Difference between revisions of "Carotid endarterectomy"
(I've started the surgical page on Carotid endarterectomy) |
|||
| Line 17: | Line 17: | ||
|- | |- | ||
|Neurologic | |Neurologic | ||
| | |Evaluate plaque location and adequacy of collateral flow with carotid angiograms prior to surgery | ||
|- | |- | ||
|Cardiovascular | |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 | |Respiratory | ||
| | |ABGs, Spirometry, and CXRs are useful only if otherwise indicated from the H&P | ||
|- | |- | ||
|Hematologic | |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 <!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | === Labs and studies <!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | ||
=== Operating room setup <!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | === Operating room setup <!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | ||
=== Patient preparation and premedication <!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | === Patient preparation and premedication <!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | ||
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 <!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | === Regional and neuraxial techniques <!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | ||
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 == | == Intraoperative management == | ||
| Line 53: | Line 44: | ||
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. --> === | ||
=== 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. | |||
=== 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. --> === | ||
Revision as of 22:37, 27 June 2021
| 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 | |
| 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
Induction and airway management
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
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.
Emergence
Postoperative management
Disposition
Pain management
Potential complications
Procedure variants
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |