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SRNA3CoExisting > Student Presentations (CEA) > Flashcards

Student Presentations (CEA) Flashcards

1
Q

GETA Advantages

A

GETA & muscle relaxation provide optimal surgical field
More control of VS
Greater patient comfort
Cerebral protection : Can regulate PO2, PCO2, and MAP

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2
Q

How does GETA provide cerebral Protection?

A

Cerebral protection by decreasing CMRO2 and redistributing BF to potential ischemia areas

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3
Q

With GETA Maintain hemodynamic stability →

A

cerebral perfusion and minimize cardiac depression

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4
Q

CEA REGIONAL Advantages:

A

Maintain BP stability
Facilitate continuous neurological assessment of the awake patient
Decreases length of stay in ICU

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5
Q

CEA REGIONAL DISADVANTAGES:

A 
Phrenic nerve paralysis 
Hemorrhage
Absence of cerebral protection 
Conversion to general may be difficult 
CN dysfunction
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6
Q

Hemodynamic management of Hypotension

Measures to control BP

A

Inhaled agents at 1 MAC Titrate vasoactive agents

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7
Q

Measure to control BP with Hypotension : Vasopressors

A

Infusion 40-80 mcg/min IV bolus 40-200 mcg Phenylephrine
Vasopressor IV bolus 5-10 mg Ephedrine
Antithrombotic Infusion 42 mL/hr Dextran

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8
Q

Why phenylephrine good with hemodynamics management of hypotension

A

Phenylephrine drip arterial>venous

Increases SVR, CVP, ICP (increases CBF)

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9
Q

Hemodynamic management of Hypotension

Measures to control BP Ephedrine : Mechanism of action, may cause?

A

Direct alpha/beta agonist and indirect by releasing NE postsynaptic nerve terminals. may cause bronchospasm. I

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10
Q

Hemodynamic management of Hypotension Ephedrine and PVR

A

ncreases PVR, bronchodilates,

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11
Q

Ephedrine max dose and when to avoid?

A

Max dose 50 mg. avoid tachy.

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12
Q

Dextran Mechanism of action

A

decreases platelet aggregation (and Factor 8 vW) which improves collateral circulation.This can also prevent a thrombus from forming at the suture line

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13
Q

Dextran should be started

A

slowly and patient observed for possible allergic reactions.

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14
Q

Dextran improves

A

Improves blood flow through microcirculation by decreasing blood viscosity Prolong bleeding time (max 20mL/kg/day)

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15
Q

Hemodynamics management of Hypertension

Esp. HTN • due to

A

carotid sinus stimulation or loss of baroreceptors

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16
Q

Hemodynamics management of Hypertension Short acting

A

IV bolus 100 mcg/mL Nitroglycerine

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17
Q

Hemodynamics management of Hypertension Long acting

A

IV bolus 5-10 mg Hydralazine

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18
Q

Hemodynamics management of Hypertension Selective β-blocker

A

Short acting IV bolus 0.5-1 mg/kg Esmolol

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19
Q

Hemodynamics management of Hypertension α1 Nonselective β-blocker

A

Long acting IV bolus 10-20 mg Labetalol

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20
Q

Why is esmolol a good choice?

A

Esmolol is a good choice short onset 2 mins and duration 10-30 mins T(1/2) 9 mins

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21
Q

Labetalol dosing

A

5-200 mcg/min Drip titrated to effect. IV push (100mcg/ml)

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22
Q

NTG cerebral dilations and

A

helps cerebral perfusion (primary venous dilator) being replaced by

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23
Q

Labetalol prevent

A

HTN post CEA 10-20 mg q10 mins

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24
Q

Hydralazine primary

A

arterial dilator.

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25
Q

Hydralazine onset, duration and max dose

A

Onset 10-20 mins/Duration 3-6 hrs. Can give every 15 mins MAX dose

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26
Q

Hemodynamic control during cross-clamping

Placed from

A

the proximal (common carotid artery) to the distal (internal carotid artery) Maintains cerebral blood flow during carotid artery cross-clamping

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27
Q

BEFORE clamp is applied you want to

A

decrease BP to help prevent spike in BP. This is when Heparin is given and can cause hypotension

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28
Q

Surgeon will ask for heparin

A

bolus BEFORE carotid clamping. Once you give the heparin, announce to surgeon 3-minute mark and this is when the carotid clamp is being placed. •

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29
Q

DURING clamping you want to keep

A

patients deep

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30
Q

Vessel clamped first

A

Internal carotid is cross-clamped first. •

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31
Q

Clamping and MAP

A

MAP 10-20% above baseline to enhance collateral circulation.

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32
Q

SBP and Clamping and why?

A

SBP < 160 as a guideline, surgeon may have preference This is to avoid cerebral hyperperfusion, excessive bleeding, and myocardial stress. •

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33
Q

Clamping, AFTER by the time the clamp is removed, where do you want preload?

A

preload at baseline or just above.

34
Q

After clamp is removed what do you do?

A

Give protamine 0.5 mg for every 100 units of heparin given. Give slowly because it can cause hypotension • Be sure to document clamp time.

35
Q

Heparin binds to

A

Antithrombin 3

36
Q

Order of clamping:

A

internal → common → external (ICE)

37
Q

When unclamping, the order is reversed

A

external → common →internal

38
Q

ASA/antihypertensives

A

continued

39
Q

Anytime you are using heparin and protamine,

A

have ACT available but may not use for this case

40
Q

allow for neurological assessments

A

Low-dose narcotics

41
Q

Intraop medication 2 meds and common practice is?

A

Fentanyl 1-2 mcg/kg or remifentanil infusion 0.05 mcg/kg/min

Balanced general anesthesia is common practice.

42
Q

IV anesthetics and VA

A

Combination of IV and inhalation agents with narcotics. • Iso up to 0.6% • Sevo 1% • Remifentanil can reduce MAC requirements

43
Q

If using Nitrous, can be used up to

A

50% but may increase the size of air emboli (can increase CBF and CMRO2). • Turn off during cross-clamping.

44
Q

Propofol may be administered for its

A

neuroprotective properties

45
Q

Propofol has neuroprotective properties because it will

A

decrease cerebral metabolic rate of O2 consumption, constrict normally reactive cerebral blood vessels and lead to a redistribution of CBF toward potentially ischemic areas.

46
Q

Etomidate and any of the non-depolarizing NMB and fentanyl have

A

minimal effects on CBF and cerebral metabolic oxygen consumption

47
Q

Remember…. CMRO2 and CBF

A

CMRO2 ↑ or ↓ so does CBF. (normal 3.0-3.8 mL O2/100 gm brain

48
Q

Aspirin or antiplatelet therapy is

A

usually started preoperative to decrease the risk of preop thrombotic complications.

49
Q

Aspirin can

A

be continued until the day of surgery

50
Q

Premedication

A

midazolam 1-3 mg is preferable to opiates

51
Q

Antibiotics

A

Cefazolin 1-2 g IV q 6 hours

52
Q

Coumadin should be

A

stopped 5-7 days before surgery and aspirin may continued

53
Q

Avoid large doses of

A

benzodiazepines to avoid longer sedation and hypercarbia w/ depressed respirations

54
Q

CEA patients:Be aware that these patients may

A

have been treated with platelet anti-aggregates Aspirin should be continued up to the day of surgery

55
Q

CEA and positioning

A

Supine with shoulder roll HOB slightly elevated with head is slightly extended and tilted away from operative side.

56
Q

CEA and arms positioninig

A

Bilateral arms are tucked at side.

57
Q

Secure ETT on

A

pposite of side of mouth from operative side

58
Q

Positioning concerns Cardiac Measure BP

A

in arm with higher reading

59
Q

Aortocaval compression : Resp disturbances

A

Respiratory ↓ FRC

60
Q

Neurological : Head and blood flow (position)

A

Hyperextension & lateral rotation of head may lead to cerebral ischemia Nerve injury

61
Q

If BP different,

A

BP cuff must be placed on extremity with higher reading. (measured intraop and postop)

62
Q

Aortocaval compression may occur in

A

obese patients. S/S hypotension Decreased FRC due to displacement of diaphragm.

63
Q

Smoking cessation

A

at least the night before to increase O2 carrying capacity by decreasing CO2 levels

64
Q

Laying arm supine to prevent.

A

Ulnar nerve injury.

65
Q

Risk of what nerve injury with head positioning

A

Cervical plexus injury due to head/neck position. •Avoid overstretching

66
Q

Cranial nerve injury:

A 
Recurrent/superior laryngeal nerve 
Hypoglossal nerve (tongue deviates to the side of injury)
67
Q

Lower lip weakness

A

Mandibular br. Of facial nerve

68
Q

Post op complications: Hyperperfusion syndrome

A

Hyperperfusion syndrome occurs from long-term loss of autoregulation.
The brain is not used to increased BF and cerebral vessels cannot constrict to compensate for increased BF. (hemorrhage and cerebral edema can occur.

69
Q

Post op complications: Hyperperfusion syndrome signs and symptoms

A

WATCH for confusion and seizures. Pts may c/o ipsilateral HA, blurred vision, and facial or eye pain.(Hyperemia)

70
Q

Post op complications: HTN: when does it occur

A

HTN occurs d/t loss of baroreceptors (may take a few days to achieve BP control).
Occurs in the immediate post-operative period, often with pts with pre-existing HTN.

71
Q

Post OP HTN peaks when

A

Peaks 2-3 hrs after surgery and may persist for 24 hrs.

72
Q

Post OP HTN and why it needs to be treated?

A

Needs to be treated to avoid cerebral edema, MI, and hematoma formation. Be sure BP cuff is on same arm as intraop

73
Q

Post op complications. Hypotension related to

A

Related to volume status of patient. Can be treated with fluids, some may need vasopressors.

74
Q

Post OP HOTN may be also related to ? What should you monitor

A

myocardial ischemia. MONITOR EKG FOR ISCHEMIC CHANGES

75
Q

HOtN monitor in what leads for ischemic changes?

A

CHANGES IN LEADS 2, V4, V5.

76
Q

Post OP Leading cause of death after CEA

A

MI

77
Q

Hematoma formation and bleeding is common d/t .

A

heparin and dextran. Patient may need to return to OR to cauterize bleeding.

78
Q

Must be assessed and treated promptly

A

Swelling; because it can compromise airway.

79
Q

If intubation required, use a

A

Smaller tube.

80
Q

Post OP Complications common complication and occurs due to

A

inadequate blood flow through the circle of Willis during carotid clamping or from embolized debris

81
Q

Patients are routinely

A

monitored in ICU to observe for any postop complications

SRNA3CoExisting (16 decks)

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