1. VASCULAR ANAESTHESIA TIPS AND TRICKS OR HOW NOT TO GET CAUGHT! DR KEVIN M SADLER STH

2. AIMS OF THE TALK Vascular operations that may end up done by a non-vascular anaesthetist It’s NOT rocket science! We don’t need to be a separate specialty! Carotid Surgery Aortic Surgery Peripheral Arterial Surgery Amputations

3. CAROTID ENDARTERECTOMY THE NEW EMERGENCY VASCULAR OPERATION

4. CAROTID ENDARTERECTOMY Government targets – originally 2 days now 2 weeks (NICE) May be seen on emergency lists and at weekends Does NOT need a vascular anaesthetist! DOES need a quality anaesthetic!

5. CAROTID ENDARTERECTOMY CVA – commonest cause of adult neurol deficit CVA – 3 rd commonest cause of death in UK Incidence in England and Wales >130,000/yr Cost £7b in 2005 Studies show CEA improves outcome if >70% stenosis ACST showed improvement in asympomatic pts.

6. CAROTID ENDARTERECTOMY Risk of further event is highest in 1 st 72 hours High risk persists for >6 weeks CEA most effective if done within 2 weeks The major complications intra- and post-op CVA, MI and death (combined 30 day incidence should be <5% in centres) GALA trial published 2008

7. CAROTID ENDARTERECTOMY The operation – eversion seldom done

8. CAROTID ENDARTERECTOMY The operation – standard Shunt used where neurol monitoring impossible Monitoring methods used

9. GALA TRIAL Published 2008 Compared all types of GA with all types of LA Aimed n=5000 achieved 3500 Proved…No technique is better than any other Hinted...CVA rate slightly higher under GA Hinted…MI rate slightly higher under LA What to choose?

10. IT’S NOT WHAT YOU DO… AdvantagesDisadvantages General anaesthesia Immobility Lack of direct neurological monitoring during surgery Potential for neuroprotection Intraoperative hypotension Controlled ventilation and CO 2 Postoperative hypertension Attenuated stress response Increased rate of shunt use Delayed recovery from GA may mask postoperative neurological complications Regional anaesthesia Allows direct real-time neurological monitoring Risks associated with sitting blocks (deep cervical plexus blockade) Avoids the risks of airway intervention Patient stress/pain causing increased risk of myocardial ischaemia Reduced shunt rate Restricted access to airway during surgery Reduced hospital stay Requires co-operative patient, able to lie flat Allows arterial closure at ‘normal’ arterial pressure: may reduce risk of postoperative haematoma Risk of requirement to convert to GA during surgery

11. CEA - WHAT DO I DO? Surgeon there first then I do LA (he likes it)  IVI, art line on contralateral side  Superficial cervical plexus block (other blocks available)  Positioning and catheter  Sedation  Monitoring  BP control (during and after) Me there first or slow surgeon then I do GA  As above with GA (careful!!)  LMA? ETT? Pros and cons of each Block the carotid sinus nerve? Pros and cons

12. CEA - WHAT SHOULD YOU DO? Don’t be afraid! It’s just a GA with attention to detail! Unless you really feel inclined to do LA Choose an appropriate airway that YOU like Try a block – it’s not hard! Be as smooth as you can and jump on BP (Aim for normal +20% when shunted) Consider blocking carotid sinus nerve Consider a deep extubation Control BP post-op +/-20% of normal