Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Advanced Principles of Anesthesia > Week 10 - Anesthesia for Vascular Disease > Flashcards

Week 10 - Anesthesia for Vascular Disease Flashcards

1
Q

What is Atherosclerosis? Where are the most common sites?

A

Chronic disorder of the arterial wall that involves development of atheromatous plaque that compromises the blood supply to any or all of the vital organs or the extremities and leads to the clinical manifestations of myocardial infarction (MI), stroke, and gangrene

  • most common cause of occlusive disease
  • most common sites are coronary arteries, carotid bifurcation, abdominal aorta, and iliac and femoral arteries
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the risk factors for atherosclerosis?

A
  • Cigarette smoking
  • High cholesterol
  • Elevated Triglycerides
  • Diabetes Mellitus
  • Obesity/Sedentary Lifestyle
  • Genetic Predisposition
  • Male gender > risk than Females
  • C reactive Protein – Link btw inflammation and atherosclerosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is peripheral vascular disease? What are the symptoms?

A

The result of atherosclerosis and atheromatous plaque formation

Symptoms: claudication, skin ulcerations, gangrene, impotence

Extent of overall disability is determined by the development of collateral blood flow – early on the collateral flow can meet the O2 needs but as disease progresses these needs cannot be met leading to limb ischemia

*mortality for PVD is 2-6x higher than general public

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are common co-existing diseases in patients with peripheral vascular disease?

A
  • CAD
  • Hx of MI
  • Hx of angina
  • HTN
  • CHF
  • Pulmonary Disease
  • Renal Insufficiency
  • Diabetes
  • Cerebrovascular Disease
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are patient renal function considerations for vascular surgery?

A

Preop creatinine clearance <60 mL/min = independent predictor of short and long term mortality after elective vascular surgery

Careful attention to volume status – fluctuation of intravascular volume and CO can significantly compromise renal perfusion during intraop and postop periods

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the advantages of perioperative beta blockade in vascular procedures?

A
  • Periop beta blocker and statin admin decrease risk of death in vascular surgery pts w/ renal impairment
  • Advantages include affects myocardial O2 supply and demand and judicious use is recommended for pts at high risk for MI
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are the advantages of perioperative statin therapy in vascular surgery?

A

Lipid lowering properties as well as anti-inflammatory, plaque stabilizing and antioxidant effects

  • should be initiated 30 days prior to surgical procedure
  • has emerged as promising therapy for prevention of cardiac complications in vascular surgery pts
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Is antiplatelet therapy recommended in vascular surgery?

A

Remains controversial topic

-POISE 2 trial showed periop ASA does NOT prevent MI, does NOT alter risk of periop cardiac event, but DID increase risk of major bleeding

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What ekg lead is best to assess cardiac ischemia?

A

V5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are common vascular procedures?

A
  • Transluminal Angioplasty
  • Endartarectomy
  • Thrombectomies
  • Endovascular Stenting
  • Arterial bypass: aortofemoral, axillofemoral, femofemoral, femoropopliteal
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the anesthetic management for vascular procedures?

A
  • Multiple PIVs (large bore, cordis, RIC)
  • A line is a must (use arm w/ higher pressure if variation)
  • GETA vs Regional/MAC (be mindful of volume status, hidden blood loss, monitor labs as needed, frequent blood draws)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are the cardiovascular benefits of epidural anesthesia in vascular surgery?

A
  • Decreases myocardial oxygen demand and afterload
  • Increases endocardial perfusion at ischemic zone
  • Increases hemodynamic stability
  • Decreases blood loss
  • Decreases general anesthetic medication requirements
  • Redistributes blood to lower extremities
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are the pulmonary benefits of epidural anesthesia in vascular surgery?

A
  • Decreased effect on FVC, FEV, and PEFR
  • Decreases ventilation perfusion mismatch
  • Improves atrioventricular oxygen differentiation
  • Decreases pulmonary postop complications
  • Decreases incidence of thromboembolism
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the postop considerations for vascular surgery?

A

Pain management – combination of IV narcotic and/or epidural pain management is needed (improves pt comfort, decrease cardiac instability due to more relaxed physiologic state)

Appropriate post op monitoring is important (PACU, ICU, etc)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What are the risk factors for abdominal aortic aneurysms?

A 
Obesity
Smoking (most highly correlated - 5x)
HTN
Diabetes
Gender
Age
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are absolute contraindications to elective AAA repair procedure?

A

Intractable angina
Recent MI
Severe pulmonary dysfunction
Chronic renal insufficiency

17
Q

What are the criteria for high risk AAA repair?

A 
Greater then 70 years old
Female
Various cardiac issues (including hx of MI)
Angina
CHF
DM
Stroke
COPD
Emphysema
18
Q

What are the anesthetic considerations of elective AAA repair?

A
  • Pt optimization prior to surgery (thorough H&P)
  • Appropriate vascular access (multiple large IVs, +/- central line, A line, blood in room)
  • Standard 12 lead monitors
  • TEE (detect changes on ventricular wall motion/fluid status)
19
Q

Why is use of intraop TEE beneficial for vascular surgery?

A
  • Vital for monitoring and maintaining cardiac function for successful surgical outcome
  • TEE able to show wall abnormalities much sooner than EKG
  • When TEE used pts w/ ventricular diastolic dysfunction have a decreased incidence of developing CHF and Afib
  • Most common abnormalities detected by TEE = hypovolemia, low EF, RV failure, segmental wall motion abnormalities and PE
20
Q

What are the hemodynamic alterations with cross clamping the aorta?

A

Hypertension above clamp
Hypotension below clamp

-complex metabolic and humoral responses involving sympathetic and renin-angiotensin systems (increased afterload, MAP, and SVR)

21
Q

What are the metabolic changes with cross clamping the aorta?

A
  • Decreased total body oxygen consumption
  • Decreased total body CO2 production
  • Increased mixed venous oxygen saturation
  • Decreased total body oxygen extraction
  • Increased catecholamine release
  • Respiratory alkalosis
  • Metabolic acidosis
22
Q

What occurs once the aorta is clamped?

A

Clamp Aorta –> decrease arterial flow and increase CVP/SFP –> decrease cord perfusion –> O2 supply < Demand –> Ischemia –> ATP deficit, cells lose resting membrane potentials –> free radicals, excitatory neurotransmitters, nitric oxide –> Neurotoxins –> decreased blood flow, decreased O2 delivery, cell injury

23
Q

What occurs with aortic cross clamp release?

A
  • Metabolic liberation as a result of anaerobic metabolism (lactate = vasodilation and vasomotor paralysis)
  • SVR decreases and blood sequestered into previously dilated veins = decreased venous return = reactive hyperemia

Decreased Preload/Afterload
*declamping shock syndrome

24
Q

What are the hemodynamic changes do unclamping the aorta?

A
  • Decreased arterial blood pressure
  • Decreased myocardial contractility
  • Decreased SVR
  • Decreased CVP
  • Decreased preload
  • Decreased CO
  • Increased pulmonary artery pressure
25
Q

What are the metabolic changes to unclamping the aorta?

A
  • Increased lactate
  • Increased total body oxygen consumption
  • Decreased mixed venous oxygen saturation
  • Increased prostaglandins
  • Increased activated complement
  • Increased myocardial depressant factors
  • Decreased temperature
  • Metabolic acidosis
26
Q

What are intraop considerations for general anesthesia for AAA repair?

A
  • Depressed cardiac stability and hemodynamic instability r/t inhalational agents — should be avoided or reduced in pts w/ severe dysfunction and low EF
  • Opioids provide cardiac stability and should be used in this pt population
27
Q

What are the intraop considerations for regional anesthesia during AAA repair?

A
  • Commonly used as primary or in conjunction w/ GA
  • Benefits: decrease preload and afterload, preserved myocardial oxygenation, reduced stress response and excellent muscle relaxation
  • Disadvantages: anticoagulation and possibility of epidural hematoma, pt laying still for hours
28
Q

What are the intraop anesthetic considerations for AAA repair?

A
  • Careful consideration of intravascular volume and assessment of hemodynamics is key
  • Adequate vascular access is a must
  • Hydration (crystalloid as maintenance - approx 10 mL/kg/hr)
  • Colloid very effective
  • Blood available (type and cross match)
29
Q

How do you ensure renal protection and preservation during AAA repair?

A
  • Adequate hydration prior to clamping and cross clamping
  • Avoid severe and prolonged hypotension
  • Short clamp time (surgeon – <30 min)
  • Renal protective agents: mannitol, dopamine, lasix, N-acetylcysteine
30
Q

What are postop anesthetic considerations for AAA repair?

A
  • Should be aimed at optimizing organ systems
  • Most common complications include cardiac, pulmonary and renal systems
  • Plan for ICU postop for close monitoring for at least 24 hours
  • Maintain adequate BP, intravascular fluid volume, and myocardial oxygenation
31
Q

What are the common symptoms of a ruptured AAA?

A

Abdominal discomfort/back pain

Hypotension

Pulsatile mass

32
Q

What are the anesthetic considerations for ruptured AAA?

A
  • Class A Emergency
  • Stabilization of BP and hemodynamics and venous access are early priorities
  • Gentle induction (etomidate – cardiac function preservation)
  • Maintain cardiac stability until blood loss from aorta is controlled by surgical intervention
33
Q

What are intraop anesthetic considerations for thoracic aortic aneurysms?

A
  • Advanced hemodynamic monitoring
  • TEE for cardiac monitoring in pts w/ dysfunction
  • Lumbar drain to access CSF
  • Monitoring of SSEPs and MEPs to assess for spinal cord ischemia
  • Monitor for renal dysfunction and ensure adequate hydration
34
Q

What are the advantages of endovascular aortic aneurysm repairs?

A
  • No aortic cross clamp
  • Improved hemodynamic stability
  • Decreased incidence of embolic events
  • Decreased blood loss
  • Reduced stress response
  • Decreased risk of renal dysfunction
  • Decreased pain and discomfort
35
Q

What are intraop anesthetic considerations for endovascular aortic aneurysm repairs?

A

Regional vs GETA

  • Advanced hemodynamic monitoring: A line, multiple large bore PIVs, central line
  • Cell saver
  • Rapid transfuse and blood available
  • Hidden blood loss
  • Heparin and protamine
  • Vasoactive drips available and ready

*Be prepared to convert to open

Advanced Principles of Anesthesia (31 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions