Term
| Vascular surgery requires the _______ with resulting _____ which can cause organ damage and production of ______. |
|
Definition
| interruption of arterial blood flow, tissue ischemia, anaerobic metabolites. |
|
|
Term
| Clamping and unclamping of arteries causes changes in ________ and activation of _______. |
|
Definition
| left ventricular afterload, cardiovascular reflexes |
|
|
Term
| T/F: Patients undergoing major vascular surgery usually have underlying involvement of one or more organ systems. |
|
Definition
|
|
Term
| ________is the major factor of morbidity intraoperatively and postoperatively with vascular pts. |
|
Definition
|
|
Term
| ______is the most common etiology for peripheral vascular disease. |
|
Definition
|
|
Term
| plaques can develop into ________ or cause the __________. |
|
Definition
| total obstructive lesions, formation of connective tissue. |
|
|
Term
| Aneurism formation and dissection as well as emboli formation are the later stages of atherosclerosis where there is a loss of ______ that lead to _____. |
|
Definition
| arterial wall compliance, ulceration. |
|
|
Term
| List the 5 major arterial sites that are particularly susceptible to atherosclerotic lesions: _______, ______,_____,_____,______. |
|
Definition
coronary arteries
carotid bifurcation
infrarenal abdominal aorta
iliac arteries
superficial femoral artery |
|
|
Term
| Emboli can form as the _____ is exposed to the blood. |
|
Definition
|
|
Term
| The main reasons why the 5 most common sites are prone to atherosclerosis are due to _______ and _____. |
|
Definition
| bifurcations, changes in hemodynamic shear forces. |
|
|
Term
| Name 3 main factors in hemodynamic shear forces. |
|
Definition
| velocity, elasticity, pulsatile flow |
|
|
Term
| In general, most of the causes of atherosclerosis are/are not self-inflicted? |
|
Definition
| they are. smoking, sedentary, DM, HTN, hyperlipidemia, and obesity. The only 3 that are not modifiable are age, male gender and family history. |
|
|
Term
| T/F: The pathophysiology of atherosclerosis on a cellular level is known. |
|
Definition
|
|
Term
| T/F: Men have a genetic susceptibility to atherosclerosis. |
|
Definition
|
|
Term
| Endothelial injury caused by ______ allows the blood to come in contact with _____. Then, _____ adherence and degranulation stimulate ______ migration from the ____ to the _____. Thus this is a _______ problem. |
|
Definition
| hemodynamic shear stress, subendothelium, platelet, arterial smooth muscle cell, media, intima. Connective tissue. |
|
|
Term
the cellular response includes:
migration of ______ from the blood to the intima, intimal ______ accumulations, intimal _______ proliferation, _____-_____ macrophage _____, and organic _____ deposition. |
|
Definition
| macrophages, lipid, smooth muscle, lipid-laden, necrosis, calcium |
|
|
Term
| Disruption of the plaque can cause plaque ____ and ____ with resulting _____ and _____ distal to that acute thrombosis. |
|
Definition
| rupture, ulceration, spasm, ischemia. |
|
|
Term
| ______ therapy is the mainstay of medical therapy for PVD. |
|
Definition
|
|
Term
| You should continue your pt on ASA until the DOS for ____ and _____ surgery. |
|
Definition
| carotid, lower extremity vascular. (bigger vascular cases--AAA--individualize the ASA therapy) |
|
|
Term
| Name 3 drugs to systemically anticoagulate a pt with acute ischemia. |
|
Definition
| Heparin, Coumadin, Dextran (imporoves microcirculation) |
|
|
Term
| What is the primary concern regarding antiplatelet therapy and regional anesthesia? |
|
Definition
| Hematoma; specifically a spinal or epidural hematoma. |
|
|
Term
| You want to do a regional technique for a fem-pop bypass. When can heparin be given? Lovenox? |
|
Definition
Heparin: 60 minutes after the spinal; Lovenox: 2 hours after the spinal.
You should monitor the PTT/ACT levels so that they are 1.5-2 times normal. |
|
|
Term
| Heparin or Lovenox is more likely to cause a spinal/epidural hematoma? |
|
Definition
| Lovenox. It has a higher bioavailability and a longer half-life than heparin. |
|
|
Term
| WIth lovenox, the FDA reported that emergency surgery to evacuate an epidural hematoma occurred in ______% of pts and that paraplegia occurred in ____% of pts. |
|
Definition
|
|
Term
| Men/women are more likely to have a spinal/epidural hematoma? |
|
Definition
|
|
Term
Half-life of heparin:
Half-life of lovenox: |
|
Definition
|
|
Term
| A pt received a lovenox injection at 8 pm the previous evening, when is the earliest time a spinal/epidural can be safely performed? |
|
Definition
| 6 am (10-12 hours after the last dose) |
|
|
Term
| With a CEA, an epidural catheter should/should not be left in overnight and removed the next day? |
|
Definition
| should. The first dose of LMWH should be started 2 hours AFTER catheter removal. |
|
|
Term
| Pts with heparin antibodies develop ______. |
|
Definition
| decreased platelet counts. This is HIT. Heparin induced thrombocytopenia. |
|
|
Term
| _____ is one of the most common immune-mediated drug reactions. |
|
Definition
|
|
Term
| HIT is caused by _____ antibodies that recognize complexes of ____ and ____ leading to _____ activation. |
|
Definition
| igG, heparin, platelet factor 4, platelet |
|
|
Term
| With HIT, there are procoagulant, platelet-derived microparticles and possibly the activation of _____ that cause ____ generation. |
|
Definition
|
|
Term
| Patients with HIT can be anticoagulated with a ______ inhibitory agent such as _____ or ____. These agents have longer/shorter half-lives than heparin and their metabolism depends on _____. |
|
Definition
| thrombin, Argatroban, Lepirudin, longer, renal function. |
|
|
Term
| T/F: the interactions of Lepirudin and Argatroban and regional anesthesia are not clear. |
|
Definition
|
|
Term
| T/F: Attempts at controlling BP or electrolyte imbalances rapidly may be more hazardous than leaving the condition untreated. |
|
Definition
|
|
Term
| The patients with the greatest risk for perioperative and postop complications have _____ CAD, poor _____ and ______ (or greater) |
|
Definition
| left main, LV function, triple vessel CAD |
|
|
Term
| ____ almost always indicated increased perioperative risk. |
|
Definition
|
|
Term
| A ______ is one of your best indicators for perioperative complications. |
|
Definition
|
|
Term
| besides anything other than NSR on an EKG, what is another big concern on an EKG, and what leads will you specifically look at? |
|
Definition
| LVH: Big S waves in V1, large R waves in V5 and T wave inversion with asymmetry in V5-6. |
|
|
Term
| Raby et al found that ____ of pts with preop ischemia had intraop complications. |
|
Definition
|
|
Term
| What is the cutoff for EF in pts receiving major vascular surgery? Why? |
|
Definition
| want an EF > 35% because studies indicate that 80% of those with an EF < 35% suffered MIs after major vascular surgery. |
|
|
Term
| Name 3 methods to determine preop cardiac risk for major vascular surgery. |
|
Definition
| EKG, holter monitoring and dipyridamole-thallium scan. |
|
|
Term
| Mass-General's dipyridamole-thallium scan yielded two important observations: ______ is not a risk factor by itself and an area of _______ is associated with an adverse outcome. |
|
Definition
| old MI, area of redistriubution |
|
|
Term
| If a pt is found to have a markedly positive dipyridamole-thallium scan, what might be your recommendation? |
|
Definition
| To have a CABG before, in conjunction with or very soon after vascular sx. You should also quantify the degree of redistribution. |
|
|
Term
| Should pts with a negative dipyridamole-thallium scan have a PA catheter and extended ICU care? |
|
Definition
| Not necessarily. They are at a lower cardiac risk than someone with a positive scan. |
|
|
Term
| Name 5 cardiac risk-reducing interventions for major vascular sx. |
|
Definition
1. Invasive monitoring (art lines)
2. Forced air warming (bair hugger, hotline)
3. stress-reducing anesth technique (regional, high-dose narcotic)
4. perioperative beta blockade*****
5. Prolonged ICU care |
|
|
Term
| State the timelines for peripheral vascular sx after angioplasty; after CABG. |
|
Definition
| 1 week s/p angioplasty, 6-8 weeks s/p CABG |
|
|
Term
| If you are doing the anesthesia for a combined AAA and CABG sx, in general, which procedure would you expect to occur first? |
|
Definition
| the CABG then the AAA so that the heart is healthier to withstand the changing preload and afterload associated with aortic cross-clamping. |
|
|
Term
| Elective AAA repair should probably be performed before, simultaneously or within 2 weeks of CABG because of the increased risk for ______. |
|
Definition
| aneurism rupture after CABG. |
|
|
Term
| Two main goals for perioperative cardiac monitoring are: |
|
Definition
1. Detect myocardial ischemia
2. Identify abn of preload, afterload and ventricular function |
|
|
Term
| ST segment depression occurs in __-__% of pts undergoing vascular sx. |
|
Definition
|
|
Term
| The greatest sensitivity for detecting myocardial ischemia is through the use of ___ or ___, especially in combination with _____. |
|
Definition
| V5 or V4, Lead II...take-home; monitor 2 leads |
|
|
Term
| Holter monitoring has shown that intraoperative time may be the most/least stressful for pts with CAD. |
|
Definition
| LEAST. Pts are more likely to have ischemic episodes and an MI during emergence and in the immediate postop period. |
|
|
Term
| hypothermia and shivering can increase stress by ___-___% |
|
Definition
|
|
Term
| why might pts in the immediate postop period be more likely to have a thrombotic ischemic cardiac event? |
|
Definition
|
|
Term
| Which is a better indicator for mocardial ischemia PA cath or TEE? |
|
Definition
| TEE. You will see abn wall motion. Most PCWP elevations appear to be associated with tachycardia and HTN suggesting inadequate anesthesia. |
|
|
Term
| T/F: Nifedipine and NTG have been proven to reduce the risk of intraoperative myocardial ischemia. |
|
Definition
| F. Nifedipine precipitously drops the BP and can lead to an MI, and prophylactic NTG has not been shown to decrease the incidence of cardiac ischemia in pts with CAD. |
|
|
Term
| Name 4 adverse effects of Esmolol. |
|
Definition
Take this as a general beta-blockade question.
1. Increase SVR
2. Decreased CO
3. Bronchospasm
4. Conduction delays |
|
|
Term
| Epidural anesthesia reduces preload/afterload/both. |
|
Definition
| Both. It will decrease myocardial oxygen demand, but the concern is with neuraxial hematoma. |
|
|
Term
| The use of alpha-2 agonists with major vascular surgery (clonidine, mivazerol, dexmedetomidine) reduces ____, ____ and _____. |
|
Definition
|
|
Term
| In general for vascular pts, you don't want the HCT to be less than ___%, but for high-risk pts, you want the HCT to a minimum of ____%. |
|
Definition
|
|
Term
| Hypothermia causes increased _______ and _______. |
|
Definition
| adrenergic tone, postoperative myocardial ischemia...so aggressively warm pts and conserve heat during/after sx. |
|
|
Term
| Besides beta blockade, what other drug can help to control a pt's hemodynamics and not impede his emergence? |
|
Definition
|
|
Term
| Hypertrophied hearts are more prone to systolic/diastolic dysfunction and can lead to _____ postoperatively. |
|
Definition
| diastolic, pulmonary edema |
|
|
Term
| The hypertrophied LV of a chronic HTN pt can lead to increased risk for _____ ischemia. |
|
Definition
|
|
Term
| beta adrenergic blockers are well-tolerated in pts with claudication, despite concerns of peripheral ____ and ____. |
|
Definition
| vasoconstriction, bronchospasm |
|
|
Term
| Both calcium channel blockers and ACEI are used in major vascular sx, but name a complication of ACEI in pts with renal stenosis. |
|
Definition
prerenal azotemia.
ACEI also cause hypotension following induction of anesthesia by decreasing sympathetic tone and HR. |
|
|
Term
| A diabetic may have ____ to ____ of their normal insulin dose on DOS. |
|
Definition
1/3 to 1/2. Best evidence practice states that glucose levels should be monitored throughout the surgery.
***CAD is ubiquitous in DM pts*** |
|
|
Term
What do all of these have in common?
Elevated fibrinogen
Antithrombin III deficiency
Protein C/Protein S deficiency
HIT syndrome |
|
Definition
| hypercoagulable states which may lead to occlusion of vascular grafts. |
|
|
Term
| Pts with preop renal insufficiency have ______ of postop renal failure, as well as ________ complications and death. |
|
Definition
|
|
Term
| Ideally, when should dialysis pts have dialysis before sx? |
|
Definition
| The day before sx. If the day of; anticipate hypovolemia |
|
|
Term
| What drug might you want to avoid in pts with renal failure? |
|
Definition
|
|
Term
| ______ and mitral valve ____ are more common in pts undergoing dialysis, which can predispose them to ______ postoperatively. |
|
Definition
LVH (big S in V1, big R in V5, T invert V5-V6)
calcification
pulmonary edema |
|
|
Term
| _____ is the most common cause of carotid artery disease. |
|
Definition
|
|
Term
| carotid artery plaques are found bilaterally in the bifurcations ___% of the time. |
|
Definition
|
|
Term
| Changes in the _______ of the lumen and ______ of blood cause a buildup of plaque in the carotid arteries. |
|
Definition
| internal diameter, turbulence |
|
|
Term
| Formation of plaque at the carotid bifurcation is probably due to altered _________ accompanying the _________into ____ of different sizes. |
|
Definition
| hemodyanmic conditions, division of a vessel, lumens |
|
|
Term
| ______ or ______ from plaque can cause a ____ or a _____. |
|
Definition
| Thrombosis, debris, stroke, TIA |
|
|
Term
| How can some pts have 100% occlusion of their carotid artery and not have a CVA? |
|
Definition
| Because the occlusion gradually occurred, and there is enough collateral circulation from the Circle of Willis. |
|
|
Term
|
Definition
| transient attacks of monocular blindness on the ipsilateral side |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| ___-___% is considered to be a "high grade stenosis" |
|
Definition
|
|
Term
| > 72 hours, usually with neurological deficits afterwards |
|
Definition
|
|
Term
| Used to predict the extent of stenosis |
|
Definition
| Duplex scan. Presence of high velocities and turbulent flow. |
|
|
Term
| Provides measurements as to the size and morphology of atheromatous plaque. |
|
Definition
Angiography.
Can also document aortic arch and intracranial disease.
Carries about a 1% risk of neuro deficit. |
|
|
Term
| Which of the following does not produce similar symptoms of carotid artery disease: intracerebral tubors, AVM, A fib, valvular heart disease, dialated cardiomyopathy |
|
Definition
|
|
Term
| What is the max diastolic BP that is acceptable for a CEA? |
|
Definition
|
|
Term
| Pharmacological treatments of carotid artery disease may include aspirin and/or _________. Aggrenox has the two drugs combined. |
|
Definition
|
|
Term
| hyper/hypoglycemia may adversely affect neurological outcome after temporary or global ischemic events. Avoid ______ solutions also. |
|
Definition
|
|
Term
| A pt comes to you for CEA sx and is on coumadin. Advise him to stop the coumadin ____ days before sx. If he is started on a heparin gtt, make sure the gtt is turned off _____ hours prior to surgery. |
|
Definition
|
|
Term
| Studies report different/similar M&M with CEA sx under GA or MAC/regional. Therefore, there is clear/no clear evidence to support a technique. |
|
Definition
|
|
Term
| Sensory blockade of ____-_____ must be achieved for a regional to work for a CEA sx. |
|
Definition
|
|
Term
| What is the most accurate neurological monitoring device? |
|
Definition
|
|
Term
| One benefit of doing a CEA under GA is ______ protection. |
|
Definition
| cerebral. Decreased CMRO2, decreased CBF, redistributed blood flow to ischemic areas |
|
|
Term
| Name two big complications of a cervical plexus block. |
|
Definition
| Local anesthetic toxicity, total spinal |
|
|
Term
| Goal of induction for CEA. |
|
Definition
| Maintain stable hemodynamics |
|
|
Term
| What is the preferred induction agent for a pt undergoing CEA sx? |
|
Definition
| There is no preferred induction agent; just know how to use your drugs. You can put a carotid to sleep with 80 mg propofol and have stable hemodyanmics. Do a SLOW induction and be prepared to use vasopressors if the pt gets hypotensive. |
|
|
Term
| Can you use N2O for a carotid case? |
|
Definition
| yes, barring no pt contraindications |
|
|
Term
| State the ranges for a remifentanil gtt |
|
Definition
| 0.05 mcg/kg/min-0.6mcg/kg/min |
|
|
Term
| While Isoflurane has some potential to protect against cerebral ischemia more than the other inhalational agents, you would need _____ MAC to achieve a max protection. |
|
Definition
|
|
Term
| How do we know that ISO can be cerebral protective? |
|
Definition
| because it shows decreased frequency of EEG-detected cerebral ischemic changes during CEA. |
|
|
Term
| 2 main goals of intraoperative management are: |
|
Definition
cerebral protection
coronary protection...and these two goals are often in conflict. |
|
|
Term
| During CEA surgery, maintain the pt's BP within_________range. |
|
Definition
|
|
Term
| Increasing the BP to augment cerebral blood flow can increase afterload or contractility which _________consumption |
|
Definition
| increases myocardial oxygen |
|
|
Term
| Blood flow in the hypoperfused areas of the brain are thought to be _______ dependent |
|
Definition
|
|
Term
| ________ is thought to be the major cause of CVA during and after CEA sx, accounting for _____-____% of deficits. |
|
Definition
|
|
Term
| Most embolic events with a CEA occur preop/induction/maintenence/emergence/postop |
|
Definition
|
|
Term
| In general, what is better for a CEA pt: deep anesthesia and phenylephrine or light anesthesia without phenylephrine |
|
Definition
| light anesthesia without phenylephrine |
|
|
Term
| Phenylephrine _____ ejection fraction and causes ____ in pts with CAD. |
|
Definition
|
|
Term
| In addition to maintaining the pts BP within _____ for a CEA, you should also maintain the CO@ ______. |
|
Definition
| within high-normal range, within high-normal range |
|
|
Term
| why does moderate hyperglycemia worsen neurological injury? |
|
Definition
| Due to increased anarobic glycolysis that increases cerebral lactic acidosis. |
|
|
Term
| Avoid fluids with _____ and ______ for CEA pts. |
|
Definition
|
|
Term
| Hemodilution with ____ or ____ may be used to reduce blood viscosity and improve microcirculation; decreasing cerebral ischemia and helping to prevent thromboembolic events. |
|
Definition
|
|
Term
| If no shunt is used in a CEA, collateral blood flow via ________ supplies the brain. |
|
Definition
|
|
Term
| Shunt placement is associated with an embolic stroke rate of ____% which is high/low. |
|
Definition
|
|
Term
| 3 technical problems of shunt placement for CEA: |
|
Definition
1. air embolism
2. kinking of shunt
3. injury to vessel wall |
|
|
Term
| If the surgeon does not use a shunt for a CEA, he can either _______ for a pulse, or more/less commonly, measure _______. |
|
Definition
| palpate the distal end of the clamped carotid artery, the stump pressure (mean pressure distal to the carotid clamp) |
|
|
Term
| A stump pressure above ____ torr is considered to be sufficient to prevent ischemia. |
|
Definition
|
|
Term
| With measuring a stump pressure, there are a large number of false positives/negatives, meaning there is/is not enough pressure for collateral circulation to the brain. |
|
Definition
|
|
Term
| Transcrania doppler studies, intraoperative EEG evaluations, MEPs/SSEPs |
|
Definition
| Other methods surgeons determine if they need a shunt for a CEA |
|
|
Term
| best indicator for need of a shunt for CEA. |
|
Definition
|
|
Term
| T/F: No monitoring of neurophysiologic monitors has been shown to improve the neurological outcome of pts. |
|
Definition
| True. Probably because EMBOLISM, NOT HYPOPERFUSION is the most common cause of perioperative stroke. |
|
|
Term
| Prior to cross-clamping, _____ is given. |
|
Definition
| Heparin, 50-100 units/kg (usually 5,000-10,000 units) |
|
|
Term
| Hypertension/hypotension and tachycardia/bradycardia tend to occur with clamping of the carotids. Hypertention/hypotension and tachycardia/bradycardia tend to occur with unclamping the carotids. |
|
Definition
| Hypotension, bradycardia, hypotension, bradycardia |
|
|
Term
| If you encounter repeated episodes of hypotension and bradycardia with clamping the carotids, you can ask the surgeon to give ______ to ________. If the surgeon does this, anticipate _________ postoperatively. |
|
Definition
local infiltration of lidocaine, abolish the vagal response.
hypertension |
|
|
Term
| It is important to be aware of your narcotics for CEA cases because______. |
|
Definition
| You will need to do a neuro assessment in the OR after extubation. |
|
|
Term
| With CEA surgery postoperatively, hypo/hypertension is more common. |
|
Definition
|
|
Term
| Postop from CEA surgery, ____ and ____ can precipitate myocardia ischemia and failure, and ______edema and/or hemorrhage. |
|
Definition
| HTN, tachycardia, cerebral |
|
|
Term
| Postop HTN should be treated when the systolic is > ____ and diastolic is >_____ |
|
Definition
|
|
Term
| Hyperperfusion syndrome is an ______ of CBF of up to ______% and occurs ______ days postop. |
|
Definition
| increase, 200, several days (so you will not usually see this unless you do your f/u visit several days postop) |
|
|
Term
| Ipsilateral h/a, face/eye pain, sz, cerebral hemorrhage |
|
Definition
| cerebral hyperperfusion syndrome |
|
|
Term
| What is the most common postop complicatio from a CEA? |
|
Definition
|
|
Term
| Related to airway, what is a postop complication of CEA sx? |
|
Definition
| Recurrent laryngeal nerve injury--horseness, dysphagia but NO RESPIRATORY complications |
|
|
Term
| Wound hematomas occur in ___% of CEA cases postoperatively. |
|
Definition
|
|
Term
| 5 year mortality rate of untreated AAA_____. 10 year mortality rate of untreated AAA_____. |
|
Definition
|
|
Term
| ______ is thought to be the primary cause of AAA in _____% of pts. |
|
Definition
|
|
Term
| Formula for law of La Place: |
|
Definition
T = P x r
T is wall tension, P is transmural pressure, r is vessel radius. |
|
|
