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Prodigy Quick Review > Vascular Surgery > Flashcards

Vascular Surgery Flashcards

1
Q

What are the most common symptoms seen in
patients who are presenting for carotid
endarterectomy?

A

Patients often present with symptoms such as unilateral
weakness or numbness, unilateral blindness, a recent history of
transient ischemic attacks or cerebrovascular accident.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 406.

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2
Q

What are the most common indications for carotid

endarterectomy (CEA)?

A

CEA is indicated for patients who exhibit symptomatic carotid
artery occlusion with a narrowing of 60-90%.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 406.

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3
Q

Under which types of anesthesia can carotid

endarterectomy be performed?

A

CEA can be perform with the patient under general anesthesia
or under local anesthesia with the patient awake.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 406.

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4
Q

What is the mortality rate of postoperative stroke
versus postoperative myocardial infarction following
carotid endarterectomy?

A

The mortality rate in patients who suffer a stroke following
carotid endarterectomy is 15% versus 49% for those who suffer
an MI following a carotid endarterectomy.
Nagelhout JJ, Zaglaniczny KL. Nurse Anesthesia. 4th ed.
Philadelphia, PA: WB Saunders Company; 2010: 547.

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5
Q

Carotid surgery can be performed under regional
anesthesia by blocking the nerves originating from
which spinal levels?

A

Carotid surgery can be performed under local anesthesia by
performing a blockade of the superficial and deep cervical
plexuses which derive innervation from the C2-C4 nerve roots.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 483.

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6
Q

Where is the incision for carotid endarterectomy

typically made?

A

The incision is made anterior to the sternocleidomastoid from
below the earlobe to the base of the neck.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 406.

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7
Q

What is the purpose of a shunt during carotid

endarterectomy?

A

If the blood flow from one artery is occluded and collateral
circulation is not sufficient, the patient will suffer cerebral
ischemia. A shunt alleviates the concerns for insufficient blood
flow as it allows blood to bypass the surgical site to the brain
while the operation proceeds.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 580.

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8
Q

During carotid endarterectomy, a distal stump
pressure less than what value is an indicator that a
shunt should be placed?

A

A carotid stump pressure (the pressure in the distal internal
carotid artery after carotid clamping) less than 50 mmHg
indicates inadequate collateral perfusion which could result in
hypoperfusion of the brain during the surgery and is an indicator
that a shunt should be placed to ensure adequate perfusion.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 580.

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9
Q

What are the indications for performing a carotid

stent rather than a carotid endarterectomy?

A

Contralateral laryngeal nerve damage, previous neck radiation
therapy, over 80 years of age, severe pulmonary disease, CHF,
severe left ventricular function, MI in the last month, unstable
angina, and contralateral carotid artery occlusion.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 584.

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10
Q

How is a carotid stent performed?

A

The patient receives diagnostic angiograms and/or highresolution
MRI to identify the morphology of the lesion. The
femoral artery is cannulated and a sheath is threaded through
the femoral artery. It is threaded through the aortic arch and
then into the affected carotid artery. A device is deployed which
protects the distal artery from emboli during the procedure.
Angioplasty of the affected area is performed with a 5 mm
balloon and then the stent is deployed.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 584.

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11
Q

What is the most effective means of assessing

cerebral blood flow during a carotid endarterectomy?

A

A regional anesthetic allows the patient to be awake during the
surgery which allows for assessment of the patient’s neurologic
status during cross-clamping.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 581.

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12
Q

What is the incidence of significant coronary artery
disease in the population of patients undergoing
carotid endarterectomy?

A

30% of patients undergoing carotid endarterectomy have
significant CAD.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 407.

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13
Q

What are the advantages to using a general

anesthetic technique for carotid endarterectomy?

A

It provides a motionless field, overcomes the need for patient
cooperation during the surgery, and the use of volatile agents
provide a degree of protection against cerebral ischemia by
decreasing the CMRO2.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 582.

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14
Q

What are the advantages to performing an ‘awake’

carotid endarterectomy with regional anesthesia?

A

Studies have demonstrated that CEA performed under regional
anesthesia is associated with a lower risk for perioperative
stroke, a 10% decrease in the risk of perioperative MI, fewer
adverse cardiac events, and less intraoperative hemodynamic
variability.
Longnecker DE, Newman MF, Brown DL, Zapol WM.
Anesthesiology. 2nd ed. New York: McGraw-Hill; 2012: 1020.

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15
Q

What type of regional anesthetic is performed for an

awake carotid endarterectomy?

A

A deep and superficial cervical plexus block with
supplementation by a local field block as needed.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 137.

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16
Q

What is the purpose of performing a carotid

endarterectomy under regional anesthesia?

A

It allows the surgeon to perform a ‘test occlusion’ of the carotid
artery to determine if collateral circulation to the brain is
adequate to prevent cerebral ischemia. If after 2-3 minutes, the
patient did not experience neurologic changes, the surgery
proceeds normally. If the patient develops symptoms, a shunt
is inserted or the procedure is converted to a general anesthetic.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 137.

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17
Q

What is the main disadvantage of an ‘awake’ carotid

endarterectomy with regional anesthesia?

A

If the patient suddenly develops neurologic symptoms 10
minutes into the procedure or experiences a seizure, general
anesthesia must be instituted and the conditions for conversion
to a general anesthetic are not ideal this late into the procedure.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 137.

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18
Q

How does postoperative hypertension following

carotid endarterectomy correlate with morbidity?

A

Patients who exhibit a systolic blood pressure greater than 180
mmHg exhibit an increased incidence of stroke, TIA, and
myocardial infarction.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 582.

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19
Q

How should ventilation be managed during a carotid

endarterectomy?

A

You should strive to maintain normocarbia. Both hypercarbia
and hypocarbia can result in alterations in cerebral blood flow.
Hypocarbia can constrict cerebral blood vessels and potentially
reduce blood flow. Hypercarbia can dilate vessels and
potentially result in a steal phenomenon in which areas of
decreased perfusion suffer increased ischemia at the expense
of increased perfusion to normal vessels.
Longnecker DE, Newman MF, Brown DL, Zapol WM.
Anesthesiology. 2nd ed. New York: McGraw-Hill; 2012: 1021.

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20
Q

Is anticoagulation utilized during carotid
endarterectomy? What about carotid stent
placement?

A

Yes, heparin in the range of 5,000-10,000 units are
administered for both procedures.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 585.

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21
Q

Which ECG leads would be most appropriate to
monitor in a patient undergoing carotid
endarterectomy?

A

Patients undergoing carotid endarterectomy are at high risk for
ischemic events during the perioperative period. Monitoring
leads II and V5 offers the greatest opportunity for detecting
ischemic changes should they occur.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1126.

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22
Q

What is the dose of protamine for the reversal of

heparin following a carotid procedure?

A

Protamine is administered with a dose of 0.5 mg per 100 units
of heparin given about 10 minutes after the repair is complete.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 137.

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23
Q

What nerves are at risk for damage during a carotid

endarterectomy?

A

Phrenic, vagus, recurrent and superior laryngeal nerves, ansa
hypoglossi, and hypoglossal
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 406.

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24
Q

What drugs should be used to control blood pressure

during a carotid endarterectomy and why?

A

During a carotid endarterectomy, it is advised to maintain the
patient’s MAP slightly above their highest recorded preoperative
pressure (usually a MAP between 80-100 mmHg). For severe
hypertension, labetalol may be used, but nitroglycerin is
preferred for its swift onset and short duration of action as
labetalol could result in postoperative hypotension due to its
long duration of action. For hypotension, a pure alpha-agonist
such as phenylephrine is preferred because it has minimal
dysrhythmogenic potential.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 139.

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25
Q

Following a carotid endarterectomy, the surgeon
asks the patient to smile, say “EEE”, shrug his
shoulders, swallow, and stick his tongue out. What
specific cranial nerve is each of these tests
assessing?

A

Smile: facial nerve, say “EEE”: superior and recurrent laryngeal
nerves, shrug shoulders: spinal accessory nerve, swallow:
glossopharyngeal, stick his tongue out: hypoglossal nerve.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 583.

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26
Q

During carotid endarterectomy, a patient exhibits
profound bradycardia. What is the likely cause of
this, how should it be treated, and how can a
recurrence be prevented?

A

Bradycardia caused by manipulation of the baroreceptors in the
carotid sinus should initially be treated with atropine. To lessen
the likelihood that this will occur again, the surgeon can infiltrate
the area around the carotid sinus with lidocaine. Beware
however, that the infiltration itself can precipitate a baroreceptor
response.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 482.

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27
Q

Why is it important to avoid hypotension during crossclamping
of the carotid artery?

A

During carotid cross-clamping, it is imperative that the patient
suffer no intraoperative hypotension because the areas of the
brain served by the clamped carotid artery will rely on blood flow
from the contralateral carotid artery through the circle of Willis.
For this reason, it is important to maintain adequate perfusion
pressure so that the side that is clamped is not hypoperfused.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 135.

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28
Q

Why is it important to avoid hypotension during crossclamping
of the carotid artery?

A

During carotid cross-clamping, it is imperative that the patient
suffer no intraoperative hypotension because the areas of the
brain served by the clamped carotid artery will rely on blood flow
from the contralateral carotid artery through the circle of Willis.
For this reason, it is important to maintain adequate perfusion
pressure so that the side that is clamped is not hypoperfused.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 135.

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29
Q

What is the mortality rate following a carotid

endarterectomy?

A

0.5-2.5%
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 579.

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30
Q

What is the relationship between the occurrence of a
transient ischemic attack and the occurrence of
cerebrovascular accidents?

A

Over half of all strokes are preceded by a transient ischemic
attack. The risk of stroke is 30% within two years of the first TIA.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 578.

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31
Q

What is the perioperative incidence for myocardial
infarction when a carotid endarterectomy is
performed?

A

2-5%. Myocardial infarction is the greatest contributor to the
risk of morbidity following a carotid endarterectomy.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 579.

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32
Q

What is the incidence of males undergoing carotid

endarterectomy compared to that of females?

A

Males are three times more likely to undergo a carotid
endarterectomy than females.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 407.

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33
Q

What is the incidence of damage to the recurrent
and superior laryngeal nerves during carotid
endarterectomy?

A

39%
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 407.

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34
Q

What is a pharmacologic method for decreasing the
cerebral metabolism for protection against ischemia
during periods of decreased cerebral blood flow?

A

Propofol has been shown to reduce cerebral metabolism by
40%.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 580.

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35
Q

Unilateral blindness occurs in 25% of patients
presenting for carotid endarterectomy. What is the
pathophysiology behind this symptom?

A

Microthrombi break free from the carotid lesion and travel into
the internal carotid artery and then obstruct the opthalmic artery.
Nagelhout JJ, Zaglaniczny KL. Nurse Anesthesia. 4th ed.
Philadelphia, PA: WB Saunders Company; 2010: 547.

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36
Q

What is the incidence of correctable coronary artery
disease in patients presenting for carotid
endarterectomy and what does this imply?

A

26% of patients undergoing carotid endarterectomy have
correctable coronary artery disease. This implies that close
preoperative evaluation of patients presenting for this surgery
may identify those that need further cardiac assessment and
possibly treatment prior to undergoing surgery. Not all patients
will need a cardiac catheterization with stenting, but
approximately 1/4 of them may require some therapeutic
intervention which would dramatically decrease their risk for
perioperative morbidity.
Nagelhout JJ, Zaglaniczny KL. Nurse Anesthesia. 4th ed.
Philadelphia, PA: WB Saunders Company; 2010: 547.

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37
Q

What are the three major branches of the common

carotid artery near the bifurcation?

A

The internal carotid artery, the external carotid artery, and the
superior thyroid artery.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 134.

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38
Q

What methods of monitoring cerebral perfusion are
commonly used during carotid cross-clamping during
a carotid endarterectomy?

A

EEG, somatosensory evoked potentials, internal carotid artery
stump pressure, and transcranial doppler. During awake
carotid endarterectomy, the patient’s neurologic status and
responsiveness is the indicator of cerebral perfusion.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 135.

39
Q

How should blood pressure be maintained during

carotid cross-clamp?

A

Mild hypertension (a MAP between 90 and 110) should be
maintained during cross-clamping.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 135.

40
Q

How should blood pressure be maintained at the end

of a carotid endarterectomy?

A

You should strive to maintain a mean arterial pressure between
80 and 100 mmHg. Hypotension could result in loss of patency
of the carotid artery while hypertension could stress the fragile
tissues that were underneath the lesion or the incision site in
the carotid artery and result in massive hemorrhage.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 135.

41
Q

What is the most common cause of occlusive

vascular disease of the lower extremities?

A

Atherosclerosis
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 561.

42
Q

What are the symptoms of peripheral vascular

disease?

A

Claudication, skin ulcers, gangrene, and impotence.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 561.

43
Q

What is the incidence of coronary artery disease in

patients presenting for vascular surgery?

A

The incidence of significant coronary artery disease (stenosis
>70%) in patients presenting for vascular surgery is 37% in
patients with no symptoms of CAD and 78% in patients with
symptoms of CAD.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1115.

44
Q

What are the two major contributing factors to the

development of peripheral vascular disease?

A

Diabetes mellitus and smoking
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 561.

45
Q

What types of surgeries may be implemented to treat

ischemia from peripheral vascular disease?

A

Transluminal angioplasty, endarterectomy, thrombectomy,
stenting, and arterial bypass surgery.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 561.

46
Q

What is the most common causative factor in the
mortality of patients undergoing surgery for vasoocclusive
disease?

A

Events related to atherosclerotic cardiovascular disease are
responsible for more than half of the perioperative deaths in
patients undergoing surgery for vaso-occlusive disease.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 561.

47
Q

What are the cardiovascular benefits of using
epidural anesthesia technique for patients
undergoing vascular surgery?

A

It decreases myocardial afterload, MVO2, is associated with
less variability in sympathetic tone, decreased endocardial
ischemia, results in less blood loss, and redistributes blood to
the lower extremities.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 562.

48
Q

What are the renal benefits of using epidural
anesthesia technique for patients undergoing
vascular surgery?

A

It results in less renovascular constriction and increases blood
flow to the renal cortex.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 562.

49
Q

What are the endocrine benefits of using epidural
anesthesia technique for patients undergoing
vascular surgery?

A

It inhibits the stress response to surgery and thereby inhibits
catecholamine and cortisol release. Epidural anesthesia also
inhibits hyperglycemia, lymphopenia, and granulocytosis, and
blocks sympathetic tone which aids in revascularization of the
lower extremities.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 562.

50
Q

What vessels comprise the arterial supply to the

spinal cord?

A

Two posterior spinal arteries provide 25% of spinal cord blood
flow. The anterior spinal artery, which arises from a series of
aortic radicular arteries comprises the other 75% of the arterial
flow.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1122.

51
Q

What are the pulmonary benefits of using an epidural
anesthesia technique for patients undergoing
vascular surgery?

A

It is associated with decreased V:Q mismatching, improves
oxygenation, decreased incidence of thromboembolism, and
decreased incidence of postoperative pulmonary complications.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 562.

52
Q

Why is hypotension such a significant factor in spinal

cord perfusion?

A

The flow to the spinal arteries depends on collateral supply.
Periods of hypotension will shunt a significant portion of the
spinal cord blood supply to the mesentery and can result in
spinal cord ischemia. This scenario can occur with the
placement of a single, high aortic cross-clamp.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1122.

53
Q

What is the incidence of spinal cord ischemia in

patients undergoing surgery involving aortic crossclamp?

A

The incidence is between 1% and 11%
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1122.

54
Q

What is the primary blood supply to the

thoracolumbar spinal cord?

A

The artery of Adamkiewicz is an aortic radicular artery that
supplies most of the blood flow to the anterior spinal artery.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1122.

55
Q

At what vertebral level does the artery of

Adamkiewicz connect with the anterior spinal artery?

A

In 75% of patients, it joins the anterior spinal artery between T8
and T12. In the other 10%, it connects between L1 and L2.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1122.

56
Q

What are the risk factors for abdominal aortic

aneurysm formation?

A

Advanced age, smoking more than 40 years, hypertension, low
HDL cholesterol, high plasma fibrinogen levels, and low platelet
count.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1128.

57
Q

Aortic aneurysms can be large enough to compress
other anatomic structures. What structures are
commonly compressed and what symptoms are
produced?

A

Patients with thoracic aortic aneurysm are often asymptomatic
initially. Early presenting symptoms are due to compression of
anatomic structures by the aneurysm. Compression of the
esophagus can result in dysphagia. Compression of the
trachea can cause stridor. Compression of the left recurrent
laryngeal nerve can cause hoarseness. Compression of the
lungs can cause dyspnea. Compression of the vena cava can
cause edema.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 155.

58
Q

How does the incidence of abdominal aortic
aneurysm formation differ between males and
females?

A

The incidence is four times greater in male patients.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1128.

59
Q

How does the incidence of abdominal aortic
aneurysm formation differ between males and
females?

A

The incidence is four times greater in male patients.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1128.

60
Q

What is the mortality rate for surgical repair for an

intact abdominal aortic aneurysm?

A

The rate ranges (depending on the study) between 1% and
11%, but most resources report a 5% mortality.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 5596.

61
Q

What is the mortality rate from a ruptured aortic

aneurysm?

A

85%
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1128.

62
Q

What is the factor that determines the risk of rupture

of an abdominal aortic aneurysm?

A

The absolute diameter of the aneurysmal sac is the primary
determinant of the risk of rupture. The risk for rupture over a 6
year period is 1% for an aneurysm less than 4 cm in diameter,
2% for aneurysms between 4.0 and 4.9 cm in diameter, and
20% for aneurysms greater than 5 cm.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1128.

63
Q

How does blood pressure change above and below

the clamp when the aorta is cross-clamped?

A

Hypertension exists above the level of the clamp and
hypotension occurs below the level of the clamp.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 564.

64
Q

How are the mean arterial pressure and systemic
vascular resistance affected by the release of an
aortic cross-clamp?

A

They both decrease
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 566.

65
Q

How does aortic cross-clamping affect mean arterial
pressure and systemic vascular resistance proximal
to the clamp?

A

Aortic cross-clamping increases the MAP and SVR by about
50%.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1134.

66
Q

What is the most sensitive indicator of cardiac
ischemia during thoracic surgery when the aorta is
cross-clamped?

A

Although TEE and 12-lead ECG have little advantage over
preoperative clinical data and two-lead ECG monitoring in noncardiac
surgery, the advantage of TEE during cardiac or
thoracic surgery is clear. In one study, TEE detected wallmotion
abnormalities in 11 out of 12 patients, while the
pulmonary artery occlusive pressure remained unchanged in 10
of them. Additionally, during the period of ischemia, no
significant changes occurred in the heart rate or systolic
pressure.
Yao FF. Anesthesiology: Problem-Oriented Patient
Management. 7th ed. Philadelphia: Lippincott, Williams, and
Wilkins; 2012: 129-130.

67
Q

What pharmacologic agent has been shown to
decrease the morbidity rate 10-fold in patients
undergoing surgery for aortic aneurysm repair and
what is the mechanism for its action?

A

Because these patients have a high incidence for coronary
artery disease, the ability of beta-blockers to improve the
balance between supply and demand in the myocardium has
been shown to reduce the perioperative morbidity of patients
undergoing aortic aneurysm repair ten-fold.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 561

68
Q

What commonly used techniques to preserve renal
function during aortic clamping have shown to be of
little benefit?

A

The administration of mannitol, dopamine, and fenoldapam
have all been shown to have little consequence on the
development of renal failure following aortic clamping.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1120.

69
Q

How does the incidence of acute renal failure
following abdominal aortic aneurysm repair compare
when the surgery involves infrarenal aortic clamping
versus suprarenal aortic clamping?

A

Infrarenal clamping is associated with a lower incidence of
postoperative acute renal failure than suprarenal clamping.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1120.

70
Q

What are the preventative measures that reduce the

risk of spinal cord ischemia during aortic crossclamping?

A

Short surgery, short aortic cross-clamp duration, preservation of
normal cardiac function, and high perfusion pressures.
Hypothermia and CSF drainage can also reduce the risk of
spinal cord ischemia.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1133.

71
Q

How can you offset the drop in mean arterial
pressure and SVR associated with the release of an
aortic cross-clamp?

A

In anticipation of the ensuing hypotension, it is prudent to
administer IV fluids to normalize the preload, discontinue any
vasodilators currently infusing, and administer sodium
bicarbonate to offset the acidosis (this is common practice, but
is controversial with some researchers speculating that it
increases the risk of hypotension by increasing acidity within
cardiac myocytes).
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 421.

72
Q

How is mannitol beneficial when administered before

and after the release of an aortic cross-clamp?

A

Mannitol increases urine output during aortic cross-clamp, but
this effect has not been shown to alter renal outcomes after
surgery involving aortic cross-clamping. It does, however serve
as a free radical scavenger which may be of benefit after the
release of the aortic cross-clamp.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1120.

73
Q

How is the cardiac output affected by the release of

an aortic cross-clamp?

A

It decreases slightly.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 566.

74
Q

How is the pulmonary artery pressure affected by the

release of an aortic clamp?

A

It increases
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 566.

75
Q

How does the presence of preoperative renal
insufficiency affect the outcome of patients
undergoing abdominal aneurysm repair?

A

The most important predictor of acute renal failure after thoracic
aortic surgery is preoperative renal function. The mortality rate
is significantly higher in patients with pre-existing renal
insufficiency compared to those who undergo AAA surgery with
normal renal function.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1120.

76
Q

What is typically responsible for most of the blood
loss that occurs during an abdominal aortic
aneurysm repair?

A

Most of the blood loss is due to back-bleeding from the lumbar
and inferior mesenteric arteries once the vessels have been
clamped and the aneurysm incised.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 567.

77
Q

What is the most common cause of perioperative
mortality following an abdominal aortic aneurysm
repair?

A

Myocardial infarction is responsible for 40-70% of the deaths
surrounding abdominal aortic aneurysm repair.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 674.

78
Q

Following thoracic aortic surgery, a patient exhibits
anterior spinal artery syndrome. What symptoms are
associated with this disorder?

A

Cross-clamping the thoracic aorta introduces a risk for anterior
spinal cord syndrome. The incidence is 0.2% for elective
infrarenal aortic surgery, 8% for elective thoracic aneurysm
repair, and up to 40% for emergency repair of aortic dissection
or rupture. The symptoms include flaccid paralysis of the lower
extremities and loss of control of the bowels and bladder.
Sensation and proprioception are not affected.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 157-158.

79
Q

What two techniques have been shown to be
effective at preventing acute renal failure following
aortic clamping?

A

Adequate hydration during clamping and after clamp release
has been shown to be an important factor in renal outcomes.
The direct instillation of crystalloid or blood chilled to 4 degrees
Celsius into the renal arteries to produce profound renal
hypothermia has also been shown to be protective during
periods of protracted ischemia.
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC,
Ortega R. Clinical Anesthesia. 7th ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2013: 1120-1121.

80
Q

How does cross-clamping the thoracic aorta affect

cerebrospinal fluid pressure?

A

The cross clamp results in redistribution of the blood volume
with vascular engorgement in the cranial vault. The increased
pressure forces cerebrospinal fluid into the spinal compartment
and increases CSF pressure. A spinal fluid drain is sometimes
used to help prevent inordinant increases in CSF pressure.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 158-159.

81
Q

How does one-lung ventilation affect intrapulmonary

shunting?

A

During two-lung ventilation, about 60% of the pulmonary blood
flow goes to the dependent lung. Therefore, when one-lung
ventilation is instituted, you would expect the patient to
experience approximately a 40% shunt as blood that is unable
to be oxygenated travels through the nondependent lung.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 674.

82
Q

What are the side-effects of intentional lung collapse

for surgery?

A

Intentional lung collapse on the operative side is commonly
used to enhanced visualization of the operative field. Side
effects are primarily due to the large intrapulmonary shunt that
develops because the upper lung is still being perfused but not
ventilated. The PA-a gradient widens and hypoxemia typically
ensues. One-lung ventilation does not appreciably change the
arterial CO2 tension. If a patient has a PAC placed in the
nondependent lung, and that lung is collapsed for surgical
access, the cardiac output and mixed venous oxygen tension
may both be falsely decreased.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 549.

83
Q

Arterial emboli are most likely to lodge at what

location?

A

Although emboli frequently lodge at the iliac, femoral, or
popliteal arteries, 50% of all embolic events involve the
common femoral artery.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 438.

84
Q

What are the elements of Virchow’s triad?

A

Virchow’s triad is a set of three factors that predict a high risk for
pulmonary embolism. Virchow’s triad includes
hypercoagulability, venous stasis, and vessel wall abnormalities.
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th ed. St. Louis,
MO: Elsevier Saunders Company; 2014: 629-630.

85
Q

What patients are at the highest risk for embolus

formation that requires surgical intervention?

A

Patients with a history of MI, mitral stenosis, or atrial fibrillation.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 438.

86
Q

What artery is typically occluded by upper extremity

emboli?

A

The brachial artery
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 438.

87
Q

Where should the arterial line be placed in a patient

undergoing surgery on the ascending aorta?

A

During surgery on the ascending aorta, it may become
necessary to clamp the innominate artery which would occlude
the right radial artery. Monitoring pressures in the left radial,
femoral, or dorsalis pedis arteries would be suitable alternatives.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 478.

88
Q

How can hypothermia be used to provide cerebral

protection against ischemia?

A

A decrease in the core temperature by 1 degree Celsius is
associated with a 8% decrease in CMRO2. Hypothermia
between 12 and 20 degrees Celsius has been shown to protect
against ischemia for 30 to 60 minutes. Mild hypothermia (33-35
degrees Celsius) has not been shown to provide significant
protection.
Miller RD, Pardo MC. Basics of Anesthesia. 6th ed.
Philadelphia: Elsevier Saunders; 2011: 408.

89
Q

You are about to anesthetize a patient with endstage
renal disease for the placement of an
arteriovenous dialysis graft. What anesthetic
medications should you avoid? What medications
are considered safe for administration to this patient?

A

Patients with end-stage renal disease have decreased renal
elimination of many drugs, including opioids. Because of the
prolonged excretion of the metabolite normeperidine,
meperidine should probably be avoided in these patients.
Volatile agents, propofol, fentanyl, hydromorphone, remifentanil,
nitrous oxide, and sufentanil are generally regarded as
acceptable for use in renal failure patients. Single dose
morphine is considered acceptable for use in patients with renal
failure, but repeated doses or a continuous infusion can result in
prolonged sedation.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s
Clinical Anesthesiology. 5th ed. New York, NY: McGraw-Hill;
2013: 664

90
Q

How should you prepare for a patient undergoing an

endovascular aortic stent placement?

A

Patient preparation for an aortic stent is similar to that of an
open abdominal aortic aneurysm. Two large bore IVs or a
central line and peripheral IV are mandatory. The patient should
be typed and screened, if not cross matched. It is also a good
idea to have vasoactive drugs hanging and ready to infuse. An
arterial line is required in order to assess blood pressure on a
beat by beat basis and to fine tune titration of vasopressors. It is
important to note that these patients may have significant
peripheral vascular disease and it may be extremely difficult to
cannulate the radial artery. The anesthetic technique is usually
general endotracheal, but the procedure can be performed
under an epidural block or even IV sedation. Muscle relaxation
is not necessary.
Vascular Web. Endovascular Stents. [Online] June 23, 2008
.

91
Q

What anesthetic plans would be acceptable for a

patient undergoing varicose vein stripping?

A

Anesthesia for varicose vein stripping may be performed under
epidural or spinal anesthesia (T10-T12 level usually preferable),
local anesthesia using field block (often improved by ilioinguinal
and iliohypogastric blocks) with or without sedation, or general
anesthesia using ETT or LMA.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 460

92
Q

What pulmonary complications can occur when the

thoracic aorta is cross-clamped?

A

Cross-clamping the thoracic aorta is associated with significant
decreases in blood flow in the distal anterior spinal artery and
renal artery. Pulmonary complications can arise from aortic
cross-clamp due to increased pulmonary vascular resistance
with resulting increased pulmonary capillary permeability and
pulmonary edema.
Hines RL, Marschall KE. Anesthesia & Co-Existing Diseases.
6th ed. Philadelphia, PA: Elsevier-Saunders; 2012: 158-159.

93
Q

What is a portosystemic shunt used to treat?

A

Portal hypertension develops when the splanchnic venous
return to the heart becomes impeded. This results in
congestion of the venous return and leads to esophageal
varices, which carries a 50% mortality rate with the first episode
of hemorrhage. A portocaval or portosystemic shunt is
performed to anastamose the portal vein to the inferior vena
cava to decompress the portal venous system.
Jaffe RA, Schmiesing CA, Golianu B. Anesthesiologist’s
Manual of Surgical Procedures. 5th ed. Philadelphia, PA:
Wolters Kluwer Health, 2014: 445.

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