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Tomas VG, Hollis N, Ouanes JPP. Regional Anesthesia for Vascular Surgery and Pain Management. Anesthesiol Clin 2022; 40:751-773. [PMID: 36328627 DOI: 10.1016/j.anclin.2022.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Patients undergoing vascular surgery tend to have significant systemic comorbidities. Vascular surgery itself is also associated with greater cardiac morbidity and overall mortality than other types of noncardiac surgery. Regional anesthesia is amenable as the primary anesthetic technique for vascular surgery or as an adjunct to general anesthesia. When used as the primary anesthetic, regional anesthesia techniques avoid complications associated with general anesthesia in this challenging patient population. In this article, the authors describe regional anesthetic techniques for carotid endarterectomy, arteriovenous fistula creation, lower extremity bypass surgery, and amputation.
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Affiliation(s)
- Vicente Garcia Tomas
- Department of Anesthesiology, Regional Anesthesia and Acute Pain Medicine, Northwestern University Feinberg School of Medicine Chicago, 251 E. Huron St F5-704, Chicago, IL 60611, USA.
| | - Nicole Hollis
- Department of Anesthesiology, West Virginia University, 1 Medical Center Drive PO Box 8255, Morgantown, WV 26508, USA
| | - Jean-Pierre P Ouanes
- Cornell Medicine, Hospital for Special Surgery, Florida, 300 Palm Beach Lakes Boulevard, West Palm Beach, FL 33401, USA
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Reslan OM, McPhee JT, Brener BJ, Row HT, Eberhardt RT, Raffetto JD. Peri-Procedural Management of Hemodynamic Instability in Patients Undergoing Carotid Revascularization. Ann Vasc Surg 2022; 85:406-417. [PMID: 35395375 DOI: 10.1016/j.avsg.2022.03.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/14/2022] [Accepted: 03/24/2022] [Indexed: 11/28/2022]
Abstract
Acute perioperative changes in arterial pressure occur frequently, particularly in patients with cardiovascular disease or those receiving vasoactive medications, or in relation to certain cardiovascular surgical procedures. Hemodynamic Instability (HI) are common in patients undergoing carotid revascularization because of unique patho-physiological and surgical factors. The operation, by necessity, disrupts the afferent pathway of the baroreflex, which can lead to postendarterectomy HI. Poor arterial pressure control is associated with increased morbidity and mortality after carotid revascularization, but good control of arterial pressure is often difficult to achieve in practice. The incidence, implications, and etiology of HI associated with carotid surgery are reviewed, and some recommendations made for its management. Close monitoring and titration of therapy are probably the most important considerations rather than specific choice of agents.
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Affiliation(s)
- Ossama M Reslan
- VA Fargo HCS, Fargo ND, Division of Vascular Surgery, Department of Surgery; University of North Dakota School of Medicine & Health Sciences, Department of Surgery.
| | - James T McPhee
- VA Boston HCS, West Roxbury MA, Division of Vascular Surgery, Department of Surgery; Boston University School of Medicine, Boston Medical Center
| | - Bruce J Brener
- Newark Beth Israel Medical Center, Division of Vascular Surgery, Department of Surgery
| | - Hunter T Row
- University of North Dakota School of Medicine & Health Sciences, Department of Surgery
| | - Robert T Eberhardt
- Boston University School of Medicine, Boston Medical Center; Division of Cardiovascular Medicine, Department of Medicine
| | - Joseph D Raffetto
- VA Boston HCS, West Roxbury MA, Division of Vascular Surgery, Department of Surgery; Harvard Medical School, Brigham and Women's Hospital
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Sadri L, Shan D, Mejia-Sierra L, Lam Q, Heilman JG, Balchander D, Noonan K, Pineda DM. An Enhanced Recovery After Surgery Protocol Decreases the Use of Narcotics in Infrainguinal Bypass Patients. Vasc Endovascular Surg 2022; 56:465-471. [PMID: 35315304 DOI: 10.1177/15385744221075012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES "Enhanced recovery after surgery" (ERAS) protocols use a multisystem approach to target homeostatic physiology via opioid-minimizing analgesia. The aim of this study is to determine if an ERAS protocol for lower extremity bypass surgery improves pain control and decreases narcotics. METHODS From July 2020 through June 2021, all patients that underwent infrainguinal lower extremity bypass procedures were subject to the ERAS protocol and compared to a "pre-ERAS" group between June 2016 through May 2020. Preoperatively, ERAS patients were given celecoxib, gabapentin, and acetaminophen while postoperatively they were given standing acetaminophen, gabapentin, ketorolac, and tramadol with as needed use of oxycodone. Pain scores were recorded using a numerical rating pain scale. Demographics, length of stay, 30-day complications, and disposition metrics were recorded. RESULTS There were 50 patients in the ERAS group, compared to 114 before its implementation. The mean age was 70.5 (ERAS group) versus 68.7 (pre-ERAS group) and a majority were male (P > .05). Enhanced recovery after surgery patients were less likely to have chronic kidney disease (P = .01). Enhanced recovery after surgery patients had improved length of stay (3.6 ± 2.3 days vs 4.8 ± 3.2 days, ERAS vs pre-ERAS, P = .01). There was no significant difference between groups for the remaining demographics (P > .05). One patient (2%) in the ERAS group used patient-controlled analgesia, compared to 30 patients (26%) in the pre-ERAS group (P < .001). Cumulative pain control in the first 12 hours was significantly better in the ERAS group (P = .05). Pain control at discharge was similar between the 2 groups (3 pain score vs 3 pain score, pre-ERAS vs ERAS, P > .05). CONCLUSION Our study utilized a multisystem approach to optimize the physiologic stress response to vascular surgery while reducing high potency narcotic use. We show that an ERAS protocol provides noninferior pain control with less potent pain medication and improves the length of stay for patients undergoing infrainguinal bypass surgery.
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Affiliation(s)
- Lili Sadri
- Department of Vascular Surgery, 389402Abington-Jefferson Health, Abington, PA, USA
| | - Deepak Shan
- Department of Vascular Surgery, 389402Abington-Jefferson Health, Abington, PA, USA
| | - Luis Mejia-Sierra
- Department of Vascular Surgery, 389402Abington-Jefferson Health, Abington, PA, USA
| | - QuynhDiem Lam
- Department of Vascular Surgery, 389402Abington-Jefferson Health, Abington, PA, USA
| | - Jaclyn G Heilman
- Department of Vascular Surgery, 389402Abington-Jefferson Health, Abington, PA, USA
| | - Divya Balchander
- Department of Vascular Surgery, 389402Abington-Jefferson Health, Abington, PA, USA
| | - Kristin Noonan
- Department of Vascular Surgery, 389402Abington-Jefferson Health, Abington, PA, USA
| | - Danielle M Pineda
- Department of Vascular Surgery, 389402Abington-Jefferson Health, Abington, PA, USA
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Bozzani A, Arici V, Ticozzelli G, Pregnolato S, Boschini S, Fellegara R, Carando S, Ragni F, Sterpetti AV. Intraoperative Cerebral Monitoring During Carotid Surgery: A Narrative Review. Ann Vasc Surg 2021; 78:36-44. [PMID: 34537350 DOI: 10.1016/j.avsg.2021.06.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/16/2021] [Accepted: 06/22/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intra-operative neurological monitoring (IONM) during carotid endarterectomy (CEA) aims to reduce neurological morbidity of surgery. OBJECTIVE This narrative review analyses the role and results of different methods of IONM. METHODS review articles on PUBMED and Cochrane Library, by searching key words related to IONM and CEA, from 2000 up to date. RESULTS regional anesthesia in some centers represents the "gold standard". The most often used alternative techniques are: stump pressure, electroencephalogram, somatosensory evoked potentials, transcranical doppler ultrasound, near infrared spectroscopy and routine shunting. Every technique shows limitations. Regional anesthesia can make difficult prompt intubation when needed. Stump pressure shows a wide operative range. Electroencephalogram is unable to detect ischemia in sub-cortical regions of the brain. Somatosensory evoked potentials certainly demonstrate the presence of cerebral ischemia, but are no more specific or sensitive than the electroencephalogram. Transcranical doppler monitoring is undoubtedly operator-dependent and suffers from the limitations that the probe has to be placed relatively near to the surgical site and may impede the operator, especially if it needs constant adjustments; moreover, an acoustic window may not be found in 10% -20% of the subjects. Near infrared spectroscopy appears to have a high negative predictive value for cerebral ischemia, but has a poor positive predictive value and low specificity, because predominantly estimates venous oxygenation as this makes up about 80% of cerebral blood volume. The data on the use of Routine Shunting (RS) from RCTs are limited. CONCLUSIONS currently, with no clear consensus on monitoring technique, choice should be guided by local expertise and complication rates. With reflection, best practice may dictate that a standard technique is selected as suggested above and this remains the default position for individual practice. Nevertheless, current techniques for monitoring cerebral perfusion during CEA are associated with false negative and false positive resulting in inappropriate shunt insertion.
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Affiliation(s)
- Antonio Bozzani
- Vascular and Endovascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Vittorio Arici
- Vascular and Endovascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giulia Ticozzelli
- Anesthesiology and Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Sandro Pregnolato
- Anesthesiology and Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Stefano Boschini
- Vascular and Endovascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Raffaele Fellegara
- Vascular and Endovascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Simona Carando
- Vascular and Endovascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Franco Ragni
- Vascular and Endovascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Djedovic M, Hadzimehmedagic A, Rustempasic N, Granov N, Haxhibeqiri-Karabdic I. The Impact of Unilateral and Bilateral Eversion Carotid Endarterectomy on Postoperative Hemodynamic Parameters. Med Arch 2021; 75:194-198. [PMID: 34483449 PMCID: PMC8385746 DOI: 10.5455/medarh.2021.75.194-198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 06/20/2021] [Indexed: 11/07/2022] Open
Abstract
Background: Carotid endarterectomy (CEA) is an effective and safe treatment of stenosed carotid arteries, and is a preventive operation with well-defined indications. It is associated with a loss of the baroreceptor reflex and postoperatively increased hemodynamic parameters. Objective: The aim of the study was to confirm the sensitivity of baroreceptors and the impact on arterial pressure and heart rate in unilateral and bilateral eversion carotid endarterectomies. Methods: A retrospective study was conducted with 30 patients treated with E-CEA in local anesthesia at the Clinic for cardiovascular surgery from December 2019 to May 2021, due to stenosis of the carotid arteries. Patients were divided into two groups: 15 patients in group A (patients with unilateral E-CEA; 15 patients in group B: patients with bilateral E-CEA). Results: Out of the total of 30 patients included in the research, 15 patients in groups A and B respectively, there were no statistically significant differences in regards to gender (p= 0,245) and preoperative risk factors: smoking (p=0,449); hypertension (p=0,388); diabetes (p= 0,714); hyperlipidemia (p=0.388), coronary disease (p=0.461) and symptomatic stenosis of the carotid arteries (p=0.449). Noted were the statistically significant differences in values of systolic and diastolic pressure on the 3rd postoperative days in patients with bilateral E-CEA (p=0,001; p=0,001), a statistically significant difference in the heart rate was not found in the analyzed groups in the postoperative period (p=0,225; p=0,994). Conclusion: This study identified statistically significant differences in values of systolic and diastolic pressure in the early postoperative period. In his period, early detection and correction of these hemodynamic disorders are needed.
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Affiliation(s)
- Muhamed Djedovic
- Clinic of Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Amel Hadzimehmedagic
- Clinic of Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Nedzad Rustempasic
- Clinic of Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Nermir Granov
- Clinic of Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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Bomberg H, Lorenzana D, Aguirre J, Eichenberger U. [Peripheral Regional Anaesthesia for Perioperative Analgesia]. PRAXIS 2021; 110:579-589. [PMID: 34344186 DOI: 10.1024/1661-8157/a003682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Peripheral Regional Anaesthesia for Perioperative Analgesia Abstract. Peripheral regional anaesthesia is the actual gold standard of opioid-sparing perioperative analgesia and is mainly used for surgery of the shoulder, arm and leg. Well-trained anaesthesiologists are the prerequisite for the correct individual risk-benefit assessment and the performance of the nerve blocks using a combination of ultrasound guidance and peripheral nerve stimulation (dual guidance). The postoperative care of the patients requires trained staff.
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Affiliation(s)
- Hagen Bomberg
- Abteilung für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinik Balgrist, Zürich
| | - David Lorenzana
- Abteilung für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinik Balgrist, Zürich
| | - José Aguirre
- Abteilung für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinik Balgrist, Zürich
| | - Urs Eichenberger
- Abteilung für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinik Balgrist, Zürich
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Anesthetic type and hospital outcomes after carotid endarterectomy from the Vascular Quality Initiative database. J Vasc Surg 2018; 67:1419-1428. [DOI: 10.1016/j.jvs.2017.09.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 09/12/2017] [Indexed: 11/21/2022]
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Stojanovic MD, Markovic DZ, Vukovic AZ, Dinic VD, Nikolic AN, Maricic TG, Janković RJ. Enhanced Recovery after Vascular Surgery. Front Med (Lausanne) 2018; 5:2. [PMID: 29404329 PMCID: PMC5785721 DOI: 10.3389/fmed.2018.00002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 01/03/2018] [Indexed: 12/22/2022] Open
Abstract
The beginnings of the enhanced recovery after surgery (ERAS) program were first developed for patients in colorectal surgery, and after it was established as the standard of care in this surgical field, it began to be applied in many others surgical areas. This is multimodal, evidence-based approach program and includes simultaneous optimization of preoperative status of patients, adequate selection of surgical procedure and postoperative management. The aim of this program is to reduce complications, the length of hospital stay and to improve the patients outcome. Over the past decades, special attention was directed to the postoperative management in vascular surgery, especially after major vascular surgery because of the great risk of multiorgan failure, such as: respiratory failure, myocardial infarction, hemodynamic instability, coagulopathy, renal failure, neurological disorders, and intra-abdominal complications. Although a lot of effort was put into it, there is no unique acceptable program for ERAS in this surgical field, and there is still a need to point out the factors responsible for postoperative outcomes of these patients. So far, it is known that special attention should be paid to already existing diseases, type and the duration of the surgical intervention, hemodynamic and fluid management, nutrition, pain management, and early mobilization of patients.
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Affiliation(s)
- Milena D Stojanovic
- Center for Anesthesiology, Reanimatology and Intensive Care, Clinical Center Nis, Nis, Serbia
| | - Danica Z Markovic
- Center for Anesthesiology, Reanimatology and Intensive Care, Clinical Center Nis, Nis, Serbia
| | - Anita Z Vukovic
- Center for Anesthesiology, Reanimatology and Intensive Care, Clinical Center Nis, Nis, Serbia
| | - Vesna D Dinic
- Center for Anesthesiology, Reanimatology and Intensive Care, Clinical Center Nis, Nis, Serbia
| | - Aleksandar N Nikolic
- Center for Anesthesiology, Reanimatology and Intensive Care, Clinical Center Nis, Nis, Serbia
| | - Tijana G Maricic
- Center for Anesthesiology, Reanimatology and Intensive Care, Clinical Center Nis, Nis, Serbia
| | - Radmilo J Janković
- Center for Anesthesiology, Reanimatology and Intensive Care, Clinical Center Nis, Nis, Serbia.,School of Medicine, University of Nis, Nis, Serbia
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Local anaesthesia for carotid endarterectomy: Con: decrease the stress for all. Eur J Anaesthesiol 2016; 33:238-40. [PMID: 26928168 DOI: 10.1097/eja.0000000000000377] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Choi YS, Jo YY, Jung WS, Lee MG. Ultrasound-guided superficial cervical plexus block for carotid endarterectomy in a patient with Lemierre syndrome -A case report-. Anesth Pain Med (Seoul) 2016. [DOI: 10.17085/apm.2016.11.4.345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Yun Suk Choi
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, Jeju, Korea
| | - Youn Yi Jo
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Wol Seon Jung
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Mi Geum Lee
- Department of Anesthesiology and Pain Medicine, Gachon University Gil Medical Center, Incheon, Korea
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Sivakumar H, Peyton P. Poor agreement in significant findings between meta-analyses and subsequent large randomized trials in perioperative medicine. Br J Anaesth 2016; 117:431-441. [DOI: 10.1093/bja/aew170] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Leblanc I, Chterev V, Rekik M, Boura B, Costanzo A, Bourel P, Combes M, Philip I. Safety and efficiency of ultrasound-guided intermediate cervical plexus block for carotid surgery. Anaesth Crit Care Pain Med 2016; 35:109-14. [DOI: 10.1016/j.accpm.2015.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 07/15/2015] [Accepted: 08/11/2015] [Indexed: 11/16/2022]
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CHERPRENET AL, RAMBOURDIN-PERRAUD M, LAFORÊT S, FAURE M, GUESMI N, BAUD C, ROSSET E, SCHOEFFLER P, DUALÉ C. Local anaesthetic infiltration at the end of carotid endarterectomy improves post-operative analgesia. Acta Anaesthesiol Scand 2015; 59:107-14. [PMID: 25348807 DOI: 10.1111/aas.12431] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 09/22/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Wound infiltration at the end of carotid endarterectomy under general anaesthesia is a simple technique that can be delegated to the surgeon. It was hypothesised that this technique could improve early post-operative analgesia by reducing the need for post-operative opioids. METHODS Forty patients underwent carotid endarterectomy under general anaesthesia with desflurane and remifentanil supplemented with morphine for post-operative analgesia. In a prospective double-blinded randomised study, patients were allocated pre-operatively to receive either subcutaneous infiltration of both wound edges with 20 ml of 0.75% ropivacaine or infiltration with isotonic saline. The primary outcome was morphine consumption while in the post-anaesthesia care unit (PACU). Pain scores at rest and movement, sedation, and patient satisfaction were the other main outcomes used to assess post-operative analgesia. RESULTS The median dose of morphine administered in the PACU was 2 mg [0-3] in the ropivacaine vs. 4 mg [3-6] in the placebo group (P = 0.0004, Mann-Whitney's test). Pain at rest and at movement was lower in the ropivacaine group throughout observation in the PACU. No difference was found for both pain and opioid consumption after discharge from the PACU or for patient satisfaction. Sedative events in the early post-operative period were less frequent in the ropivacaine group. CONCLUSIONS Local anaesthetic wound infiltration performed before closure reduces the need for additional opioids, lowers the immediate post-operative pain and improves alertness. These results argue for the use of local infiltration anaesthesia for carotid endarterectomy.
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Affiliation(s)
- A.-L. CHERPRENET
- Anesthésie-Réanimation; BLOC-ARCHI; CHU Clermont-Ferrand; Clermont-Ferrand France
| | | | - S. LAFORÊT
- Anesthésie-Réanimation; BLOC-ARCHI; CHU Clermont-Ferrand; Clermont-Ferrand France
| | - M. FAURE
- Anesthésie-Réanimation; BLOC-ARCHI; CHU Clermont-Ferrand; Clermont-Ferrand France
| | - N. GUESMI
- Anesthésie-Réanimation; BLOC-ARCHI; CHU Clermont-Ferrand; Clermont-Ferrand France
| | - C. BAUD
- Anesthésie-Réanimation; BLOC-ARCHI; CHU Clermont-Ferrand; Clermont-Ferrand France
| | - E. ROSSET
- Chirurgie Vasculaire; BLOC-ARCHI; CHU Clermont-Ferrand; Clermont-Ferrand France
- Univ Clermont1; Clermont-Ferrand France
| | - P. SCHOEFFLER
- Anesthésie-Réanimation; BLOC-ARCHI; CHU Clermont-Ferrand; Clermont-Ferrand France
- Univ Clermont1; Clermont-Ferrand France
- U1107 ‘Neuro-Dol’; Inserm; Clermont-Ferrand France
| | - C. DUALÉ
- U1107 ‘Neuro-Dol’; Inserm; Clermont-Ferrand France
- Inserm CIC 1405; Clermont-Ferrand France
- Centre de Pharmacologie Clinique; CHU Clermont-Ferrand; Clermont-Ferrand France
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Abstract
Patients presenting for vascular surgery present a challenge to anesthesiologists because of their severe systemic comorbidities. Regional anesthesia has been used as a primary anesthetic technique for many vascular procedures to avoid the cardiovascular and pulmonary perturbations associated with general anesthesia. In this article the use of regional anesthesia for carotid endarterectomy, open and endovascular abdominal aortic aneurysm repair, infrainguinal arterial bypass, lower extremity amputation, and arteriovenous fistula formation is described. A focus is placed on reviewing the literature comparing anesthetic techniques, with brief descriptions of the techniques themselves.
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Affiliation(s)
- James Flaherty
- Stanford Hospital and Clinics, 300 Pasteur Drive, Room H3580, Stanford, CA 94305, USA.
| | - Jean-Louis Horn
- Stanford Hospital and Clinics, 300 Pasteur Drive, Room H3580, Stanford, CA 94305, USA
| | - Ryan Derby
- Stanford Hospital and Clinics, 300 Pasteur Drive, Room H3580, Stanford, CA 94305, USA
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Unic-Stojanovic D, Babic S, Neskovic V. General Versus Regional Anesthesia for Carotid Endarterectomy. J Cardiothorac Vasc Anesth 2013; 27:1379-83. [DOI: 10.1053/j.jvca.2012.09.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Indexed: 11/11/2022]
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Gotlib Conn L, Rotstein OD, Greco E, Tricco AC, Perrier L, Soobiah C, Moloney T. Enhanced recovery after vascular surgery: protocol for a systematic review. Syst Rev 2012; 1:52. [PMID: 23121841 PMCID: PMC3534637 DOI: 10.1186/2046-4053-1-52] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 10/29/2012] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The enhanced recovery after surgery (ERAS) programme is a multimodal evidence-based approach to surgical care which begins in the preoperative setting and extends through to patient discharge in the postoperative period. The primary components of ERAS include the introduction of preoperative patient education; reduction in perioperative use of nasogastric tubes and drains; the use of multimodal analgesia; goal-directed fluid management; early removal of Foley catheter; early mobilization, and early oral nutrition. The ERAS approach has gradually evolved to become the standard of care in colorectal surgery and is presently being used in other specialty areas such as vascular surgery. Currently there is little evidence available for the implementation of ERAS in this field. We plan to conduct a systematic review of this literature with a view to incorporating ERAS principles into the management of major elective vascular surgery procedures. METHODS We will search EMBASE (OVID, 1947 to June 2012), Medline (OVID, 1948 to June 2012), and Cochrane Central Register of Controlled Trials (Wiley, Issue 1, 2012). Searches will be performed with no year or language restrictions. For inclusion, studies must look at adult patients over 18 years. Major elective vascular surgery includes carotid, bypass, aneurysm and amputation procedures. Studies must have evaluated usual care against an ERAS intervention in the preoperative, perioperative or postoperative period of care. Primary outcome measures are length of stay, decreased complication rate, and patient satisfaction or expectations. Only randomized controlled trials will be included. DISCUSSION Most ERAS approaches have been considered in the context of colorectal surgery. Given the increasing use of multiple yet different aspects of this pathway in vascular surgery, it is timely to systematically review the evidence for their independent or combined outcomes, with a view to implementing them in this clinical setting. Results from this review will have important implications for vascular surgeons, anaesthetists, nurses, and other health care professionals when making evidenced-based decisions about the use of ERAS in daily practice.
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Affiliation(s)
- Lesley Gotlib Conn
- Department of Surgery, St, Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
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Regional versus general anesthesia for carotid endarterectomy: The American College of Surgeons National Surgical Quality Improvement Program perspective. Surgery 2012; 152:309-14. [DOI: 10.1016/j.surg.2012.05.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Accepted: 05/10/2012] [Indexed: 11/19/2022]
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Ben-Dor I, Looser PM, Maluenda G, Weddington TC, Kambouris NG, Barbash IM, Hauville C, Okubagzi P, Corso PJ, Satler LF, Pichard AD, Waksman R. Transcatheter aortic valve replacement under monitored anesthesia care versus general anesthesia with intubation. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2012; 13:207-10. [DOI: 10.1016/j.carrev.2012.02.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 02/17/2012] [Indexed: 10/28/2022]
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Guay J. Endovascular Stenting or Carotid Endarterectomy for Treatment of Carotid Stenosis: A Meta-analysis. J Cardiothorac Vasc Anesth 2011; 25:1024-9. [DOI: 10.1053/j.jvca.2011.01.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Indexed: 11/11/2022]
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Attigah N, Kutter J, Demirel S, Hakimi M, Hinz U, Motsch J, Böckler D. Assessment of Patients’ Satisfaction in Carotid Surgery under Local Anaesthesia by Psychometrical Testing – A Prospective Cohort Study. Eur J Vasc Endovasc Surg 2011; 41:76-82. [DOI: 10.1016/j.ejvs.2010.08.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 08/20/2010] [Indexed: 10/19/2022]
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Surgical Management of Asymptomatic Carotid Stenosis. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10076-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Perioperative outcome of carotid endarterectomy with regional anesthesia: two decades of experience from the Caribbean. J Clin Anesth 2010; 22:169-73. [DOI: 10.1016/j.jclinane.2009.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2008] [Revised: 04/28/2009] [Accepted: 05/19/2009] [Indexed: 11/19/2022]
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Vetrugno L, Di Luca E, Drigo D, Fregonese V, Gonano N, Giordano F. Wake-up test decrease shunts insertion during carotid endarterectomy under general anesthesia. Vasc Endovascular Surg 2010; 44:174-8. [PMID: 20150229 DOI: 10.1177/1538574409359428] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The use of locoregional anesthesia versus general anesthesia (GE) in carotid endarterectomy (CEA) has been a debatable issue in clinical studies for the past several years. In our study, GE with wake-up tests (WUTs) during carotid cross-clamping was used instead of stump pressure (SP) to directly assess the neurological status of the patient to determine whether shunting was needed. Our study assessed the percentage of patients under light sedation and mechanically ventilated needing shunting based on WUT compared to a systolic stump pressure (SPs) cutoff value of <or=40 mm Hg. DESIGN Retrospective, observational study. SETTING University hospital clinic. PARTICIPANTS Three hundred fifty-one patients (American Society of Anesthesiologists physical class II-III) with carotid artery stenosis scheduled for CEA under GE. INTERVENTIONS The WUT was used to assess the neurological status in patients undergoing CEA, which involved the gradual reduction of depth of anesthesia until the patient was capable of responding to a verbal stimulus and provide full collaboration while only receiving remifentanil. A positive WUT indicated that patient was not able to carry out the order. MEASUREMENTS AND MAIN RESULTS Of 343 patients, 20 (5.8%) were shunted due to a positive WUT after cross-clamping in comparison to 45 patients (12.8%) based on the SPs <or=40 mm Hg criteria. CONCLUSION Wake-up test can be used to directly assess the neurological status in patients undergoing CEA to determine whether shunting is required. Our results showed that less patients required shunting based on WUT compared to the SP criteria.
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Affiliation(s)
- Luigi Vetrugno
- Cardiothoracic and Vascular Anesthesia, University-Hospital of Udine, Udine, Italy.
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Basciani RM, Eberle B. Percutaneous aortic valve implants under sedation: our initial experience. Catheter Cardiovasc Interv 2009; 74:148-9; author reply 150. [PMID: 19360874 DOI: 10.1002/ccd.22026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Matchett GA, Allard MW, Martin RD, Zhang JH. Neuroprotective effect of volatile anesthetic agents: molecular mechanisms. Neurol Res 2009; 31:128-34. [PMID: 19298752 DOI: 10.1179/174313209x393546] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Intra-operative cerebral ischemia can be catastrophic, and volatile anesthetic agents have been recognized for their potential neuroprotective properties since the 1960s. In this review, we examine the neuroprotective effects of five volatile anesthetic agents in current or recent clinical use: isoflurane, sevoflurane, desflurane, halothane and enflurane. METHODS A review of publications in the National Library of Medicine and National Institutes of Health database from 1970 to 2007 was conducted. RESULTS Volatile anesthetic agents have been shown to be neuroprotective in multiple animal works of ischemic brain injury. Short-term neuroprotection (<1 week post-ischemia) in experimental cerebral ischemia has been reported in multiple works, although long-term neuroprotection (> or = 1 week post-ischemia) remains controversial. Comparison works have not demonstrated superiority of one specific volatile agent over another in experimental models of brain injury. Relatively few human works have examined the protective effects of volatile anesthetic agents and conclusive evidence of a neuroprotective effect has yet to emerge from human works. CONCLUSION Proposed mechanisms related to the neuroprotective effect of volatile anesthetic agents include activation of ATP-dependent potassium channels, up-regulation of nitric oxide synthase, reduction of excitotoxic stressors and cerebral metabolic rate, augmentation of peri-ischemic cerebral blood flow and up-regulation of antiapoptotic factors including MAP kinases.
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Affiliation(s)
- Gerald A Matchett
- Department of Anesthesiology, School of Medicine, Loma Linda University, Loma Linda, CA 92350, USA
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Stoneham M, Thompson J. Arterial pressure management and carotid endarterectomy. Br J Anaesth 2009; 102:442-52. [DOI: 10.1093/bja/aep012] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Affiliation(s)
- Joanne Guay
- University of Montreal, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada H1T 2M4.
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Vetrugno L, Bassi F, Roccato A, Giordano F. It Is Nice to “Wake Up” Patients for Combined Carotid Endarterectomy and Coronary Artery Bypass Graft Surgery. J Cardiothorac Vasc Anesth 2008; 22:943-4; author reply 944-5. [DOI: 10.1053/j.jvca.2007.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2007] [Indexed: 11/11/2022]
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Current World Literature. Curr Opin Anaesthesiol 2008; 21:684-93. [DOI: 10.1097/aco.0b013e328312c01b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Heyer EJ, Gold MI, Kirby EW, Zurica J, Mitchell E, Halazun HJ, Teverbaugh L, Sciacca RR, Solomon RA, Quest DO, Maldonado TS, Riles TS, Connolly ES. A study of cognitive dysfunction in patients having carotid endarterectomy performed with regional anesthesia. Anesth Analg 2008; 107:636-42. [PMID: 18633045 DOI: 10.1213/ane.0b013e3181770d84] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In previous studies, we found that approximately 25% of patients having carotid endarterectomy with general anesthesia (CEA general) develop cognitive dysfunction compared with a surgical control Group 1 day and 1 mo after surgery. In this study, we tested the hypothesis that patients having CEA with regional anesthesia (CEA regional) will develop significant cognitive dysfunction 1 day after surgery compared with a control group of patients receiving sedation 1 day after surgery. We did not study persistence of dysfunction. METHODS To test this hypothesis, we enrolled 60 patients in a prospective study. CEA regional was performed with superficial and deep cervical plexus blocks in 41 patients. The control group consisted of 19 patients having coronary angiography or coronary artery stenting performed with sedation. A control group is necessary to account for the "practice effect" associated with repeated cognitive testing. The patients from the CEA regional group were enrolled at New York Medical Center and the control group at Columbia-Presbyterian Medical Center. The cognitive performance of all patients was evaluated using a previously validated battery of neuropsychometric tests. Differences in performance, 1 day after compared with before surgery, were evaluated by both event-rate and group-rate analyses. RESULTS On postoperative day 1, 24.4% of patients undergoing CEA regional had significant cognitive dysfunction, where "significant" was defined as a total deficit score > or =2 SD worse than the mean performance in the control group. CONCLUSIONS Patients undergoing CEA regional had an incidence of cognitive dysfunction which was not different than patients having CEA general as previously published and compared with a contemporaneously enrolled group.
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Affiliation(s)
- Eric J Heyer
- Department of Anesthesiology, Columbia University, 620 West 168th Street, New York, NY 10032, USA.
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Wie meistens: „More data are needed“. Anaesthesist 2008; 57:113. [DOI: 10.1007/s00101-008-1328-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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