WikiAnesthesia - User contributions [en]

Transcarotid Artery Endovascular Revascularization

2022-11-11T15:42:03Z

Ajaksic1:

{{Infobox surgical procedure
| anesthesia_type = GA or MAC
| airway = ETT vs Natural Airway
| lines_access = PIV x 2 (one large bore), A-line
| monitors = Standard, 5 Lead
| considerations_preoperative = DAPT morning of surgery, beta-blockers, volume status, baseline neuro exam
| considerations_intraoperative = - Bradycardia/asystole during carotid balloon inflation (prevent with glyco)
- Maintaining elevated SBP goal during flow reversal & monitoring rSO2
- Cerebral Hyperperfusion after stenting deployment (Maintain lowered SBP goal discussed with surgeon)
| considerations_postoperative = - Post-Stent hypotension & bradycardia (incr risk for MI, ischemic stroke, stent thrombosis
- Early neurological assessment after extubation and during the immediate postop period
}}

Goal: Restoring laminar blood flow through a stenotic carotid artery narrowed by atherosclerotic or neointimal hyperplastic disease.

Also referred to as a TCAR, a transcarotid artery endovascular revascularization is an alternative to carotid endarterectomy for the management of carotid stenosis in patients who are determined to be poor open repair candidates based on high surgical risk or lesion location (such as a high/distal carotid artery bifurcation or a carotid lesion close to the skull base, that would make carotid endarterectomy (CEA) technically difficult).1 Transcarotid artery revascularization (TCAR) is an alternative to transfemoral carotid artery stenting (TF-CAS) and is meant to decrease the risk for micro-embolic strokes through flow reversal through the carotid during stent placement (see below).1,2,3,4

== Overview ==

=== Surgical procedure: ===
The common carotid artery (CCA) is exposed via a small incision superior to the clavicle.

A flexible sheath is inserted into the CCA proximal to the lesion being stented and the distal end (outside the vessel) is connected to a flow reversal system (FRS).

At the same time the femoral vein is also being accessed either percutaneously or via surgical exposure, and a 2nd flexible sheath is inserted. The extraluminal end of the femoral sheath is attached to the other end of the flow reversal system (FRS).

Once connected blood flow from the high pressure CCA to the low pressure femoral vein through the FRS. After flow reversal wires are threaded past the lesion, if indicated pre-dilation of the vessel with balloon angioplasty occurs at this time, followed by deployment of the intralumenal stent. The FRS acts as a filter removing any plaques or disrupted intralumenal, decreasing the risk of micro-embolic strokes.

After successful placement, flow reversal is turned off and blood flow resumes in its normal direction. Sheaths removed and arteriotomy closed. 2,3,4

Video with overview of steps: TCAR | TransCarotid Artery Revascularization Procedure Narrated Animation | Silk Road Medical | https://www.youtube.com/watch?v=MI2s4rv0dJA 4

=== Indications: 2,5 ===
General indications for carotid revascularization for stenotic atherosclerotic lesions are the same, regardless of revascularization approach (CEA, TF-CAS, TCAR).

- Asymptomatic Carotid Stenosis: Atherosclerotic narrowing of the extracranial ICA of 80-99% without recent stroke or TIA & with life expectancy of >5years. Of note, asymptomatic chronic compete (100%) occlusion not managed with revascularization procedures.

- Symptomatic Carotid Stenosis: Stroke or TIA referable to the appropriate carotid artery vascular distribution within the previous six months AND carotid stenosis > 50%.. Ideally revascularization within 2 weeks of symptom onset.

Stent placement is preferred to carotid endarterectomy if the patient have ANY of a number of comorbid medical disease or anatomical factors (see below) that would complicate the hemodynamic management intraoperatively putting the patient at elevated risk for CV complications (hemodynamic instability / vasoplegia, MI, stroke, arrhythmia, etc) or surgical/airway access.

Medical:

* Age > 75
* Congestive Heart Failure
* LVEF < 35%
* >2 diseased coronaries w/ 70% stenosis
* Unstable angina or abnormal stress test
* MI within 6 weeks
* Need for additional open heart surgery
* Need for major surgery (including vascular)
* Uncontrolled diabetes
* Severe pulmonary disease
Anatomic:

*Prior head/neck surgery or irradiation
* Spinal immobility
* Restenosis post carotid endarterectomy (CEA)
* Surgically inaccessible lesion
* Laryngeal palsy; Laryngectomy
* Permanent contralateral cranial nerve injury
* Contralateral occlusion
* Severe tandem lesions
* Bilateral stenosis requiring treatment

== Preoperative management ==

=== Patient evaluation:===
Assess for the listed conditions/diseases above.
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Neck mobility, ability to tolerated surgical positioning. Prior neck radiation
|-
|Neurologic
|Baseline neurologic exam, post operatively at risk for micro-embolic strokes. Assess if carotid stenosis is symptomatic (see below)
|-
|Cardiovascular
|Exercise tolerance, assess for listed cardiovascular comorbid diseases above
|-
|Pulmonary
|Exercise tolerance
|-
|Gastrointestinal
|
|-
|Hematologic
|Ensure taking dual anti-platelet therapy per surgical team's directions
|-
|Renal
|Current volume status, relative hypovolemia may adversely affect ability to induce HTN during flow reversal
|-
|Endocrine
|Check BG
|-
|Other
|
|}
=== Labs and studies ===
All carotid surgeries are considered high-risk & pre-surgical testing should follow AHA/ACA guidelines for high-risk noncardiac surgery.6

* CBC, electrolytes, creatinine, PT/INR/aPTT
* T&C; consider requesting to have 2 units of pRBC on hold
* 12 lead EKG
* Consider Stress Test (exercise or pharmacology) if:
** Poor or unknown functional status
** Calculated risk for major adverse cardiovascular events (MACE) is >1% on the VQI or NSQIP calculator
* TTE if concerned for CHF, pulmonary HTN, or valvular disease (may impair ability to safely induce needed hypertension intraoperatively)
* Per surgical team's preference either CT angiogram v Carotid ultrasound to define anatomy

=== Operating Room Setup3 ===
TCAR can be preformed under GA or MAC with regional anesthesia. If planning to use MAC, have supplies for full conversion to GA emergently.

Have appropriate ''vasoactive'' medication available to ''quickly'' titrate blood pressure intraoperatively

- Push Medications: consider Epi, NE, Phenylephrine, Nitroglycerin, Esmolol, Nicardipine

- Prepared Drips: Norepinephrine (or preferred short acting vasopressor) spiked & in line, consider having for vasodilatory drip of choice in room

Additional Medications: Heparin & Protamine

=== Patient Preparation & Premedication3 ===
- Verify that patient is taking Dual Antiplatelet Therapy (DAPT; Aspirin / Plavix) & a statin for the last 7 days including the morning of surgery. If dose not taken, discuss giving preOP with surgical team

- Continue home beta-blockers

- Verify medication that impact BP control or cause refractory hypotension compromising cerebral blood flow on induction or during flow reversal (ARB/ACEi) have not been taken

=== Regional & Neuraxial Techniques11, 3 ===
Superficial Cervical Plexus Block

- With block procedure can be preformed with MAC

- Benefit in GA cases by decreasing opioid requirement, allows for more rapid neurologic assessment postoperatively

== Intraoperative management3 ==

=== Monitoring & Access ===
- Standard ASA monitors, 5 lead EKG

- Pre-induction arterial line

- PIV x 2 (note vasoactive medications will be in PIVs, make sure lines are well secured & running smoothly)

- Cerebral oximetry to monitor adequacy of collateral circulation via the Circle of Willis during flow reversal; ideally placed and calibrate while patient is awake.

- Intraoperative ACT monitoring during heparinization (target 250-350; verify goal with surgical team)

=== Induction & Airway Management3 ===
- If planning on MAC with natural airway & superficial cervical plexus block, consider sedation with dexmedetomidine or remifentanil infusion.

GA: Slow controlled induction, goal to maintain BP at baseline to prevent decreased cerebral perfusion

=== Positioning2,3 ===
- Supine, neck extended, shoulder roll, head turned away from surgical site

- Run lines & monitors outside of fluoroscopy path to optimize surgical field

=== Maintenance & Surgical Considerations3 ===
TIVA/Balanced anesthetic/inhalational anesthetic are reasonable

Have clear communication with the surgical team about what stage of the surgery they are in, critical for BP management/patient safety during a TCAR.

- Surgical Exposure: maintain BP at baseline or slightly higher

- '''Carotid Balloon Inflation''': Can cause Bradycardia/asystole due to proximity near carotid baroreceptors. Give preventative glycopyrrolate (unless patient has contraindications to having a further elevated HR; baseline HR > 90 or severe CAD)

- '''Flow Reversal''': Maintain SBP >160 or 20% above baseline SBP to aid perfusion via Circle of Willis. Closely monitor cerebral oximeter (rSO2) during this time.

*If cerebral oximeter (rSO2) decreases by >10%, treat by either increasing FiO2 or augmenting BP up to 20% above baseline (or both). Note that drops in rSO2 of >12% from baseline shown as a reliable, sensitive, and specific threshold for the detection of brain ischemia.

- Stent Deployment: Risk for '''acute cerebral hyperperfusion'''. Stop vasopressors, have closed loop communication about BP goal with surgical team and give push vasoactive medications as needed to meet goals (commonly SBP 110-140). Not uncommon to require boluses of nitroglycerin/esmolol/nicardipine to achieve this rapidly

- During Closing, '''post-stent hypotension & bradycardia''' is common due to persistent carotid baroreceptor stimulation & may require vasopressor support to insure adequate cerebral perfusion until hemodynamics stabilize.

=== Emergence3 ===
- Avoid bucking due to neck incision & carotid artery puncture.

- Consider remifentanil, dexmedetomidine, or appropriate opioid titration prior to emergence

- If hypertensive (BP above goal) after extubation have short acting vasodilatory medications available (nitroglycerin/esmolol), if persistent consider longer acting anti-hypertensive medications (Labetalol/Hydralazine) ; be mindful to monitor closely postoperatively, remains at risk for post-stent hypotension (see above)

== Postoperative management ==

=== Disposition ===
Requires close neurologic and hemodynamic monitoring postoperatively

Consider ICU vs PACU/IMC.

=== Pain management ===
- Opioids

- Regional anesthesia

=== Potential complications3 ===

* Bleeding due to catheter dislodgement: higher risk during MAC as opposed to GA
*Hematoma: Neck and groin access sites
*Embolic stroke: More likely during surgical exposure or during device placement secondary to to insufficient flow reversal
*Reperfusion Injury: Acute cerebral hyperperfusion due to ipsilateral ACA/MCA distribution now seeing higher pressure and flow since no longer obstructed by stenotic segment of carotid artery. Stroke like syndrome which can manifest as encephalopathy or unilateral sensory / motor deficits, seizure, or rarely, intracranial hemorrhage
* Stroke due to hypoperfusion (watershed infarction): Possibly due to insufficient collateral flow via Circle of Willis or post-stent hypotension (see Maintenance & surgical considerations)
* Stent Thrombosis: More likely if persistently hypotensive
*Myocardial ischemia/ infarction: Monitor for post-stent hypotension

== References ==
1.) Malas MB, Leal J, Kashyap V, Cambria RP, Kwolek CJ, Criado E. Technical aspects of transcarotid artery revascularization using the ENROUTE transcarotid neuroprotection and stent system. '' J Vasc Surg''. 2017;65(3):916-920. doi:10.1016/j.jvs.2016.11.042

2.) Columbo JA, Martinez-Camblor P, O’Malley AJ, et al. Association of Adoption of Transcarotid Artery Revascularization With Center-Level Perioperative Outcomes. ''JAMA Netw Open.'' 2021;4(2):e2037885. doi:10.1001/jamanetworkopen.2020.37885

3.) Ankam A, Kinthala S, Madabhushi P. Anesthetic Considerations for Transcarotid Artery Revascularization: Experience and Review of Forty Cases From a Single Medical Center. Cureus. 2020 Dec 24;12(12):e12250. doi: 10.7759/cureus.12250. PMID: 33505816; PMCID: PMC7822093.

4.) Silk Road Medical. TCAR surveillance project. Accessed January 1, 2020. <nowiki>https://silkroadmed.com/tcar-surveillance-project/</nowiki>

5.) Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Stroke 2011; 42:e464.

6.) ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery—Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
[[Category:Surgical procedures]]

Transcarotid Artery Endovascular Revascularization

2022-11-11T15:40:24Z

Ajaksic1: Finished article, updated citations

{{Infobox surgical procedure
| anesthesia_type = GA or MAC
| airway = ETT vs Natural Airway
| lines_access = PIV x 2 (one large bore), A-line
| monitors = Standard, 5 Lead
| considerations_preoperative = DAPT morning of surgery, beta-blockers, volume status, baseline neuro exam
| considerations_intraoperative = - Bradycardia/asystole during carotid balloon inflation
- Maintaining SBP goal during flow reversal & monitoring rSO2
- Cerebral Hyperperfusion after stenting (Maintain SBP goal discussed with surgeon)
| considerations_postoperative = - Post-Stent hypotension & bradycardia (incr risk for MI, ischemic stroke, stent thrombosis
- Early neurological assessment after extubation and during the immediate postop period
}}

Goal: Restoring laminar blood flow through a stenotic carotid artery narrowed by atherosclerotic or neointimal hyperplastic disease.

Also referred to as a TCAR, a transcarotid artery endovascular revascularization is an alternative to carotid endarterectomy for the management of carotid stenosis in patients who are determined to be poor open repair candidates based on high surgical risk or lesion location (such as a high/distal carotid artery bifurcation or a carotid lesion close to the skull base, that would make carotid endarterectomy (CEA) technically difficult).1 Transcarotid artery revascularization (TCAR) is an alternative to transfemoral carotid artery stenting (TF-CAS) and is meant to decrease the risk for micro-embolic strokes through flow reversal through the carotid during stent placement (see below).1,2,3,4

== Overview ==

=== Surgical procedure: ===
The common carotid artery (CCA) is exposed via a small incision superior to the clavicle.

A flexible sheath is inserted into the CCA proximal to the lesion being stented and the distal end (outside the vessel) is connected to a flow reversal system (FRS).

At the same time the femoral vein is also being accessed either percutaneously or via surgical exposure, and a 2nd flexible sheath is inserted. The extraluminal end of the femoral sheath is attached to the other end of the flow reversal system (FRS).

Once connected blood flow from the high pressure CCA to the low pressure femoral vein through the FRS. After flow reversal wires are threaded past the lesion, if indicated pre-dilation of the vessel with balloon angioplasty occurs at this time, followed by deployment of the intralumenal stent. The FRS acts as a filter removing any plaques or disrupted intralumenal, decreasing the risk of micro-embolic strokes.

After successful placement, flow reversal is turned off and blood flow resumes in its normal direction. Sheaths removed and arteriotomy closed. 2,3,4

Video with overview of steps: TCAR | TransCarotid Artery Revascularization Procedure Narrated Animation | Silk Road Medical | https://www.youtube.com/watch?v=MI2s4rv0dJA 4

=== Indications: 2,5 ===
General indications for carotid revascularization for stenotic atherosclerotic lesions are the same, regardless of revascularization approach (CEA, TF-CAS, TCAR).

- Asymptomatic Carotid Stenosis: Atherosclerotic narrowing of the extracranial ICA of 80-99% without recent stroke or TIA & with life expectancy of >5years. Of note, asymptomatic chronic compete (100%) occlusion not managed with revascularization procedures.

- Symptomatic Carotid Stenosis: Stroke or TIA referable to the appropriate carotid artery vascular distribution within the previous six months AND carotid stenosis > 50%.. Ideally revascularization within 2 weeks of symptom onset.

Stent placement is preferred to carotid endarterectomy if the patient have ANY of a number of comorbid medical disease or anatomical factors (see below) that would complicate the hemodynamic management intraoperatively putting the patient at elevated risk for CV complications (hemodynamic instability / vasoplegia, MI, stroke, arrhythmia, etc) or surgical/airway access.

Medical:

* Age > 75
* Congestive Heart Failure
* LVEF < 35%
* >2 diseased coronaries w/ 70% stenosis
* Unstable angina or abnormal stress test
* MI within 6 weeks
* Need for additional open heart surgery
* Need for major surgery (including vascular)
* Uncontrolled diabetes
* Severe pulmonary disease
Anatomic:

*Prior head/neck surgery or irradiation
* Spinal immobility
* Restenosis post carotid endarterectomy (CEA)
* Surgically inaccessible lesion
* Laryngeal palsy; Laryngectomy
* Permanent contralateral cranial nerve injury
* Contralateral occlusion
* Severe tandem lesions
* Bilateral stenosis requiring treatment

== Preoperative management ==

=== Patient evaluation:===
Assess for the listed conditions/diseases above.
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Neck mobility, ability to tolerated surgical positioning. Prior neck radiation
|-
|Neurologic
|Baseline neurologic exam, post operatively at risk for micro-embolic strokes. Assess if carotid stenosis is symptomatic (see below)
|-
|Cardiovascular
|Exercise tolerance, assess for listed cardiovascular comorbid diseases above
|-
|Pulmonary
|Exercise tolerance
|-
|Gastrointestinal
|
|-
|Hematologic
|Ensure taking dual anti-platelet therapy per surgical team's directions
|-
|Renal
|Current volume status, relative hypovolemia may adversely affect ability to induce HTN during flow reversal
|-
|Endocrine
|Check BG
|-
|Other
|
|}
=== Labs and studies ===
All carotid surgeries are considered high-risk & pre-surgical testing should follow AHA/ACA guidelines for high-risk noncardiac surgery.6

* CBC, electrolytes, creatinine, PT/INR/aPTT
* T&C; consider requesting to have 2 units of pRBC on hold
* 12 lead EKG
* Consider Stress Test (exercise or pharmacology) if:
** Poor or unknown functional status
** Calculated risk for major adverse cardiovascular events (MACE) is >1% on the VQI or NSQIP calculator
* TTE if concerned for CHF, pulmonary HTN, or valvular disease (may impair ability to safely induce needed hypertension intraoperatively)
* Per surgical team's preference either CT angiogram v Carotid ultrasound to define anatomy

=== Operating Room Setup3 ===
TCAR can be preformed under GA or MAC with regional anesthesia. If planning to use MAC, have supplies for full conversion to GA emergently.

Have appropriate ''vasoactive'' medication available to ''quickly'' titrate blood pressure intraoperatively

- Push Medications: consider Epi, NE, Phenylephrine, Nitroglycerin, Esmolol, Nicardipine

- Prepared Drips: Norepinephrine (or preferred short acting vasopressor) spiked & in line, consider having for vasodilatory drip of choice in room

Additional Medications: Heparin & Protamine

=== Patient Preparation & Premedication3 ===
- Verify that patient is taking Dual Antiplatelet Therapy (DAPT; Aspirin / Plavix) & a statin for the last 7 days including the morning of surgery. If dose not taken, discuss giving preOP with surgical team

- Continue home beta-blockers

- Verify medication that impact BP control or cause refractory hypotension compromising cerebral blood flow on induction or during flow reversal (ARB/ACEi) have not been taken

=== Regional & Neuraxial Techniques11, 3 ===
Superficial Cervical Plexus Block

- With block procedure can be preformed with MAC

- Benefit in GA cases by decreasing opioid requirement, allows for more rapid neurologic assessment postoperatively

== Intraoperative management3 ==

=== Monitoring & Access ===
- Standard ASA monitors, 5 lead EKG

- Pre-induction arterial line

- PIV x 2 (note vasoactive medications will be in PIVs, make sure lines are well secured & running smoothly)

- Cerebral oximetry to monitor adequacy of collateral circulation via the Circle of Willis during flow reversal; ideally placed and calibrate while patient is awake.

- Intraoperative ACT monitoring during heparinization (target 250-350; verify goal with surgical team)

=== Induction & Airway Management3 ===
- If planning on MAC with natural airway & superficial cervical plexus block, consider sedation with dexmedetomidine or remifentanil infusion.

GA: Slow controlled induction, goal to maintain BP at baseline to prevent decreased cerebral perfusion

=== Positioning2,3 ===
- Supine, neck extended, shoulder roll, head turned away from surgical site

- Run lines & monitors outside of fluoroscopy path to optimize surgical field

=== Maintenance & Surgical Considerations3 ===
TIVA/Balanced anesthetic/inhalational anesthetic are reasonable

Have clear communication with the surgical team about what stage of the surgery they are in, critical for BP management/patient safety during a TCAR.

- Surgical Exposure: maintain BP at baseline or slightly higher

- '''Carotid Balloon Inflation''': Can cause Bradycardia/asystole due to proximity near carotid baroreceptors. Give preventative glycopyrrolate (unless patient has contraindications to having a further elevated HR; baseline HR > 90 or severe CAD)

- '''Flow Reversal''': Maintain SBP >160 or 20% above baseline SBP to aid perfusion via Circle of Willis. Closely monitor cerebral oximeter (rSO2) during this time.

*If cerebral oximeter (rSO2) decreases by >10%, treat by either increasing FiO2 or augmenting BP up to 20% above baseline (or both). Note that drops in rSO2 of >12% from baseline shown as a reliable, sensitive, and specific threshold for the detection of brain ischemia.

- Stent Deployment: Risk for '''acute cerebral hyperperfusion'''. Stop vasopressors, have closed loop communication about BP goal with surgical team and give push vasoactive medications as needed to meet goals (commonly SBP 110-140). Not uncommon to require boluses of nitroglycerin/esmolol/nicardipine to achieve this rapidly

- During Closing, '''post-stent hypotension & bradycardia''' is common due to persistent carotid baroreceptor stimulation & may require vasopressor support to insure adequate cerebral perfusion until hemodynamics stabilize.

=== Emergence3 ===
- Avoid bucking due to neck incision & carotid artery puncture.

- Consider remifentanil, dexmedetomidine, or appropriate opioid titration prior to emergence

- If hypertensive (BP above goal) after extubation have short acting vasodilatory medications available (nitroglycerin/esmolol), if persistent consider longer acting anti-hypertensive medications (Labetalol/Hydralazine) ; be mindful to monitor closely postoperatively, remains at risk for post-stent hypotension (see above)

== Postoperative management ==

=== Disposition ===
Requires close neurologic and hemodynamic monitoring postoperatively

Consider ICU vs PACU/IMC.

=== Pain management ===
- Opioids

- Regional anesthesia

=== Potential complications3 ===

* Bleeding due to catheter dislodgement: higher risk during MAC as opposed to GA
*Hematoma: Neck and groin access sites
*Embolic stroke: More likely during surgical exposure or during device placement secondary to to insufficient flow reversal
*Reperfusion Injury: Acute cerebral hyperperfusion due to ipsilateral ACA/MCA distribution now seeing higher pressure and flow since no longer obstructed by stenotic segment of carotid artery. Stroke like syndrome which can manifest as encephalopathy or unilateral sensory / motor deficits, seizure, or rarely, intracranial hemorrhage
* Stroke due to hypoperfusion (watershed infarction): Possibly due to insufficient collateral flow via Circle of Willis or post-stent hypotension (see Maintenance & surgical considerations)
* Stent Thrombosis: More likely if persistently hypotensive
*Myocardial ischemia/ infarction: Monitor for post-stent hypotension

== References ==
1.) Malas MB, Leal J, Kashyap V, Cambria RP, Kwolek CJ, Criado E. Technical aspects of transcarotid artery revascularization using the ENROUTE transcarotid neuroprotection and stent system. '' J Vasc Surg''. 2017;65(3):916-920. doi:10.1016/j.jvs.2016.11.042

2.) Columbo JA, Martinez-Camblor P, O’Malley AJ, et al. Association of Adoption of Transcarotid Artery Revascularization With Center-Level Perioperative Outcomes. ''JAMA Netw Open.'' 2021;4(2):e2037885. doi:10.1001/jamanetworkopen.2020.37885

3.) Ankam A, Kinthala S, Madabhushi P. Anesthetic Considerations for Transcarotid Artery Revascularization: Experience and Review of Forty Cases From a Single Medical Center. Cureus. 2020 Dec 24;12(12):e12250. doi: 10.7759/cureus.12250. PMID: 33505816; PMCID: PMC7822093.

4.) Silk Road Medical. TCAR surveillance project. Accessed January 1, 2020. <nowiki>https://silkroadmed.com/tcar-surveillance-project/</nowiki>

5.) Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Stroke 2011; 42:e464.

6.) ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery—Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
[[Category:Surgical procedures]]

Transcarotid Artery Endovascular Revascularization

2022-11-10T19:32:20Z

Ajaksic1: Need to add citations

{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Also referred to as a TCAR, a transcarotid artery endovascular revascularization is an alternative to carotid endarterectomy for the management of carotid stenosis in patients who are determined to be poor open repair candidates based on high surgical risk or lesion location (distal lesions). Transcarotid artery revascularization (TCAR) is an alternative to trans-femoral stenting and is meant to decrease the risk for micro-embolic strokes through flow reversal through the carotid during stent placement (see below).

Goal: Restoring laminar blood flow through a stenotic carotid artery narrowed by atherosclerotic or neointimal hyperplastic disease.

== Overview ==

=== Surgical procedure: ===
The common carotid artery (CCA) is exposed via a small incision superior to the clavicle.

A flexible sheath is inserted into the CCA proximal to the lesion being stented and the distal end (outside the vessel) is connected to a flow reversal system (FRS).

At the same time the femoral vein is also being accessed either percutaneously or via surgical exposure, and a 2nd flexible sheath is inserted. The extraluminal end of the femoral sheath is attached to the other end of the flow reversal system (FRS).

Once connected blood flow from the high pressure CCA to the low pressure femoral vein through the FRS. After flow reversal wires are threaded past the lesion, if indicated pre-dilation of the vessel with balloon angioplasty occurs at this time, followed by deployment of the intralumenal stent. The FRS acts as a filter removing any plaques or disrupted intralumenal, decreasing the risk of micro-embolic strokes.

After successful placement, flow reversal is turned off and blood flow resumes in its normal direction. Sheaths removed and arteriotomy closed.

Video with overview of steps: TCAR | TransCarotid Artery Revascularization Procedure Narrated Animation | Silk Road Medical | https://www.youtube.com/watch?v=MI2s4rv0dJA

=== Indications: ===
Stent placement is preferred to carotid endarterectomy if the patient have ANY of a number of comorbid medical disease or anatomical factors (see below) that would complicate the hemodynamic management intraoperatively putting the patient at elevated risk for CV complications (hemodynamic instability / vasoplegia, MI, stroke, arrhythmia, etc) or surgical/airway access.

Medical:

* Age > 75
* Congestive Heart Failure
* LVEF < 35%
* >2 diseased coronaries w/ 70% stenosis
* Unstable angina or abnormal stress test
* MI within 6 weeks
* Need for additional open heart surgery
* Need for major surgery (including vascular)
* Uncontrolled diabetes
* Severe pulmonary disease
Anatomic:

*Prior head/neck surgery or irradiation
* Spinal immobility
* Restenosis post carotid endarterectomy (CEA)
* Surgically inaccessible lesion
* Laryngeal palsy; Laryngectomy
* Permanent contralateral cranial nerve injury
* Contralateral occlusion
* Severe tandem lesions
* Bilateral stenosis requiring treatment

== Preoperative management ==

=== Patient evaluation:===
Assess for the listed conditions/diseases above.
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Neck mobility, ability to tolerated surgical positioning. Prior neck radiation
|-
|Neurologic
|Baseline neurologic exam, post operatively at risk for micro-embolic strokes. Assess if carotid stenosis is symptomatic (see below)
|-
|Cardiovascular
|Exercise tolerance, assess for listed cardiovascular comorbid diseases above
|-
|Pulmonary
|Exercise tolerance
|-
|Gastrointestinal
|
|-
|Hematologic
|Ensure taking dual anti-platelet therapy per surgical team's directions
|-
|Renal
|Current volume status, relative hypovolemia may adversely affect ability to induce HTN during flow reversal
|-
|Endocrine
|Check BG
|-
|Other
|
|}
- Symptomatic Carotid Stenosis: Stroke or TIA referable to the appropriate carotid artery distribution within the previous six months AND carotid stenosis > 50%.

- Asymptomatic Carotid Stenosis: Atherosclerotic narrowing of the extracranial ICA (>80%) without recent stroke or TIA (Of note, vertigo and syncope are not typical manifestations)

=== Labs and studies ===
All carotid surgeries are considered high-risk & pre-surgical testing should follow AHA/ACA guidelines for high-risk noncardiac surgery.

* CBC, electrolytes, creatinine, PT/INR/aPTT
* T&C; consider requesting to have 2 units of pRBC on hold
* 12 lead EKG
* Consider Stress Test (exercise or pharmacology) if:
** Poor or unknown functional status
** Calculated risk for major adverse cardiovascular events (MACE) is >1% on the VQI or NSQIP calculator
* TTE if concerned for CHF, pulmonary HTN, or valvular disease (may impair ability to safely induce needed hypertension intraoperatively)
* Per surgical team's preference either CT angiogram v Carotid ultrasound to define anatomy

=== Operating room setup ===
TCAR can be preformed under GA or MAC with regional anesthesia. If planning to use MAC, have supplies for full conversion to GA emergently.

Have appropriate vasoactive medication available quickly titrate blood pressure intraoperatively

- Push Medications: consider Epi, NE, Phenylephrine, Nitroglycerin, Esmolol, Nicardipine

- Prepared Drips: Norepinephrine (or preferred short acting vasopressor) spiked & in line, consider having for vasodilatory drip of choice in room

Additional Medications: Heparin & Protamine

Run lines & monitors outside of fluoroscopy path to optimize surgical field

=== Patient preparation and premedication ===
- Verify that patient is taking Dual Antiplatelet Therapy (DAPT; Aspirin / Plavix) & a statin for the last 7 days including the morning of surgery. If dose not taken, discuss giving preOP with surgical team

- Continue home beta-blockers

- Verify medication that impact BP control or cause refractory hypotension compromising cerebral blood flow on induction or during flow reversal (ARB/ACEi) have not been taken

=== Regional and neuraxial techniques ===
Superficial Cervical Plexus Block

- With block procedure can be preformed with MAC

- Benefit in GA cases by decreasing opioid requirement, allows for more rapid neurologic assessment postoperatively

== Intraoperative management ==

=== Monitoring and access ===
- Standard ASA monitors, 5 lead EKG

- Pre-induction arterial line

- PIV x 2 (note vasoactive medications will be in PIVs, make sure lines are stable/running well)

- Cerebral oximetry to monitor adequacy of collateral circulation via the Circle of Willis during flow reversal; ideally placed and calibrate while patient is awake.

- Intraoperative ACT monitoring during heparinization (target 250-350; verify goal with surgical team)

=== Induction and airway management ===
- If planning on MAC with natural airway & superficial cervical plexus block, consider sedation with remifentanil infusion.

GA: Slow controlled induction, goal to maintain BP at baseline to prevent decreased cerebral perfusion

=== Positioning ===
- Supine, neck extended, shoulder roll, head turned away from surgical site

=== Maintenance and surgical considerations ===
TIVA/Balanced anesthetic/inhalational anesthetic are reasonable

Have clear communication with the surgical team about what stage of the surgery they are in, critical for BP management/patient safety during a TCAR.

- Surgical Exposure: maintain BP at baseline or slightly higher

- Carotid Balloon Inflation: Can cause Bradycardia/asystole due to proximity near carotid baroreceptors. Give preventative glycopyrrolate (unless patient has contraindications to having a further elevated HR; baseline HR > 90 or severe CAD)

- Flow Reversal: Maintain SBP >160 or 20% above baseline SBP to aid perfusion via Circle of Willis. Closely monitor cerebral oximeter (rSO2) during this time.

- Stent Deployment: Risk for acute cerebral hyperperfusion. Stop vasopressors, have closed loop communication about BP goal with surgical team and give push vasoactive medications as needed to meet goals (commonly SBP 110-140). Not uncommon to require boluses of nitroglycerin/esmolol/nicardipine to achieve this rapidly

- During Closing, post-stent Hypotension is common due to persistent carotid baroreceptor stimulation and may require vasopressor support to insure adequate cerebral perfusion until hemodynamics stabilize.

=== Emergence ===
- Avoid bucking due to neck incision & carotid artery puncture.

- Consider remifentanil, dexmedetomidine, or appropriate opioid titration prior to emergence

== Postoperative management ==

=== Disposition ===
- PACU -> IMC for close neurologic and hemodynamic monitoring

=== Pain management ===
- Opioids

- Regional anesthesia

=== Potential complications ===

* Embolic stroke : during exposure or due to insufficient flow reversal
* Stroke due to hypoperfusion / insufficient collateral flow via Circle of Willis; watershed infarct
* Bleeding due to catheter dislodgement: higher risk during MAC as opposed to GA
* Reperfusion injury: ipsilateral ACA/MCA distribution now seeing higher pressure and flow since no longer obstructed by stenotic segment of carotid artery. Stroke like syndrome which can manifest as encephalopathy or unilateral sensory / motor deficits, seizure, or rarely, intracranial hemorrhage

*

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|Supine
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==
1.) Columbo JA, Martinez-Camblor P, O’Malley AJ, et al. Association of Adoption of Transcarotid Artery Revascularization With Center-Level Perioperative Outcomes. ''JAMA Netw Open.'' 2021;4(2):e2037885. doi:10.1001/jamanetworkopen.2020.37885

2.) Ankam A, Kinthala S, Madabhushi P. Anesthetic Considerations for Transcarotid Artery Revascularization: Experience and Review of Forty Cases From a Single Medical Center. Cureus. 2020 Dec 24;12(12):e12250. doi: 10.7759/cureus.12250. PMID: 33505816; PMCID: PMC7822093.

3.) Silk Road Medical. TCAR surveillance project. Accessed January 1, 2020. <nowiki>https://silkroadmed.com/tcar-surveillance-project/</nowiki>
[[Category:Surgical procedures]]

Transcarotid Artery Endovascular Revascularization

2022-11-10T18:59:30Z

Ajaksic1:

{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Also referred to as a TCAR, a transcarotid artery endovascular revascularization is an alternative to carotid endarterectomy for the management of carotid stenosis in patients who are determined to be poor open repair candidates based on high surgical risk or lesion location (distal lesions). Transcarotid artery revascularization (TCAR) is an alternative to trans-femoral stenting and is meant to decrease the risk for micro-embolic strokes through flow reversal through the carotid during stent placement (see below).

Goal: Restoring laminar blood flow through a stenotic carotid artery narrowed by atherosclerotic or neointimal hyperplastic disease.

== Overview ==

=== Surgical procedure: ===
The common carotid artery (CCA) is exposed via a small incision superior to the clavicle.

A flexible sheath is inserted into the CCA proximal to the lesion being stented and the distal end (outside the vessel) is connected to a flow reversal system (FRS).

At the same time the femoral vein is also being accessed either percutaneously or via surgical exposure, and a 2nd flexible sheath is inserted. The extraluminal end of the femoral sheath is attached to the other end of the flow reversal system (FRS).

Once connected blood flow from the high pressure CCA to the low pressure femoral vein through the FRS. After flow reversal wires are threaded past the lesion, if indicated pre-dilation of the vessel with balloon angioplasty occurs at this time, followed by deployment of the intralumenal stent. The FRS acts as a filter removing any plaques or disrupted intralumenal, decreasing the risk of micro-embolic strokes.

After successful placement, flow reversal is turned off and blood flow resumes in its normal direction. Sheaths removed and arteriotomy closed.

Video with overview of steps: TCAR | TransCarotid Artery Revascularization Procedure Narrated Animation | Silk Road Medical | https://www.youtube.com/watch?v=MI2s4rv0dJA

=== Indications: ===
Stent placement is preferred to carotid endarterectomy if the patient have ANY of a number of comorbid medical disease or anatomical factors (see below) that would complicate the hemodynamic management intraoperatively putting the patient at elevated risk for CV complications (hemodynamic instability / vasoplegia, MI, stroke, arrhythmia, etc) or surgical/airway access.

Medical:

* Age > 75
* Congestive Heart Failure
* LVEF < 35%
* >2 diseased coronaries w/ 70% stenosis
* Unstable angina or abnormal stress test
* MI within 6 weeks
* Need for additional open heart surgery
* Need for major surgery (including vascular)
* Uncontrolled diabetes
* Severe pulmonary disease
Anatomic:

*Prior head/neck surgery or irradiation
* Spinal immobility
* Restenosis post carotid endarterectomy (CEA)
* Surgically inaccessible lesion
* Laryngeal palsy; Laryngectomy
* Permanent contralateral cranial nerve injury
* Contralateral occlusion
* Severe tandem lesions
* Bilateral stenosis requiring treatment

== Preoperative management ==

=== Patient evaluation:===
Assess for the listed conditions/diseases above.
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Neck mobility, ability to tolerated surgical positioning. Prior neck radiation
|-
|Neurologic
|Baseline neurologic exam, post operatively at risk for micro-embolic strokes. Assess if carotid stenosis is symptomatic (see below)
|-
|Cardiovascular
|Exercise tolerance, assess for listed cardiovascular comorbid diseases above
|-
|Pulmonary
|Exercise tolerance
|-
|Gastrointestinal
|
|-
|Hematologic
|Ensure taking dual anti-platelet therapy per surgical team's directions
|-
|Renal
|Current volume status, relative hypovolemia may adversely affect ability to induce HTN during flow reversal
|-
|Endocrine
|Check BG
|-
|Other
|
|}
- Symptomatic Carotid Stenosis: Stroke or TIA referable to the appropriate carotid artery distribution within the previous six months AND carotid stenosis > 50%.

- Asymptomatic Carotid Stenosis: Atherosclerotic narrowing of the extracranial ICA (>80%) without recent stroke or TIA (Of note, vertigo and syncope are not typical manifestations)

=== Labs and studies ===
All carotid surgeries are considered high-risk & pre-surgical testing should follow AHA/ACA guidelines for high-risk noncardiac surgery.

* CBC, electrolytes, creatinine, PT/INR/aPTT
* T&C; consider requesting to have 2 units of pRBC on hold
* 12 lead EKG
* Consider Stress Test (exercise or pharmacology) if:
** Poor or unknown functional status
** Calculated risk for major adverse cardiovascular events (MACE) is >1% on the VQI or NSQIP calculator
* TTE if concerned for CHF, pulmonary HTN, or valvular disease (may impair ability to safely induce needed hypertension intraoperatively)
* Per surgical team's preference either CT angiogram v Carotid ultrasound to define anatomy

=== Operating room setup ===
TCAR can be preformed under GA or MAC with regional anesthesia

If planning to use MAC, have supplies for full conversion to GA

Have appropriate vasoactive medication available quickly titrate blood pressure intraoperatively

- Push Medications: consider Nitroglycerin, Epinephrine, Phenylephrine

- Prepared Drips: Norepinephrine (or preferred short acting pressor), can consider supplies for vasodilatory drip in room

Run lines & monitors outside of fluoroscopy path to optimize surgical field

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===
Superficial Cervical Plexus Block

- With block procedure can be preformed with MAC

- Benefit in GA cases by decreasing opioid requirement, allows for more rapid neurologic assessment postoperatively

== Intraoperative management ==

=== Monitoring and access ===
- Standard ASA monitors, 5 lead EKG

- Pre-induction arterial line

- PIV x 2 (note vasoactive medications will be in PIVs, make sure lines are stable/running well)

- Cerebral oximetry to monitor adequacy of collateral circulation via the Circle of Willis during flow reversal

- Intraoperative ACT monitoring during heparinization (target 250-350; verify goal with surgical team)

=== Induction and airway management ===
If planning on MAC with natural airway & superficial cervical plexus block, consider sedation with remifentanil infusion

=== Positioning ===
Supine with head turned contralateral to site of planned procedure

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===
- Micro-embolic stroke; check neurologic exam

-

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|Supine
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==
1.) Columbo JA, Martinez-Camblor P, O’Malley AJ, et al. Association of Adoption of Transcarotid Artery Revascularization With Center-Level Perioperative Outcomes. ''JAMA Netw Open.'' 2021;4(2):e2037885. doi:10.1001/jamanetworkopen.2020.37885

2.) Ankam A, Kinthala S, Madabhushi P. Anesthetic Considerations for Transcarotid Artery Revascularization: Experience and Review of Forty Cases From a Single Medical Center. Cureus. 2020 Dec 24;12(12):e12250. doi: 10.7759/cureus.12250. PMID: 33505816; PMCID: PMC7822093.

3.) Silk Road Medical. TCAR surveillance project. Accessed January 1, 2020. <nowiki>https://silkroadmed.com/tcar-surveillance-project/</nowiki>
[[Category:Surgical procedures]]

Transcarotid Artery Endovascular Revascularization

2022-11-10T13:46:59Z

Ajaksic1:

Transcarotid Artery Endovascular Revascularization

2022-11-10T12:58:47Z

Ajaksic1: (Just an interval save, wrote this article yesterday & did not save by mistake...trying to not repeat mistake)

Arterial line

2022-08-18T16:43:28Z

Ajaksic1: A significant amount

Indications:

Hemodynamic monitoring in specific circumstances including
- Expected significant blood loss (multilevel spine, trauma, major ortho surg)
- Clinically unstable patients (severe or labile hypertension or hypotension with concern for sepsis, cardiogenic shock, ect)
- Surgical need for tight BP control (neurosurgical/vascular procedures; CNS aneurysm coiling, carotid surg)
- Measurement of MAP crucial to derive cerebral perfusion pressure or coronary perfusion pressure (CPP): Neurosurgery, cardiac, beach-chair, semi-Fowler's ENT

Frequent blood sampling for blood gas analysis &/or diagnostic tests to guide intraoperative management (electrolytes, iCal, Lactic acid, Hb, coagulation studies, TEG, ACT, PTH, ect)

Unable to obtain a non-invasive blood pressure or NIBP ineffective/impractical
- Morbidly obese patients where NIBP cuff pressures are unreliable
- Significant concern for NlBP cuff trauma; patient with very low PLT count or high INR
- Cases where arm positioning make cuff potentially traumatic to med nerve (thoracotomy)

Contraindications:
- Abnormal Allen's test
- Infection at desired site
- Thrombus or traumatic injury at or proximal to desired site
- Altered anatomy at desired site (AV fistula, vascular graft, prior surgeries)
- Active Raynaud syndrome or thromboangiitis obliterans (particularly in radial)

Common Arterial Line Supplies:
- Towel rolled into a cylinder (placed under the hand to put the wrist into extension)
- Chlorhexidine prep
- Sterile Gloves
- Sterile towels/covering
- Transparent dressing
- Sterile gauze
- Plastic tape
- Pre-flushed A-line tubing with 3 Way Stopcock & sterile 10cc NS syringe attached
- Arterial Catheter (common brands; Arrow, Angiocatheter; note size & gage vary depending on the artery you are trying to cannulate)
(roll 1 into wrist support)
- +/- US Gel & probe cover
- +/- benzoin adhesive

Preparation:
- Check collateral perfusion with Allen test:
* compress ulnar/radial, have patient make fist until hand blanches; release ulnar or radial compression, if blanching resolves within 5sec reassuring allens test. Repeat releasing the other artery.
- 1% Lidocaine with 27-30g needle if pre-induction a-line planned
- Optimize Ergonomics (Bed Height)
- Position Wrist placed rolled up towel under wrist to put into dorsiflexion (brings radial artery closer to skin) & secure hand to arm-board or other surface
- Sterilize field with Chlorhexidine stick
- Put on sterile gloves then place sterile drape/towels around wrist keeping only the cleaned skin in view
- If self contained or Integrated Arterial Catheter, check to make sure wire threads smoothly

Blind Approach:
- Locate pulse Palpate w/ Tips of Finger (not pads) & trace trajectory
- Holding the arterial catheter like a pencil Bevel UP insert the needle at a 30-45° angle
- Advance until flash with pulsatile blood or if no flash widthdraw needle without exiting skin and either change the angle of approach or fan medially or laterally based on the patients anatomy until you have pulsatile flash.
- Once (+) blood return flatten angle to 10-15° & advance slightly to remain within lumen of vessel
If using Angiocatheter:
- Remove introducer leaving catheter in place if continues to have pulsatile flow threat guidewire
- NOTE: Guidewire should thread smoothly. Stop if meeting resistance at risk of dissecting artery wall
If using Integrated Arterial Catheter (Arrow):
- ***

- After guidewire in place thread the catheter over the wire into the vessel (commonly a twisting motion is used)
- Once catheter in vessel, hold proximal pressure and remove guidewire (pulsatile flow)
- Connect prepared a-line tubing w/ stopcock off to PT (NO Bubbles)
- Open stopcock to patient and draw back until blood in syringe & flush (be careful to NEVER inject bubbles through an A-line)
- Turn stopcock off to patient, hold catheter in place at skin & carefully clean site of blood/gel then apply dressing
- Connect arterial line transducer, level & zero

(incomplete)

'''Practical Skills'''
Drawing Labs Off A-line:
-

Arterial line

2022-08-18T15:20:08Z

Ajaksic1: Started A-line page. Indications written. more to come

Electroconvulsive therapy

2021-08-22T02:24:34Z

Ajaksic1:

# Background:<ref name=":0">{{Cite book|last=Murray, Michael J, Steven H. Rose, Denise J. Wedel, C T. Wass, Barry A. Harrison, and Jeff T. Mueller.|first=|title=Faust's Anesthesiology Review|publisher=|year=2015|isbn=|location=Print|pages=Anesthesia for Electroconvulsive Therapy; 490-492}}</ref><ref name=":1">{{Cite book|last=Pardo, Manuel, Ronald D Miller|first=|title=Basics of Anesthesia 7th Edition|publisher=|year=2017|isbn=0323401155|location=Print|pages=669-671}}</ref>
#* Seizures induced by ECT are generalized seizures that consist of a 2 to 3 second latent phase is followed by a tonic (prolonged muscular contraction) phase lasting 10 to 12 seconds, then a clonic (repeated contraction) phase of 30 to 50 seconds.
#* Seizure duration monitored by EEG; goal seizure duration 30-60 seconds. If seizure > 120s consider termination with midazolam/propofol.
#* Initial session may require a dose titration to determine the appropriate electrical stimulus to evoke a seizure.
#* Configuration of electrode placement: Left unilateral, Right unilateral (most common, fewer memory side effects), & Bifrontal
#* Both the duration of individual seizure & cumulative seizure time between treatments correlated w/ clinical improvement of depression. Total # of treatments determined by Pt’s clinical response.
#* Repeated rounds of ECT ↑ seizure threshold (try to decrease dose of methohexital or other induction agent if possible to limit size of electrical charge administered)
# Morbidity and Mortality Rates:<ref name=":0" />
#* Mortality risk <1 in 75,000 treatments.
#* Most common adverse events: Transient arrhythmias (10%–40%), gastric aspiration (2.5%), & MSK disorders (0.4%), including fractures.
#* Additional adverse events: Pulmonary edema, HA, memory disturbance, & agitation. Very rarely takotsubo cardiomyopathy, febrile reactions, or neurologic dysfunction may occur.
# Indications:<ref name=":1" /><ref name=":2">{{Cite web|last=ACCRAC|date=2019-03-13|title=Episode 112: Anesthesia for ECT with Christina Miller|url=http://accrac.com/episode-112-anesthesia-for-ect-with-christina-miller/|access-date=2021-08-22|website=ACCRAC Podcast|language=en}}</ref>
#* Refractory Depression (unipolar and bipolar types), Depression with Psychotic features, Catatonia, and schizophrenia
# ABSOLUTE Contraindications:<ref name=":0" /><ref name=":2" />
#* Untreated Pheochromocytoma
#* Intracranial mass/↑ ICP
#* Recent MI or Stroke w/in last 30 days
# Relative Contraindications:<ref name=":0" />
#* Angina pectoris, CHF
#* COPD
#* Glaucoma, Retinal detachment
#* High-risk pregnancy
#* Severe osteoporosis (fracture risk)
#* Thrombophlebitis
# Physiologic Changes:<ref name=":0" /><ref name=":2" />
#* ECT stimulus -> short initial parasympathetic response caused by vagal nerve stimulation followed by a large sympathetic discharge
#* ''Cardiovascular''
#** 1st: Parasympathetic response may cause '''asystole''', bradycardia, PVCs, '''hypotension''', & ventricular escape rhythm.
#***''If known profound parasympathetic response, can blunt w/ glycopyrrolate pre-induciton''
#** 2nd: Sympathetic tone ↑ with seizure generation -> ↑ HR, PVCs, bigeminy, trigeminy, sinus tachycardia, '''ST segment changes''' (↑ myocardial O2 consumption) & '''severe HTN'''.
#*** Often resolves quickly, but if Pt requires intervention consider nitroglycerin, esmolol, or labetalol
#* ''Respiratory'': Parasympathetic discharge -> at risk for laryngospasm, bronchoconstriction/wheezing
#* ''Neuro:'' Initial constriction of cerebral vessels is followed by ↑ cerebral blood flow (1.5–7 times baseline) secondary to ↑ cerebral O2 consumption & ↑BP -> ↑ICP
#* ''Neuroendocrine'': ↑ corticotropin, cortisol, & catecholamines.
#** Effects on glucose levels vary; consider Pre/Post glucose in insulin dependent patients.
#* ''GI'': ↑ intragastric pressure
#* ''Eye'': ↑ intraocular pressure
# Pre-Induction Considerations: <ref name=":0" /><ref name=":1" /><ref name=":2" />
#* ''Medication Management'':
#** Can continue MAO inhibitors, TCAs, SSRIs, & antipsychotics w/ ECT
#** MAO Inhibitors: Avoid ephedrine (indirect-acting sympathomimetics cause exaggerated BP). Be aware they ↓ plasma cholinesterase activity → ↑ succinylcholine duration
#** Lithium – Risk for delayed awakening, memory loss, and postictal confusion. Hold for 12hr before ECT
#** ''Benzodiazepines'' – Hold for 12hr before ECT. May need to give flumazenil before ECT to have an adequate seizure duration.
#* ''Pacemaker vs Implantable Cardioverter-Defibrillator (ICD)'':
#** Pacemaker
#*** If ''Not'' dependent on the device, a magnet should be available in event of device failure.
#*** If Dependent on pacemaker, program device to asynchronous mode & a backup pacing mode should be available.
#** ICD:
#*** Risk that the device misinterprets muscle movements as an abnormal cardiac rhythm and a discharge is possible.
#*** Device should be deactivated & an external defibrillator should be immediately available with placement of external defibrillator pads strongly considered.
#** For a patient with an ICD & who is pacemaker dependent, the EP service should be consulted or in any other cases with pacing concerns.
# Position: Supine or with HOB elevated
# Monitors: Standard ASA monitors with 5 lead ECG. Single lead EEG
# Access: PIV x 1
# Management of Induction & Seizure Sequelae: <ref name=":0" /><ref name=":1" /><ref name=":2" />
##'''Induction''':
##* Methohexital (Brevital) 0.5 to 1 mg/kg; least effect on Sz threshold
##* Etomidate: 0.2 to 0.3 mg/kg; maintains hemodynamic stability
##* Propofol: ↑ seizure threshold & ↓ seizure duration. Need higher stimulus voltages to achieve adequate seizure. ''May be useful in patients with history of long seizures''.
##* Ketamine: can cause post-ECT confusion.
##* Remifentanil 200-400 mcg as an adjunct to lower dose of methohexital needed; net '''↓''' Sz threshold. Monitor for ↓HR/↓BP & chest wall rigidity. If unable to ventilate or very small TV, consider succinylcholine.
##* Sevoflurane can be used for inhalational induction when no IV access possible.
## '''Paralytic''':
### Succinylcholine 1- 1.5 mg/kg, titrate to adequate paralysis
### Rocuronium - Low dose & only if patient has contraindication to succinylcholine (reverse with sugammadex)
## '''Initial PARAsympathetic discharge''':
### Glycopyrrolate 0.2mg to prevent bradycardia. Usually given prior to induction agents
## '''Subsequent Sympathetic discharge''':
### Nitroglycerin &/or Beta blockers (esmolol, labetalol) can be used to attenuate sympathetic response.
### ''Hyperglycemia'' often seen in insulin dependent Pt -> BG Pre/Post
## '''Post-ECT Delirium''' (or if flumazenil given pre-induction):
### Midazolam 1-2mg
# General Procedural Steps: <ref name=":1" /><ref name=":2" />
## Pre-oxygenate well prior to induction
## Once induction medications given & patient unconscious start mask ventilating & give paralytic
## Hyperventilate -> Hypocarbia (↓ seizure threshold)
## Bite guard placed prior to ECT initiation
## After ECT & seizure completed remove bite guard and provide supportive airway management until patient regains consciousness.
#

Electroconvulsive therapy

2021-08-22T02:19:40Z

Ajaksic1:

# Background:<ref name=":0">{{Cite book|last=Murray, Michael J, Steven H. Rose, Denise J. Wedel, C T. Wass, Barry A. Harrison, and Jeff T. Mueller.|first=|title=Faust's Anesthesiology Review|publisher=|year=2015|isbn=|location=Print|pages=Anesthesia for Electroconvulsive Therapy; 490-492}}</ref><ref name=":1">{{Cite book|last=Pardo, Manuel, Ronald D Miller|first=|title=Basics of Anesthesia 7th Edition|publisher=|year=2017|isbn=0323401155|location=Print|pages=669-671}}</ref>
#* Seizures induced by ECT are generalized seizures that consist of a 2 to 3 second latent phase is followed by a tonic (prolonged muscular contraction) phase lasting 10 to 12 seconds, then a clonic (repeated contraction) phase of 30 to 50 seconds.
#* Seizure duration monitored by EEG; goal seizure duration 30-60 seconds. If seizure > 120s consider termination with midazolam/propofol.
#* Initial session may require a dose titration to determine the appropriate electrical stimulus to evoke a seizure.
#* Configuration of electrode placement: Left unilateral, Right unilateral (most common, fewer memory side effects), & Bifrontal
#* Both the duration of individual seizure & cumulative seizure time between treatments correlated w/ clinical improvement of depression. Total # of treatments determined by Pt’s clinical response.
#* Repeated rounds of ECT ↑ seizure threshold (try to decrease dose of methohexital or other induction agent if possible to limit size of electrical charge administered)
# Morbidity and Mortality Rates:<ref name=":0" />
#* Mortality risk <1 in 75,000 treatments.
#* Most common adverse events: Transient arrhythmias (10%–40%), gastric aspiration (2.5%), & MSK disorders (0.4%), including fractures.
#* Additional adverse events: Pulmonary edema, HA, memory disturbance, & agitation. Very rarely takotsubo cardiomyopathy, febrile reactions, or neurologic dysfunction may occur.
# Indications:<ref name=":1" /><ref name=":2">{{Cite web|last=ACCRAC|date=2019-03-13|title=Episode 112: Anesthesia for ECT with Christina Miller|url=http://accrac.com/episode-112-anesthesia-for-ect-with-christina-miller/|access-date=2021-08-22|website=ACCRAC Podcast|language=en}}</ref>
#* Refractory Depression (unipolar and bipolar types), Depression with Psychotic features, Catatonia, and schizophrenia
# ABSOLUTE Contraindications:<ref name=":0" /><ref name=":2" />
#* Untreated Pheochromocytoma
#* Intracranial mass/↑ ICP
#* Recent MI or Stroke w/in last 30 days
# Relative Contraindications:<ref name=":0" />
#* Angina pectoris, CHF
#* COPD
#* Glaucoma, Retinal detachment
#* High-risk pregnancy
#* Severe osteoporosis (fracture risk)
#* Thrombophlebitis
# Physiologic Changes:<ref name=":0" /><ref name=":2" />
#* ECT stimulus -> short initial parasympathetic response caused by vagal nerve stimulation followed by a large sympathetic discharge
#* ''Cardiovascular''
#** 1st: Parasympathetic response may cause '''asystole''', bradycardia, PVCs, '''hypotension''', & ventricular escape rhythm.
#***''If known profound parasympathetic response, can blunt w/ glycopyrrolate pre-induciton''
#** 2nd: Sympathetic tone ↑ with seizure generation -> ↑ HR, PVCs, bigeminy, trigeminy, sinus tachycardia, '''ST segment changes''' (↑ myocardial O2 consumption) & '''severe HTN'''.
#*** Often resolves quickly, but if Pt requires intervention consider nitroglycerin, esmolol, or labetalol
#* ''Respiratory'': Parasympathetic discharge -> at risk for laryngospasm, bronchoconstriction/wheezing
#* ''Neuro:'' Initial constriction of cerebral vessels is followed by ↑ cerebral blood flow (1.5–7 times baseline) secondary to ↑ cerebral O2 consumption & ↑BP -> ↑ICP
#* ''Neuroendocrine'': ↑ corticotropin, cortisol, & catecholamines.
#** Effects on glucose levels vary; consider Pre/Post glucose in insulin dependent patients.
#* ''GI'': ↑ intragastric pressure
#* ''Eye'': ↑ intraocular pressure
# Pre-Induction Considerations: <ref name=":0" /><ref name=":1" /><ref name=":2" />
#* ''Medication Management'':
#** Can continue MAO inhibitors, TCAs, SSRIs, & antipsychotics w/ ECT
#** MAO Inhibitors: Avoid ephedrine (indirect-acting sympathomimetics cause exaggerated BP). Be aware they ↓ plasma cholinesterase activity → ↑ succinylcholine duration
#** Lithium – Risk for delayed awakening, memory loss, and postictal confusion. Hold for 12hr before ECT
#** ''Benzodiazepines'' – Hold for 12hr before ECT. May need to give flumazenil before ECT to have an adequate seizure duration.
#* ''Pacemaker vs Implantable Cardioverter-Defibrillator (ICD)'':
#** Pacemaker
#*** If ''Not'' dependent on the device, a magnet should be available in event of device failure.
#*** If Dependent on pacemaker, program device to asynchronous mode & a backup pacing mode should be available.
#** ICD:
#*** Risk that the device misinterprets muscle movements as an abnormal cardiac rhythm and a discharge is possible.
#*** Device should be deactivated & an external defibrillator should be immediately available with placement of external defibrillator pads strongly considered.
#** For a patient with an ICD & who is pacemaker dependent, the EP service should be consulted or in any other cases with pacing concerns.
# Position: Supine or with HOB elevated
# Monitors: Standard ASA monitors with 5 lead ECG. Single lead EEG
# Access: PIV x 1
# Management of Induction & Seizure Sequelae: <ref name=":0" /><ref name=":1" /><ref name=":2" />
##'''Induction''':
##* Methohexital (Brevital) 0.5 to 1 mg/kg; least effect on Sz threshold
##* Etomidate: 0.2 to 0.3 mg/kg; maintains hemodynamic stability
##* Propofol: ↑ seizure threshold & '''↓''' seizure duration. Need higher stimulus voltages to achieve adequate seizure. ''May be useful in patients with history of long seizures''.
##* Ketamine: can cause post-ECT
##* Remifentanil 200-400 mcg as an adjunct to lower dose of methohexital needed; net '''↓''' Sz threshold. Watch out for chest wall rigidity (difficult to mask) give succinylcholine asap if unable to ventilate.
##* Sevoflurane can be used for inhalational induction when no IV access possible.
## '''Paralytic''':
### Succinylcholine 1- 1.5 mg/kg, titrate to adequate paralysis
### Rocuronium - Low dose & only if patient has contraindication to succinylcholine (reverse with sugammadex)
## '''Initial PARAsympathetic discharge''':
### '''Glycopyrrolate''' 0.2mg to prevent bradycardia. Usually given prior to induction agents
## '''Subsequent Sympathetic discharge''':
### Nitroglycerin &/or Beta blockers (esmolol, labetalol) can be used to attenuate sympathetic response.
### ''Hyperglycemia'' often seen in insulin dependent Pt -> BG Pre/Post
## '''Post-ECT delirium''' (or if flumazenil given Pre-Induction):
### Midazolam
# General Procedural Steps: <ref name=":1" /><ref name=":2" />
## Preoxygenate well prior to induction
## Once induction medications given & patient unconscious start mask ventilating & give paralytic
## Hyperventilate -> Hypocarbia (↓ seizure threshold)
## Bite guard placed prior to ECT initiation
## After ECT & seizure completed remove bite guard and provide supportive airway management until patient regains consciousness.

#

Electroconvulsive therapy

2021-08-22T02:16:07Z

Ajaksic1:

# Background:<ref name=":0">{{Cite book|last=Murray, Michael J, Steven H. Rose, Denise J. Wedel, C T. Wass, Barry A. Harrison, and Jeff T. Mueller.|first=|title=Faust's Anesthesiology Review|publisher=|year=2015|isbn=|location=Print|pages=Anesthesia for Electroconvulsive Therapy; 490-492}}</ref><ref name=":1">{{Cite book|last=Pardo, Manuel, Ronald D Miller|first=|title=Basics of Anesthesia 7th Edition|publisher=|year=2017|isbn=0323401155|location=Print|pages=669-671}}</ref>
#* Seizures induced by ECT are generalized seizures that consist of a 2 to 3 second latent phase is followed by a tonic (prolonged muscular contraction) phase lasting 10 to 12 seconds, then a clonic (repeated contraction) phase of 30 to 50 seconds.
#* Seizure duration monitored by EEG; goal seizure duration 30-60 seconds. If seizure > 120s consider termination with midazolam/propofol.
#* Initial session may require a dose titration to determine the appropriate electrical stimulus to evoke a seizure.
#* Configuration of electrode placement: Left unilateral, Right unilateral (most common, fewer memory side effects), & Bifrontal
#* Both the duration of individual seizure & cumulative seizure time between treatments correlated w/ clinical improvement of depression. Total # of treatments determined by Pt’s clinical response.
#* Repeated rounds of ECT ↑ seizure threshold (try to decrease dose of methohexital or other induction agent if possible to limit size of electrical charge administered)
# Morbidity and Mortality Rates:<ref name=":0" />
#* Mortality risk <1 in 75,000 treatments.
#* Most common adverse events: Transient arrhythmias (10%–40%), gastric aspiration (2.5%), & MSK disorders (0.4%), including fractures.
#* Additional adverse events: Pulmonary edema, HA, memory disturbance, & agitation. Very rarely takotsubo cardiomyopathy, febrile reactions, or neurologic dysfunction may occur.
# Indications:<ref name=":1" /><ref name=":2">{{Cite web|last=ACCRAC|date=2019-03-13|title=Episode 112: Anesthesia for ECT with Christina Miller|url=http://accrac.com/episode-112-anesthesia-for-ect-with-christina-miller/|access-date=2021-08-22|website=ACCRAC Podcast|language=en}}</ref>
#* Refractory Depression (unipolar and bipolar types), Depression with Psychotic features, Catatonia, and schizophrenia
# ABSOLUTE Contraindications:<ref name=":0" /><ref name=":2" />
#* Untreated Pheochromocytoma
#* Intracranial mass/↑ ICP
#* Recent MI or Stroke w/in last 30 days
# Relative Contraindications:<ref name=":0" />
#* Angina pectoris, CHF
#* COPD
#* Glaucoma, Retinal detachment
#* High-risk pregnancy
#* Severe osteoporosis (fracture risk)
#* Thrombophlebitis
# Physiologic Changes:<ref name=":0" /><ref name=":2" />
#* ECT stimulus -> short initial parasympathetic response caused by vagal nerve stimulation followed by a large sympathetic discharge
#* ''Cardiovascular''
#** 1st: Parasympathetic discharge may cause '''asystole''', bradycardia, PVCs, '''hypotension''', & ventricular escape rhythm.
#*** ''If known profound parasympathetic response, can blunt with a small dose of glycopyrrolate pre-induciton''
#** 2nd: Sympathetic tone increases with seizure generation
#*** Presents as increased HR, PVCs, bigeminy, trigeminy, sinus tachycardia, '''ST segment changes''' (↑ myocardial O2 consumption) & '''severe HTN'''.
#*** Often resolves quickly, but if Pt requires intervention, consider esmolol or labetalol for tachycardia or HTN
#* ''Respiratory'':
#** During initial parasympathetic discharge at risk for laryngospasm, bronchoconstriction/wheezing
#* ''Neuro'':
#** Initial constriction of cerebral vessels is followed by ↑ cerebral blood flow (1.5–7 times baseline) secondary to ↑ cerebral O2 consumption & elevated BP -> ↑ ICP
#* ''Neuroendocrine'':
#** ↑ corticotropin, cortisol, & catecholamines.
#** Effects on glucose levels vary; consider Pre/Post glucose in insulin dependent patients.
#* ''GI'': ↑ intragastric pressure
#* ''Eye'': ↑ intraocular pressure
# Pre-Induction Considerations: <ref name=":0" /><ref name=":1" /><ref name=":2" />
#* ''Medication Management'':
#** Can continue MAO inhibitors, TCAs, SSRIs, & antipsychotics w/ ECT
#** MAO Inhibitors: Avoid ephedrine (indirect-acting sympathomimetics cause exaggerated BP). Be aware they ↓ plasma cholinesterase activity → ↑ succinylcholine duration
#** Lithium – Risk for delayed awakening, memory loss, and postictal confusion. Hold for 12hr before ECT
#** ''Benzodiazepines'' – Hold for 12hr before ECT. May need to give flumazenil before ECT to have an adequate seizure duration.
#* ''Pacemaker vs Implantable Cardioverter-Defibrillator (ICD)'':
#** Pacemaker
#*** If ''Not'' dependent on the device, a magnet should be available in event of device failure.
#*** If Dependent on pacemaker, program device to asynchronous mode & a backup pacing mode should be available.
#** ICD:
#*** Risk that the device misinterprets muscle movements as an abnormal cardiac rhythm and a discharge is possible.
#*** Device should be deactivated & an external defibrillator should be immediately available with placement of external defibrillator pads strongly considered.
#** For a patient with an ICD & who is pacemaker dependent, the EP service should be consulted or in any other cases with pacing concerns.
# Position: Supine or with HOB elevated
# Monitors: Standard ASA monitors with 5 lead ECG. Single lead EEG
# Access: PIV x 1
# Management of Induction & Seizure Sequelae: <ref name=":0" /><ref name=":1" /><ref name=":2" />
##'''Induction''':
##* Methohexital (Brevital) 0.5 to 1 mg/kg; least effect on Sz threshold
##* Etomidate: 0.2 to 0.3 mg/kg; maintains hemodynamic stability
##* Propofol: ↑ seizure threshold & '''↓''' seizure duration. Need higher stimulus voltages to achieve adequate seizure. ''May be useful in patients with history of long seizures''.
##* Ketamine: can cause post-ECT
##* Remifentanil 200-400 mcg as an adjunct to lower dose of methohexital needed; net '''↓''' Sz threshold. Watch out for chest wall rigidity (difficult to mask) give succinylcholine asap if unable to ventilate.
##* Sevoflurane can be used for inhalational induction when no IV access possible.
## '''Paralytic''':
### Succinylcholine 1- 1.5 mg/kg, titrate to adequate paralysis
### Rocuronium - Low dose & only if patient has contraindication to succinylcholine (reverse with sugammadex)
## '''Initial PARAsympathetic discharge''':
### '''Glycopyrrolate''' 0.2mg to prevent bradycardia. Usually given prior to induction agents
## '''Subsequent Sympathetic discharge''':
### Nitroglycerin &/or Beta blockers (esmolol, labetalol) can be used to attenuate sympathetic response.
### ''Hyperglycemia'' often seen in insulin dependent Pt -> BG Pre/Post
## '''Post-ECT delirium''' (or if flumazenil given Pre-Induction):
### Midazolam
# General Procedural Steps: <ref name=":1" /><ref name=":2" />
## Preoxygenate well prior to induction
## Once induction medications given & patient unconscious start mask ventilating & give paralytic
## Hyperventilate -> Hypocarbia (↓ seizure threshold)
## Bite guard placed prior to ECT initiation
## After ECT & seizure completed remove bite guard and provide supportive airway management until patient regains consciousness.

#

Electroconvulsive therapy

2021-08-22T02:12:19Z

Ajaksic1:

# Background:<ref name=":0">{{Cite book|last=Murray, Michael J, Steven H. Rose, Denise J. Wedel, C T. Wass, Barry A. Harrison, and Jeff T. Mueller.|first=|title=Faust's Anesthesiology Review|publisher=|year=2015|isbn=|location=Print|pages=Anesthesia for Electroconvulsive Therapy; 490-492}}</ref><ref name=":1">{{Cite book|last=Pardo, Manuel, Ronald D Miller|first=|title=Basics of Anesthesia 7th Edition|publisher=|year=2017|isbn=0323401155|location=Print|pages=669-671}}</ref>
#* Seizures induced by ECT are generalized seizures that consist of a 2 to 3 second latent phase is followed by a tonic (prolonged muscular contraction) phase lasting 10 to 12 seconds, then a clonic (repeated contraction) phase of 30 to 50 seconds.
#* Seizure duration monitored by EEG; goal seizure duration 30-60 seconds. If seizure > 120s consider termination with midazolam/propofol.
#* Initial session may require a dose titration to determine the appropriate electrical stimulus to evoke a seizure, which requires an appropriate duration of anesthesia & neuromuscular blockade.
#* Configuration of electrode placement: Left unilateral, Right unilateral, & Bifrontal
#** Right unilateral most commonly used to minimize side effects of ECT (ex; short- term cognitive dysfunction)
#* Both the duration of individual Seizure & cumulative seizure time between treatments correlated with clinical improvement of depression. The total # of treatments determined by Pt’s clinical response.
#* Repeated rounds of ECT ↑ seizure threshold (try to decrease dose of methohexital or other induction agent if possible to limit size of electrical charge administered)
# Morbidity and Mortality Rates:<ref name=":0" />
#* Mortality risk <1 in 75,000 treatments.
#* Most common adverse events: Transient arrhythmias (10%–40%), gastric aspiration (2.5%), & MSK disorders (0.4%), including fractures.
#* Additional adverse events: Pulmonary edema, HA, memory disturbance, & agitation. Very rarely takotsubo cardiomyopathy, febrile reactions, or neurologic dysfunction may occur.
# Indications:<ref name=":1" /><ref name=":2">{{Cite web|last=ACCRAC|date=2019-03-13|title=Episode 112: Anesthesia for ECT with Christina Miller|url=http://accrac.com/episode-112-anesthesia-for-ect-with-christina-miller/|access-date=2021-08-22|website=ACCRAC Podcast|language=en}}</ref>
#* Refractory Depression (unipolar and bipolar types), Depression with Psychotic features, Catatonia, and schizophrenia
# ABSOLUTE Contraindications:<ref name=":0" /><ref name=":2" />
#* Untreated Pheochromocytoma
#* Intracranial mass/↑ ICP
#* Recent MI or Stroke w/in last 30 days
# Relative Contraindications:<ref name=":0" />
#* Angina pectoris, CHF
#* COPD
#* Glaucoma, Retinal detachment
#* High-risk pregnancy
#* Severe osteoporosis (fracture risk)
#* Thrombophlebitis
# Physiologic Changes:<ref name=":0" /><ref name=":2" />
#* ECT stimulus -> short initial parasympathetic response caused by vagal nerve stimulation followed by a large sympathetic discharge
#* ''Cardiovascular''
#** 1st: Parasympathetic discharge may cause '''asystole''', bradycardia, PVCs, '''hypotension''', & ventricular escape rhythm.
#*** ''If known profound parasympathetic response, can blunt with a small dose of glycopyrrolate pre-induciton''
#** 2nd: Sympathetic tone increases with seizure generation
#*** Presents as increased HR, PVCs, bigeminy, trigeminy, sinus tachycardia, '''ST segment changes''' (↑ myocardial O2 consumption) & '''severe HTN'''.
#*** Often resolves quickly, but if Pt requires intervention, consider esmolol or labetalol for tachycardia or HTN
#* ''Respiratory'':
#** During initial parasympathetic discharge at risk for laryngospasm, bronchoconstriction/wheezing
#* ''Neuro'':
#** Initial constriction of cerebral vessels is followed by ↑ cerebral blood flow (1.5–7 times baseline) secondary to ↑ cerebral O2 consumption & elevated BP -> ↑ ICP
#** Preoxygenation prevent cerebral hypoxia.
#* ''Neuroendocrine'':
#** ↑ corticotropin, cortisol, & catecholamines.
#** Effects on glucose levels vary; consider Pre/Post glucose in insulin dependent patients.
#* ''GI'': ↑ intragastric pressure
#* ''Eye'': ↑ intraocular pressure
# Pre-Induction Considerations: <ref name=":0" /><ref name=":1" /><ref name=":2" />
#* ''Medication Management'':
#** Can continue MAO inhibitors, TCAs, SSRIs, & antipsychotics w/ ECT
#** MAO Inhibitors: Avoid ephedrine (indirect-acting sympathomimetics cause exaggerated BP). Be aware they ↓ plasma cholinesterase activity → ↑ succinylcholine duration
#** Lithium – Risk for delayed awakening, memory loss, and postictal confusion. Hold for 12hr before ECT
#** ''Benzodiazepines'' – Hold for 12hr before ECT. May need to give flumazenil before ECT to have an adequate seizure duration.
#* ''Pacemaker vs Implantable Cardioverter-Defibrillator (ICD)'':
#** Pacemaker
#*** If ''Not'' dependent on the device, a magnet should be available in event of device failure.
#*** If Dependent on pacemaker, program device to asynchronous mode & a backup pacing mode should be available.
#** ICD:
#*** Risk that the device misinterprets muscle movements as an abnormal cardiac rhythm and a discharge is possible.
#*** Device should be deactivated & an external defibrillator should be immediately available with placement of external defibrillator pads strongly considered.
#** For a patient with an ICD & who is pacemaker dependent, the EP service should be consulted or in any other cases with pacing concerns.
# Position: Supine or with HOB elevated
# Monitors: Standard ASA monitors with 5 lead ECG. Single lead EEG
# Access: PIV x 1
# Management of Induction & Seizure Sequelae: <ref name=":0" /><ref name=":1" /><ref name=":2" />
## '''Induction''':
##* Methohexital (Brevital) 0.5 to 1 mg/kg; least effect on Sz threshold
##* Etomidate: 0.2 to 0.3 mg/kg; maintains hemodynamic stability
##* Propofol: ↑ seizure threshold & '''↓''' seizure duration. Need higher stimulus voltages to achieve adequate seizure. ''May be useful in patients with history of long seizures''.
##* Ketamine: can cause post-ECT
##* Remifentanil 200-400 mcg as an adjunct to lower dose of methohexital needed; net '''↓''' Sz threshold. Watch out for chest wall rigidity (difficult to mask) give succinylcholine asap if unable to ventilate.
##* Sevoflurane can be used for inhalational induction when no IV access possible.
## '''Paralytic''':
### Succinylcholine 1- 1.5 mg/kg, titrate to adequate paralysis
### Rocuronium - Low dose & only if patient has contraindication to succinylcholine (reverse with sugammadex)
## '''Initial PARAsympathetic discharge''':
### '''Glycopyrrolate''' 0.2mg to prevent bradycardia. Usually given prior to induction agents
## '''Subsequent Sympathetic discharge''':
### Nitroglycerin &/ot Beta blockers (esmolol, labetalol) can be used to attenuate sympathetic response.
### ''Hyperglycemia'' often seen in insulin dependent Pt -> BG Pre/Post
## '''Post-ECT delirium''' (or if flumazenil given Pre-Induction):
### Midazolam
# General Procedural Steps: <ref name=":1" /><ref name=":2" />
## Preoxygenate well prior to induction
## Once induction medications given & patient unconscious start mask ventilating & give paralytic
## Hyperventilate -> Hypocarbia (↓ seizure threshold)
## Bite guard placed prior to ECT initiation
## After ECT & seizure completed remove bite guard and provide supportive airway management until patient regains consciousness.

#

Electroconvulsive therapy

2021-08-22T02:10:54Z

Ajaksic1: Made public article

# Background:<ref name=":0">{{Cite book|last=Murray, Michael J, Steven H. Rose, Denise J. Wedel, C T. Wass, Barry A. Harrison, and Jeff T. Mueller.|first=|title=Faust's Anesthesiology Review|publisher=|year=2015|isbn=|location=Print|pages=Anesthesia for Electroconvulsive Therapy; 490-492}}</ref><ref name=":1">{{Cite book|last=Pardo, Manuel, Ronald D Miller|first=|title=Basics of Anesthesia 7th Edition|publisher=|year=2017|isbn=0323401155|location=Print|pages=669-671}}</ref>
#* Seizures induced by ECT are generalized seizures that consist of a 2 to 3 second latent phase is followed by a tonic (prolonged muscular contraction) phase lasting 10 to 12 seconds, then a clonic (repeated contraction) phase of 30 to 50 seconds.
#* Seizure duration monitored by EEG; goal seizure duration 30-60 seconds. If seizure > 120s consider termination with midazolam/propofol.
#* Initial session may require a dose titration to determine the appropriate electrical stimulus to evoke a seizure, which requires an appropriate duration of anesthesia & neuromuscular blockade.
#* Configuration of electrode placement: Left unilateral, Right unilateral, & Bifrontal
#** Right unilateral most commonly used to minimize side effects of ECT (ex; short- term cognitive dysfunction)
#* Both the duration of individual Seizure & cumulative seizure time between treatments correlated with clinical improvement of depression. The total # of treatments determined by Pt’s clinical response.
#* Repeated rounds of ECT ↑ seizure threshold (try to decrease dose of methohexital or other induction agent if possible to limit size of electrical charge administered)
# Morbidity and Mortality Rates:<ref name=":0" />
#* Mortality risk <1 in 75,000 treatments.
#* Most common adverse outcomes:Transient arrhythmias (10%–40%), gastric aspiration (2.5%), & MSK disorders (0.4%), including fractures.
#* Additional adverse events: Pulmonary edema, HA, memory disturbance, & agitation. Very rarely takotsubo cardiomyopathy, febrile reactions, or neurologic dysfunction may occur.
# Indications:<ref name=":1" /><ref name=":2">{{Cite web|last=ACCRAC|date=2019-03-13|title=Episode 112: Anesthesia for ECT with Christina Miller|url=http://accrac.com/episode-112-anesthesia-for-ect-with-christina-miller/|access-date=2021-08-22|website=ACCRAC Podcast|language=en}}</ref>
#* Refractory Depression (unipolar and bipolar types), Depression with Psychotic features, Catatonia, and schizophrenia
# ABSOLUTE Contraindications:<ref name=":0" /><ref name=":2" />
#* Untreated Pheochromocytoma
#* Intracranial mass/↑ ICP
#* Recent MI or Stroke w/in last 30 days
# Relative Contraindications:<ref name=":0" />
#* Angina pectoris, CHF
#* COPD
#* Glaucoma, Retinal detachment
#* High-risk pregnancy
#* Severe osteoporosis (fracture risk)
#* Thrombophlebitis
# Physiologic Changes:<ref name=":0" /><ref name=":2" />
#* ECT stimulus -> short initial parasympathetic response caused by vagal nerve stimulation followed by a large sympathetic discharge
#* ''Cardiovascular''
#** 1st: Parasympathetic discharge may cause '''asystole''', bradycardia, PVCs, '''hypotension''', & ventricular escape rhythm.
#*** ''If known profound parasympathetic response, can blunt with a small dose of glycopyrrolate pre-induciton''
#** 2nd: Sympathetic tone increases with seizure generation
#*** Presents as increased HR, PVCs, bigeminy, trigeminy, sinus tachycardia, '''ST segment changes''' (↑ myocardial O2 consumption) & '''severe HTN'''.
#*** Often resolves quickly, but if Pt requires intervention, consider esmolol or labetalol for tachycardia or HTN
#* ''Respiratory'':
#** During initial parasympathetic discharge at risk for laryngospasm, bronchoconstriction/wheezing
#* ''Neuro'':
#** Initial constriction of cerebral vessels is followed by ↑ cerebral blood flow (1.5–7 times baseline) secondary to ↑ cerebral O2 consumption & elevated BP -> ↑ ICP
#** Preoxygenation prevent cerebral hypoxia.
#* ''Neuroendocrine'':
#** ↑ corticotropin, cortisol, & catecholamines.
#** Effects on glucose levels vary; consider Pre/Post glucose in insulin dependent patients.
#* ''GI'': ↑ intragastric pressure
#* ''Eye'': ↑ intraocular pressure
# Pre-Induction Considerations: <ref name=":0" /><ref name=":1" /><ref name=":2" />
#* ''Medication Management'':
#** Can continue MAO inhibitors, TCAs, SSRIs, & antipsychotics w/ ECT
#** MAO Inhibitors: Avoid ephedrine (indirect-acting sympathomimetics cause exaggerated BP). Be aware they ↓ plasma cholinesterase activity → ↑ succinylcholine duration
#** Lithium – Risk for delayed awakening, memory loss, and postictal confusion. Hold for 12hr before ECT
#** ''Benzodiazepines'' – Hold for 12hr before ECT. May need to give flumazenil before ECT to have an adequate seizure duration.
#* ''Pacemaker vs Implantable Cardioverter-Defibrillator (ICD)'':
#** Pacemaker
#*** If ''Not'' dependent on the device, a magnet should be available in event of device failure.
#*** If Dependent on pacemaker, program device to asynchronous mode & a backup pacing mode should be available.
#** ICD:
#*** Risk that the device misinterprets muscle movements as an abnormal cardiac rhythm and a discharge is possible.
#*** Device should be deactivated & an external defibrillator should be immediately available with placement of external defibrillator pads strongly considered.
#** For a patient with an ICD & who is pacemaker dependent, the EP service should be consulted or in any other cases with pacing concerns.
# Position: Supine or with HOB elevated
# Monitors: Standard ASA monitors with 5 lead ECG. Single lead EEG
# Access: PIV x 1
# Management of Induction & Seizure Sequelae: <ref name=":0" /><ref name=":1" /><ref name=":2" />
## '''Induction''':
##* Methohexital (Brevital) 0.5 to 1 mg/kg; least effect on Sz threshold
##* Etomidate: 0.2 to 0.3 mg/kg; maintains hemodynamic stability
##* Propofol: ↑ seizure threshold & '''↓''' seizure duration. Need higher stimulus voltages to achieve adequate seizure. ''May be useful in patients with history of long seizures''.
##* Ketamine: can cause post-ECT
##* Remifentanil 200-400 mcg as an adjunct to lower dose of methohexital needed; net '''↓''' Sz threshold. Watch out for chest wall rigidity (difficult to mask) give succinylcholine asap if unable to ventilate.
##* Sevoflurane can be used for inhalational induction when no IV access possible.
## '''Paralytic''':
### Succinylcholine 1- 1.5 mg/kg, titrate to adequate paralysis
### Rocuronium - Low dose & only if patient has contraindication to succinylcholine (reverse with sugammadex)
## '''Initial PARAsympathetic discharge''':
### '''Glycopyrrolate''' 0.2mg to prevent bradycardia. Usually given prior to induction agents
## '''Subsequent Sympathetic discharge''':
### Nitroglycerin &/ot Beta blockers (esmolol, labetalol) can be used to attenuate sympathetic response.
### ''Hyperglycemia'' often seen in insulin dependent Pt -> BG Pre/Post
## '''Post-ECT delirium''' (or if flumazenil given Pre-Induction):
### Midazolam
# General Procedural Steps: <ref name=":1" /><ref name=":2" />
## Preoxygenate well prior to induction
## Once induction medications given & patient unconscious start mask ventilating & give paralytic
## Hyperventilate -> Hypocarbia (↓ seizure threshold)
## Bite guard placed prior to ECT initiation
## After ECT & seizure completed remove bite guard and provide supportive airway management until patient regains consciousness.

#