GUIDELINE FOR RECOVERY ROOM MANAGEMENT OF PATIENTS AFTER CAROTID ENDARTERECTOMY

Transcription

1 GUIDELINE FOR RECOVERY ROOM MANAGEMENT OF PATIENTS AFTER CAROTID ENDARTERECTOMY Full Title of Guideline: Author (include and role): Guideline for Recovery Room Management of Patients after Carotid Endarterectomy Prerna Mehrotra (SpR in Anaesthesia) Avninder Chana (Consultant Anaesthetist: Based on original guideline pilot: Mark Brown, Gerrie van der Walt, Arani Pillai, Bryn Baxendale (Consultant Anaesthetists) Division & Speciality: Scope (Target audience, state if Trust wide): Review date (when this version goes out of date): Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis): Changes from previous version (not applicable if this is a new guideline, enter below if extensive): Summary of evidence base this guideline has been created from: Clinical Support Division (Anaesthesia and Critical Care). Recovery room nursing staff, anaesthetists and surgeons caring for patients in the immediate period after carotid endarterectomy surgery. September 2020 Adult patients who have undergone carotid endarterectomy surgery and are in the recovery room post -operatively. N/A Based on evidence level 3-5; including international, national, and local guidelines for best practice. This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date or outside of the Trust.

2 1. CAROTID ENDARTERECTOMY 1.1 Indications and Procedure Carotid endarterectomy (CEA) is a vascular surgical procedure in which atheromatous plaque is removed from the carotid artery in the neck. It is indicated in patients with symptomatic stenosis of one or both carotid arteries, as determined by arterial duplex scanning. The procedure is carried out under local, regional or general anaesthesia. Surgical access to the carotid artery is gained by a cervical incision anterior to the sternocleidomastoid, followed by dissection to the carotid sheath. The artery is clamped (with or without the use of a shunt), arteriotomy performed and atheroma evacuated, before closure which may include a patch. 1.2 Perioperative complications Manipulation of the carotid artery can result in haemodynamic instability both intra- and postoperatively. Attention to haemodynamic monitoring is essential to avoid periods of low cerebral blood flow, which could result in cerebral ischaemia. Hypertension should also be avoided, as this may stress suture lines, and increase the likelihood of a neck haematoma which can compromise the airway, needing emergency evacuation. The incidence of a new major stroke occurring post CEA is 2-5% i,ii,iii. This usually manifests as new neurological deficits, and has a mortality approaching 5% iv. A rare complication of carotid endarterectomy is cerebral hyperperfusion syndrome (CHS). This occurs from increased cerebral blood following carotid revascularisation. The clinical features include ipsilateral headache, seizures and focal neurological symptoms. CHS should be managed promptly to prevent intracranial haemorrhage. Risk factors for CHS include hypertension, high grade stenosis with low collateral flow, intra-operative ischaemia and contralateral carotid ischaemia v. 2. PERIOPERATIVE MANAGEMENT 2.1 Preoperative considerations Adequate blood pressure control is required to prevent post-operative complications. The patient s usual antihypertensive medication should have been continued prior to surgery. Anticoagulants require special consideration. Antiplatelet agents such as clopidogrel are associated with an increased risk of post-operative wound haematoma. However, this must be balanced against the risk of thromboembolic complications following stopping drug therapy.

3 2.2 Intraoperative considerations Large bore intravenous access and invasive arterial monitoring will be sited before the procedure, normally on the side opposite the procedure site. The procedure can be performed under local infiltration, regional anaesthesia, with/without sedation, or general anaesthesia (GALA trial vi ). A combination of these may have been used. The patient will have received intravenous unfractionated heparin intraoperatively. 2.3 Post operative management Key handover points to recovery team i. Presence of pre-existing neurological deficits ii. Post operative blood pressure (BP) limits to be set by anaesthetist and surgeon at WHO sign out (see section for guidance) iii. Functioning arterial pressure monitoring iv. Contact details for anaesthetist and surgeon while in recovery Minimum monitoring in recovery i. Continuous arterial pressure monitoring ii. Neurological observations: every 15 minutes for first hour, then every 30 minutes. a. GCS b. Sudden change in vision c. Facial weakness (pupil reaction only if severe hypertension or other neurology) d. Bilateral limb power (upper and lower limbs) graded on MRC scale (0-5)

4 2.3.3 Management of blood pressure in recovery

5 2.3.4 Guidance on setting post-operative blood pressure limits Typical BP range = baseline +/- 30%, using preoperative assessment / ward readings to determine baseline. This range should be used to trigger patient review, but may be adjusted for the individual patient. REDUCE maximum limit in patients at risk of cerebral hypertension syndrome Poorly controlled hypertension Stroke within last 30 days Significant contralateral carotid stenosis Intraoperative shunt use RAISE minimum limit in patients at risk from hypotension Severe coronary artery disease Metallic prosthetic valve(s) Moderate/Severe aortic stenosis Renal artery stenosis Significant contralateral carotid stenosis Administration of IV antihypertensive agents in recovery SEEK SENIOR HELP IF UNFAMILIAR WITH THESE AGENTS, AS PRECIPITOUS CHANGES IN BLOOD PRESSURE CAN HAVE DETRIMENTAL EFFECTS. i. HYDRALAZINE titrate slow IV bolus: 5mg every 20 minutes; maximum 10mg over 40 minutes. Onset minutes. ii. LABETALOL titrate slow IV bolus: 10mg every 2 minutes; maximum 100mg over 20 minutes. Onset 5-10 minutes Haematoma after carotid endarterectomy Rapid development of a neck haematoma can compromise the airway, and must be managed as an emergency. Watch for stridor, crowing or noisy respiration, dysphonia, aphonia, choking, drooling and gagging, blood loss into neck drain. Immediate management: i. Sit patient up and give high flow oxygen ii. Check drain is open and patent iii. Apply pressure iv. CONTACT VASCULAR SURGEON AND ANAESTHETIST

6 2.3.7 Acute neurological change after carotid endarterectomy Changes in neurological observations after carotid endarterectomy may indicate a significant problem, such as thrombosis (occlusion of carotid artery), or cerebral hyperperfusion syndrome. Any change in neurological observations is an URGENT PROBLEM. i. Contact Vascular surgeon and Anaesthetist urgently ii. Follow BP control guidelines. 3. CONTACT DETAILS The surgeon and anaesthetist involved in the case should be contacted in working hours should any problems occur. Out of hours contact: 3 rd on call anaesthetist bleep or phone Vascular registrar on call ( hrs) bleep General surgical registrar on call ( hrs) bleep Vascular Consultant on call via switchboard 4. REFERENCES i Hill MD, Brooks W, Mackey A, et al. Stroke after carotid stenting and endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Circulation 2012; 126: ii Faggioli G, Pini R, Mauro R, et al. Perioperative outcome of carotid endarterectomy according to type and timing of neurologic symptoms and computed tomography findings. Ann Vasc Surg 2013; 27: iii Goldberg JB, Goodney PP, Kumbhani SR, et al. Brain injury after carotid revascularization: outcomes, mechanisms, and opportunities for improvement. Ann Vasc Surg 2011; 25: iv Lewis SC, Warlow CP, Bodenham AR, et al. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet. 2008; 372: v Maas MB, Kwolek CJ, Hirsch JA et al. Clinical risk predictors for cerebral hyperperfusion syndrome after carotid endarterectomy. J Neurol Neurosurg Psychiatry. 2013; 84: vi GALA trial collaborative group. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet. 2008; 372: