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Anesthesia for Surgery of the Carotid Artery. Presented by R2 林至芃 2000.6.22. Indications for CEA. Really helpful?! Symptomatic patients ( CAS >70%+ TIA, RIND, mild stroke within 6 months). Preoperative Considerations.

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anesthesia for surgery of the carotid artery
Anesthesia for Surgery of the Carotid Artery
  • Presented by R2 林至芃
  • 2000.6.22
indications for cea
Indications for CEA
  • Really helpful?!
  • Symptomatic patients ( CAS >70%+ TIA, RIND, mild stroke within 6 months)
preoperative considerations
Preoperative Considerations
  • Risk factors for peri-op complication:angiographic characters, Age >75.symptom status, severe HTN, before CABG, ICA thrombus, Hx of angina
  • PAOD! => carotid duplex?
  • Coexistent CAD! => major cause of M/M
preoperative considerations4
Preoperative Considerations
  • Internal CAS => impaired cerebrovascular reactivity + reduced ability to dilate intracerebral arterioles when CPP decline
  • TCD for MCA blood flow velocity:a. predict cerebral ischemic riskb. identify asymptomatic patient
preoperative considerations5
Preoperative Considerations
  • Pre-op BP control, but how long?!
  • Poorly controlled HTN :labile intra and post-op BP!
  • BP reduction: gradually!! and stable!
  • Diabetic patient: avoid hyperglycemia
intraoperative considerations
Intraoperative Considerations
  • Goal:Risk factors modification for myocardial and cerebral ischemia.Maintain adequate CPP without stressing the heart!.Continual adjustment of CV parametersPrompt intervention
cerebral monitoring
Cerebral Monitoring
  • No consensus!
  • Xenon blood flow, TCD, cerebral oximetry, SEP, EEG, continual NE under RA
  • processed EEG: not so sensitive!
  • TCD: D/D hemodynamic and embolic eventair or particulate emboli?
  • Cerebral oximetry: to be determined!
cerebral protection
Cerebral protection
  • Carotid shunt: not guarantee! emboli?
  • BP control: as pre-op level, or higher potential myocardial risks=> TEE? Holter?
  • BP fluctuation => deactivation (clamping) and re-activation (after declamping) of carotid sinus baroreceptor!=> local?! => increased intra and post-op hypertension
ventilatory management
Ventilatory management
  • Normocapnia!!
  • Inverse steal?!Hyperventilation=>redistribute blood from intact cerebrovascular reactivity to CO2 to impaired area? Decreased cerebral blood flow?
  • Hypercapnia=> intracerebral steal
temperature management
Temperature management
  • Normothermia!!
  • JAMA 1997
choice of anesthesia
Choice of anesthesia
  • predict cerebral ischemia after ICA clamping!
  • lower incidence of post-op hemodynamic liability?
  • shorter post-op hospital stay?
  • Rate of adverse cardiac outcome?
  • Success of RA for CEA: gentle surgeon’s hands
choice of anesthesia12
Choice of anesthesia
  • RA: superficial; deep cervical plexus block
  • RA not ideal for: long OP time, difficult vascular anatomy, short neck.
  • Even RA, anesthesiologist should be ready!
  • Most anesthetic induction agents : no difference!(thiopental, etomidate)
  • Isoflurane!
hemodynamic stability
Hemodynamic Stability
  • Enhanced with moderate dose of narcoticsavoid dose compromise rapid emergenceRemifentanyl!!
  • Beta-blocker:minimise surges in HR and BPperi-op beta blockade=> beneficial effect on cardiac outcome
  • atropine for reflex bradycardia
  • IVF+phylnephrine for hypotension
minimally invasive carotid artery surgery
Minimally invasive carotid artery surgery
  • Percutaneous angioplasty and stenting.
  • Sedation for cannulation, patient awake during balloon inflation
  • anti-cholinergics to attenuate baroreceptor response during balloon inflation or stenting
  • hemodynamic control.
postoperative neurologic dysfunction
Postoperative neurologic dysfunction
  • 1/2~2/3 surgical etiology (ischemia during carotid clamping, postop thomboembolism)
  • most common: emboli!
  • 20% stroke => intraop hemodynamic origin
post op hyperperfusion syndrome
Post-op hyperperfusion syndrome
  • Abrupt increase in blood flow with loss of autoregulation in surgically reperfused brain
  • P’t with severe HTN
  • Headache, signs of transient ischemia, seizure, cerebral edema, ICH
  • MCA blood flow =>pressure dependent
  • meticulous BP control!
post op bp liability
Post-op BP liability
  • After CEA, carotid sinus sense sudden increase in BP => trigger baroreceptor mediated systemic hypotension!
  • Anesthetise carotid sinus nerve, surgically induced carotid sinus nerve paresis.
cranial nerve and carotid body dysfunction
Cranial nerve and carotid body dysfunction
  • Recurrent laryngeal nerve dysfunction 5-6%
  • Bilateral CEA=> loss of carotid body function => increase resting PaCO2
  • unilateral CEA => impaired ventilatory response to mild hypoxemia.
airway and ventilation problems
Airway and ventilation problems
  • Upper airway obstruction after CEA: rare but potentially fetal!!
  • Hematoma!!
  • Tissue edema ,more common, secondary to venous and lymphatic congestion => edematous supraglottic mucosal fold => not responding to steroid! => difficult intubation and mask ventilation!!
airway and ventilation problems20
Airway and ventilation problems
  • Phrenic nerve paresis (60-70%) after cervical plexus block (RA)
  • little clinical consequence except mild increased PaCO2
  • COPD!! Pre-existing contralateral diaphragmatic dysfunction!!