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Advance Anesthesia II > Vascular Surgery > Flashcards

Vascular Surgery Flashcards

1
Q

Peripheal Vascular Disease Etiology:

A
  • Occlusion of the vascular lumen
  • Blood pooling hypercoagulability
  • Micro-thrombi or Atheromatous debri (If the lipd cap ruptures)
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2
Q

PVD Pathology:

A
  • Stenosis
  • Thrombosis
  • Embolism
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3
Q

PVD Results in:

A
  • Decrease blood flow
  • Acute organ ischemia
  • CVA, PE, MI
  • Aneurysm
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4
Q

PVD leads to weakning of:

A
  • Arterial Wall
  • Cause aneurysm
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5
Q

Factors related to Atherosclerotic lesions:

A
  1. Advance age
  2. Smoking
  3. Hypertension
  4. Diabetes Mellitus
  5. Insulin resistance
  6. Obesity
  7. Family Hx and Genetic predisposition
  8. Physical inactivity
  9. Sex male > female
  10. Homocysteine
  11. Eleveated C-reactive protein
  12. Elevated lipoprotein
  13. Hypertriglyceridemia
  14. Hyperlipidemia
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6
Q

PVD Common signs and symptoms:

A
  • Claudication
  • Ulcerations
  • Gangrene
  • Impotence
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7
Q

PVD Surgical therapy treatment options:

A
  • Transluminal angioplasty
  • Endarterectomy
  • Thrombectomy
  • Endovascular stening and arterial bypass
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8
Q

PVD Common maneuvers used to Bypass:

A
  • Aorto-Femoral
  • Axillo-Femoral
  • Femoro-Femoral
  • Femoro-Popliteal
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9
Q

PVD Preop Evaluation:

A
  • 50% mortality with PVD —> adverse cardiac events
  • 42% of Pts with abdominal Aortic Aneurysm repair have CAD
  • 5 yr AAA repair survival rate 86%
  • Needs to optimize cardiac function to decrease morbidity and mortality
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10
Q

PVD Pre-Op Pharmacological Management
Beta-blockers ( Metoprolol):

A
  • Tenfold decrease in cardiac morbidity
  • Instituted days to weeks prior surgery
  • Titrate dose to HR between 50-60 bpm
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11
Q

Statins ( Cardioprotective effect):

A
  • Decrease vascular inflammation
  • Decrease incidence of thrombogenesis
  • Enhance nitric oxide bioavailability
  • Stabilize atheroscerotic plaques
  • Decrease lipid concentration
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12
Q

PVD Monitoring:

A
  • Cardiac function
  • Detection of myocardial ischemia (primary objective)
  • Monitoring based on coexisting disease and type of surgery
  • ECG
  • TEE
  • PAC
  • Arterial line
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13
Q

Befenefit of Arterial line in PVD:

A
  • Allows near-real time BP values
  • Guides treatment decisions
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14
Q

PVD Anesthesia Selection:

A
  • Goal: maintain hemodynamic control
  • Avoid intraoperative HTN
  • Avoid Hypotension
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15
Q

PVD General Anesthesia:

A
  • Consider IV and Inhaled anesthetics
  • Decrease rate of oxygen demand
  • Protects neurologic and cardiac tissue
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16
Q

PVD Epidural Anesthesia Benefits:

A
  • Decrease rate of MI, Stroke and Respiratory failure
  • Decrease rate of MI vs Opioid for postop pain
  • High risk for Epidural Hematoma
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17
Q

PVD Postoperative Conditions:

A
  • Pain: enhaces SNS stimulation
  • Narcotics: cardiac stability
  • Acute pain increases inflammatory mediators
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18
Q

Inflammatory mediators due to Acute Pain:

A
  • Creatinine kinase
  • C-Reactive protein
  • Interlukin (IL)-6
  • Tumor necrosis factor (TNF)
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19
Q

Prevention of PostOP Condition for PVD:

A
  • LMWH (bridge time for oral anticoagulants)
  • Restart Oral anticoag postop after bleeding is decrease
  • Low HCT concentration
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20
Q

Abdominal Aortic Aneurysm (AAA)
Incidence and Mortality:

A
  • 3-10% Pts >50 yrs
  • 2-6 times Men > Women
  • 2-3 times White > Black
  • Mortality in 1950 18-30%
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21
Q

Elective AAA surgery mortality is:

A

< 5%

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22
Q

5 and 10-year mortality if untreated AAA?

A
  • 5 year mortality 81%
  • 10 year mortality 100%
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23
Q

Mortality of undetected AAA?

A

35-94%

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24
Q

AAA current mortality

A

1-11%

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25
Q

Surgery is recommended if AAA measures:

A

AAA > 5.5 cm or greater in diameter

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26
Q

AAA Risk factors:

A
  • Atherosclerosis (most common)
  • Smoking
  • Male gender white > black
  • Hypertension
  • Advaced age
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27
Q

AAA Diagnosis:

A
  • Physical examination
  • Pulsatile abdominal mass
  • Discover by accident by PCP
  • < 30% AAA identified during routine physical examination
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28
Q

AAA Additional risk factors:

A
  • Presence of carotid artery or PVD
  • Obesity
  • Diabetes
  • All these increase rate of AAA detection to 90%
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29
Q

Abdominal Aortic Reconstruction
Contraindications:

A
  • Intractable angina pectoris
  • Recent MI
  • Severe pulmonary obstruction
  • Chronic renal insufficieny
  • Physiological age > chronological age
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30
Q

Law of Palace Formula

A

T=P x r

  • T = Wall tension
  • P = Transmural pressure
  • r = Vessel radius
  • Increased wall tension; Increase vessel radius and intramural pressure
  • Increase wall tension, decrease wall thickness
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31
Q

Rupture risk for AAA <4 cm?

A

0%/yr

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32
Q

Rupture risk for AAA 4-5 cm?

A

0.5% - 5%/yr

%/Year

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33
Q

Rupture risk for AAA 5-6 cm?

A

3-15%/yr

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34
Q

Rupture risk for AAA 6-7 cm?

A

10-20%/yr

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35
Q

Rupture risk for AAA 7-8 cm?

A

20-40%/yr

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36
Q

Rupture risk for AAA > 8 cm?

A

30-50%/yr

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37
Q

Aneurysm Rupture CV major goals:

A
  • Beta-blockers and Statins
  • Preop fluid loading
  • Restoration of intravascular volume
  • Large bore IV’s and central lines
  • Avialability of blood and blood products
  • Rapid transfuser and blood salvage should be confirmed
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38
Q

Aneurysm Rupture Monitoring:

A
  • Routine
  • ECG Lead II ( dysrhythmias)
  • ECG Lead V ( ST- segments changes)
  • Pulse Oxymeter
  • Capnography
  • Esophageal stethoscope
  • Indwelling urine catheter
  • Peripheral neurostimulator
  • Invasive monitoring
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39
Q

Primary method for Intraop Cardiac assessment:

A
  • TEE
  • For patients undergoing Heart and Aortic surgery
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40
Q

Aortic Cross-Clamping:

A
  • Most dramatic physiological change occur in this period
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41
Q

Hemodynamic Effect of above cross-clamp

A

Hypertension

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42
Q

Hemodynamic Effect of below cross-clamp

A

Hypotension

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43
Q

Hormones elevated during Aortic Cross-Clamping:

A
  • Catecholamines
  • Aldosternone
  • Cortisol level
  • Stress hormone levels
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44
Q

Hemodynamic effects of Aortic Cross-Clamping:

A
  • Increase afterload
  • Increase MAP and SVR
  • Increase CO/ unchanged
  • Increase PAOP/ unchanged
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45
Q

Causes of Metabolic Alterations:

A
  • Lack of blood flow to distal structures
  • Tissue ischemia
  • Anaerobic metabolism
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46
Q

Lack of flow flow to distal structure leads to:

A
  • Hypoxic enverironment
  • Ischemic environment
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47
Q

Anaerobic metabolism effect:

A

Accumulation of serum lactate

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48
Q

Mesenteric traction syndrome:

A
  • D/t Surgical maneuver to expose the aorta
  • Decrease BP & SVR
  • Tachycardia
  • Increase CO
  • Facial flushing
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49
Q

Effects on Regional Circulation:

A

Acute Kidney Injury

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50
Q

AKI associated with:

A
  • Mortality rate
  • Long-term CV events after surgery
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51
Q

Clamp above renal arteries leads to:

A
  • Severe AKI
  • In open surgical repair patients
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52
Q

Suprarenal cross-clamp > 30 mins leads to:

A

Postop Renal failure

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53
Q

How to protect the Kidneys?

A
  • Renal-dose Dopamine
  • Mannitol
  • Sodium Bicarbonate
  • Loop diuretics

Not fully proven to improve postop renal function

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54
Q

What interventions really reduces the incidence of AKI?

A
  1. Balanced crystalloids
  2. Hyperchloremic solutions
  3. Avoid Nephrotoxic drugs
  4. Avoid NSAIDs
  5. Avoid Aminoglycoside Abx Preop
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55
Q

When does Spinal cord schemia occurs?

A

During aortic occlusion

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56
Q

Spinal cord ischemia causes:

A

Paraplegia (1-13%)

Spinal cord damage

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57
Q

Spinal cord Longitudinal blood is supply by:

A
  • One anterior spinal artery 80%
  • Two posterior & two post-lateral spinal arterial 20%
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58
Q

Spinal cord Transversed blood is supply by:

A
  • Greater radicular artery (Adamkiewicz)
  • Originates between T8-T12
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59
Q

How is spinal cord function monitor?

A
  • SSEP
  • MEP
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60
Q

Spinal cord protection strategies:

A
  • Distal aortic perfusion
  • CSF drainage
  • Mild hypothermia
  • Maintenance of normotension SBP > 120 mmHg
  • Day 2 Postop decreases incidence of paraplegia
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61
Q

Ischemic Colon Injury is most attributed to:

A

Manipulation of the anterior messenteric artery

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62
Q

What part of the colon does the Messentaric artery supplies blood to?

A

Left colon

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63
Q

Which artery is commonly sacrified during colon surgery?

A

Messentaric artery

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64
Q

Mucosal ischemia occurs in ___________ on patient going to AAA repair

A

10%

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65
Q

Restoration of circulating blood is paramount before:

A

The release of aortic clamp

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66
Q

What components characterized Ischemic Perfusion Injury?

A
  1. Metabolic
  2. Thrombotic
  3. Inflammatory
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67
Q

Most important interventions to protect from AKI:

A
  • Aggressive Hemodynamic stabilization
  • Minimization of Aortic clamp times
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68
Q

IntraOp solution used for Renal perfusion:

A
  • Cold solution
  • Renal protective
  • Decrease incidence of AKI
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69
Q

Atrial Natriuretic Peptide (ANP) cause:

A
  • Vasodilation of Preglomerular artery
  • Inhibition of angiotensin axis
  • Prostaglandin release

Promotes Renal vascular dilation

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70
Q

What promotes Renal vascular dilation?

A

ANP

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71
Q

Declamping shock syndrome:

A

Hemodynamic instability

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72
Q

Ischemic Perfusion Injury consequences:

A
  • Tissue edema
  • ARDs
  • Compartment syndrome
  • Bacterial translocation
  • Renal failure
  • Multisystem organ failure
  • Non-reflow phenomenon
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73
Q

When does Non-flow phenomenon occurs?

A

When Microvasculature is occluded

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74
Q

Microvasulature is occluded by:

A
  • Platelets
  • Neutrophils
  • Thrombi
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75
Q

Effects of Non-reflow phenomenon:

A
  • Inadequate perfusion
  • Increase cellular necrosis
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76
Q

Advantages of Retroperitoneal Approach:

A
  • Exposure for Juxtarenal and suprarenal aneurysm
  • Decreased fluid loss
  • Improved postop respiratory function
  • Better-tolerated incisional pain
  • Avoid formation of intraabdominal adhesions
  • Does not elicit mesenteric traction syndrome
77
Q

Disadvantages of Retroperitoneal approach:

A
  • Inaccessibility to distal right renal artery
78
Q

Transperitoneal Approach Advantages:

A
  • Familiarity
  • Access to infrarenal aorta and Iliac vessels
  • Visualization of intraabdominal viscera
  • Rapid opening and closure
  • Versatility
79
Q

Transperitoneal Approach Disadvantages:

A
  • Increases fluid losses
  • Less postop ileus
  • More postop respiratory complications
  • Increased postop incisional pain
80
Q

Total blood loss in Aneurysm Repair is affected by:

A
  • The surgical approach
  • Duration of surgery
  • Experience of surgeon
81
Q

Most blood loss during aneurysm repair is due to:

A
  • Back bleeding from lumbar Inferior messenteric arteries
  • After vessels are clamped and aneurysm is opened
82
Q

3 options available for autologous transfusion:

A
  • Preoperative deposit
  • Intraoperative phlebotomy and Hemodilution
  • Intraoperative blood salvage

Autologous via cell sever system is a standard procedure.

83
Q

Intraoperative Aneurysm Repair Management
Anesthetic selection objective:

A
  • Provide optimum analgesia and amnesia
  • Facilitate relaxation
  • Keep hemodynamic stability
  • Preserve renal blood flow
84
Q

Aneurysm Repair General Anesthesia:

A
  • All inhalation agents depress the myocardium
  • Myocardium depression is dose-dependent
  • Administer gases at lower concentrations
85
Q

Aneurysm Repair General Anesthesia Benefits:

A
  • Alter autonomic responses
  • Reversibility
  • Rapid emergece
  • Potential early extubation
  • Nuerologic protection
  • Cardioprotection
  • Opiods
  • Provide Cardiovascular stability
  • Attractive for ischemic heart disease and Ventricular dysfunction PTs.
  • SNS inhibtion decreases SVR and HR
  • **Caution with decreased EF patients **
86
Q

Aneurysm Repair Epidural Benefits:

A
  • Decreases Preload and Afterload
  • Preserved myocardial oxygenation
  • Decreases stress hormones
  • Excellent muscle relaxant
  • Decreases postop thromboembolism
  • Increases graft flow to LE
  • Decreases pulmonary complications
  • Improved postop analgesia
87
Q

Aneurysm Repair Epidural Disadvantages:

A
  • Anticoagulation
  • Epidural hematoma
  • Severe hypotension
88
Q

Aneurysm Repair Fluid Management :

A
  • Crystalloids at 10 mL/kg per Hr
  • Initial blood loss replaced with cyrstaloid at ratio 3:1
  • Crystalloid + Colloid acceptable
  • Maintain cardiac filling pressures, CO
  • Urine ouput at least 1mL/kg per Hr
  • Patients with limited cardiac reserve –> CHF if hypervolemia occurs
89
Q

Juxtarenal aneurysm located at the level of:

A
  • Renal arteries
  • Spare the renal orifice
90
Q

Suprarenal Aortic Aneurysm includes

A
  • At least one renal artery
  • May involve visceral vessels
91
Q

Classification of Abdominal Aortic Aneurysm:

A
92
Q

Potential complications of Juxtarenal or Suprarenal Aortic Occlusion:

A
  • Renal Failure
  • Hemorrhage
  • Distal arterial occlusion
  • Infarction
  • Pulmonary or Cardiac dysfunction
  • Impotence
  • Paraplegia
  • Thrombosis
  • Pseudoaneurysm formation
  • Aortoenteric fistula
93
Q

Ruptured AAA Mortality:

A
  • 80-90% mortality
  • Postop mortality 40-50%
94
Q

Most common symptoms of ruptured AAA:

A
  • Severe abdominal discomfort or back pain
  • ALOC d/t hypotension
  • Pulsatile abdominal mass
95
Q

Vasopressor for Ruptured AAA:

A
  • Phynelephrine
  • Epinephrine
96
Q

Type of Fluids for Ruptured AAA:

A
  • Crystalloids
  • Colloids
  • Blood products
  • Blood salvage provision available STAT
97
Q

Reason for Coagulopathies after massive IVF and blood adminstration?

A

Dilutional Thrombocytopenia

98
Q

What decreases the total transfusion requirements in a ruptured AAA?

A

Fresh Frozen Plasma

99
Q

Labs for Rupture AAA:

A
  • H & H
  • Calcium
100
Q

Citrate in blood causes:

A
  • Hypocalcemia
  • Positive inotrope
  • Increase bleeding
101
Q

Hypocalcemia treatment:

A

Calcium chloride

102
Q

Hypocalcemia Tx is guided by:

A

Calcium Ionized levels

103
Q

How does Calcium behave during Alkalosis?

A
  • There is a decrease in ionized calcium levels (↓ Ionized [Ca²⁺]).
  • Allowing more calcium ions to bind to albumin.
104
Q

Thoracic Aortic Aneurysm Mortality Rate:

A
  • Elective repair 22%
  • If Rupture 54%
105
Q

Thoracic Aortic Aneurysm Dissection:

A
  • Spontaneous tear witin the intima
  • Allows blood flow through a false passage
106
Q

Thoracic Aortic Aneurysm Types:

A
  1. True Aneurysm
  2. False Aneurysm
107
Q

True Thoracic Aortic Aneurysm:

A

Involces 3 layers

108
Q

False Thoracic Aortic Aneurysm:

A

Involves the Adventia only

109
Q

Thoracic Aortic Aneurysm are classified by:

A
  1. Shape
  2. Fusiform
  3. Saccular
110
Q

DeBakey Acute Aortic Dissection Classification:

A
  • Type I
  • Type II
  • Type III
111
Q

DeBakey Type I

A
  • Originates in the ascending aorta
  • Extends at least to aortic arch and beyond
112
Q

DeBakey Type II

A
  • Originates in the ascending aorta
  • Confined to this segment
113
Q

DeBakey Type III

A
  • Originates in the descending aorta
  • usually distal to left subclavian artery
  • Extend distally
114
Q

Stanford Acute Aortic dissection Classifications:

A
  1. Stanford Type A
  2. Stanford Type B
115
Q

Stanford Type A?

A
  • Dissection involve the ascending aorta
  • With or without extention into descending aorta
116
Q

Stanford Type B?

A
  • Dissection that do not involve the ascending aorta
117
Q

Crawford Classification of Thoracoabdominal Aortic Aneurysm

A
118
Q

Etiology of Thoracic Aortic Aneurysm?

A
  • Artherosclerosis (most common)
  • Marfan syndrome
119
Q

Atheroscleroic Lesions occurs most common in the:

A
  • Descending Aorta
  • Distal Thoracic aorta
120
Q

Most common classification of Thoracic aortic aneurysm?

A

Fusiform

121
Q

Horseness 2/2 Thoracic AA due to:

A

Intrusion on LRL Nerve

Impingement (intrusion)

122
Q

Complete CPB systemic Heparinization dose:

A

400 units/kg

123
Q

Arterial line and Pulse oxymeter location during CPB for Thoracic AA?

A

Right side d/t intrusion on left subclavian artery

124
Q

Patient positioning during CPB for Thoracic AA

A
  • Right lateral decubitus
  • Left-sided thoracotomy
125
Q

Aortic Dissection

A
  • Spontaneous tear of the vessel wall intima
  • Allows passage of blood along a false lumen
126
Q

Aortic dissection most common factor:

A

Hypertension

Contributes to progression of lesion

127
Q

Aortic Dissection Most serious complication:

A

Aneurysm Rupture

128
Q

Types of Aortic Dissections?

A
  • Type A
  • Type B
129
Q

Which Aortic Dissection Type can be medically managed?

A

Type B

130
Q

Which Aortic Dissection Type needs surgery ?

A

Type A

131
Q

Anesthesia for Ascending and Transverse Aorta requires:

A

CPB

132
Q

When is surgery recommended for Descending Thoracic and Thoraco-abdominal aneurysm?

A

Size > 6 cm

133
Q

Descending Thoracic and Thoraco-Abdominal Aneurysm:

A
  • Most patients are asymptomatic
  • Surgical decision based on the size, extent, and rate of expansion of the aneurysm
134
Q

Thoracoabdominal Aortic Aneurysm Etiology:

A
  1. Degenerative
  2. Mechanical (Hemodynamics)
  3. Connective Tissue
  4. Inflammatory (Non-infectious)
  5. Infectious
  6. Anastomosis
135
Q

Most common devastating consequence of thoracic surgery?

A

Paraplegia

136
Q

Descending Thoracic and Thoraco-Abdominal Aneurysm Preop Assessment Include:

A
  • Cardiac Function
  • Renal Function
  • Neurological Function
137
Q

Descending Thoracic and Thoracoabdominal Aneurysm Hoarseness

A
  • Compression of RLN
  • LRL nerve most succeptible d/t proximity to aortic arch
  • Bilateral RLN compresion leads to respiratory compromise
138
Q

Spinal Cord Ischemia
Depends on:

A
  • Type of aneurysm
  • Surgical technique
  • Cross-clamp time
  • Use of spinal coard protection interventions
  • Categorized into immediate and delayed paraplegia
  • Paraplegia incidence 0-3% if surgery clamp are < than 10 min
139
Q

Delayed Paraplegia Risk Factors:

A
  • Type 2 aneurysm
  • Emergency procedures
  • Number of sacrificed segmental segments
  • Renal failure
140
Q

Most Postoperative Risk Factor for Delayed Paraplegia:

A
  • Hemodynamic instability by A-Fib
  • Bleeding
  • Multiorgan failure
  • Sepsis
141
Q

Interventions to protect spinal cord during Thoracic Aortic Cross-Clamping:

A
  • Routine CSF drainage : Pressure < 10 mmHg CSF
  • Endorphin receptor blockade (Naloxone infusion inhibit edema formation)
  • Moderate intraop hypothermia < 35 deg C
  • Avoid hypotension MAP > 90 mmHg
  • Optimize cardiac function
  • Avoid SNP–> Steal phenomenon–> decrease spinal cord blood flow
142
Q

Thoracoabdominal AA Neurologic Deficit Factors:

A
  • Level of aortic clamp application
  • Ischemic time
  • Embolization or Thrombosis (intercostal arteries)
  • Failure to revasculate intercostal arteries
  • Urgency of surgical intervention
143
Q

Late Complication of Thoracoabdominal AA Repair:

A
  1. Delayed paraplegia
  2. Graft thrombosis
  3. Fistula formation
  4. False aneurysm
  5. Graft infection
144
Q

Early Complications of Thoracoabdominal AA Repair:

A
  1. Respiratory failure (most common)
  2. Hemorrhage
  3. MI
  4. CHF
  5. Early paraplegia
  6. Embolization/Thrombosis
  7. Distal artery occlusion
  8. Bowel ischemia
  9. Sexual dysfunction
  10. Infection
  11. Renal failure
  12. CVA
145
Q

RLN dysfunction leads to:

A

Breathing difficulties post extubation

146
Q

EVAR associated with:

A

30 day outcome Vs OSR

147
Q

AA Repair -Reinterventions are more frequent with:

A

EVAR than OSR

148
Q

Endoleak?

A
  • Inability of endovascular stent graph to isolate blood flow
149
Q

Endoleak is diagnosed by:

A

PostOp CT 15-52% of Pts

150
Q

Majority of Endoleaks are:

A

Type II

151
Q

What % of Endoleaks close spontaneously?

A

70% the first month after intervention

152
Q

Intervention to correct Endoleak complications

A
  • Implantation of 2nd Graft
  • Open repair
153
Q

Major EVAR Advantages:

A
  • Absence of aortic clamping
  • No incision from the xyphoid to pubis
  • Hemodynamically stability
  • Decrease embolitic events
  • Decrease blood loss
  • Decrease stress response
  • Decrease renal dysfunction
  • Decrease Postop discomfort
154
Q

EVAR Anesthetic Techniques:

A
  • General anesthesia
  • Neuraxial blockade
  • Local anesthetic + Sedation
155
Q

EVAR PostOp exam and Contrast CT recommendations:

A
  • 1, 6, 12, & 18 months
  • Then Anually
  • Abdominal x-ray regularly
156
Q

Second most common vascular operation in the US?

A

Carotid Endarterectomy (CEA)

157
Q

Most CVAs Etiology are:

A

More Ischemic > Hemorrhagics

158
Q

50% of all strokes are preceed by:

A

TIA

159
Q

CEA benefits patients with:

A

> 70% stenosis

160
Q

When is CEA less beneficial?

A

In symptomatic patients with 50-69% stenosis

161
Q

Carotid stenosis is the primary cause of:

A

~ 20% of all strokes

162
Q

CEA preop MI rate?

A

2-5%

163
Q

CEA Preop Mortality?

A

0.5-2.5%

164
Q

CEA surgical interventions most beneficial in:

A
  • Men > 75 yrs
  • Within 2 wks of last ischemic event
165
Q

Factors contributing to Morbidity during CEA:

A
  • Hx of stroke
  • Operative timing
  • Hyperglycemia
  • Multiple comorbidities
  • Age
  • Contralateral carotid artery disease
  • Progressing stroke
  • Ulcerative lession
  • Intraop hemodynamic instability
  • Surgery with shunt
  • Surgery without shunt
166
Q

CEA common symptoms:

A
  • Lightheadedness
  • ALOC
  • Aphasia
  • Acute motor deficit
  • Carotid bruit
  • Amaurosis fugax
167
Q

Amaurosis fugax ?

A

transient lost of vision in one or both eyes

168
Q

Carotid Stenosis Standard Diagnosis Techniques:

A
  • Duplex ultrasound
  • Digital substraction angiography
  • CT angiography
  • Magnetic resonance angiography
169
Q

CEA Preoperative Assessment:

A
  • Preexisting cardiac disease
  • HTN, ischemic heart disease
  • Valvular dysfunction
  • Cardiac arrythmias
  • Cardiac conduction abnormalities with or without ventricular failure
  • Disease severity, stability , prior treatment
  • Comorbidity (DM PVD, COPD, Obesity)
  • Type of surgery impacts postop cardiac events within 30 days post surgery
170
Q

High Cardiac Risk Surgeries > 5%:

A
  1. Aortic Surgery
  2. Major Vascular Surgery
  3. Peripheral Vascular Surgery
171
Q

Intermediate Cardiac Risk Surgeries 1-5%:

A
  1. Intraperitoneal
  2. Transplant (renal, liver, pulmonary)
  3. Carotid
  4. Peripheral arterial angioplasty
  5. Endovascular aneurysm repair
  6. Head and Neck Surgery
  7. Major Neurologic/Orthopedic (spine, hip)
  8. Intrathoracic
  9. Major urologic
172
Q

Low Cardiac Risk Procedures < 1%:

A
  1. Breast
  2. Dental
  3. Endoscopic
  4. Superficial
  5. Endocrine
  6. Cataract
  7. Gynecologic
  8. Reconstructive
  9. Minor orthopedic (knee surgery)
  10. Minor urologic
173
Q

CEA Intraoperative Considerations

A
  • Normal cerebral flow 50 mL/100 G/min
  • Cellular death occur at < 6 mL/100G/min
  • Cerebral autoregulation: MAP 60-160 mmHg
174
Q
  • All anesthetic agents decrease cerebral metabolic rate, except:
A

KETAMINE

175
Q

Cerebral monitoring during CEA:

A
  • EEG (gold standard)
  • Carotid Stump Pressure
176
Q

EEG limitations?

A

Detects superficial layers of the brain changes

177
Q

EEG Role in CEA?

A

Most sensitive and Specific measure CBF responsiveness in an awake patient

178
Q

What’s the criteria for shunt placement?

A

Stump pressure < 40-50 mmHg

179
Q

Carotid Stump Pressure function:

A

Gross measure of the pressure in the circle of willis

180
Q

Inadequate cerebral perfusion symtoms:

A
  • Dizziness
  • Contralateral weakness
  • Loss of conciousness
181
Q

Cerebral Protection during CEA:

A
  • Increase collateral flow
  • Decrease Cerebral metabolic requirements
  • Avoid hyperglycemia, hemodilution
  • Maintain normocarbia and tigh control of BP
  • Propofol decrease CMRO2 40% below normal values
  • Avoid Nitros oxide (potential pneumocephalus)
182
Q

Blood Pressure Control during CEA

A
  • Maintain MAP at 20% or greater than Preop MAP value
  • Pt to continue taking anti HTN meds until day of surgery
183
Q

Anesthetic Management
Goals specific to CEA:

A
  • Optimize perfusion to the brain
  • Minimize myocardial workload
  • Ensure cardiovascular stability
  • Allow rapid emergence
184
Q

Protamine and CEA:

A
  • Decision based on surgeon impresion
  • Associated with hypotension
  • Anaphylasis is rare (threathening side effect)
185
Q

Regional Anesthesia CEA

A
  • Requires deep and superficial plexus block CN II, III, & IV
  • Fewer hemodynamic fluctuations
  • Fewer intraop vasoactive medication requirement
186
Q

CEA Postoperative considerations

A
  • Hypertesion (most common problem)
  • Postop BP 140/80 mmHg recommended
  • Hemorrhage ( warrants sx intervention)
187
Q

Cerebral Hypoperfusion Syndrome Symptoms:

A
  • Headache
  • Visual disturbances
  • ALOC
  • Seizures
188
Q

Intial manifestion of Hemorrhage post CEA

A

Airway obstruction

189
Q

RLN damage 2/2 tracheal deviation will manifest with:

A

Inspiratory stridor

Advance Anesthesia II (7 decks)

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