TY  - CHAP
M1  - Book, Section
TI  - Anesthesia for Major Vascular Surgery
A1  - Lemm, John
A1  - Nicoara, Alina
A1  - Swaminathan, Madhav
A2  - Longnecker, David E.
A2  - Mackey, Sean C.
A2  - Newman, Mark F.
A2  - Sandberg, Warren S.
A2  - Zapol, Warren M.
Y1  - 2017
N1  - 
T2  - Anesthesiology, 3e
AB  - KEY  POINTSAtherosclerosis  is  the  primary  process  leading  to  myocardial  infarction,  stroke,  chronic  mesenteric  ischemia,  renovascular  hypertension,  extremity  ischemia,  and  aneurysmal  disease.  These  pathologic  states  occur  years  after  the  slow  onset  of  plaque  formation  in  the  vascular  wall.  The  precise  mechanism  of  final  injury  is  one  or  more  of  the  following:  (a)  plaque  enlargement  reducing  blood  flow;  (b)  complete  occlusion  of  arteries  at  sites  of  advanced  plaques;  and  (c)  arterial  embolism  of  plaque-associated  thrombi  or  atheromatous  debris.The  assessment  of  the  surgical  patient  undergoing  vascular  surgery  is  a  complex  process  that  requires  integration  of  multiple  areas  of  expertise.  The  classic  concept  of  clearing  a  patient  for  surgery  has  been  replaced  with  an  integrated  approach  of  interdisciplinary  cooperation  that  focuses  on  assessment  of  existing  disorders,  optimization  of  resilience  and  reserve  in  anticipation  of  increased  preoperative  demand,  avoidance  of  therapeutic  conflicts,  and  identification  of  potential  procedure-specific  risks.Patients  presenting  for  major  vascular  surgery  usually  have  either  overt  or  occult  involvement  of  several  organ  systems.  The  vascular  patient  population  has  a  high  incidence  of  significant  coronary  artery  disease  (CAD);  for  example,  left  ventricular  systolic  dysfunction  (left  ventricular  ejection  fraction  less  than  40%)  is  five  times  more  common  in  patients  with  cerebrovascular  disease  or  peripheral  arterial  disease  compared  with  matched  controls.The  current  standards  for  preoperative  cardiac  evaluation  of  these  patients  are  the  guidelines  published  by  the  American  College  of  Cardiology  and  the  American  Heart  Association  initially  in  1996  and  revised  in  2002,  2007,  and  most  recently  in  2014.  Where  surgery-specific  risk  and  clinical  risk  factors  were  once  factored  individually  in  the  algorithm,  they  are  now  part  of  the  composite  risk  assessment  tools.  Importantly,  the  2014  guidelines  now  only  support  additional  cardiovascular  testing  (ie,  stress  testing,  echocardiography,  24-hour  ambulatory  monitoring)  when  a  patient  has  an  elevated  risk  of  major  adverse  cardiac  events  and  poor  or  unknown  functional  capacity  and  further  testing  will  affect  decision-making  or  perioperative  care.Vascular  surgery  patients  require  intensive  perioperative  monitoring  for  two  primary  reasons:  (a)  These  patients  often  have  systemic  manifestations  of  atherosclerotic  vascular  disease  and  are  at  risk  for  cardiac,  cerebral,  renal,  and  spinal  cord  ischemia,  all  of  which  can  be  diagnosed  and  treated  using  appropriate  monitors;  and  (2)  vascular  procedures  involve  major  physiologic  changes,  including  significant  third-space  losses,  blood  loss,  and  the  complications  of  transfusion  (coagulopathies,  hypocalcemia,  hypothermia,  and  acidosis).  There  can  also  be  significant  changes  in  the  hemodynamic  profile  associated  with  the  application  and  release  of  vascular  clamps.Monitoring  of  the  awake  patient  is  the  gold  standard  for  neurologic  assessment  during  carotid  endarterectomy  (CEA)  and  may  allow  for  the  prompt  identification  of  patients  who  would  benefit  from  shunt  placement.  Change  in  contralateral  strength  or  consciousness  in  the  setting  of  adequate  mean  arterial  pressure  is  an  indication  for  shunt  placement.One  of  the  goals  of  anesthesia  for  CEA  is  to  avoid  hemodynamic  extremes  during  induction,  incision,  surgical  manipulation,  emergence,  and  extubation.  The  blood  pressure  during  carotid  occlusion  should  be  maintained  at  or  up  to  20%  higher  than  the  patient’s  highest  recorded  resting  blood  pressure  when  awake  to  maintain  adequate  collateral  blood  flow.  The  patient  should  be  sufficiently  ...
SN  - 
PB  - McGraw-Hill Education
CY  - New York, NY
Y2  - 2024/04/20
UR  - accessanesthesiology.mhmedical.com/content.aspx?aid=1144122385
ER  -