ANAESTHETIC MANAGEMENT OF PATIENTS UNDERGOING CAROTID ENDARTRECTOMY

Abstract

SUMMARY S troke is one of the most common causes of death and is the main cause of persistent and acquired disability in adults worldwide. Considering demographic changes, a further increase in stroke rates is expected. Moreover, stroke is expected to increasingly affect younger patients. The World Health Organization refers to stroke as the incoming epidemic of the 21st century. Therefore, currently, strategies for stroke prevention are of prime importance, particularly with regard to the recent studies suggesting that 85% of all strokes may be preventable. Carotid endartrectomy is a procedure that prevents stroke in symptomatic patients with high-grade and moderate-grade ICA stenosis of more than 50%. In asymptomatic patients with high-grade stenosis.The benefit is less and highly sensitive to the periprocedure stroke risk. High-risk patients, such as those with comorbid medical conditions, should be considered for CAS if they have high-grade symptomatic stenosis. The best anesthetic technique for an open carotid endarterectomy is debatable. Having an awake and appropriately responsive patient is clearly the most sensitive monitor of adequate cerebral perfusion, but with respect to the major complications of stroke MI, and death, there is no evidence of advantages of one anesthesia technique over the other. Because of that, several additional outcomes need to be taken into account when choosing the technique. Regional anaesthesia is a popular choice for patients undergoing carotid endarterectomy (CEA). Neurological function is easily assessed during carotid crossclamping; haemodynamic control is predictable; and hospital stay is consistently shorter compared with general anaesthesia (GA). Despite these purported benefits, mortality and stroke rates associated with CEA remain around 5% for both regional anaesthesia and GA. Regional anaesthetic techniques for CEA have improved with improved methods of location of peripheral nerves including nerve stimulators and ultrasound together with a modification in the classification of cervical plexus blocks. There have also been improvements in local anaesthetic, sedative, and arterial pressure-controlling drugs in patients undergoing CEA, together with advances in the management of patients who develop neurological deficit after carotid cross-clamping. A key decision for all involved in the operation of CEA is whether or not a shunt is to be inserted. In the awake patient, the anaesthetist should remain in constant verbal contact with the patient during and after cross-clamping. This should consist of more than simply asking the patient if they feel alright. It is appropriate to check frequently that the patient is orientated in time and place and can perform simple mental tasks such as counting backwards from 100. The patient should be asked to demonstrate that they can move the side of their body contralateral to surgery. If the patient’s hand is under the drapes, a squeaky toy or a fluid