Vascular Surgery Flashcards
(189 cards)
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)
2
Q
PVD Pathology:
A
- Stenosis
- Thrombosis
- Embolism
3
Q
PVD Results in:
A
- Decrease blood flow
- Acute organ ischemia
- CVA, PE, MI
- Aneurysm
4
Q
PVD leads to weakning of:
A
- Arterial Wall
- Cause aneurysm
5
Q
Factors related to Atherosclerotic lesions:
A
- Advance age
- Smoking
- Hypertension
- Diabetes Mellitus
- Insulin resistance
- Obesity
- Family Hx and Genetic predisposition
- Physical inactivity
- Sex male > female
- Homocysteine
- Eleveated C-reactive protein
- Elevated lipoprotein
- Hypertriglyceridemia
- Hyperlipidemia
6
Q
PVD Common signs and symptoms:
A
- Claudication
- Ulcerations
- Gangrene
- Impotence
7
Q
PVD Surgical therapy treatment options:
A
- Transluminal angioplasty
- Endarterectomy
- Thrombectomy
- Endovascular stening and arterial bypass
8
Q
PVD Common maneuvers used to Bypass:
A
- Aorto-Femoral
- Axillo-Femoral
- Femoro-Femoral
- Femoro-Popliteal
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
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
11
Q
Statins ( Cardioprotective effect):
A
- Decrease vascular inflammation
- Decrease incidence of thrombogenesis
- Enhance nitric oxide bioavailability
- Stabilize atheroscerotic plaques
- Decrease lipid concentration
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
13
Q
Befenefit of Arterial line in PVD:
A
- Allows near-real time BP values
- Guides treatment decisions
14
Q
PVD Anesthesia Selection:
A
- Goal: maintain hemodynamic control
- Avoid intraoperative HTN
- Avoid Hypotension
15
Q
PVD General Anesthesia:
A
- Consider IV and Inhaled anesthetics
- Decrease rate of oxygen demand
- Protects neurologic and cardiac tissue
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
17
Q
PVD Postoperative Conditions:
A
- Pain: enhaces SNS stimulation
- Narcotics: cardiac stability
- Acute pain increases inflammatory mediators
18
Q
Inflammatory mediators due to Acute Pain:
A
- Creatinine kinase
- C-Reactive protein
- Interlukin (IL)-6
- Tumor necrosis factor (TNF)
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
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%
21
Q
Elective AAA surgery mortality is:
A
< 5%
22
Q
5 and 10-year mortality if untreated AAA?
A
- 5 year mortality 81%
- 10 year mortality 100%
23
Q
Mortality of undetected AAA?
A
35-94%
24
Q
AAA current mortality
A
1-11%
25
Surgery is recommended if AAA measures:
AAA > 5.5 cm or greater in diameter
26
AAA Risk factors:
- **Atherosclerosis (most common)**
- Smoking
- Male gender white > black
- Hypertension
- Advaced age
27
AAA Diagnosis:
- Physical examination
- Pulsatile abdominal mass
- **Discover by accident by PCP**
- **< 30% AAA identified during routine physical examination**
28
AAA Additional risk factors:
- Presence of carotid artery or PVD
- Obesity
- Diabetes
- All these increase rate of AAA detection to 90%
29
Abdominal Aortic Reconstruction
Contraindications:
* Intractable angina pectoris
* Recent MI
* Severe pulmonary obstruction
* Chronic renal insufficieny
* Physiological age > chronological age
30
Law of Palace Formula
**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
31
Rupture risk for AAA <4 cm?
0%/yr
32
Rupture risk for AAA 4-5 cm?
0.5% - 5%/yr
| %/Year
33
Rupture risk for AAA 5-6 cm?
3-15%/yr
34
Rupture risk for AAA 6-7 cm?
10-20%/yr
35
Rupture risk for AAA 7-8 cm?
20-40%/yr
36
Rupture risk for AAA > 8 cm?
30-50%/yr
37
Aneurysm Rupture CV major goals:
* 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
38
Aneurysm Rupture Monitoring:
- Routine
- ECG Lead II ( dysrhythmias)
- ECG Lead V ( ST- segments changes)
- Pulse Oxymeter
- Capnography
- Esophageal stethoscope
- Indwelling urine catheter
- Peripheral neurostimulator
- Invasive monitoring
39
Primary method for Intraop Cardiac assessment:
* TEE
* For patients undergoing Heart and Aortic surgery
40
Aortic Cross-Clamping:
* Most dramatic physiological change occur in this period
41
Hemodynamic Effect of above cross-clamp
Hypertension
42
Hemodynamic Effect of below cross-clamp
Hypotension
43
Hormones elevated during Aortic Cross-Clamping:
* Catecholamines
* Aldosternone
* Cortisol level
* Stress hormone levels
44
Hemodynamic effects of Aortic Cross-Clamping:
* Increase afterload
* Increase MAP and SVR
* Increase CO/ unchanged
* Increase PAOP/ unchanged
45
Causes of Metabolic Alterations:
* Lack of blood flow to distal structures
* Tissue ischemia
* Anaerobic metabolism
46
Lack of flow flow to distal structure leads to:
* Hypoxic enverironment
* Ischemic environment
47
Anaerobic metabolism effect:
Accumulation of serum lactate
48
Mesenteric traction syndrome:
- D/t Surgical maneuver to expose the aorta
- Decrease BP & SVR
- Tachycardia
- Increase CO
- Facial flushing
49
Effects on Regional Circulation:
Acute Kidney Injury
50
AKI associated with:
* Mortality rate
* Long-term CV events after surgery
51
Clamp above renal arteries leads to:
* Severe AKI
* In open surgical repair patients
52
Suprarenal cross-clamp > 30 mins leads to:
Postop Renal failure
53
How to protect the Kidneys?
- Renal-dose Dopamine
- Mannitol
- Sodium Bicarbonate
- Loop diuretics
| Not fully proven to improve postop renal function
54
What interventions really reduces the incidence of AKI?
1. Balanced crystalloids
2. Hyperchloremic solutions
3. Avoid Nephrotoxic drugs
4. Avoid NSAIDs
5. Avoid Aminoglycoside Abx Preop
55
When does Spinal cord schemia occurs?
During aortic occlusion
56
Spinal cord ischemia causes:
Paraplegia (1-13%)
| Spinal cord damage
57
Spinal cord Longitudinal blood is supply by:
* One anterior spinal artery 80%
* Two posterior & two post-lateral spinal arterial 20%
58
Spinal cord Transversed blood is supply by:
* Greater radicular artery (Adamkiewicz)
* Originates between T8-T12
59
How is spinal cord function monitor?
* SSEP
* MEP
60
Spinal cord protection strategies:
- Distal aortic perfusion
- CSF drainage
- Mild hypothermia
- Maintenance of normotension SBP > 120 mmHg
- Day 2 Postop decreases incidence of paraplegia
61
Ischemic Colon Injury is most attributed to:
Manipulation of the anterior messenteric artery
62
What part of the colon does the Messentaric artery supplies blood to?
Left colon
63
Which artery is commonly sacrified during colon surgery?
Messentaric artery
64
Mucosal ischemia occurs in ___________ on patient going to AAA repair
10%
65
Restoration of circulating blood is paramount before:
The release of aortic clamp
66
What components characterized Ischemic Perfusion Injury?
1. Metabolic
2. Thrombotic
3. Inflammatory
67
Most important interventions to protect from AKI:
* Aggressive Hemodynamic stabilization
* Minimization of Aortic clamp times
68
IntraOp solution used for Renal perfusion:
* **Cold solution**
* Renal protective
* Decrease incidence of AKI
69
Atrial Natriuretic Peptide (ANP) cause:
* Vasodilation of Preglomerular artery
* Inhibition of angiotensin axis
* Prostaglandin release
| Promotes Renal vascular dilation
70
What promotes Renal vascular dilation?
ANP
71
Declamping shock syndrome:
Hemodynamic instability
72
Ischemic Perfusion Injury consequences:
* Tissue edema
* ARDs
* Compartment syndrome
* Bacterial translocation
* Renal failure
* Multisystem organ failure
* Non-reflow phenomenon
73
When does Non-flow phenomenon occurs?
When Microvasculature is occluded
74
Microvasulature is occluded by:
* Platelets
* Neutrophils
* Thrombi
75
Effects of Non-reflow phenomenon:
* Inadequate perfusion
* Increase cellular necrosis
76
Advantages of Retroperitoneal Approach:
* 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
Disadvantages of Retroperitoneal approach:
* Inaccessibility to distal right renal artery
78
Transperitoneal Approach Advantages:
* Familiarity
* Access to infrarenal aorta and Iliac vessels
* Visualization of intraabdominal viscera
* Rapid opening and closure
* Versatility
79
Transperitoneal Approach Disadvantages:
* Increases fluid losses
* Less postop ileus
* More postop respiratory complications
* Increased postop incisional pain
80
Total blood loss in Aneurysm Repair is affected by:
- The surgical approach
- Duration of surgery
- Experience of surgeon
81
Most blood loss during aneurysm repair is due to:
- Back bleeding from lumbar Inferior messenteric arteries
- After vessels are clamped and aneurysm is opened
82
3 options available for autologous transfusion:
- Preoperative deposit
- Intraoperative phlebotomy and Hemodilution
- Intraoperative blood salvage
| Autologous via cell sever system is a standard procedure.
83
Intraoperative Aneurysm Repair Management
Anesthetic selection objective:
- Provide optimum analgesia and amnesia
- Facilitate relaxation
- Keep hemodynamic stability
- **Preserve renal blood flow**
84
Aneurysm Repair General Anesthesia:
- All inhalation agents depress the myocardium
- Myocardium depression is dose-dependent
- Administer gases at lower concentrations
85
Aneurysm Repair General Anesthesia Benefits:
- 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
Aneurysm Repair **Epidural Benefits:**
- 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
Aneurysm Repair **Epidural Disadvantages:**
* Anticoagulation
* Epidural hematoma
* Severe hypotension
88
Aneurysm Repair Fluid Management :
- 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
Juxtarenal aneurysm located at the level of:
* Renal arteries
* Spare the renal orifice
90
Suprarenal Aortic Aneurysm includes
* At least one renal artery
* May involve visceral vessels
91
Classification of Abdominal Aortic Aneurysm:
92
Potential complications of Juxtarenal or Suprarenal Aortic Occlusion:
* Renal Failure
* Hemorrhage
* Distal arterial occlusion
* Infarction
* Pulmonary or Cardiac dysfunction
* Impotence
* Paraplegia
* Thrombosis
* Pseudoaneurysm formation
* Aortoenteric fistula
93
Ruptured AAA Mortality:
- 80-90% mortality
- Postop mortality 40-50%
94
Most common symptoms of ruptured AAA:
* Severe abdominal discomfort or back pain
* ALOC d/t hypotension
* Pulsatile abdominal mass
95
Vasopressor for Ruptured AAA:
* Phynelephrine
* Epinephrine
96
Type of Fluids for Ruptured AAA:
* Crystalloids
* Colloids
* Blood products
* Blood salvage provision available STAT
97
Reason for Coagulopathies after massive IVF and blood adminstration?
Dilutional Thrombocytopenia
98
What decreases the total transfusion requirements in a ruptured AAA?
Fresh Frozen Plasma
99
Labs for Rupture AAA:
* H & H
* Calcium
100
Citrate in blood causes:
* Hypocalcemia
* Positive inotrope
* Increase bleeding
101
Hypocalcemia treatment:
Calcium chloride
102
Hypocalcemia Tx is guided by:
Calcium Ionized levels
103
How does Calcium behave during Alkalosis?
* There is a decrease in ionized calcium levels (↓ Ionized [Ca²⁺]).
* Allowing more calcium ions to bind to albumin.
104
Thoracic Aortic Aneurysm Mortality Rate:
* Elective repair 22%
* If Rupture 54%
105
Thoracic Aortic Aneurysm Dissection:
* Spontaneous tear witin the intima
* Allows blood flow through a false passage
106
Thoracic Aortic Aneurysm Types:
1. True Aneurysm
2. False Aneurysm
107
True Thoracic Aortic Aneurysm:
Involces 3 layers
108
False Thoracic Aortic Aneurysm:
Involves the Adventia only
109
Thoracic Aortic Aneurysm are classified by:
1. Shape
2. Fusiform
3. Saccular
110
**DeBakey** Acute Aortic Dissection Classification:
* Type I
* Type II
* Type III
111
DeBakey Type I
* Originates in the ascending aorta
* Extends at least to aortic arch and beyond
112
DeBakey Type II
* Originates in the ascending aorta
* Confined to this segment
113
DeBakey Type III
* Originates in the descending aorta
* usually distal to left subclavian artery
* Extend distally
114
Stanford Acute Aortic dissection Classifications:
1. Stanford Type A
2. Stanford Type B
115
Stanford Type A?
* Dissection involve the ascending aorta
* With or without extention into descending aorta
116
Stanford Type B?
* Dissection that do not involve the ascending aorta
117
Crawford Classification of Thoracoabdominal Aortic Aneurysm
118
Etiology of Thoracic Aortic Aneurysm?
* Artherosclerosis (most common)
* Marfan syndrome
119
Atheroscleroic Lesions occurs most common in the:
* Descending Aorta
* Distal Thoracic aorta
120
Most common classification of Thoracic aortic aneurysm?
Fusiform
121
Horseness 2/2 Thoracic AA due to:
Intrusion on LRL Nerve
| Impingement (intrusion)
122
Complete CPB systemic Heparinization dose:
400 units/kg
123
Arterial line and Pulse oxymeter location during CPB for Thoracic AA?
Right side d/t intrusion on left subclavian artery
124
Patient positioning during CPB for Thoracic AA
* Right lateral decubitus
* Left-sided thoracotomy
125
Aortic Dissection
* Spontaneous tear of the vessel wall intima
* Allows passage of blood along a false lumen
126
Aortic dissection most common factor:
Hypertension
| Contributes to progression of lesion
127
Aortic Dissection Most serious complication:
Aneurysm Rupture
128
Types of Aortic Dissections?
* Type A
* Type B
129
Which **Aortic Dissection Type** can be **medically managed**?
Type B
130
Which **Aortic Dissection Type** **needs surgery** ?
Type A
131
Anesthesia for Ascending and Transverse Aorta requires:
CPB
132
When is surgery recommended for Descending Thoracic and Thoraco-abdominal aneurysm?
Size > 6 cm
133
Descending Thoracic and Thoraco-Abdominal Aneurysm:
- Most patients are asymptomatic
- Surgical decision based on the size, extent, and rate of expansion of the aneurysm
134
Thoracoabdominal Aortic Aneurysm Etiology:
1. Degenerative
2. Mechanical (Hemodynamics)
3. Connective Tissue
4. Inflammatory (Non-infectious)
5. Infectious
6. Anastomosis
135
Most common devastating consequence of thoracic surgery?
Paraplegia
136
Descending Thoracic and Thoraco-Abdominal Aneurysm Preop Assessment Include:
* Cardiac Function
* Renal Function
* Neurological Function
137
Descending Thoracic and Thoracoabdominal Aneurysm **Hoarseness**
* Compression of RLN
* LRL nerve most succeptible d/t proximity to aortic arch
* Bilateral RLN compresion leads to respiratory compromise
138
Spinal Cord Ischemia
Depends on:
- 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
Delayed Paraplegia Risk Factors:
- Type 2 aneurysm
- Emergency procedures
- Number of sacrificed segmental segments
- Renal failure
140
Most Postoperative Risk Factor for Delayed Paraplegia:
- Hemodynamic instability by A-Fib
- Bleeding
- Multiorgan failure
- Sepsis
141
Interventions to protect spinal cord during Thoracic Aortic Cross-Clamping:
- 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
Thoracoabdominal AA Neurologic Deficit Factors:
- Level of aortic clamp application
- Ischemic time
- Embolization or Thrombosis (intercostal arteries)
- Failure to revasculate intercostal arteries
- Urgency of surgical intervention
143
Late Complication of Thoracoabdominal AA Repair:
1. Delayed paraplegia
2. Graft thrombosis
3. Fistula formation
4. False aneurysm
5. Graft infection
144
Early Complications of Thoracoabdominal AA Repair:
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
RLN dysfunction leads to:
Breathing difficulties post extubation
146
EVAR associated with:
30 day outcome Vs OSR
147
AA Repair -Reinterventions are more frequent with:
EVAR than OSR
148
Endoleak?
* Inability of endovascular stent graph to isolate blood flow
149
Endoleak is diagnosed by:
PostOp CT 15-52% of Pts
150
Majority of Endoleaks are:
Type II
151
What % of Endoleaks close spontaneously?
70% the first month after intervention
152
Intervention to correct Endoleak complications
* Implantation of 2nd Graft
* Open repair
153
Major **EVAR Advantages:**
* 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
EVAR Anesthetic Techniques:
* General anesthesia
* Neuraxial blockade
* Local anesthetic + Sedation
155
EVAR PostOp exam and Contrast CT recommendations:
* 1, 6, 12, & 18 months
* Then Anually
* Abdominal x-ray regularly
156
Second most common vascular operation in the US?
Carotid Endarterectomy (CEA)
157
Most CVAs Etiology are:
More Ischemic > Hemorrhagics
158
50% of all strokes are preceed by:
TIA
159
CEA benefits patients with:
> 70% stenosis
160
When is CEA less beneficial?
In symptomatic patients with 50-69% stenosis
161
Carotid stenosis is the primary cause of:
~ 20% of all strokes
162
CEA preop MI rate?
2-5%
163
CEA Preop Mortality?
0.5-2.5%
164
CEA surgical interventions most beneficial in:
* Men > 75 yrs
* Within 2 wks of last ischemic event
165
Factors contributing to Morbidity during CEA:
* 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
CEA common symptoms:
- Lightheadedness
- ALOC
- Aphasia
- Acute motor deficit
- **Carotid bruit**
- **Amaurosis fugax**
167
Amaurosis fugax ?
transient lost of vision in one or both eyes
168
Carotid Stenosis Standard Diagnosis Techniques:
- Duplex ultrasound
- Digital substraction angiography
- CT angiography
- Magnetic resonance angiography
169
CEA Preoperative Assessment:
- 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
High Cardiac Risk Surgeries > 5%:
1. Aortic Surgery
2. Major Vascular Surgery
3. Peripheral Vascular Surgery
171
Intermediate Cardiac Risk Surgeries 1-5%:
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
Low Cardiac Risk Procedures < 1%:
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
CEA Intraoperative Considerations
- Normal cerebral flow 50 mL/100 G/min
- Cellular death occur at < 6 mL/100G/min
- Cerebral autoregulation: MAP 60-160 mmHg
174
- All anesthetic agents decrease cerebral metabolic rate, except:
KETAMINE
175
Cerebral monitoring during CEA:
* **EEG (gold standard)**
* Carotid Stump Pressure
176
EEG limitations?
Detects superficial layers of the brain changes
177
EEG Role in CEA?
Most sensitive and Specific measure CBF responsiveness in an awake patient
178
What's the criteria for shunt placement?
Stump pressure < 40-50 mmHg
179
Carotid Stump Pressure function:
Gross measure of the pressure in the circle of willis
180
Inadequate cerebral perfusion symtoms:
- Dizziness
- Contralateral weakness
- Loss of conciousness
181
Cerebral Protection during CEA:
- 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
Blood Pressure Control during CEA
- Maintain MAP at 20% or greater than Preop MAP value
- Pt to continue taking anti HTN meds until day of surgery
183
Anesthetic Management
Goals specific to CEA:
- Optimize perfusion to the brain
- Minimize myocardial workload
- Ensure cardiovascular stability
- Allow rapid emergence
184
Protamine and CEA:
- Decision based on surgeon impresion
- **Associated with hypotension**
- Anaphylasis is rare (threathening side effect)
185
Regional Anesthesia CEA
- **Requires deep and superficial plexus block CN II, III, & IV**
- Fewer hemodynamic fluctuations
- Fewer intraop vasoactive medication requirement
186
CEA Postoperative considerations
- Hypertesion (most common problem)
- Postop BP 140/80 mmHg recommended
- Hemorrhage ( warrants sx intervention)
187
Cerebral Hypoperfusion Syndrome Symptoms:
* Headache
* Visual disturbances
* ALOC
* Seizures
188
Intial manifestion of Hemorrhage post CEA
Airway obstruction
189
RLN damage 2/2 tracheal deviation will manifest with:
Inspiratory stridor
