carotid endarterectomy

[anbuitachi]

What are your techniques for CEAs? We only do general here. Occasionally we put on cerebral oximetry. But in the books they mention so many monitors available. I'm curious as to what other places do? Do people use these monitors? (MCA dopplers.. jugular bulbs sats etc..). If you do them awake, do you just do superficial cervical block? Any sedation? How often are you doing neuro/strength exams? What are your extubation techniques?

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[Lecithin5]

What are your techniques for CEAs? We only do general here. Occasionally we put on cerebral oximetry. But in the books they mention so many monitors available. I'm curious as to what other places do? Do people use these monitors? (MCA dopplers.. jugular bulbs sats etc..). If you do them awake, do you just do superficial cervical block? Any sedation? How often are you doing neuro/strength exams? What are your extubation techniques?

I try to avoid preop sedation. Propofol, remi, and phenyl gtt's- pts wake up nice and crisp. At times surgeon measures stump. At other 'lean' facilities, I simply use volatile with phenyl gtt. Haven't really done one under regional, but ultrasound guided superficial cervical plexus block would be the way to go.

 

[vector2]

General, sometimes with cOx. Sub 1 Mac volatile, remi running at 0.1-0.2 typically, neo gtt. Will typically give some lido, iv Tylenol, whiff of dilaudid before emergence, and try to pull tube the second airway reflexes return as long as the airway was reassuring.

 

[facted]

Prop/remi/phenylephrine gtt. Most of the surgeons I've worked with across institutions use neuro monitoring, though I'm not aware of evidence for that. Most important from our perspective, gotta wake up the pt smoothly on a dime and make sure they can follow commands soon after wakeup. Plus, they can have inhibited co2 sensors, so long acting narcotics can be especially problematic.

 

[ambiturner]

I'm old fashioned, volatile, fent boluses, phenylephrine gtt. I used to do these with 1 IV which is torture if you're running drips, now I just put the second one in. I've only done these with EEG, the other methods are fun oral boards questions but rarely used.

Have done them awake, superficial cervical plexus pre op with extra as needed by surgeon but it's not fun for anyone, but on the plus side you don't need neuromonitoring.

 

[dhb]

Cervical plexus, volatile ga, aline and i put cOx because the surgeon likes to see the number.

 

[deleted162650]

Don't do many these days (by product of a white collar pt population in a land where no one smokes). In my former gig though we did a bunch, and was blessed with great vascular surgeons. Cases were all 50-70 mins skin to skin with clamp times hovering around 7 mins. No shunting (ever) and no special monitoring of any kind.

Anesthetic: No midaz. Fentanyl titrated to somnolence. Push 'em over the edge with some prop then roc. Lowish Sevo. Neo gtt for SBP >165 during X-clamp. Sevo off early and wake-up off nitrous and residual fent (important not to give any additional fent after initial load). Pts woke up snappy with brief neuro exam as soon as ETT out in OR. PACU. Done.

 

[dhb]

The different surgeons i worked with never emphazised the neuro exam too much. If the patients moves his legs and arms with a little jaw thrust it's enough.

 

[GassmanMD]

Superficial cervical plexus block.

 

[Ezekiel2517]

Depends on surgeon. Cox, neuromonitoring, etc. Sometimes I go remi/gas, or just gas with a little fentanyl. I'm ready to immediately control the BP on emergence and extubation, post- extubation. Gotta pay close attention to these patients postop, from the pacu to the icu or whatever floor they go to. The worst complications from this case occur in the first 24 hours postop.

 

[anbuitachi]

Anyone do deep extubation to prevent buking then check neuro exam after they wake up?

 

[Noyac]

Prop/remi/phenylephrine gtt. Most of the surgeons I've worked with across institutions use neuro monitoring, though I'm not aware of evidence for that. Most important from our perspective, gotta wake up the pt smoothly on a dime and make sure they can follow commands soon after wakeup. Plus, they can have inhibited co2 sensors, so long acting narcotics can be especially problematic.

not much of an issue unless they have had the other side done already. I have never seen it be very problematic.

 

[Noyac]

Anyone do deep extubation to prevent buking then check neuro exam after they wake up?

Nothing really wrong with it but I prefer the awake extubation. Depends on airway.

 

[Noyac]

I have done the occasional “awake” CEA. ITS painful for everyone mostly. I did the superficial as well as the deep cervical plexus block. It’s not the surgical dissection that is so painful but the constant communication needed and then if they get ischemic, you’re hosed. Now you are fighting to keep them still while the surgeon tries to establish flow and it usually will end up with some form of sedation either mild to complete GA. Now you need an airway and it’s under all kinds of ****.

 

[Twiggidy]

Anyone do deep extubation to prevent buking then check neuro exam after they wake up?

yeah. deep-ish

i give very little narcotic and no midaz because i need then to wake up and old folks wake up better with all that stuff. we do GETA and the surgeon pretty much does a field block at the end so most arent in a lot of pain

 

[leaverus]

I'm old fashioned, volatile, fent boluses, phenylephrine gtt. I used to do these with 1 IV which is torture if you're running drips, now I just put the second one in. I've only done these with EEG, the other methods are fun oral boards questions but rarely used.

same here. never monitor. our surgeon always shunts.

 

[Orin]

Done them both ways back in residency.

Remifentanil is a great drug.

If they're awake, superficial + deep + a little field across the neck block plus that titrated to pain.
If they're asleep, remi + prop with a little pressor.

The block folks are way easier hemodynamically to manage though

 

[drmwvr]

GETA with Desflurane and zemuron with phenylephrine gtt. A little fentanyl with the a line in pre op. Everyone gets a shunt and surgeons are pretty quick. 30 of prop on skin and everything gets turned off. Any purposeful movement gets the tube pulled. Awake before we leave the room.

As an aside, cerebral hyperperfusion syndrome can occur after the patient goes home and is lethal. Aggressive BP management is mandatory (though an infusion is rarely necessary) for excessive SBP. I travel off of my OR level to the basement for recovery so I monitor the patient on the way down.

 

[anbuitachi]

GETA with Desflurane and zemuron with phenylephrine gtt. A little fentanyl with the a line in pre op. Everyone gets a shunt and surgeons are pretty quick. 30 of prop on skin and everything gets turned off. Any purposeful movement gets the tube pulled. Awake before we leave the room.

As an aside, cerebral hyperperfusion syndrome can occur after the patient goes home and is lethal. Aggressive BP management is mandatory (though an infusion is rarely necessary) for excessive SBP. I travel off of my OR level to the basement for recovery so I monitor the patient on the way down.

What BPs do you tank them to after surgery for those who had severe stenosis ?

 

[dhb]

The block folks are way easier hemodynamically to manage though

This is why i like the block

 

[turnupthevapor]

If the surgeon is good I do straight regional.....superficial cervical plexus block (now known as intermediate cervical plexus block) I also run a touch of remi

 

[drmwvr]

What BPs do you tank them to after surgery for those who had severe stenosis ?

Less than 150.

 

[Noyac]

The block folks are way easier hemodynamically to manage though

It also helps tremendously if your surgeon is liberal with the local at the carotid bulb.

 

[deleted162650]

It also helps tremendously if your surgeon is liberal with the local at the carotid bulb.

Ya, I wish they would all just do this empirically instead of only after there's a problem. I remember doing a carotid-carotid bypass case where the patient went asystolic from them dicking around with the bulb. Amazing how fast a little lido fixes things.

Lidocaine solves all problems - temporarily.

 

[Noyac]

Ya, I wish they would all just do this empirically instead of only after there's a problem. I remember doing a carotid-carotid bypass case where the patient went asystolic from them dicking around with the bulb. Amazing how fast a little lido fixes things.

Lidocaine solves all problems - temporarily.

My surgeon does it empirically, every case, every time.