Peter G. Pappas, M.D., F.A.C.P.

• Professor of Medicine
• Medicine and Infectious Diseases
• University of Alabama at Birmingham
• Birmingham, Alabama

It is extremely important that long-term cardiac and respiratory medications be given the morning of surgery depression trigger definition buy wellbutrin 300 mg amex. Chapter 69: Anesthesia for Vascular Surgery 2143 standardization or control of perioperative treatments depression symptoms at night buy discount wellbutrin 300 mg on-line, use of nonequivalent modalities for postoperative pain relief anxiety disorder treatment buy discount wellbutrin 300mg,74 anxiety 24 hour hotline generic wellbutrin 300mg otc,78 depression symptoms webmd purchase wellbutrin with mastercard,81 mood disorder 29383 wellbutrin 300 mg discount,115-117 and possible investigator bias. Many clinical trials have attempted to optimize the delivery and management of anesthetic techniques, which may mask the true risks associated with the anesthetic. An example is the strict hemodynamic control, transfusion thresholds, and postoperative analgesia regimens that have been used in clinical trials. In general, it is often best to choose the anesthetic and analgesic techniques that are most familiar to a particular institution-for example, because unfamiliarity and mismanagement of epidural catheters can cause serious complications. I think that overall optimization of perioperative care, rather than anesthetic or analgesic selection, is the most important factor in improving outcome after vascular surgery. In some situations, one anesthetic technique (regional or general) is preferable to the other. The patient may have a preference for one technique over another based on multiple factors. Regional techniques should be avoided in patients who are uncooperative, demented, or unable to lie flat. Needle or catheter placement can be difficult in patients with severe spine deformity or previous spinal instrumentation. Local infection, neurologic disease affecting the lower part of the body, and hemostasis-altering drugs are all considered, to varying degrees, a contraindication to regional anesthesia. Anticoagulant and antiplatelet therapy is common in the vascular surgery population and often precludes the use of spinal or epidural techniques. Symptomatic bleeding within the neuraxis (spinal or epidural hematoma) is a potentially devastating complication of neuraxial anesthesia that can lead to permanent neurologic injury. I view preoperative anticoagulation with heparin or warfarin and any active thrombolytic therapy as contraindications to the use of spinal and epidural anesthesia. In patients in whom such agents have recently been discontinued, very careful consideration should be given on an individual basis before performing neuraxial techniques. The anesthesiologist must take into consideration the specific drug used, the duration of discontinuance, current coagulation status, and concomitant administration of medications affecting hemostasis. The use of regional techniques during intraoperative systemic heparinization does not appear to represent a significant risk. Although it has been recommended that surgery be canceled when blood is obtained through the neuraxial needle, support for this recommendation is lacking. Much more importantly, it has also been recommended that epidural catheters not be removed until anticoagulants have been discontinued in the postoperative period. Current recommendations suggest that regional techniques be delayed at least References References 74, 76, 78, 81, 83, 115-117. In general, when a regional technique is desired for a patient with any question of a coagulation abnormality, spinal anesthesia with the smallest diameter needle is preferable to epidural anesthesia. A comprehensive consensus report on neuraxial anesthesia and anticoagulation is available and should be read by all clinicians. Continuous catheter techniques can be used to provide both anesthesia and postoperative analgesia. High-resolution ultrasound imaging of neural structures, percutaneous electrode guidance, and the use of stimulating catheters have been introduced into clinical practice. Peripheral nerve blocks are probably associated with fewer systemic and neuraxial side effects, but little clinical information is available in the vascular surgical population. Because of the large volume of local anesthetics frequently used for peripheral nerve blocks, the issue of systemic toxicity must be considered. Caution should be considered with the use of peripheral nerve block in an anticoagulated patient, particularly when the neural structures are deep or located in close proximity to vascular structures. Because regional anesthesia does not require airway instrumentation, neuromuscular blocking agents, or volatile agents, it has traditionally been a prevailing belief that regional anesthesia is preferable in patients with significant pulmonary disease. Although it is true that instrumentation of the airway may precipitate bronchospasm or increase the risk for nosocomial infection, general anesthesia with endotracheal intubation does allow complete airway and ventilation control, the ability to effectively administer inhaled bronchodilators, and the ability to easily suction airway secretions. A reduction in time to extubation after aortic surgery is a fairly consistent theme with regional anesthesia and analgesia, but this does not appear to have any impact on clinically relevant pulmonary outcomes. Although epidural analgesia can provide excellent postoperative pain control and may improve postoperative lung function. Overall, little evidence from well-designed clinical studies exists to demonstrate improved pulmonary outcome with regional anesthesia and analgesia. Three studies (Bode and associates,117 Christopherson and co-workers,39 and Cook and colleagues,120) compared pure regional (spinal or epidural) versus general anesthetic techniques in lower extremity vascular patients. Tuman and colleagues116 compared combined epidural and general versus general anesthetics in aortic and lower extremity surgical patients. Six studies (Baron and co-workers,74 Bois and co-workers,80 Boylan and associates,83 Davies and associates,76 Garnett and colleagues,80 and Norris and colleagues40) compared epidural and nonepidural anesthetic or analgesic techniques (or both) in aortic surgical patients. The results of these studies, involving more than 1300 patients, are shown in Table 69-8. Only the study by Tuman and colleagues116 reported a difference in cardiac outcome. Outcome was significantly improved by epidural anesthesia and analgesia, but only when more subtle outcomes. In these studies from my institution, strict intraoperative and postoperative protocols were used to guide and optimize perioperative management and postoperative analgesia. Bode and colleagues117 described the largest randomized trial, which included a spinal anesthesia group in addition to general and epidural groups. Of note, a failed spinal or epidural technique in this trial was associated with 9% mortality, as opposed to 2% for all successful general and regional anesthetics. Two of the studies (Tuman and colleagues116 and Christopherson and co-workers39) reported a fivefold greater incidence of graft occlusion after general (relative to regional) anesthesia. Most graft occlusions occurred in the first 1 to 3 days after surgery, after which the established difference in the incidence of graft occlusion between anesthetic techniques was maintained over time (6 weeks and beyond). This time course suggests that anesthetic technique may have played a role in graft occlusion. For example, intraoperative intravascular angioscopy was used to inspect the grafts to confirm patency before completion of surgery, and all patients were cared for in an intensive care setting for 48 hours after surgery. Thus, optimization of care with respect to graft patency may negate any beneficial effect of regional techniques. It is also important to keep in mind that none of these studies were specifically designed to evaluate surgical outcome. Cumulative probability of reoperation for regrafting, thrombectomy, or amputation over a 6-week follow-up period. Reoperation was significantly more frequent after general than after epidural anesthesia. Perioperative Ischemia Randomized Anesthesia Trial Study Group, Anesthesiology 79:422-434, 1993. Perioperative Ischemia Randomized Anesthesia Trial Study Group, Anesthesiology 79:435-443, 1993. A retrospective review of more than 300 primary femoropopliteal-tibial bypass procedures reported no differences in graft thrombosis rates for epidural (14%) or general anesthesia (9. General anesthesia is associated with a hypercoagulable state in the early postoperative period, whereas regional anesthesia attenuates this effect. Tuman and colleagues116 demonstrated this by thromboelastography and Rosenfeld and co-workers123 by increased plasminogen activator inhibitor. Fibrinolysis is decreased after general anesthesia and is normal after regional anesthesia. These findings may be related to attenuation of the surgical stress response with regional anesthesia because a link appears to exist among stress, catecholamines, and acute-phase reactants, such as plasminogen activator inhibitor and fibrinogen. In the postoperative period, Breslow and associates126 demonstrated differences in the adrenergic response with general versus regional anesthesia. Epinephrine and norepinephrine are increased after general anesthesia relative to regional anesthesia. The cortisol response after general anesthesia is also greater than after regional anesthesia. In studies comparing epidural analgesia with parenteral opioid analgesia for control of postoperative pain after major surgery, improved pain control with epidural techniques is often reported. A recent meta-analysis review supports the view that epidural analgesia provides better postoperative analgesia than parenteral opioids. Of particular note, patient-controlled epidural analgesia outperforms both intermittent-bolus and continuous-infusion epidural analgesia. Thus, the mode of delivery is an important factor with both epidural and parenteral opioid analgesia. The clinician also needs to keep in mind that the superior pain control reported with epidural techniques is relative, with adequate pain control consistently reported for parenteral analgesia. Plasma norepinephrine (A) and epinephrine (B) concentrations before induction of anesthesia (P), at skin closure (C), and at 1, 6, 12, and 18 hours after lower extremity revascularization. General anesthesia is usually delivered with use of a balanced technique consisting of opioids, volatile inhaled anesthetics, N2O, and neuromuscular blockade. Induction of anesthesia should proceed in a controlled fashion such that a stable hemodynamic profile is maintained. Because virtually all patients are extubated in the operating room, high doses of opioid are generally avoided. The goal is to maintain stable hemodynamics and prevent myocardial ischemia during the intraoperative and postoperative periods. Disadvantages of spinal anesthesia include the limited duration of action in the setting of a surgical procedure that is somewhat unpredictable in length and complexity. The level of sympathetic block is somewhat less controllable than with the epidural technique. Hypotension can occur with either technique and should be treated promptly with judicious use of fluids and vasopressors. An advantage of an epidural technique is the ability to continue drug delivery into the postoperative period for analgesia and attenuation of the stress response. The dermatomes that need to be anesthetized are innervated at the same level where the catheter is inserted, because the incision is usually in the L1 to L4 region. Small volumes of local anesthetic are recommended because a T10 block is generally sufficient. Usually, 9 to 12 mL (including the test dose) is sufficient for the initial dose, and more drug is given as needed. Because vascular surgery patients are generally advanced in age and thus prone to higher block levels, larger doses may result in high sympathetic blockade with significant hypotension. Congestive heart failure may result in the postoperative period when the sympathectomy resolves and the intravascular space contracts. When administering an epidural test dose, careful attention should be directed to both heart rate and blood pressure. Blood pressure may be a more reliable indicator of an intravascular injection because vascular surgery patients may have little or no increase in heart rate as a result of -blocker therapy and decreased -adrenergic responsiveness secondary to aging. I think this approach is more physiologic than administration of large fluid volumes. Intravascular volume should be optimized, significant anemia avoided (hemoglobin maintained at > 9. Peripheral pulses should be checked frequently to verify lower extremity graft patency. Increasing arterial blood pressure augmentation and anticoagulants may be necessary when peripheral perfusion is limited. For epidural patient-controlled analgesia, a dilute concentration of local anesthetic should be used to allow neurologic evaluation of the lower extremities to rule out spinal or epidural hematoma. Fentanyl 5 g/mL can be added and the solution infused at 2 mL/hr, with an on-demand (patient-controlled analgesia) bolus of 2 to 4 mL and a lockout interval of 10 minutes. The principal cause of carotid artery disease is atherosclerosis, which most commonly involves the bifurcation of the common carotid artery with frequent extension into both the internal and external carotid arteries. The clinical manifestations of carotid artery disease represent a spectrum of conditions, with fatal or debilitating stroke secondary to cerebral infarction at one end of the spectrum and ranging successively through nondebilitating stroke, transient ischemic attack, and amaurosis fugax (transient attack of monocular blindness) to an asymptomatic bruit. Cerebrovascular sequelae of carotid atherosclerosis may result either from embolization of thrombus or atheromatous debris or from a reduction in flow (hypoperfusion) secondary to stenosis. The latter probably accounts for less than 10% of the cerebrovascular sequelae of carotid atherosclerosis. Although much is known about the genesis and evolution of atherosclerosis, significantly less is known about the circumstances that lead to plaque instability and rupture. Regardless of the mechanism, the degree of cerebral injury depends on such factors as plaque morphology, characteristics of the embolus, duration of hypoperfusion, cerebrovascular vasoreactivity, integrity of the circle of Willis, and cerebral collateral circulation. A multisociety guideline is available for the management of carotid artery disease. It is the fourth leading cause of death and the leading cause of serious, long-term disability in the United States. The direct and indirect costs of stroke in the United States in 2008 are estimated at $65. Well-defined risk factors exist in patients with stroke, the most important of which is hypertension. Despite a well-documented decline in stroke mortality, the annual incidence rate of stroke may be increasing. The incidence of perioperative stroke in unselected patients, patients with asymptomatic carotid bruit, and patients with at least 50% carotid stenosis undergoing general anesthesia and surgery is approximately 0.

The spectrum of recovery sites after these procedures may vary from postprocedure units to a coronary intensive care unit depression symptoms hair loss buy wellbutrin master card. Most of these procedures are done on an outpatient basis anxiety 1 purchase wellbutrin master card, and anesthesia is tailored to ensure rapid recovery after implantation mood disorder nos in dsm 5 generic wellbutrin 300mg. In addition anxiety 5 weeks pregnant 300mg wellbutrin fast delivery, they may require close hemodynamic monitoring during testing of the device depression symptoms exhaustion generic wellbutrin 300 mg without prescription. When general anesthesia is chosen bipolar depression pathophysiology wellbutrin 300mg with visa, in addition to standard monitoring, an arterial line may be added. General anesthesia also may be requested for anxious and extremely nervous patients. Usually the diagnostic portions of the ablation study are done during the same procedure. Mapping and ablation catheters were placed under the guidance of intracardiac echocardiography. The current generated by radiofrequency is alternating current and is delivered at cycle lengths of 300 to 750 kHz when used for catheter ablation. The degree of tissue heating is inversely proportional to the radius to the fourth power. Although electric injury may be a contributing factor, the primary mechanism of tissue destruction by radiofrequency current is thermal injury. Acute lesions created by a radiofrequency current consist of a central zone of coagulation necrosis surrounded by a zone of hemorrhage and inflammation. The principal disadvantage is the risk for complications, which varies depending on the type of ablation procedure and skill of the operator. These advantages include the absence of skeletal and cardiac muscle stimulation, minimal discomfort during delivery of energy, the possibility of performing the procedure in conscious patients, and the discrete nature of resulting lesions. In a few cases, general anesthesia may be required if the patient is anxious or cannot tolerate lying in the supine position for an extended period. General anesthesia may be implemented for these patients with standard American Society of Anesthesiologists monitors with adequate vascular access. Because it is curative in many patients, it is offered to all patients who would otherwise be committed to long-term drug therapy. Emphasis has shifted from pharmacologic therapy to nonpharmacologic therapy of tachyarrhythmias; this has led to a significant increase in the numbers of radiofrequency catheter ablations and defibrillator implantations. Initially, ablation was performed with direct electric Chapter 68: Anesthesia for Correction of Cardiac Arrhythmias 2105 these procedures over the use of antiarrhythmic drugs. Patients who are being cared for in these areas are sicker with significant comorbidities. The role of conscious sedation will continue to diminish in the performance of these procedures. These patients will require full monitoring and care under the direction of an anesthesiologist. Prevost J, Batelli F: La mort par les courants electriques: courant alternative a bas voltage, J Physiol Path Gen 1:399-412, 1899. Hooker D, Kouwnehoven W, Langworthy D: the effect of alternating electrical currents on the heart, Elect Eng 55:444-454, 1936. Anonymous: Classification of cardiac arrhythmias and conduction disturbances, Am Heart J 98:263-267, 1979. Kjekshus J, Swedberg K, Snapinn S: Effects of enalapril on longterm mortality in severe congestive heart failure. Linde C, Gadler F, Edner M, et al: Results of atrioventricular synchronous pacing with optimized delay in patients with severe congestive heart failure, Am J Cardiol 75:919-923, 1995. Wazni O, Wilkoff B, Salid W: Catheter ablation for atrial fibrillation, N Engl J Med 365:2296-2304, 2011. Furman S, Robinson G: the use of an intracardiac pacemaker in the correction of total heart block, Surg Forum 9:245-248, 1958. Auricchio A, Stellbrink C, Sack S, et al: Long-term clinical effect of hemodynamically optimized cardiac resynchronization therapy in patients with heart failure and ventricular conduction delay, J Am Coll Cardiol 39:2026-2033, 2002. In the beginning: from dogs to humans, Pacing Clin Electrophysiol 18(3 Pt 2):506-511, 1995. Mehra R, Cybulski Z: Tachyarrhythmia termination: lead system and hardware design. Schmitt C, Montero M, Melichercik J: Significance of supraventricular tachyarrhythmias in patients with implanted pacing cardioverter defibrillators, Pacing Clin Electrophysiol 17(3 Pt 1):295-302, 1994. Primo J, Geelen P, Brugada J, et al: Hypertrophic cardiomyopathy: role of the implantable cardioverter-defibrillator, J Am Coll Cardiol 31:1081-1085, 1998. Calkins H, Sousa J, el-Atassi R, et al: Diagnosis and cure of the Wolff-Parkinson-White syndrome or paroxysmal supraventricular tachycardias during a single electrophysiologic test, N Engl J Med 324:1612-1618, 1991. Borggrefe M, Hindricks G, Haverkamp W, et al: Catheter ablation using radiofrequency energy, Clin Cardiol 13:127-131, 1990. Raiten J, Elkassabany N, Gao W, et al: Medical intelligence article: novel uses of high frequency ventilation outside the operating room, Anesth Analg 112:1110-1113, 2011. Multicenter Automatic Defibrillator Implantation Trial Investigators, N Engl J Med 335:1933-1940, 1996. Prophylactic coronary revascularization has not been shown to reduce perioperative or long-term morbidity after major vascular surgery. Antiplatelet therapy requires special consideration and must be individualized to each patient. Endoleak, or the inability to obtain or maintain complete exclusion of the aneurysm sac from arterial blood flow, is a complication specific to endovascular aortic repair. Given the frequent occurrence of coexisting disease in elderly patients (see also Chapter 80), the hemodynamic and metabolic stress associated with arterial cross-clamping and unclamping, and the ischemic insults to vital organs, including the brain, heart, kidneys, and spinal cord, perioperative morbidity and mortality are more frequent with vascular surgery than with most other surgical procedures. Anesthesia care must focus on preservation of vital organ function, with a strong emphasis on the heart, which is the single most important cause of morbidity after vascular surgery. The clinical controversies associated with vascular surgery are diverse and involve aspects of preoperative, surgical, anesthetic, and postoperative management. A specific anesthetic technique has not been established because vascular procedures often lend themselves to local, regional, general, or combined techniques. In the 1970s, vascular surgery was recognized as a risk factor for perioperative cardiac morbidity. In the 1980s, the focus shifted to risk stratification in an effort to identify patients who were at the most frequent risk for morbid outcomes. In the 1990s, intensive clinical investigation involving anesthetic technique, sympatholytic drugs, hemodynamic control, and analgesic technique was undertaken and provided important insight into the prevention, treatment, and mechanisms of cardiac and other morbidity. During this time, a guideline-based approach to health care was initiated, primarily in the United States (see also Chapter 102). Additionally, over the last decade the multidisciplinary field of endovascular surgery has provided less invasive approaches or alternatives to conventional vascular reconstruction. These less invasive procedures, initially offered to patients traditionally considered unfit for open surgery, are being widely applied to the larger cohort of patients undergoing vascular surgery. The goal of this chapter is to review issues related to the perioperative care of patients undergoing vascular surgery and to address the underlying controversies. For simplicity, the five major categories of vascular surgical procedures are discussed separately: abdominal aortic surgery, thoracoabdominal aortic surgery, endovascular aortic surgery, lower extremity vascular surgery, and carotid surgery. The lesions of atherosclerosis occur primarily in large and medium-sized arteries and tend to form at sites with disturbed laminar flow, such as branch points. The most common sites are the coronary arteries, carotid bifurcation, abdominal aorta, and iliac and femoral arteries. Although atherosclerotic lesions result from a variety of complex pathogenetic processes, progression of atherosclerosis occurs in several stages. The fatty streak lesion consists largely of T cells and lipidladen macrophages called foam cells. With the progressive accumulation of apoptotic and degenerated foam cells, cell debris, and cholesterol crystals, the fatty streak progresses to an atheromatous plaque with a necrotic lipid core. A more complex lesion develops with the formation of a fibrous cap of variable thickness composed of collagen and proliferated smooth muscle cells. The advanced lesions of atherosclerosis represent a progression of the fibroatheromatous plaque, with an expanded lipid-rich core, accumulation of calcium, and disruption of endothelial integrity. Atherothrombosis may lead to complete vascular occlusion at the site of plaque rupture or detach to become an embolus that can block blood flow distal to its origin. The American Heart Association Committee on Vascular Lesions has provided a numerical classification of histologically defined atherosclerotic lesion types. The diagram lists the main histologic characteristics of each sequential step (lesion type). Thick or differentiate between the relative ease with which lesions develop at specific sites, or they indicate the relative frequency and importance of a pathway section. Established pharmacologic strategies against atherosclerosis are largely limited to treating hypertension and hyperlipidemia and controlling hemostasis to prevent thrombotic complications. Inflammation in the arterial wall plays a fundamental role in both atherogenesis and atheroprogression. As a result of this new understanding, inflammation has become a therapeutic target in the prevention and treatment of atherosclerosis and its complications. Because of the systemic nature of atherosclerotic disease, patients with vascular disease frequently have arterial disease affecting multiple vascular territories. This perioperative and long-term morbidity and mortality persist despite aggressive medical and surgical therapy. This evidence-based approach to perioperative evaluation and management was updated in 2002 and 2007,9,10 and in 2009. A stepwise approach (simplified from the 2007 guidelines) to perioperative cardiac evaluation and care for noncardiac surgery is provided in Chapter 38. Thus, preoperative testing should not be performed unless it is likely to influence patient care. The particular challenge that the vascular surgery patient presents is emphasized throughout the document. Aspects of the updated guidelines and their evidencebased approach will be discussed throughout this chapter. In these instances, the patient must proceed to surgery with careful perioperative medical management and surveillance. The challenge for clinicians is to accurately assess risk for cardiac morbidity while maintaining a cost-effective, clinically relevant, and evidence-based strategy. After assessment of cardiac risk, the additional challenge exists of modifying perioperative management to reduce risk by adjusting or adding cardiac medications. Coordination is essential among surgeons, anesthesiologists, and cardiologists, each of whom may have different criteria for risk assessment and different objectives for risk modification. The results of these Clinical Risk Indices Assessing cardiac risk in patients before vascular surgery is a controversial and difficult task (see also Chapters 37 and 38). Although risk indices are a cost-effective screening method for determining which patients may require further cardiac evaluation. Risk indices do not provide specific risk prediction for individuals, but rather place patients in general risk categories, most commonly designated as low (cardiac risk generally < 1%), intermediate (cardiac risk of 1% to 5%), or high (cardiac risk often > 5%). Clinical risk variables identified by logistic regression in vascular surgery cohorts can be used along with noninvasive cardiac testing to optimize preoperative assessment of cardiac risk before vascular surgery. Previous Percutaneous Coronary Intervention the role of prophylactic percutaneous coronary revascularization in the preoperative management of vascular surgery patients is controversial. These interventions require placement of a large-diameter introducer sheath in the femoral artery, which predisposes to pseudoaneurysm and compromised blood flow to the lower extremities. Current perioperative guidelines provide a comprehensive review of this topic and offer recommendations based on clinical data and expert opinion. In general, noninvasive cardiac testing before vascular surgery is best directed at patients considered to be at intermediate clinical risk. Such testing should not be undertaken if it is unlikely to alter patient management and should not be considered as a preliminary step leading to coronary revascularization. A revascularization procedure is rarely needed solely for the purpose of getting a patient through the perioperative period. Extensive cardiac evaluation before vascular operations can result in morbidity, delays, and patient refusal to undergo vascular surgery. Two randomized clinical trials have been performed to determine the impact of prophylactic coronary artery revascularization on outcome after open aortic and lower extremity arterial vascular surgery. Although the trial was not designed to test the short-term benefit of prophylactic revascularization, perioperative outcomes were not decreased, including death (3. Long-term survival in patients randomized to undergo coronary artery revascularization or no coronary artery revascularization before elective major vascular surgery (Coronary Artery Revascularization Prophylaxix trial). KaplanMeier estimates were used to generate survival curves from the time of randomization for all patients. Coronary angiography showed two-vessel disease in 24%, three-vessel disease in 67%, and left main coronary artery disease in 8%. The incidence of the composite end point at 1 year was similar, 49% versus 44%, respectively. As noted previously, this trial has come under scrutiny based on concerns of unfortunate scientific misconduct by the principal investigator. When clinical assessment suggests severe pulmonary compromise, pulmonary function tests may be useful in evaluating and optimizing respiratory function (see also Chapters 39 and 51). Preoperative analysis of arterial blood gases should be used to establish a baseline for postoperative comparison.

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