Term
| What accounts for 80% of CVA's? |
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Definition
| Ischemic Cerebral vascular disease |
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Term
| What is the most common site of atheroscelrosis in the brain? |
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Definition
| Proximal Internal Carotid Artery |
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Term
| What is the treatment goal for the patient undergoing a CEA? |
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Definition
| To reduce the risk of recurrent stroke |
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Term
| What artery branches off of the Brachiocephalic artery? |
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Definition
| Right common carotid artery |
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Term
| Where does the Left common carotid artery branch from? |
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Definition
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Term
| What do the common carotids bifurcate into? |
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Definition
| The internal and external carotid arteries |
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Term
| What does the internal carotid artery branch into and supply? |
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Definition
*Branches into the middle and anterior cerebral arteries
*Supplies the ocular globe via the opthalmic artery, and the cerebral hemispheres. |
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Term
| What does the external carotid artery supply? |
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Definition
| The neck, face, scalp, oral, nasal cavities and meningies. |
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Term
| What three nerves run in close proximity to the neck vessels? |
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Definition
Hypoglossal nerve(IX)
Recurrent Laryngeal Nerve (branch of vagus)
Vagus nerve (X) |
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Term
| What does the carotid sinus contain? |
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Definition
| Contains baroreceptors or stretch receptors and carotid bodies. |
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Term
| Where are the carotid sinuses located? |
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Definition
| Above the carotid bifurcation |
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Term
| What happens when the carotid sinus is manipulated? |
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Definition
| Afferent impulses are sent to the vasomotor center via the glossopharyngeal nerve. |
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Term
| What is the efferent response to carotid sinus stimulation? |
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Definition
| Vagal in nature causing bradycardia and possibly hypotension |
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Term
| What two manifestations are responsible for carotid stenosis? |
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Definition
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Term
| What is the term that describes monocular blindness? |
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Definition
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Term
| What is the definition for a Transient Ischemic Attack (TIA)? |
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Definition
| A neurologic event that resolves in less than 24 hours. Major strokes are preceded by TIA's |
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Term
| What is the definition of a stroke? |
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Definition
| A neurologic deficit lasting >24 hours. |
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Term
| What s/s would be present with a large embolus passing into the Middle Cerebral Artery? |
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Definition
| *Contralateral deficits that affect the face and upper extremity. |
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Term
| What are the s/s of a large emboli traveling into the Anterior Cerebral Artery? |
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Definition
| *Effects the contralateral legs producing loss of motor and sensory function. |
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Term
| How is asymptomatic carotid stenosis usually detected? |
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Definition
| As an incidental finding. A bruit can be auscultated in the neck. |
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Term
| What are indications for getting a CEA? |
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Definition
*Lesions greater than 70% with TIAs
*Severe ipsilateral carotid stenosis with mild stroke
*30-70% occlusion with ipsilateral symptoms
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Term
How long should a CEA be delayed after a CVA?
Why? |
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Definition
*4-6 weeks
*Because of a 20 fold increase in the risk of intraoperative cerebral ischemia |
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Term
| Is surgery performed on lesions that are 100%? |
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Definition
| *No, if collateral flow wasn't present around the 100% occlusion the patient would be dead. |
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Term
| What nerves are at risk of injury when the carotid sheath is opened to expose the carotid artery (4)? |
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Definition
*The Phrenic Nerve
*The Vagus Nerve
*Hypogolssal Nerve
*Recurrent Laryngeal Nerve |
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Term
How many units of heparin are typically needed to maintain an ACT>300?
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|
Definition
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Term
| When will heparinization be needed? |
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Definition
| Following complete exposure of the common, internal and external carotid |
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Term
| How are all three arteries (common, internal and external carotid) clamped and why? |
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Definition
| *Sequentially to minimize distal embolization |
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Term
| What is the onset of heparin? |
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Definition
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Term
| What is the half life of heparin? |
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Definition
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Term
| How is the carotid dissected during the CEA procedure? |
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Definition
| *From the common carotid to the ICA distal to the area of plaque. |
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Term
| How is the plaque freed from the artery? |
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Definition
| *It is endarectomized and feed from the artery |
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Term
| How is the arteriotomy closed or repaired? |
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Definition
| *With a prosthetic patch and flow is restored. |
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Term
| What is a medication and a diagnostic procedure that may or may not be performed at the end of a CEA? |
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Definition
*Use of protamine sulfate
*Angiogram |
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Term
| Why is a shunt sometimes utilized during a CEA? |
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Definition
| *To minimize cerebral ischemia by reestablishing flow to the ipsilateral cerebral hemisphere during cross clamping. |
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Term
| What pressure is measured and what parameters determine use of a shunt? |
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Definition
*Stump pressures
*<60mmHg indicates the need for a shunt |
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Term
What does a stump pressure <60 indicate?
What is the false positive rate of a stump pressure? |
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Definition
*Inadequate retrograde flow from the Circle of Willis.
*30% |
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Term
| List complications of a shunt |
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Definition
*Surgical field obstruction
*Air entrainment, embolism
*Create an intimal flap that can promote thrombus formation
*Plaque dislodgement during placement
*Blood loss from dislodgement |
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Term
| What along with a through H&P should be considered Preop? |
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Definition
*Lab studies
*Cardiac clearance with complete history of past or present illness (MI, CHF, Angina, Valvular disorder, previous surgeries or interventions)
*Cerebral blood flow studies
*Vital signs with BP in both arms
*Respiratory function
*Blood Type & Screen
*Renal Function |
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Term
| What is the greatest cause of surgical mortality in a CEA? |
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Definition
| *1-4% related to Myocardial Infarction |
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Term
| What is the greatest cause of surgical Morbidity in a CEA? |
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Definition
| *Intraoperative neurological event (Stroke) |
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Term
| What are some other common co-existing diseases in the patient undergoing a CEA? |
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Definition
*HTN
*Generalized Arteriosclerosis
*CAD
*DM
*Past Hx of CEA
*Smoking |
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Term
| What should be evaluated preop if this is the second CEA procedure? Why? |
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Definition
| *Vocal cord function may be evaluated to r/o Superior Laryngeal Nerve injury or paralysis |
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Term
| What need to be thoroughly documented Preop in the patient undergoing a CEA. |
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Definition
| *Neurological Exam with residual effects of past CVAs |
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Term
| Where should the arterial line be placed in the pt undergoing a CEA? |
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Definition
| *In the contralateral radial artery |
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Term
| What are some things to consider when setting up the room for a CEA? |
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Definition
*Arterial line set up
*Pressure line available for Stump pressure monitoring
*Standard monitors- 5 lead EKG
*Prepare for patient to possibly be turned away from anesthetist losing access to head and ipsilateral arm
*Possible intraop EEG, TCD, SSEP
*NO EKG leads under neck or head due to possible intra op angiogram |
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Term
| What are two acceptable anesthetic techniques for a CEA? |
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Definition
*Cervical plexus blockade (superficial and deep)
*general anesthesia |
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Term
| Which anesthetic option (general or regional) is the most commonly utilized option? |
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Definition
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Term
| List some advantages in using a GETA technique during a CEA |
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Definition
*Airway control
*Cerebral protection
*decreased patient movement
*length of procedure not a factor |
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Term
| *What are some disadvantages with using GETA for a CEA? |
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Definition
*More hemodynamic fluctuations
*Inability to assess neurologic function throughout procedure |
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Term
List advantages of using cervical plexus blockade for a CEA
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|
Definition
*Provision of better hemodynamic stability
*An awake patient available for immediate neurologic evaluation potentially decreasing the need for unnecessary intraoperative shunting |
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Term
| What is the best neurologic monitor of the patient undergoing a CEA? |
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Definition
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Term
| What are some disadvantages of using regional anesthesia for the patient undergoing a CEA? |
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Definition
*Technical difficulty of managing the airway of an ischemic event did occur
*Requires a quick surgeon comfortable with this technique
*Unable to provide cerebral protection
*Inability to control PaCO2/ABGs
*It requires a cooperative patient and a normal coagulation profile |
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Term
| What are complications of regional anesthesia in the cervical region used for a CEA? |
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Definition
| *Horner's Syndrome d/t stellate ganglion being affected |
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Term
| What are s/s of Horner's Syndrome? |
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Definition
| Ipsilateral ptosis, miosis, anhydrosis, squeaky voice |
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Term
| Where should blood pressure be kept intraop during a CEA? |
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Definition
| *BP should be kept in the patient's high normal range in order to maintain cerebral perfusion (Ischemic areas may have lost autoregulation) |
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Term
| How much fentanyl should be used during CEA? |
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Definition
| *5-7mcg/kg front loaded in order to avoid sedation upon emergence |
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Term
| What are some pharmacological agents that should be used with caution during a CEA? |
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Definition
*Ketamine should be avoided
*STP and propofol due to cardiac depression
*Desflurane d/t subsequent tachycardia associated with its use
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Term
| For a CEA induction should be................. |
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Definition
| *Slow and smooth allowing for endotracheal intubation without wide swings in MAP |
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Term
| What should absolutely be avoided while artery is clamped? Why? |
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Definition
*Hypotension
*Some suggest increase in MAP 20% prior to and during clamping of common carotid |
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Term
| What should absolutely avoided after artery repair in a CEA? What can occur if this happens? |
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Definition
*Hypertension
*Cerebral Hyperperfusion Syndrome (like a stroke when BP gets high) |
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|
Term
| Where should fluids generally be kept during a CEA? |
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Definition
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|
Term
| What is a normal EBL for CEA? |
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Definition
|
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Term
| What are modifications that anesthesia can control that lower CMRO2? |
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Definition
*Normocarbia (PaCO2 35-45)
*Normothermia |
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Term
| Why should hypothermia be avoided during a CEA and surgery in general? |
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Definition
| *Due to the leftward shift it causes in the oxyhemoglobin dissociation curve (makes it harder for oxygen to dissociate from hemoglobin), post op shivering, and coagulopathy |
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Term
| What should you do if bradycardia ensues d/t surgical stretching of the baroreceptors? |
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Definition
*Tell the surgeon
*Try to let the response extinguish itself
*Can localize with 1% lidocaine on field
*Treat if symptomatic
*Can give a small amount of robinol to increase HR |
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Term
| Emergence from CEA should be............... |
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Definition
*Slow, smooth and devoid of wide swings in MAP
*Avoid coughing and bucking on OET
*Can give lidocaine to attenuate laryngeal reflexes
*Fully reverse NDMR |
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Term
| What should be checked after emergence from a CEA PRIOR to leaving the OR? |
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Definition
| *Quick neuro check of bilateral muscle strength and tongue movement before leaving the OR! |
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Term
What medication should be ready for use during and after emergence of a CEA?
What medication should be used with caution? |
|
Definition
*Antihypertensive medications should be ready
*Use analgesics carefully to avoid hypoventilation |
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Term
| What is the most common cause of M&M postop in the CEA pt? |
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Definition
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Term
| What is the second most common cause of M&M postop in the CEA patient? |
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Definition
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Term
| List some causes of respiratory depression post op in the CEA patient |
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Definition
*Narcotics
*Hematomoa
*Malfunctioning carotid bodies, less sensitive |
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Term
| What are the most common life threatening complications that can occur post op in the CEA pt? |
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Definition
*Acute Carotid Occlusion
*Hemorrhage |
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|
Term
What does carotid hemorrhage present like?
What should be done? |
|
Definition
*Wound enlargement, upper airway obstruction, and tracheal deviation
*Immediate control of airway
*Returned to OR for angiography and possible reexploration. |
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|
Term
| What are the manifestations of carotid occlusion? |
|
Definition
| Neurological status changes |
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Term
| What are some causes of hemodynamic instability in the post op CEA patient? |
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Definition
*Loss of normal baroreceptor function
*Hypervolemia
*Pain
*Hypoxemia and hypercarbia leading to increased intracranial pressure |
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|
Term
| What is the goal for maintenance of MAP post op in the CEA pt? |
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Definition
| *At low normal range for the patient |
|
|
Term
| When should the baroreceptors normally reset themselves post CEA? |
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Definition
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|
Term
| What is an alternative method of intervention for carotid stenosis other than CEA? |
|
Definition
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Term
| What is the patient population that is considered for Carotid Stenting? |
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Definition
| The very high risk patients |
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