Medication Summary
Carotid bypass and reconstruction are usually performed with general anesthesia because extensive exposure of the neck and sternotomy may be necessary. If mandibular subluxation is required for high distal targets (C1 and above), nasotracheal intubation is used.
Anesthetic Agents
Class Summary
After standard monitoring equipment is attached and peripheral venous access achieved but before the arterial line is inserted, the midazolam dose is administered. Before placement of the arterial line, it should be ensured that a radial artery graft will not be used for CABG.
Propofol (Diprivan)
Propofol is a phenolic compound unrelated to other types of anticonvulsants. It has general anesthetic properties when administered intravenously. Propofol IV produces rapid hypnosis, usually within 40 seconds. The effects are reversed within 30 minutes following the discontinuation of infusion. Propofol has also been shown to have anticonvulsant properties.
Etomidate (Amidate)
Amidate is a nonbarbiturate imidazole compound with sedative properties. It is short-acting and has a rapid onset of action; the duration of action is dose dependent (15-30 minutes). Its most useful feature as an induction agent is that it produces deep sedation while causing minimal cardiovascular effects.
The major application of etomidate is induction for endotracheal intubation, particularly in patients with, or at risk for, hemodynamic compromise. Amidate has been shown to depress adrenal cortical function; however, this effect is not significant clinically during short-term administration. Since the drug is mixed in propylene glycol, continuous infusion not recommended.
Thiopental
Thiopental is a short-acting barbiturate sedative-hypnotic with rapid onset and a duration of action of 5-20 minutes. Like methohexital, it is most commonly used as an induction agent for intubation. To use thiopental as a sedative, titrate in dosage increments of 25 mg (adjust to lower dose in children).
Isoflurane (Forane, Terrell)
Isoflurane is an inhalation anesthetic. It may have a myocardial protective effect and therefore is especially useful in off-pump surgery. Isoflurane potentiates the effects of muscle relaxants. Small doses of muscle relaxants can achieve complete paralysis when administered concomitantly with isoflurane.
Neuromuscular Blockers, Nondepolarizing
Class Summary
Nondepolarizing neuromuscular blockers are used in combination with a sedative as part of the rapid-sequence intubation process.
Pancuronium
Vecuronium may increase myocardial oxygen demand. It is used to facilitate endotracheal intubation and provide neuromuscular relaxation during intubation and mechanical ventilation. It is given as an adjunct to a sedative or hypnotic agent.
Vecuronium
Vecuronium may cause bradycardia in association with opioids. It is used to facilitate endotracheal intubation and provide neuromuscular relaxation during intubation and mechanical ventilation. It is given as an adjunct to a sedative or hypnotic agent.
Rocuronium (Zemuron)
Rocuronium may cause tachycardia. It is used to facilitate endotracheal intubation and provide neuromuscular relaxation during intubation and mechanical ventilation. It is given as an adjunct to a sedative or hypnotic agent.
Atracurium
Atracurium is not considered suitable for operations of long duration. It can cause hypotension secondary to histamine release. It is used to facilitate endotracheal intubation and provide neuromuscular relaxation during intubation and mechanical ventilation. It is given as an adjunct to a sedative or hypnotic agent.
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CT scan demonstrating CCA-to-CCA bypass using retropharyngeal route. CCA = common carotid artery; PTFE = polytetrafluoroethylene (bypass graft).
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Aorta-to-CCA bypass using 8-mm Dacron graft. AA = ascending aortic arch; CCA = common carotid artery.
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CCA-to-ICA reconstruction with 6-mm PTFE graft, performed for aneurysmal disease of carotid bifurcation. CCA = common carotid artery; ECA = external carotid artery; ICA = internal carotid artery; IJ = internal jugular vein; PTFE = polytetrafluoroethylene.
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ICA is shunted during CCA-to-ICA bypass. CCA = common carotid artery; ICA = internal carotid artery.
