Postoperative Care “Carotid Endarterectomy”

General Rules

1. Vascular patients require high vigilant monitoring Options: ICU or Vascular Step Down Units.

2. Myocardial ischemia and cardiac morbidity occur most frequently in the postoperative period.

3. Almost 90% of ischemic episodes are “silent”

4. The determinants of myocardial oxygen supply and demand should be optimized for all patients

5. β-Blocker and statin therapy should be continued throughout the postoperative period

General Rules

Demand-Supply Depiction:

General Rules

6. Even in the absence of coagulopathy, bleeding through fresh vascular anastomoses may occur when significant postoperative hypertension is untreated.

7. Residual hypothermia in the early postoperative period is associated with an increased incidence of myocardial ischemia and cardiac morbidity.

General Rules

8. Avoid Stress response postoperatively like:o Control Paino Correct Anemiao Correct Hypothermiao Control Haemodynamicso Correct ventillatory insufficiency

9. When possible, extubation in the operating room is less stressful.

10. Careful sedation and expeditious weaning are desirable

Complications of CEA

Remember:

CAE is 3 times as effective as medical therapy alone in reducing incidence of stroke in patients with symptomatic

stenosis of 70 – 99%

Complication rate should be maintained at an extremely low rate <3% by surgeons to keep the beneficial effects of

carotid endarterectomy over medical therapy (Grade-A recommendation)

Complications of CEA

1. Wound Hematoma: (5.5%)• Majority are relatively small causing

little discomfort• Larger ones require evacuation• If no loss of airway Emergency

evacuation in operating room• If airway obstructed it is better to

open wound at bedside.

Complications of CEA

2. Hypertension: (73.5%)• Poorly controlled preoperative HTN

increase risk of postop complications e.g; Hematoma and Hyperperfusion syndrome

• Particular peak of rise is highest in the first 48hrs.

• Cause is Baroreceptor Failure Syndrome

• Associated with bilateral procedures• This variability persists till 12 weeks• Controlled by Hydralazine, Labetalol,

GTN, B-Blockers.

Complications of CEA

3. Hypotension: (5%)• Occurs after reactivation of

baroreceptor activity and resolves in 24-48hrs

• Responds well to fluids and low dose phenyepherine

• If persistent significant hypotension Rule out MI via cardiac enzymes & serial EKGs

Complications of CEA

4. Hyperperfusion Syndrome:• Occurs in high grade stenosis ( 90%

and above) and longstanding hypoperfusion.

• Can lead to paralysis and autoregulation failure

• Distal collaterals remain maximally dilated after endarterectomy breakthrough pressure can results in edema and haemorrhage

• Characterised by severe unilateral headache improved by upright posture

Complications of CEA

5. Intracerebral Haemorrhage: (0.6%)

• Occurs secondary to hyperperfusion syndrome (within 2 weeks)

• Associated with poor outcomes

• Strict control of blood pressure is mandatory

Complications of CEA

6. Seizures: (3%)• Fortunately these are uncommon• Caused by brain edema following

hyperperfusion syndrome• Regardless of whether or not ICU care

is provided, high risk patients, such as those with preoperative HTN, should be closely monitored for 24hrs (Grade-B recommendation)

Discharge

Patient should be made aware of the:

1. Significance of Unilateral Headache

2. Any new neurological symptom 3. Importance of Good BP Control