Position: Supine, arms tucked
Time: 2-4 hours (long)
Blood Loss: Low (10-50 ml)
Post-op Pain: Minimal (1-3)
Maintenance Paralytic: Yes

Blocks: Superficial Cervical Plexus

Cancellation – If the patient has uncontrolled hypertension, uncontrolled diabetes, or a recent MI, cancellation should be considered. MI is the most common postoperative complication.

Preoperative cerebral blood flow check – Hyperextension and lateral rotation of the head, if producing dizziness or diplopia, shows signs of compromised cerebral blood flow.

Large-bore IV – Large bore IV (recommended 18g +) is necessary due to potential for blood loss, need for multiple drips, and fluids during the procedure. Consider a 2nd IV as a precaution.

Approach – General anesthesia with ETT is most common. Consider using LTA kit to avoid coughing. You can also do a MAC/Awake with a cervical block (Rare)

Arterial Line – necessary for monitoring BP swings due to carotid wall tension changes as the surgeon clamps the carotid. Also helpful for checking ACTs throughout the case.

Neurological Check – Perform neurological checks (bilateral hand grip, move both feet, stick out tongue) before and after procedure.

Additional Documentation – Document total carotid occlusion time.

BIS monitor – Common, but not required. The level of sedation is VERY important to ensure the patient doesn’t get too “light”.

Intraop BP maintenance – This is very much surgeon preference, so check. It is sometimes suggested to keep BP 20% higher than the highest normal resting blood pressure. Others suggest normal resting pressures or a little above.

Sudden drop in HR and BP – This may due to stimulation of the carotid baroreceptors during surgery. This can be remedied by the surgeon applying 2-3 ml of 1% lidocaine to the carotid bulb.

Watch for ST changes – Most patients requiring Carotid Endarterectomy will have CAD/PVD and/or a history of MI. The anesthesia provider should monitor the ECG for any ST changes.

Watch times after heparin admin – ACT check times are usually surgeon specific. Typically check a baseline before heparin given and then every 30 minutes.

Carotid clamping – Increase systolic BP (typically 160 mmHg systolic, but ask surgeon) when clamping to provide adequate brain perfusion. Levophed or Phenylepherine drip most commonly used to increase BP.

Carotid unclamping – Decrease BP when unclamped to avoid bleeding at surgical site. Nitroglycerin drip or Cardene most commonly used to decrease BP.

Heparin reversal – Reversal of heparin is usually 10-15 minutes after the carotid artery is reopened. Reversal will be with protamine sulfate (0.5 mg/kg IV – usually the exact amount is specified by the surgeon). Give this drug slowly as it can cause severe hypotension.

Deep Extubation – recommended, if not contraindicated, to avoid coughing and HTN.

Emergence – Blood pressure control is important on emergence. Where not contraindicated, anticipate using beta blockers (labetalol and/or esmolol) and downers (Nitroglycerin) to combat hypertension on emergence. If emergence is delayed get a STAT carotid ultrasound or cerebral angiography. Surgeon will often require a quick wakeup to assess neural function.

Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it’s going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient’s arms

Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.

Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.

This is a procedure to remove the plaque from the carotid artery. This procedure is generally performed to prevent a thromboembolism, hemodynamic stroke, or transient ischemic attack. Several vessels have to be occluded in this surgery. Among these are the proximal common carotid artery, distal internal carotid artery, external carotid artery, and the superior thyroid artery. collateral circulation has to be determined as sufficient before performing the surgery. If collateral circulation is insufficient, an internal shunt between the proximal common carotid artery and the distal internal artery can be placed. To do this, another vessel is harvested (usually the greater saphenous vein) or a synthetic graft is patched to the artery to increase the diameter of the vessel.

Most common complications: MI, stroke, hemorrhage, and nerve damage.

Cerebral monitoring/oximetry may be used to ensure adequate cerebral perfusion.

Aspirin, anti-platelet, and antihypertensive therapy should be continued all the way up to the day of surgery.

Intraoperative antibiotic is usually Ancef (if not contraindicated).