamedullary layers

renal medulla is the most vunerable

no spefic way to prevent damage,

HYDRATION

best predictor: what was their preop renal status

urine volume is not a good indicator

38
Q

what are some contributing factors to renal dysfunction postop

A

atherosclerosis, emoboli, hypotension, clamp time, clamp location, needing pressors, 5 units of PRBCs, trauma to renal arteries, nephrotoxic drugs, rhabdomylosis

39
Q

what are some ways we can help prevent renal dysfunction

A

keep hydrated, no hypotension, dont give blood if you dont need to, can cool kidneys down to 4 celcius

Vascular (4 decks)

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