Anaesthesia for carotid endarterectomy

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  • Anaesthesia for carotid endarterectomy
You are a young doctor working as anaesthetist. Your patient is scheduled for a surgical procedure known as endarterectomy because of a massive bifurcation stenosis on right sided carotid artery. From the medical history we know that our patient is a 60 years old smoker with chronic hypertension and OSA. The indication for endarterectomy is a mini stroke (TIA) experienced by the patient ten days ago, currently with no neurological deficit and diagnosed with 80 % carotid stenosis. What types of anaesthesia would you choose in your position in regard to the best outcome and the patient's medical history?

Regional anaesthesia.

Correct answer

The choice of anaesthesia is individual for each patient. Regional anaesthesia is more suitable for our patient because it possesses several advantages compared to general anaesthesia. We can mention a simpler anaesthesiological technique, better circulatory stability and even lower risk of perioperative complications including myocardial infarction. The patient suffers from OSA and regional anaesthesia decreases perioperative and mainly postoperative complications associated with this disease. The hospital management will definitely be satisfied with the lower cost of this procedure as well.


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Spinal anaesthesia.

Wrong answer

Cannot be performed! The puncture of the subarachnoid space is performed in the lumbar region, most frequently below L2/3 to prevent spinal cord injury. You definitely cannot perform it in the cervical region! Select another answer!


Try again Bury the patient

General anaesthesia.

Correct answer

General anaesthesia is one of the options. There are a number of health facilities that promote this anaesthesiological technique. According to evidence-based medicine, general anaesthesia is prefered in case of an anxious patient, reluctance to stay awake, non cooperative patient or patient with neurocognitive dysfunction. Furthermore, patients prior to combined cardiovascular surgery and acute patients requiring an immediate endarterectomy treatment. The disadvantage is not significant higher risk of complications (myocardial infarction, stroke) compared with regional anaesthesia. Last but not least, there are limited options in checking the quality of consciousness throughout surgery in general anaesthesia.


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Cervical epidural anaesthesia.

Wrong answer

This answer is not completely wrong, cervical epidural anaesthesia was a common method for this procedure. Nowadays, it is considered to be obsolete, mainly because of a higher risk of complications, out of which the most serious is the application of anaesthetics into the subarachnoid space associated with total spinal anaesthesia. Among some other frequent complications we can name Horner’s syndrome, unintentional block of nerves such as n. phrenicus, n. laryngeus recurrens, n. vagus, we emphazise that the block tends to be bilateral. Furthermore, this method is associated with an increased risk of urgent conversion to general anaesthesia compared with regional anaesthesia. Try to choose a better answer.


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(CEA) Carotid endarterectomy.
(OSA) Obstructive sleep apnoea.
(TIA) Transient ischemic attack.
(EBM) Evidence based medicine.
(CPAP) Continous postive airway pressure ventilator.×
 
RR

not available

HR

75 bpm

SpO2

not available

BP

135/93 mmHg

ECG

sinus rythm, regular pace

Examination:
Medical history:
Past medical history: cardiac patient on medication, OSA patient - the use of CPAP prescribed at night
Chief complain: He suffered from TIA attack 10 days ago
Family disease: no revelant
History of the present illness: He describes that he started to experience left hand tingling, later he could not move with his hand and he had difficulties to cry out at his wife for help. He fell unconscious before ambulance came, preserved breathing.

Chronic medication: Anopyrin, Betaloc, Rosucard, Agen, Trombex.
Alergies: none

Gly

results

ABG

not available

CBC

results

biochemistry

results