FOR VASCULAR SURGERY

(lower should remain OFF until after reperfusion & stabilization)


• Foley catheter: Goal urine output >0.5 mL/kg/hr


• PRBC in the OR; may also need FFP


•  Management before clamping


• Induction of GA: Try to maintain BPs near baseline (HTN can rupture aneurysm, hypotension can cause myocardial ischemia)


• Control HR (usually with esmolol)


• Double-lumen tube (DLT) for thoracic aneurysm (L-DLT may risk hemorrhage if aneurysm is eroding bronchial wall)


• Consider deepening anesthesia prior to x-clamp to avoid HTN response BP control: Nitroprusside (SNP) causes arteriolar dilation & MAP reduction; nitroglycerin (NTG) may prevent myocardial ischemia & ↓ preload


• Maintain relative hypovolemia during preclamp phase to prevent HTN from inc afterload during x-clamp & ↓ risk of MI during x-clamp (do not overhydrate, use NTG/SNP)


•  Preparation for clamp release


• Gradually load with volume


• Wean vasodilators & have pressors ready


• Lighten anesthetic


•  Postclamp management


• Give fluid bolus, blood (if warranted)


• Gradual release of clamp can ↓ hemodynamic changes


• If severe hypotension results, reclamp & reassess


• Pressors (phenylephrine) may be needed, although not usually given prophylactically


• ↑ ventilation


• ABG before & after x-clamp removal (guide fluid & electrolyte management)


• Monitor HCT & correct coagulopathies


• Use standard extubation criteria (pts often stay intubated 2° large volume shifts)


•  Preventing renal failure


• Risk with supraceliac > suprarenal > infrarenal


• Maintain renal perfusion pressure with highest possible MAP that myocardium will tolerate


• Maintain intravascular volume


• Consider mannitol (0.5 g/kg before x-clamping), furosemide, Ca2+ blockers, dopamine, fenoldopam (not proven effective); bicarb drip


•  Preventing spinal cord ischemia


• SSEP monitoring—not useful (2/3 of cord is supplied by anterior spinal artery → motor)


• Maintain highest MAP (distal aortic perfusion pressures) that myocardium can handle


• Keep CSF pressures low (consider spinal fluid drain)


• Consider shunt to maintain distal perfusion during x-clamp


• Consider hypothermic CPB or circulatory arrest


• Consider administering steroids, barbiturates


• Consider epidural cooling


• Spinal cord perfusion pressure (SCPP)


SCPP = distal aortic pressure – (greater of spinal CSF pressure or CVP)


• If monitoring distal pressures, aim for SCPP >30 mm Hg; can drain CSF via lumbar drain, up to ∼15 mL/15 min (risk of brainstem herniation with rapid or excessive CSF drainagelimit to75 mL)


• Avoid excessive SNP (hypotension → ↓ perfusion, cerebral vasodilation → ↑ ICP transmitted to CSF)


• Avoid hyperglycemia (consider insulin infusion for glucose >200)


• Consider mild hypothermia (passive cooling to about 34°C)


•  Other complications


• Nerve injuries: Recurrent laryngeal nerve during thoracoabdominal repairs, brachial plexus injuries (poor pt positioning)


Thoracoabdominal Aortic Aneurysm (TAAA) Repair


•  Management similar to AAA (see above) with following key points


Crawford Classification of TAAA (I–IV)


•  I: Descending thoracic aortic aneurysm distal to subclavian artery


•  II: Aneurysm originating at subclavian artery to distal abdominal aorta


•  III: Aneurysm from mid–descending thoracic aorta to distal abdominal aorta


•  IV: Abdominal aortic aneurysm (below the diaphragm)


Stanford Classification of TAAA (A–B)


•  Type A: Intimal tear (acute) in aorta from ascending aorta to descending aorta


•  Type B: Intimal tear (acute or chronic) in aorta from descending aorta down


Possible Associated Findings with TAAA


•  Airway deviation/compression


•  Tracheal deviation/compression


•  Hemoptysis


•  Esophageal deviation/compression


•  Distortion & compression of central vasculature/anatomy


•  Hemothorax & mediastinal shift


•  Reduced distal perfusion


(Adapted from: Dunn P. Clinical Procedures of the MGH. Philadelphia, PA: Lippincott Williams & Wilkins.)


Anesthetic Management of TAAA


•  A-line: Ascending aneurysm, usu. placed in L radial (innominate artery may be involved); descending aneurysm, usu. placed in R radial (left subclavian may be clamped)


•  Circ arrest: If utilized, will need to pack head in ice (cover monitors so they remain dry)


•  TEE: Used intraop to detect intimal tear, coronary ostia, AI, assess embolic risk


•  Neuroprotection: Thiopental 3–10 mg/kg (may offer benefit for cerebral protection)


•  Partial bypass: May be used for descending aneurysms


•  Ventilation: One-lung ventilation often employed


•  Access: 1 large-bore peripheral IV (16- or 14-gauge) + 1 large-bore central line


BP Control During TAAA


•  If no bypass: Maintain SBP at baseline SBP + 12 of peak aortic x-clamp SBP


•  If bypass: Maintain SBP at baseline SBP


•  Can reduce proximal HTN during aortic clamp by ↑ flow to pump & ↓ flow to heart


•  SNP should be used sparingly (or not at all) during aortic clamp (risk of ↓ spinal cord & renal perfusion)


•  ↓ conc of volatile agent & turn off vasodilators before aortic unclamp


•  Volume repletion with colloid, crystalloid, blood products before & after aortic unclamp


Carotid Endarterectomy


•  Indication: History of stroke, TIA, or significant arterial occlusion on angiography


•  Morbidity: Incidence of concomitant CAD ≈ 50%; periop mortality 1–4%


•  Anesthetic techniques


• Regional advantages


• Pt can tell you of neurologic symptoms/deficits during surgery


• Less anesthesia required for pts with significant comorbidities


• Avoidance of coughing/bucking at case end


• Less postop hyper- & hypotension


• Potentially reduced ICU & hospital stay


• Regional disadvantages
“A good general is always better than a bad regional” (if regional not working, pt may be uncomfortable, moving, & tachycardic)


Some providers give “deep sedation” + regional anesthesia


(eliminates benefit of awake detection of neurologic deficits)


• Regional: Deep cervical block


• Technique: Inject anesthetic at C2, C3, C4 in line drawn between mastoid process, & C6 transverse process; needle should have slight caudal angulation, contact transverse process, withdraw 2 mm & inject


• Potential complications:


Intravertebral artery injection


Horner’s syndrome (sympathetic chain)


Hoarseness (recurrent laryngeal nerve)


• Regional: Superficial cervical block


• Technique: Inject anesthetic just posterior to sternocleidomastoid (goal to spread anesthetic subcutaneously & behind SCM) at C6 level, & fanned 2–3 cm superior & inferior


• Easy technique with minimal risk & excellent efficacy


• General anesthesia: Advantages


• Potential for brain protection by volatile and intravenous anesthetics


• General anesthesia: Disadvantages


• Necessitates careful planning & drug management to avoid HTN, coughing, & bucking during emergence & extubation


• Can get hypotension (minimal surgical stim but must keep pt still)


• No proven mortality ↓ with either technique (GA vs. regional)


•  Intraoperative shunting


• Provides blood flow from common carotid artery to internal carotid artery (distal/superior to site of x-clamp)


• Indicated in pts with significant contralateral dz


• Stump pressure: Measurement of pressure distal to site of x-clamp, need to provide well-flushed A-line tubing over drape stump pressure <50 mm Hg = indication for shunting


• Risk of plaque dislodgement, intimal injury, & air embolus


•  Hemodynamic management


• Avoid tachycardia (↑ myocardial O2 demand) & hypotension (↓ coronary flow)


• Maintain MAP slightly above baseline (optimizes collateral blood flow)
May be difficult to maintain normal MAP (minimal surgical stim)
Phenylephrine infusionideal to maintain MAP without raising heart rate


• Consider nitroglycerin for reduction of BP at induction/emergence
Esp in chronically HTN pts (may have wide swings in MAP)


• Consider esmolol/metoprolol to prevent tachycardia
Intubation, reversal of neuromuscular blockade, extubation


• Consider A-line placement prior to induction in pts with known CAD


•  Intraoperative brain monitoring has not been shown to improve outcomes


• CNS monitors:


• Awake: ↓ cardiac morbidity & HTN, shorter ICU stay


• EEG: May correlate with neuro changes


• SSEPs: Sensitive, but intermittent indicator of cortical ischemia


• Stump press poor sensitivity/specificity


• Transcranial Doppler/brain oximetry/JvO2 (unproven)


•  Perioperative complications


• Brain hypoperfusion (avoid hyperglycemia)


• Bradycardia (esp during carotid body manipulation)
Can avoid with lidocaine infiltration by surgeon


• Intraoperative stroke (consider if delayed emergence/mental status change)


• Hematoma: Evacuate hematoma 1st, manipulate airway 2nd


• Diagnosis: Progressive stridor & subjective difficulty breathing; often difficult to see hematoma (dressings/patient size)


• Treatment: Pt back to OR stat—if condition worsening, open wound prior to airway manipulation; attempts at intubation can be impossible (may result in airway swelling/bleeding, making situation worse)



ENDOVASCULAR PROCEDURES


Endovascular AAA Repair


•  Monitoring for most limited to A-line (plus large-bore IV access)


•  Pressors/vasodilators usually not needed


•  Conversion to open procedure rate <5% (should always anticipate this possibility)


•  Anesthetic options


• General


• Complex cases (inexperienced surgeon) or pt refuses regional/MAC


• Always considered as backup for conversion to open procedure


• Regional


• Spinal: Duration of procedure usually precludes this


• Epidural: Allows for ideal anesthesia of incision sites (bilateral femoral vascular access), But must be prepared to delay case if achieve bloody/traumatic tap or intravascular catheter


• Regional techniques may ↓ incidence of hypercoagulability & perioperative vessel clot formation (esp for lower extremity procedures)


• Sedation


• Ideal for thin pts (less dissection necessary) if surgeons apply local


• Pt must remain still for hrs on uncomfortable fluoroscopy bed


• Contrast induced nephropathy a concern (2° to extensive angiography) (see below)


Carotid Stent Placement


•  Requires immobile pt (minimal head/neck movement) & able to tolerate fluoroscopy table


•  Consider narcotic/α-2 agonist technique (may avoid sedation-associated confusion)


Distal Angioplasty/Thrombectomy


•  Pts with operative lower limb vascular dz have >50% incidence of concomitant CAD


•  Procedure times often long (on uncomfortable fluoroscopy bed) usually best to avoid long infusions/large doses of midazolam/propofol (problem of confusion/disorientation)


•  Always be prepared for conversion to open procedure


•  Regional techniques may ↓ incidence of hypercoagulability & perioperative vessel clot formation (esp for lower extremity procedures)


ENDOVASCULAR SAFETY CONCERNS


•  Perioperative β-blockade: Current ACC guidelines – recommend perioperative β-blockade in vascular pts found to have myocardial ischemia on preop testing


(less strong evidence for pts with low/intermediate cardiac risk)


•  Transfusion triggers: Evidence suggests vascular pts allowed to bleed below a hemoglobin level of 10 mg/dL have ↑ incidence of periop myocardial ischemia


•  Regional anesthesia & anticoagulation (see Chapter 6, Regional Anesthesia)


CONTRAST-INDUCED NEPHROPATHY (CIN)


•  ARF after ischemia or contrast thought 2° to acute tubular necrosis from


• Free-radical formation, which is promoted in acidic environment (e.g., renal medulla)


• Contrast-related ↓ in renal blood flow


• Atheroembolism


•  Tips to Avoid CIN


• Maintain plasma volume, good urine output


• NaHCO3 may be protective: D5 NaHCO3 154 mEq/L (from pharmacy)


Load: 3 mL/kg over 1 hr, given 1 hr before contrast


Maintenance: 1 mL/kg/hr until 6 hr after procedure


• Use 110 kg max weight for calculations


• If bolus leads to significant HTN → stop bolus, diurese before injecting contrast, then resume infusion


• N-acetylcysteine (free-radical scavenger)


• 600 mg PO bid starting day before surgery and through day of surgery


•  Risk Factors


• Patient factors: Renal dz, diabetes, CHF, ↑ age, anemia, LV dysfx


• Nonpatient factors: ↑ osmolar or ionic contrast, contrast viscosity & volume


PERIPHERAL VASCULAR SURGERY


•  Preop risk: Patients often have significant comorbidities (↑ risk of associated CAD)


•  Procedures: Bypass grafts (fem-pop, ilio-fem, etc.), embolectomy, pseudoaneurysm repair


•  Monitoring: Invasive monitors per pt condition (hemodynamics often labile)


(place A-line in side opposite surgery)


•  Anesthetic


• General anesthesia/regional/MAC


• Epidural & GA → associated with comparable rates of cardiac morbidity


• Continuous epidural/spinal


• ↓incidence of postop vascular graft clotting (Anesthesiology 1993:79:422)


• Continuous lumbar epidural catheter commonly used (occ spinal)


• Awake pts can notify personnel of acute MI symptoms (chest pain)


• Helpful for postop pain control


• Intraop heparin after epidural placement does not ↑ risk of epidural hematoma


• Epidural associated with ↓ incidence of reoperation for inadequate tissue perfusion (compared to GA) (Anesthesiology 1993;79[3]:422–434)


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Aug 28, 2016 | Posted by in ANESTHESIA | Comments Off on FOR VASCULAR SURGERY

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