Carlsen PVD .pptx

Jodi Carlsen DNAP, CRNA, APRN [email protected] Peripheral Vascular Disease and Anesthesia “The incidence of perioperative cardiac morbidity is 10 times more frequent in vascular surgery patients than in nonvascular surgery patients….” 1. Identify causes of peripheral vascular disease and their impac...

Jodi Carlsen DNAP, CRNA, APRN [email protected] Peripheral Vascular Disease and Anesthesia “The incidence of perioperative cardiac morbidity is 10 times more frequent in vascular surgery patients than in nonvascular surgery patients….” 1. Identify causes of peripheral vascular disease and their impact on the anesthetic plan. 2. Differentiate between acute and chronic peripheral vascular disease with respect to etiology and symptomatology. 3. List three disease states associated with peripheral vascular disease. 4. Discuss the anesthetic management and implications for patients undergoing lower extremity revascularization, embolectomy, thrombectomy, and arteriovenous fistula placement Objectives 1. Identify causes of peripheral vascular disease and their impact on the anesthetic plan. Causes of Peripheral Vascular Disease (PVD) Atherosclerosis ▪ “Most common cause of peripheral arterial disease” ▪ Risk factors ▪ Advanced age ▪ Male ▪ HTN ▪ Smoking ( one of the biggest causes) ▪ Hyperlipidemia ▪ DM ▪ Below the inguinal artery– the superficial femoral artery is the most common site of atherosclerotic involvement 1. FIBROMUSCULAR DYSPLASIA body. Progressive twisting of the blood vessels throughout the As the blood vessels become more twisted, blood flow to organs can be affected. Symptoms vary based on which blood vessels are affected. Common symptoms include headache or high blood pressure. Treatment involves managing complications with blood pressure medications or procedures to open up the blood vessels. Causes of Peripheral Vascular Disease Non-atherosclerotic causes of peripheral arterial disease (less common) ▪ Embolism ▪ Thromboangiitis obliterans (Buerger disease) ▪ Immune, Radiation, or Giant Cell Arteritis ▪ Adventitial cystic disease ▪ Fibromuscular dysplasia ▪ Homocysteinemia GIANT CELL ARTERITIS An inflammation in the blood vessels, called arteries, in the temples. This is also called giant cell arteritis. Temporo artery bypazs Just what causes the temporal arteries to become inflamed isn't known. In some cases, the swelling affects just part of an artery with sections of normal vessel in between. Symptoms include headache, scalp tenderness, jaw pain, blurred or double vision, and sudden loss of vision in one eye. Head pain can get increasingly worse, can come and go, or can stop temporarily. The condition needs prompt treatment with corticosteroid drugs to prevent permanent vision loss. 2. Adventitial cystic disease is a rare vascular disease that mostly affects young and middle-aged men. It occurs when a cyst filled with a mucus-like substance forms in one of the arteries, most commonly in the popliteal artery. This artery supplies blood to the knee joint and thigh and calf muscles. Buerger's disease (also known as thromboangiitis obliterans) 1. Affects blood vessels in the body, most commonly in the arms and legs. 2. Blood vessels swell, which can prevent blood flow, causing clots to form. 3. This can lead to pain, tissue damage, and even gangrene (the death or decay of body tissues). 2. Differentiate between acute and chronic peripheral vascular disease with respect to etiology and symptomatology. Acute Peripheral Vascular Disease Etiology Emboli Acute = Most often caused by Embolism or Thrombosis ▪ Usually originate in the heart ▪ Most common causes: A-fib and Myocardial Infarction ▪ Other less common causes: bacterial endocarditis, atrial myxoma, atheromatous debris from proximal aneurysms, and prosthetic heart valves ▪ Often lodge at vessel bifurcations ▪ Common sites: femoral artery, iliac artery, and popliteal artery bifurcations Most common sites of Acute Periphera l Vascular Disease Etiology Thrombus ▪ Most common cause: Occurs in the setting of chronic atherosclerosis ▪ Secondary to the diverse hypercoagulable state (platelet activation) in this patient population Pregnancy & Cancer ▪ Outnumber the occurrence of emboli 6:1 ▪ Common sites: femoral artery, iliac artery, and popliteal artery bifurcations ▪ Thrombosis of vascular bypass grafts can occur leading to acute ischemia/need for revascularization ▪ Hypercoagulable states- pregnancy and cancer Acute Peripheral Vascular Disease “ Six P’s” Characteristic Signs & Symptoms ▪ Pallor ▪ Pain ▪ Paresthesia ▪ Paralysis ▪ Pulselessness (usually last sign) ▪ Poikilothermia-(cold to touch) Etiology Chronic Peripher al Vascular Disease ▪ Progressive stenosis from chronic arterial occlusion secondary to atherosclerosis plaque ▪ Near complete stenosis causes thrombotic occlusion ▪ May have low/minimal symptoms in lower extremities ▪ Chronic insufficiency= collateral blood flow Chronic Peripheral Vascular Disease Symptomatol ogy ▪ Asymptomatic until multiple major vessel Claudication= pain from lack of blood flow to vessels, exacerbated by exertion, relieved by rest occlusionsChronic= occur in a Claudication ▪ Mild/moderate pain ▪ ▪ ▪ ▪ Caused by claudication Usually distal to the site of occlusion Relieved by rest Presence of claudication is associated with a high rate of overall mortality ▪ Progressive disease = Critical limb ischemia ▪ Progressive claudication ▪ Severe disabling pain, even while resting Ankle/Brachial Index ▪ Good predictor of disease progression ▪ Low ABI is one of the strongest indicators for all-cause mortality ankle-brachial index is the ratio of the blood pressure at the ankle to the blood pressure in the upper arm. Compared to the arm, lower blood pressure in the leg suggests blocked arteries due to peripheral artery disease ABI of >0.2 need a bypass Normal variation between R and L is about 10 Gangrenous extremities occur with ABI indexes 20% of patients with PAD have 70% or greater Carotid stenosis ▪ Anesthetic implications? 4. Discuss the anesthetic management and implications for patients undergoing lower extremity revascularization, embolectomy, thrombectomy, and arteriovenous fistula placement Management of Vascular Disease (lower extremity) Non-operative ▪ Lifestyle and risk factor modification ▪ Exercise ▪ Pharmacologic intervention Operative ▪ Percutaneous endovascular procedures ▪ Established interventions ▪ ▪ Thrombolytic therapy, balloon embolectomy, balloon angioplasty, stent placement Newer procedures ▪ Cryotherapy, drug-eluting stents, laser angioplasty, atherectomy ▪ Surgical reconstruction ▪ Endarterectomy, bypass grafting, and amputation Management of Vascular Disease (lower extremity) Lower extremity revascularization ▪ Performed for disabling claudication and critical limb ischemia ▪ Intervention goal: ▪ Claudication = Pain control ▪ Ischemia = Limb salvage ▪ Operative choice depends primarily on location and distribution of the occlusion Management of Vascular Disease lower ( extremity) ▪ Distal to the inguinal ligament, the procedure of choice is a femoral-popliteal bypass, using autologous saphenous vein as graft ▪ Prosthetic grafts have high failure rates, ideal to use patients own vessel if salvageable Blockage Vascular surgery is considered *High Risk* Patients often have multiple comorbidities and are at high risk for complications, 1. MI ( #1 Risk ) 2. Arrhythmias 3. Fluid volume overload 4. Renal failure (acute on chronic) 5. Emboli/thrombosis 6. Impaired wound healing, etc. Always be thinking any patient with PVD has multiple other end organ disease Anesthesia for Peripheral Vascular Surgery ▪ Pre-op Considerations ▪ Evaluate patient ▪ PMHX (Renal failure? Smoker?) ▪ PSHX/Anesthesia history ▪ Ensure appropriate respiratory and cardiac meds have been taken ▪ Acute withdrawal from beta blockers is associated with significant morbidity ▪ Consider last dose of anticoagulation/antiplatelet when planning anesthetic ▪ Aspirin is usually continued perioperatively Anesthesia for Peripheral Vascular Surgery ▪ Pre-op Considerations ▪ Room set up ▪ What drugs? ▪ What monitoring? ▪ Lines? ▪ What do they have? ▪ What do you need? ▪ Block? ▪ What type? ▪ What risks? Anesthesia for Peripheral Vascular Surgery “The most appropriate regimen of intraoperative anesthesia and post operative analgesia for high-risk patients undergoing vascular surgery remains controversial” GA vs Regional? ▪ Debated for years ▪ Early trials inadequate ▪ Bias= Many clinicians had an unsupported belief that regional > GA for advanced CV or pulmonary disease ▪ Deficiencies in design and methodology including non uniform patient populations, lack of standardization, etc. ▪ Remains to be solved Anesthesia for Peripheral Vascular Surgery Reasons not to use regional/neuraxial anesthesia in vascular surgery Demented, unable to lie flat, uncooperative Spinal deformity, previous spine surgery with hardware Local infection Neurologic disease that affects lower ext. **Anticoagulant/antiplatelet therapies Common in this patient population ASRA app ( coag app ) Epidural/spinal hematoma is a potentially devastating complication and can lead to permanent neurologic injury Anesthesia for Peripheral Vascular Surgery Regional Anesthesia ▪ Peripheral nerve blocks are “probably” a safer choice than neuraxial ▪ Very little clinical information specific to vascular patient population on the use of peripheral vs neuraxial ▪ Catheters placed with block can improve post operative pain ▪ Often thought to be superior choice than GA in patients with severe pulmonary disease ▪ Does not require airway instrumentation or NMB agents, less risk of bronchospasm ▪ Could argue intubation provides better airway control, secretion management, and a direct route for bronchodilator administration if need be Anesthesia for Peripheral Vascular Surgery Regional/Neuraxial Anesthesia vs. General Anesthesia ▪ General anesthesia is associated with a hypercoagulable state in the post operative period ▪ Regional anesthesia attenuates this affect ▪ Regional may also increase lower extremity blood flow and increase graft patency secondary to venous blood pooling ▪ This is the proposed mechanism by which it is believed that regional anesthesia > general anesthesia in vascular patients Anesthesia for Peripheral Vascular Surgery ▪However…Studies involving more than 1300 patients show no overall difference in cardiac morbidity and mortality with the use of regional/neuraxial anesthesia vs general anesthesia (when hemodynamic parameters are controlled) ▪ Overall optimization of perioperative care = most important factor in improving post operative outcomes Current Recommendation: The best anesthetic is the one that in which the provider is most familiar, being careful to tailor the anesthetic to each specific patient’s needs. Anesthetic Administration Neuraxial ▪ T10 level ▪ Be prepared to treat hypotension (secondary to sympathectomy) ▪ NOTE: Phenylephrine causes peripheral vasoconstriction – pt already suffers from PVD ▪ Epidural allows for drug delivery post operatively ▪ CHF can occur post operatively ▪ Resolve of sympathectomy can cause intravascular space contraction ▪ Phenylephrine infusion may be a better choice than fluid administration ( again note neo vasoconstrictor) ▪ May need to rely on BP more than HR to determine intravascular administration ▪ Patients often on beta blockers ▪ Patients often of advanced age = decreased beta-adrenergic responsiveness Postoperative Considerations ▪Time of greatest concern for stress response and ischemia ▪Pay close attention to pain/anxiety, and treat appropriately ▪Manage hemodynamics and monitor for ST changes ▪Optimize fluid volume status (euvolemia) ▪Avoid anemia ▪Goal hgb >9g/dL ▪Peripheral pulses will be evaluated frequently ▪Monitor for LE graft patency ▪May end up returning to OR urgently to reopen clotted/stenotic grafts Postoperative Considerations ▪ Pain control ▪ Epidural infusion (local +/- opioid) ▪ + patient-controlled option for breakthrough ▪ PCA/IV opioids ▪ Multimodal analgesia ▪ Often avoid Ketorolac (patients are often on anticoagulation post op)/renal considerations Setting Up for a Vascular Surgery Multimodal GA Precedex drip Lidocaine drip Remi fentanyl Low dose diprivan drip Carrie IV LMA MAC MAC stand alone or adjunct to Regional set up with back up ETT at all times General ETT Peripheral Vascular, Case Specific, Anesthetic Considerations Femoral-Popliteal Bypass ▪ Anesthetic options? ▪ Surgery specific considerations? Fem Pop or Femoral to Popliteal Artery Bypass Surgery 1. GA / ETT / LMA 2. Art line =/3. Heparin 100units /kg BEFORE clamping 4. Protamine at end usually 2550 mg ( SLOWLY) 5. EBL 200-500ml 6. Avoid Hypotension secondly to cannot feel pulse and graft will clot off Protamine 25% chance allergy ( salmon sperm ) Endovascular : Angioplasty, Stents ▪Anesthetic options? ▪Surgery specific considerations? Fem- Fem Bypass or Femoral to Femoral Bypass Surgery Fem- Fem Bypass or Femoral to Femoral Bypass Surgery 1. GA / ETT or Spinal 2. Art line + 3. Heparin 100units /kg BEFORE clamping 4. Protamine at end usually 25-50 mg ( SLOWLY) 5. EBL 200-700ml 6. Avoid Hypotension secondly to cannot feel pulse and graft will clot off 7. 1- 4 hours Inform surgeon of Heparin 2 min mark and every hour to repeat dose – SET TIMER AV Fistula ▪ Anesthetic options? ▪ Surgery specific considerations? AV Fistula ▪ Anesthetic options? ▪ Surgery specific considerations? 1. MAC or LMA 2. Check K+ Preop 3. Confirm last dialysis 4. 5. 0.9 NS KVO rate IV 6. 1-2 hours duration 7. Minimal EBL Veteran advice ( if MAC do not put air Hugger on …pts overheat and start to move around a lot