Barbiturate therapy in the postoperative endarterectomy patient with a neurologic deficit

Markowitz, Ira P.; Adinolfi, Michael F.; Kerstein, Morris D.

doi:10.1016/0002-9610(84)90225-3

Cited by 15 publications

(4 citation statements)

References 13 publications

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“…These drugs could improve cerebral circulation and decrease cerebral oxygen demand [12,13]. In addition to the implications on neurological outcomes, anesthesia may also be correlated with other types of major complications that may occur post-CEA, such as perioperative cardiovascular events [14].…”

Section: Evidences and Considerationsmentioning

confidence: 99%

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Anesthetic management of carotid endarterectomy: an update from Italian guidelines

Bevilacqua

Ticozzelli

Orso

et al. 2022

J Anesth Analg Crit Care

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Background and aims In order to systematically review the latest evidence on anesthesia, intraoperative neurologic monitoring, postoperative heparin reversal, and postoperative blood pressure management for carotid endarterectomy. The present review is based on a single chapter of the Italian Health Institute Guidelines for diagnosis and treatment of extracranial carotid stenosis and stroke prevention. Methods and results A systematic article review focused on the previously cited topics published between January 2016 and October 2020 has been performed; we looked for both primary and secondary studies in the extensive archive of Medline/PubMed and Cochrane library databases. We selected 14 systematic reviews and meta-analyses, 13 randomized controlled trials, 8 observational studies, and 1 narrative review. Based on this analysis, syntheses of the available evidence were shared and recommendations were indicated complying with the GRADE-SIGN version methodology. Conclusions From this up-to-date analysis, it has emerged that any type of anesthesia and neurological monitoring method is related to a better outcome after carotid endarterectomy. In addition, insufficient evidence was found to justify reversal or no-reversal of heparin at the end of surgery. Furthermore, despite a low evidence level, a suggestion for blood pressure monitoring in the postoperative period was formulated.

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Section: Evidences and Considerationsmentioning

confidence: 99%

“…11 Vascular Surgery Unit, Arcispedale Snata Maria Nuova, Reggio Emilia, Italy. 12 Stroke Unit, Neurology Department, USL Umbria 1, Cittá di Castello, Perugia, Italy. 13 Vascular Surgery Unit, IRCCS Policlinico San Donato Hospital University, San Donato Milanese, Italy.…”

Section: Supplementary Informationmentioning

confidence: 99%

Anesthetic management of carotid endarterectomy: an update from Italian guidelines

Bevilacqua

Ticozzelli

Orso

et al. 2022

J Anesth Analg Crit Care

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“…In cardiac surgery, barbiturates induce cerebral protection during hypothermic circulatory arrest (62). They have displayed beneficial cerebral effects while performing CEA without adverse cardiovascular outcomes (63,64). They reduce oxygen demand throughout relative tissue ischemia induced by arterial clamping (65,66).…”

Section: Barbiturate Infusionmentioning

confidence: 99%

A pilot protocol and review of triple neuroprotection with targeted hypothermia, controlled induced hypertension, and barbiturate infusion during emergency carotid endarterectomy for acute stroke after failed tPA or beyond 24-hour window of opportunity

Sultan¹,

Acharya²,

Barrett³

et al. 2020

Ann Transl Med

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An alternative to tissue plasminogen activator (tPA) failure has been a daunting challenge in ischemic stroke management. As tPA is time-dependent, delays can occur in definitive treatment while passively waiting to observe a clinical response to intravenous thrombolysis. Until today, uncertainty exists in the management strategy of wake-up stroke patients or those presenting beyond the therapeutic tPA window.Clinical dilemmas in these situations can prolong the transitional period of inertia, resulting in an adverse neurological outcome. We propose and review an innovative approach called triple neuro-protection (TNP), which encompasses three technical domains-targeted hypothermia, systemic induced hypertension, and barbiturates infusion, to protect the brain during carotid endarterectomy after failed tPA and/or beyond the 24-hour therapeutic mechanical thrombectomy window. This proposal assimilates discussion on the clinical evidence of the individual domains of TNP with our own clinical experience with TNP. Our first TNP was successfully employed in a 55-year-old man in 2015 while performing emergency carotid endarterectomy after he was referred to us 72 hours post tPA failure. The patient had a successful clinical outcome despite being in therapeutic inertia with 90-99% ipsilateral carotid stenosis and contralateral occlusion on presentation. In the last five years, we have safely used TNP in 25 selected cases with favourable clinical outcomes.

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“…Wells'in ilk olarak 1963'de GA'nin serebral koruyucu etkilerini bildirmesinden bu yana karotis cerrahisinde GA tercihi hala güncelliğini korumaktadır (12). İntravenöz anestezikler ve inhalasyon anestezikleri nöroprotektif etkileriyle nöronları iskemik hasara karşı korurlar (13,14). Izofluran, sevofluran ve desfluranın eşit etki gösteren konsantrasyonlarında kollateral serebral kan akımına etkileri benzer olsa da, desfluranın kan/beyin partisyon katsayısının düşük olması, kritik iskemi sırasında nöronları koruyucu etkisinin daha hızlı gerçekleşmesini sağlar (1).…”

Section: Introductionunclassified

General Anesthesia Management for Carotid Endarterectomy Surgery

Kerem¹,

Gümüş²,

Alagöl³

2014

JAREM

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Karotis endarterektomileri proflaktik operasyonlardır ve genel, lokal veya rejyonel anestezi altında gerçekleştirilebilirler. Karotis endarterektomi operasyonlarının mevcut pratik uygulamalarında anestezist ve cerrah genellikle en konforlu olabilecek anestezi tekniğini tercih ederler. Lokal anestezi uygulaması bilinçli hastanın direkt nörolojik monitorizasyonunu sağladığı için avantajlıdır. Ancak bu yöntem cerrahlar ve hastalar için stresli olabilir. Buna karşın genel anestezi altında uygulanan karotis endarterektomilerinde ise serebral iskeminin tespiti çok zor olabilir. Serebral iskeminin tespiti için pek çok monitör ve teknik vardır, fakat hiçbiri tam anlamıyla efektif ve güvenilir değildir. Ek olarak karotis endarterektomi operasyonu geçirecek hastalar hipertansiyon hastasıdırlar ve operasyon sırasında önemli derecede kalp krizi riski taşırlar. Hemodinamik stabilite için anestezi indüksiyonu dikkatlice yapılmalıdır. Direkt invazif arter basıncı, beş yollu elektrokardiyografi (EKG) ve ST segment analizi monitorize edilmelidir. Karotis arter klemplenmesine sekonder gelişebilecek serebral iskemi riskini azaltmak için yeterli serebral perfüzyon basıncı korunmalıdır. Normokarbinin, yeterli oksijenasyonun, giriş ortalama arter basıncına yakın bir arter basıcının sağlanması gerekir. Hatta ortalama arter basıncı seviyesi, giriş ortalama arter basıncının %20 kadar üzerinde tutulabilir. Karotis endarterektomilerinde peroperatif ve postoperatif riskin kontrolünde anestezistin rolü çok önemlidir. Bu cerrahi işlemin bütün aşamalarında tüm detaylara dikkat edilmesi ve güvenli bir anestezi yaklaşımı başarılı bir sonuca katkıda bulunur. Nörolojik sistemin ve kardiyovasküler fonksiyonların dikkatli bir şekilde değerlendirilmesi, optimum serebral ve kardiyovasküler perfüzyon basınçlarının sağlanması gereklidir.

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Barbiturate therapy in the postoperative endarterectomy patient with a neurologic deficit

Cited by 15 publications

References 13 publications

Anesthetic management of carotid endarterectomy: an update from Italian guidelines

Anesthetic management of carotid endarterectomy: an update from Italian guidelines

A pilot protocol and review of triple neuroprotection with targeted hypothermia, controlled induced hypertension, and barbiturate infusion during emergency carotid endarterectomy for acute stroke after failed tPA or beyond 24-hour window of opportunity

General Anesthesia Management for Carotid Endarterectomy Surgery

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