Carotid endarterectomy - Revision history

Ezekiel.egan at 20:19, 14 October 2024

2024-10-14T20:19:17Z

← Older revision		Revision as of 13:19, 14 October 2024
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	* 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.		* 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.		* Sudden bradycardia may occur with associated hemodynamic instability, so atropine or glycopyrrolate should be available.
	*Hypertension is generally avoided after unclamping in order to limit wall stress on delicate arterial suture lines. Easily titratable, and short acting anti-hypertensives such as nitroglycerin, clevidipine, nicardipine, or sodium nitroprusside, should also be immediately available.		*Hypertension is generally avoided after unclamping in order to limit wall stress on delicate arterial suture lines. Easily titratable, and short acting anti-hypertensives such as nitroglycerin, clevidipine, nicardipine, or sodium nitroprusside, should also be immediately available.

Chris.Rishel: Elaborated on anticoagulation and hemodynamic management during cross clamping

2022-07-22T00:50:47Z

Elaborated on anticoagulation and hemodynamic management during cross clamping

← Older revision		Revision as of 17:50, 21 July 2022
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	* Volatile anesthetics supplemented with opioids for analgesia and neuromuscular blockade is adequate for CEA without electrophysiologic monitoring (EP).		* 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.		* 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.		* Heparin is required prior to carotid cross-clamping
	** ACT goal is 200-250 seconds or double the baseline value.		** ACT goal is 200-250 seconds or double the baseline value
	** Typical dose is 100 units/kg		** Typical dose is 100 units/kg
			**Recheck ACT every 30 minutes while cross clamped
	* 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.		* 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.
	* Consider induction of burst suppression immediately prior to clamping for neuroprotection		* Consider induction of burst suppression immediately prior to clamping for neuroprotection
	* Induced hypertension is commonly used to promote collateral perfusion during clamping		* Induced hypertension is commonly used to promote collateral perfusion during clamping
			**Typically MAP 90-110, though will vary depending on patient factors
	* Unclamping can produce a reflex bradycardia and vasodilation effect		* Unclamping can produce a reflex bradycardia and vasodilation effect
	* Reverse heparin with protamine after unclamping		* Reverse heparin with protamine after unclamping

StephenLFreiberg: Added note for anti hypertensive use, and strategies to limit coughing on emergence

2022-07-16T13:49:43Z

Added note for anti hypertensive use, and strategies to limit coughing on emergence

← Older revision		Revision as of 06:49, 16 July 2022
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	* Wide swings in blood pressure should be expected during CEA.		* 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.		* Sudden bradycardia may occur with associated hemodynamic instability, so atropine of glycopyrrolate should be available.
			*Hypertension is generally avoided after unclamping in order to limit wall stress on delicate arterial suture lines. Easily titratable, and short acting anti-hypertensives such as nitroglycerin, clevidipine, nicardipine, or sodium nitroprusside, should also be immediately 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		* Many surgeons prefer to verify neurologic status prior to extubation
	* Use caution to avoid coughing and bucking which can lead to neck hematoma formation, hypertension, and even hemorrhagic stroke during emergence		* Use caution to avoid coughing and bucking which can lead to neck hematoma formation, hypertension, and even hemorrhagic stroke during emergence.
			*Surgeons will often hold pressure over the neck incision during emergence and extubation.
			**Common strategies to limit coughing on emergence include using an laryngotracheal topical anesthesia (LTA) during intubation, using nitrous oxide prior to emergence, or performing a "remifentanil wakeup."

	== Postoperative management ==		== Postoperative management ==

Chris.Rishel: Text replacement - "Art line" to "Arterial line"

2022-04-05T19:40:06Z

Text replacement - "Art line" to "Arterial line"

← Older revision		Revision as of 12:40, 5 April 2022
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	\| monitors = Standard		\| monitors = Standard
	5-lead ECG		5-lead ECG
	~~Art~~ line		Arterial line
	± EEG		± EEG
	± Neuromonitoring		± Neuromonitoring

Chris.Rishel at 08:02, 5 April 2022

2022-04-05T08:02:59Z

← Older revision		Revision as of 01:02, 5 April 2022
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	[[Category:Surgical procedures]]		[[Category:Surgical procedures]]
			<references />
			[[Category:Neurosurgery]]
			[[Category:Vascular surgery]]

Chris.Rishel at 07:30, 5 April 2022

2022-04-05T07:30:02Z

← Older revision		Revision as of 00:30, 5 April 2022
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	{{Infobox surgical case reference		{{Infobox surgical case reference
	\| anesthesia_type = ~~GETA vs. regional anesthesia~~		\| anesthesia_type = General
	\| airway = ~~Endotracheal Tube~~		Regional/MAC
	\| lines_access = ~~PIV x 2 18 ga or larger is adequate~~		\| airway = ETT
	\| monitors = Standard ~~monitors, arterial~~ line		\| lines_access = Large bore IV x2
	\| considerations_preoperative =		\| monitors = Standard
	\| considerations_intraoperative =		5-lead ECG
	\| considerations_postoperative =		Art line
			± EEG
			± Neuromonitoring
			ACT
			\| considerations_preoperative = Evaluate neurologic deficits
			Consider CAD/MI risk
			\| considerations_intraoperative = Heparin anticoagulation
			Decrease CMRO2 during cross clamp
			\| considerations_postoperative = Avoid hypertension (risk of hyperperfusion syndrome)
			Monitor for neck hematoma
	}}'''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%).<ref>{{Cite journal\|last=Texakalidis\|first=Pavlos\|last2=Giannopoulos\|first2=Stefanos\|last3=Kokkinidis\|first3=Damianos G.\|last4=Karasavvidis\|first4=Theofilos\|last5=Rangel-Castilla\|first5=Leonardo\|last6=Reavey-Cantwell\|first6=John\|date=2018-12\|title=Carotid Artery Endarterectomy Versus Carotid Artery Stenting for Patients with Contralateral Carotid Occlusion: A Systematic Review and Meta-Analysis\|url=http://dx.doi.org/10.1016/j.wneu.2018.08.183\|journal=World Neurosurgery\|volume=120\|pages=563–571.e3\|doi=10.1016/j.wneu.2018.08.183\|issn=1878-8750}}</ref> 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.		}}'''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%).<ref>{{Cite journal\|last=Texakalidis\|first=Pavlos\|last2=Giannopoulos\|first2=Stefanos\|last3=Kokkinidis\|first3=Damianos G.\|last4=Karasavvidis\|first4=Theofilos\|last5=Rangel-Castilla\|first5=Leonardo\|last6=Reavey-Cantwell\|first6=John\|date=2018-12\|title=Carotid Artery Endarterectomy Versus Carotid Artery Stenting for Patients with Contralateral Carotid Occlusion: A Systematic Review and Meta-Analysis\|url=http://dx.doi.org/10.1016/j.wneu.2018.08.183\|journal=World Neurosurgery\|volume=120\|pages=563–571.e3\|doi=10.1016/j.wneu.2018.08.183\|issn=1878-8750}}</ref> 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.

Eeshwar.Chandrasekar at 01:38, 15 March 2022

2022-03-15T01:38:34Z

← Older revision		Revision as of 18:38, 14 March 2022
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	* Arterial line is required as it allows prompt vasopressor titration in response to changes in blood pressure, particularly if induced-hypertension is being used during carotid clamping.<ref name=":0">{{Citation\|last=Norris\|first=Edward J.\|title=Anesthesia for Vascular Surgery\|date=2010\|url=http://dx.doi.org/10.1016/b978-0-443-06959-8.00062-5\|work=Miller's Anesthesia\|pages=1985–2044\|publisher=Elsevier\|access-date=2021-10-23}}</ref>		* Arterial line is required as it allows prompt vasopressor titration in response to changes in blood pressure, particularly if induced-hypertension is being used during carotid clamping.<ref name=":0">{{Citation\|last=Norris\|first=Edward J.\|title=Anesthesia for Vascular Surgery\|date=2010\|url=http://dx.doi.org/10.1016/b978-0-443-06959-8.00062-5\|work=Miller's Anesthesia\|pages=1985–2044\|publisher=Elsevier\|access-date=2021-10-23}}</ref>
	** Invasive blood pressure monitoring is particularly useful during the immediate postoperative period to monitor for cerebral hyperperfusion syndrome.		** Invasive blood pressure monitoring is particularly useful during the immediate postoperative period to monitor for cerebral hyperperfusion syndrome.
			*Will require second arterial line transducer if surgeon measures stump pressures
	* Central access is not typically required.<ref>{{Cite journal\|last=Nelson\|first=Priscilla\|last2=Bustillo\|first2=Maria\|date=2021-03\|title=Anesthesia for Carotid Endarterectomy, Angioplasty, and Stent\|url=https://pubmed.ncbi.nlm.nih.gov/33563385/#:~:text=Nelson%20P,%20Bustillo%20M.%20Anesthesia%20for%20Carotid%20Endarterectomy,%20Angioplasty,%20and%20Stent.%20Anesthesiol%20Clin.%202021%20Mar;39(1):37-51.%20doi:%2010.1016/j.anclin.2020.11.006.%20Epub%202021%20Jan%208.%20PMID:%2033563385.\|journal=Anesthesiology Clinics\|volume=39\|issue=1\|pages=37–51\|doi=10.1016/j.anclin.2020.11.006\|issn=1932-2275\|pmid=33563385}}</ref>		* Central access is not typically required.<ref>{{Cite journal\|last=Nelson\|first=Priscilla\|last2=Bustillo\|first2=Maria\|date=2021-03\|title=Anesthesia for Carotid Endarterectomy, Angioplasty, and Stent\|url=https://pubmed.ncbi.nlm.nih.gov/33563385/#:~:text=Nelson%20P,%20Bustillo%20M.%20Anesthesia%20for%20Carotid%20Endarterectomy,%20Angioplasty,%20and%20Stent.%20Anesthesiol%20Clin.%202021%20Mar;39(1):37-51.%20doi:%2010.1016/j.anclin.2020.11.006.%20Epub%202021%20Jan%208.%20PMID:%2033563385.\|journal=Anesthesiology Clinics\|volume=39\|issue=1\|pages=37–51\|doi=10.1016/j.anclin.2020.11.006\|issn=1932-2275\|pmid=33563385}}</ref>

Chris.Rishel: Text replacement - "|Respiratory" to "|Pulmonary"

2022-02-22T05:45:50Z

Text replacement - "|Respiratory" to "|Pulmonary"

← Older revision		Revision as of 22:45, 21 February 2022
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	\|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.		\|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~~		\|Pulmonary
	\|ABGs, Spirometry, and CXRs are useful only if otherwise indicated from the H&P		\|ABGs, Spirometry, and CXRs are useful only if otherwise indicated from the H&P
	\|-		\|-

Chris.Rishel at 19:30, 19 January 2022

2022-01-19T19:30:01Z

← Older revision		Revision as of 12:30, 19 January 2022
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	** Typical dose is 100 units/kg		** Typical dose is 100 units/kg
	* 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.		* 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.
			* Consider induction of burst suppression immediately prior to clamping for neuroprotection
			* Induced hypertension is commonly used to promote collateral perfusion during clamping
	* Unclamping can produce a reflex bradycardia and vasodilation effect		* Unclamping can produce a reflex bradycardia and vasodilation effect
	* Reverse heparin with protamine		* Reverse heparin with protamine after unclamping
	** Typical dose is 5 mg/1000 units of heparin given		** Typical dose is 5 mg/1000 units of heparin given
	** Limited evidence supports waiting 10 minutes after unclamping to reverse<ref>{{Cite journal\|last=Ercius\|first=M. S.\|last2=Chandler\|first2=W. F.\|last3=Ford\|first3=J. W.\|last4=Burkel\|first4=W. E.\|date=1983-05\|title=Early versus delayed heparin reversal after carotid endarterectomy in the dog. A scanning electron microscopy study\|url=https://pubmed.ncbi.nlm.nih.gov/6834120\|journal=Journal of Neurosurgery\|volume=58\|issue=5\|pages=708–713\|doi=10.3171/jns.1983.58.5.0708\|issn=0022-3085\|pmid=6834120}}</ref>		** Limited evidence supports waiting 10 minutes after unclamping to reverse<ref>{{Cite journal\|last=Ercius\|first=M. S.\|last2=Chandler\|first2=W. F.\|last3=Ford\|first3=J. W.\|last4=Burkel\|first4=W. E.\|date=1983-05\|title=Early versus delayed heparin reversal after carotid endarterectomy in the dog. A scanning electron microscopy study\|url=https://pubmed.ncbi.nlm.nih.gov/6834120\|journal=Journal of Neurosurgery\|volume=58\|issue=5\|pages=708–713\|doi=10.3171/jns.1983.58.5.0708\|issn=0022-3085\|pmid=6834120}}</ref>

Chris.Rishel at 19:25, 19 January 2022

2022-01-19T19:25:09Z

← Older revision		Revision as of 12:25, 19 January 2022
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	* Unclamping can produce a reflex bradycardia and vasodilation effect		* Unclamping can produce a reflex bradycardia and vasodilation effect
	* Reverse heparin with protamine		* Reverse heparin with protamine
	** Typical dose is 0.5 mg/1000 units of heparin given		** Typical dose is 5 mg/1000 units of heparin given
	** Limited evidence supports waiting 10 minutes after unclamping to reverse<ref>{{Cite journal\|last=Ercius\|first=M. S.\|last2=Chandler\|first2=W. F.\|last3=Ford\|first3=J. W.\|last4=Burkel\|first4=W. E.\|date=1983-05\|title=Early versus delayed heparin reversal after carotid endarterectomy in the dog. A scanning electron microscopy study\|url=https://pubmed.ncbi.nlm.nih.gov/6834120\|journal=Journal of Neurosurgery\|volume=58\|issue=5\|pages=708–713\|doi=10.3171/jns.1983.58.5.0708\|issn=0022-3085\|pmid=6834120}}</ref>		** Limited evidence supports waiting 10 minutes after unclamping to reverse<ref>{{Cite journal\|last=Ercius\|first=M. S.\|last2=Chandler\|first2=W. F.\|last3=Ford\|first3=J. W.\|last4=Burkel\|first4=W. E.\|date=1983-05\|title=Early versus delayed heparin reversal after carotid endarterectomy in the dog. A scanning electron microscopy study\|url=https://pubmed.ncbi.nlm.nih.gov/6834120\|journal=Journal of Neurosurgery\|volume=58\|issue=5\|pages=708–713\|doi=10.3171/jns.1983.58.5.0708\|issn=0022-3085\|pmid=6834120}}</ref>
	** Confirm normalization of ACT		** Confirm normalization of ACT