Difference between revisions of "Carotid endarterectomy"

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== Intraoperative management ==
== Intraoperative management ==
=== Monitoring and access <!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
=== Monitoring and access <!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
All patients getting CEA should have standard ASA monitors including pulse oximetry, ECG (5-lead is preferred over 3), non-invasive blood pressure, capnography, and temperature. Invasive blood pressure monitoring with an arterial line allows prompt vasopressor titration in response to changes in blood pressure, particularly if induced-hypertension is being used during carotid clamping. Invasive blood pressure monitoring is particularly useful during the immediate postoperative period to monitor for cerebral hyperperfusion syndrome.  
All patients require standard ASA monitors including pulse oximetry, ECG (5-lead is preferred over 3), non-invasive blood pressure, capnography, and temperature. Invasive blood pressure monitoring with an arterial line allows prompt vasopressor titration in response to changes in blood pressure, particularly if induced-hypertension is being used during carotid clamping. Invasive blood pressure monitoring is particularly useful during the immediate postoperative period to monitor for cerebral hyperperfusion syndrome.  
 
Neurologic monitoring including EEG, somatosensory evoked potentials (SSEPs), and motor evoked potentials (MEPs) may be used to assess cerebral perfusion. 


=== Induction and airway management <!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
=== Induction and airway management <!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
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Patients are positioned supine with the head turned away from operative site. Beach chair may be used for comfort in awake patients
Patients are positioned supine with the head turned away from operative site. Beach chair may be used for comfort in awake patients
=== Maintenance and surgical considerations <!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
=== Maintenance and surgical considerations <!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
Volatile anesthetics supplemented with opioids for analgesia and neuromuscular blockade is adequate for CEA without electrophysiologic monitoring (EP). For patients receiving EP monitoring, a total IV anesthetic with propofol and remifentanil provides excellent sedation and operating conditions. 
Heparin is required prior to carotid cross-clamping. The ACT goal is 200-250 seconds.
Carotid cross clamping may induce a severe vagal response with bradycardia and hypotension. Local anesthetic infiltration by the surgeon prior to cross clamping may improve this response. 
Unclamping can produce a reflex bradycardia and vasodilation effect


=== Blood Pressure Maintenance ===
=== Blood Pressure Maintenance ===
MAPs should be kept at or above the patient's awake MAP. A phenylephrine drip is a good choice because it's pure α-1 activity decreases the risk of arrhythmias.  
MAPs should be kept at or above the patient's awake MAP. A phenylephrine drip is a good choice because it's pure α-1 activity decreases the risk of arrhythmias. Wide swings in blood pressure should be expected during CEA. Sudden bradycardia may occur with associated hemodynamic instability, so atropine of glycopyrrolate should be available. 


=== Emergence <!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
=== Emergence <!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
Many surgeons prefer to verify neurologic status prior to extubation, but this must be weighed against the risk of surgical bleeding caused by coughing and bucking.


== Postoperative management ==
== Postoperative management ==
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=== Pain management <!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
=== Pain management <!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===


=== Potential complications <!-- List and/or describe any potential postoperative complications for this case. --> ===
=== Potential complications ===
Neurologic deficits may surface after emboli from plaque or shunts or from hypoperfusion during the procedure
 
Plaque removal during surgery may cause baroreceptor changes causing either hypotension or hypertension requiring vasoactive medications in the recovery unit


== Procedure variants <!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
== Procedure variants <!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

Revision as of 17:38, 2 July 2021

Carotid endarterectomy
Anesthesia type

GETA vs. regional anesthesia

Airway

Endotracheal Tube

Lines and access

PIV x 2 18 ga or larger is adequate

Monitors

Standard monitors, arterial line

Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
Article quality
Editor rating
Comprehensive
User likes
2

Carotid endarterectomy (CEA) is a surgical procedure for treating occlusive atherosclerotic disease involving the common and internal carotid arteries. The procedure is more effective than medical management for patients with high grade stenosis (70–99%), symptomatic moderate stenosis (50-69%), or asymptomatic high-grade stenosis (≥ 60%). CEA involves making a longitudinal incision along the anterior border of the sternocleidomastoid muscle to expose the common, internal, and external carotid arteries as well as the carotid sinus. The carotid artery is then opened and the atherosclerotic plaque is removed. Opening of the carotid artery requires occlusion of the proximal common carotid and distal internal and external carotid arteries, which requires adequate collateral flow from the contralateral common carotid artery or placement of an internal shunt between the proximal common carotid and the distal internal carotid arteries. On removal of the atherosclerotic plaque, the media and adventitia of the arteries may be re-approximated or a graft may be used. These grafts are typically synthetic, but vein grafts are occasionally used.

Preoperative management

Patient evaluation

System Considerations
Neurologic Evaluate plaque location and adequacy of collateral flow with carotid angiograms prior to surgery
Cardiovascular Preoperative ECG is useful as perioperative MI is the most common major postoperative complication. Uncontrolled hypertension or diabetes, as well as recent MI are reasons to delay the case.
Respiratory ABGs, Spirometry, and CXRs are useful only if otherwise indicated from the H&P
Hematologic Anti-platelet agents (typically aspirin) are typically initiated preoperatively and continued until the day of surgery to prevent perioperative thromboembolic complications.

Labs and studies

Operating room setup

Patient preparation and premedication

Premedication in CEA may complicate the immediate postoperative evaluation for stroke or TIA. Use of preoperative benzodiazepines and opioids should be limited. If a discussion of the operation and safety steps is inadequate to alleviate the patient's fear, a small dose of midazolam is preferred to opioid premedication.

Regional and neuraxial techniques

CEA may be performed under regional anesthesia be performing both superficial and deep cervical plexus blocks with supplemental field blocks by the surgeon. Patients receiving regional anesthesia for CEA have decreased ICU times and may have decreased need for surgical shunts. Regional anesthesia for CEA, however, does not provide cerebral protection afforded by general anesthesia and it makes conversion to GETA more challenging should the need arise.

Intraoperative management

Monitoring and access

All patients require standard ASA monitors including pulse oximetry, ECG (5-lead is preferred over 3), non-invasive blood pressure, capnography, and temperature. Invasive blood pressure monitoring with an arterial line allows prompt vasopressor titration in response to changes in blood pressure, particularly if induced-hypertension is being used during carotid clamping. Invasive blood pressure monitoring is particularly useful during the immediate postoperative period to monitor for cerebral hyperperfusion syndrome.

Neurologic monitoring including EEG, somatosensory evoked potentials (SSEPs), and motor evoked potentials (MEPs) may be used to assess cerebral perfusion.

Induction and airway management

If general anesthesia is chosen, endotracheal intubation is preferred over placing an LMA. Choice of induction medications is dependent on patient comorbidies, but caution should be used with ketamine as it increases CMRO2 at a time when cerebral blood flow is limited.

For patients undergoing regional anesthesia light sedation with midazolam, fentanyl, propofol, or dexmedetomidine is reasonable. Avoid heavy sedation as patient cooperation may be required for neurologic exam.

Positioning

Patients are positioned supine with the head turned away from operative site. Beach chair may be used for comfort in awake patients

Maintenance and surgical considerations

Volatile anesthetics supplemented with opioids for analgesia and neuromuscular blockade is adequate for CEA without electrophysiologic monitoring (EP). For patients receiving EP monitoring, a total IV anesthetic with propofol and remifentanil provides excellent sedation and operating conditions.

Heparin is required prior to carotid cross-clamping. The ACT goal is 200-250 seconds.

Carotid cross clamping may induce a severe vagal response with bradycardia and hypotension. Local anesthetic infiltration by the surgeon prior to cross clamping may improve this response.

Unclamping can produce a reflex bradycardia and vasodilation effect

Blood Pressure Maintenance

MAPs should be kept at or above the patient's awake MAP. A phenylephrine drip is a good choice because it's pure α-1 activity decreases the risk of arrhythmias. Wide swings in blood pressure should be expected during CEA. Sudden bradycardia may occur with associated hemodynamic instability, so atropine of glycopyrrolate should be available.

Emergence

Many surgeons prefer to verify neurologic status prior to extubation, but this must be weighed against the risk of surgical bleeding caused by coughing and bucking.

Postoperative management

Disposition

Pain management

Potential complications

Neurologic deficits may surface after emboli from plaque or shunts or from hypoperfusion during the procedure

Plaque removal during surgery may cause baroreceptor changes causing either hypotension or hypertension requiring vasoactive medications in the recovery unit

Procedure variants

Variant 1 Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References