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39 Cards in this Set

  • Front
  • Back
Unstable angina or current CHF Preoperative Intervention:
Coronary Angiography, strongly recommended
High risk heart cath Preoperative Intervention:
CABG, strongly recommended
1 or 2 vessel disease by CATH Preoperative Intervention:
PTCA/CABG/risk reducing stratigies--OPTIONAL
2-3 risk factors on basic evaluation Preoperative Intervention:
Dypridamole thallium scan or Dobutamine stress echocardiography--OPTIONAL
>4 risk factors on basic exam or strong positive DTS/DSE results Preoperative Intervention:
Inability to walk 2 blocks without claudication or cardiac s/s Preoperative Intervention:
Anesthetic Management of the Patient with PVD:
-Control Stress Response
-Avoid hyper/hypotension
-Avoid hypothermia
-Avoid anemia
-Maintain NSR with controlled rate
-Maximize supply and decrease demand
Postoperative Concerns for patient having vascular surgery:
-B/P, HR control
-Pain control
-Maintenance of intravascular fluid volumg
-Maintenance of nomrothermia
-Graft occlusion
Risk Factors for Hemorrhagic Stroke:
-Severe HTN
-Drug abuse
Risk Factors for Ischemic Stroke:
-Decreased blood pressure (systemic hypoperfusion)
-Carotid Disease (Embolism #1 cause of CVA in patients undergoing CEA)
-Heart Disease
Symptoms and severity of stroke depend on:
-Adequacy of collateral circulation
-Size & location of insult
-Presence of increased ICP
Indications for CEA:
-Syptomatic with >70% occlusion
-Asymptomatic with >60% stnosis
Flow Principles assoicated with carotid duplex U/S:
-U/S is 95% accurate, non-invasive, determines blood flow velocity
-Bernoulli's Law
-Poiseuille's Law
-Transitional Flow
-Turbulant Flow
Bernoulli's Law:
When solution flows thru a constricted region of a tube the velocity of flow increases and the pressure by the solution on the walls of the tube decreases
Poiseuille's Law:
-Laminar Flow, molecules at center of tube encounter least force and move at greater velocity (F=pressure gradient x 4th power of radius/viscosity x length; decrease the radius of a vessel by 1/2 then decrease flow by 16x)
-The 4th power of the radius has the most dramatic effect of flow
Turbulent Flow:
-Molecules of a solution are in a rough, tumbling pattern encountering the walls of the tube
-Flow becomes turbulent when: velocity is high, tube wall is rough, increased density of solution, change in tube diameter, kinks/bends in system
Transitional Flow:
Mixture of laminar and turbulent flow, occurs at branch points
External Carotid Artery perfuses:
-Facial artery
-Occipital artery
-Maxillary artery
-Lingual artery
-Superficial temporal artery
-Superior thyroid artery
Internal Carotid Artery perfuses:
-Middle cerebral artery
-Anterior cerebral artery
-Ophthalmic artery
Neurophysiology Regulation of Cerebral Blood Flow:
-Cerebral Perfusion Pressure
-Cerebral Vascular Autoregulation
-Carbon Dioxide
Cerebral Perfusion Pressure (CPP):
-Normal CPP = 80-100mmHg
-Normal Cerebral blood flow 50ml/100gm/min tissue
-CPP mainly dependent on MAP
-Slowing of EEG at CPP of 50mmHg
-Flat EEG at CPP of 25mmHg
Cerebral Vascular Autoregulation:
-Cerebral vascular dilates in presence of systemic hypotension
-Cerebral vascular constricts in presence of systemic HTN
-Cerebral autoregulation occurs between MAP 60-160mmHg
Effects of CO2 on Cerebral Blood Flow:
-Increased PaCO2 causes cerebral vascular dilation
-Decreased PaCO2 causes cerebral vascular constriction
Hypothermia effect on Cerebral Blood Flow:
-Cerebral blood flow changes 5-7% per degree Celsius
-hypothermia decreases both cerebral metabolic rate and cerebral blood flow
-Maintain mild hypothermia 33-35 degree for CEA
Intraoperative Monitoring during CEA:
-Standard Monitors
-Arterial Line
-EEG monitoring
-SSEP monitoring
-Stump pressures
-Transcranial doppler U/S
-IV/Intracarotid injection of xenon
-Cerebral oximetry
-Awake patient
Electroencephalographic monitoring (EEG)
gold standard, measures cortical structure integrity for GLOBAL ISCHEMIA,allows for selective shunting
-not great for focal ischemia, affected by anesthetic depth, expensive, tech to monitor, false +/-, no studies demonstrate decreases morbidity/mortality
SSEP monitoring:
monitors response of sensory cortex to electrical stimulation, posterior tibial nerve measures latency and amplitude
-controversial in how sensitive test is to measure ischemia, effected by anesthesia, no degree of increased latency or decreased amplitude that is indicitve of ischemia
Stump pressures:
measures back pressure from flow thru circle of Willis via contralateral carotid and veretebral arteries, cheap & easy
-critical low stump pressures unknown, 60mmHg is what want but <60mmHg doesn't mean perfusion inadequate, false +/-
Transcranial doppler U/S:
continous measurement of mean cerebral blood flow velocity, detects emboli that decrease blood flow and can give heparin/shunt
-probes on head, no studies,
Intravenous or intracarotid injection of xenon:
-measures cerebral blood flow before, during, after CEA by injecting Xenon and measure levels in brain with probes on head to see adequate blood flow
-expensive, expertise
BIS monitoring:
indirectly monitor cerebral blood flow by measuring cortical response, if constant level of anesthesia and suddenly decreased BIS then question event
Cerebral oximetry:
evaluates cerebral perfusion, measures O2 to cortex indirectly with sensors on head
-variabiltiy with this, no correlation between this and cerebral ischemia
Deep and superficial cervical plexus block:
Blocks C2-C4, may get ipsilateral phrenic nerve paralysis
Cranial Nerve VII:
Facial nerve, assess by smile/frown
Cranial Nerve IX:
Glossopharyngeal, assess by swallowing
Cranial Nerve X:
Vagus, controls laryngeal muscles, assess by speech;
say "e" means vocal cords closing correctly-RLN intact
Cranial Nerve XII:
Hypoglossal, assess by stick out tongue and move side to side
Postoperative Complications after CEA:
-Respiratory insufficiency
-Carotid body dysfunction
-RLN/SLN damage
-Hyperperfusion syndrome
-Postoperative stroke
Hyperperfusion syndrome:
-Associated with uncontrolled HTN, 2nd CEA, anticoagulation
-Unknown cause, increased blood flow as a r/o loss of cerebral autoregulation from cerebral ischemia, may be cushing reflex-output of catecholamines
-S/S: increased ICP, vision changes, h/a, seizures, ALOC, CVA, loss of motor control