Wake-Up Test Decrease Shunts Insertion During Carotid Endarterectomy Under General Anesthesia

Abstract

Objective: The use of locoregional anesthesia versus general anesthesia (GE) in carotid endarterectomy (CEA) has been a debatable issue in clinical studies for the past several years. In our study, GE with wake-up tests (WUTs) during carotid cross-clamping was used instead of stump pressure (SP) to directly assess the neurological status of the patient to determine whether shunting was needed. Our study assessed the percentage of patients under light sedation and mechanically ventilated needing shunting based on WUT compared to a systolic stump pressure (SPs) cutoff value of ≤40 mm Hg. Design: Retrospective, observational study. Setting: University hospital clinic. Participants: Three hundred fifty-one patients (American Society of Anesthesiologists physical class II-III) with carotid artery stenosis scheduled for CEA under GE. Interventions: The WUT was used to assess the neurological status in patients undergoing CEA, which involved the gradual reduction of depth of anesthesia until the patient was capable of responding to a verbal stimulus and provide full collaboration while only receiving remifentanil. A positive WUT indicated that patient was not able to carry out the order. Measurements and Main Results: Of 343 patients, 20 (5.8%) were shunted due to a positive WUT after cross-clamping in comparison to 45 patients (12.8%) based on the SPs ≤40 mm Hg criteria. Conclusion: Wake-up test can be used to directly assess the neurological status in patients undergoing CEA to determine whether shunting is required. Our results showed that less patients required shunting based on WUT compared to the SP criteria.

Keywords

wake-up test stump pressure carotid endarterectomy general anesthesia stroke

Get full access to this article

View all access options for this article.

References

Benington S. , Pichel AC Anesthesia for carotid endarterectomy. Curr Anaesth Crit Care. 2008;19(3):138-149.

Guay J. Regional or general anesthesia for carotid endarterectomy? Evidence from published prospective and retrospective studies. J Cardiothorac Vasc Anesth. 2007;21(1):127-132.

Rerkasem K. , Rothwell PM Local versus general anaesthesia for carotid endarterectomy. Cochrane Database Syst Rev. 2008;4: CD000126.

Guay J. Regional anesthesia for carotid surgery. Curr Opin Anaesthesiol . 2008;21(5):638-644.

Lewis SC , Warlow CP , Bodenham AR , et al and the GALA Trial Collaborative Group. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet. 2008;372(9656):2132-2142.

Paraskevas KI , Mikhailidis D. , Bell P. The GALA Trial: Will It Influence Clinical Practice? Vasc Endovascular Surg. 2009; 43(5):429-432.

Vetrugno L. , Bassi F. , Roccato A. , Giordano F. It is nice to ‘‘Wake Up’’ patients for combined carotid endarterectomy and coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth. 2008; 22(6):943-944.

Bevilacqua S. , Romagnoli S. , Ciappi F. , et al. Anesthesia for carotid endarterectomy: the third option. Patient cooperation during general anesthesia. Anesth Analg. 2009;108(6):1929-1936.

Kitagawa N. , Oda M. , Kakiuchi T. , et al. Neurological evaluation by intraoperative wake-up during carotid endarterectomy under general anesthesia. J Neurosurg Anesthesiol . 2004; 16(3):240-243.

10.

Muchada R. , Lucchesie G. Carotid endarterectomy under remifentanil. Rev Esp Anestesiol Reanim. 2001;48(10):508-512.

11.

Dorgan JC , Abbott TR , Bentley G. Intra-operative awakening to monitor spinal cord function during scoliosis surgery. Description of the technique and report of four cases. J Bone Joint Surg Br. 1984;66(5):716-719.

12.

Hays RJ , Levinson SA , Wylie EJ Intraoperative measurement of carotid back pressure as guide to operative management for carotid endarterectomy. Surgery. 1972;72(6):953-960.

13.

DeLaurentis DA , Dougherty MJ , Calligaro KD , Savarese RP , Raviola CA , Bajgier SM Carotid stump pressure, stump pulse and retrograde flow. Am J Surg. 1993;166(2):152-155.

14.

Whitely D. , Cherry KJ Jr. Predictive value of carotid artery stump pressure during carotid endarterectomy . Neurosurg Clin N Am. 1996;7(4):723-732.

15.

Ricotta JJ , Charlton MH , DeWeese JA Determining criteria for shunt placement during carotid endarterectomy: EEG versus back pressure. Ann Surg. 1983;198(5):642-645.

16.

Jacob T. , Hingorani A. , Ascher E. Carotid Artery Stump Pressure (CASP) in 113 consecutive endarterectomies under general anesthesia: an old method that survived the test of times. J Cardiovasc Surg. 2007;48(6):677-681.

17.

Harada RN , Comerota AJ , Good GM , Hashemi HA , Hulihan JF Stump pressure, electroencephalographic changes, and the contralateral carotid artery: another look at selective shunting. Am J Surg. 1995;170(2):148-153.

18.

Halsey JHJr. Risks and benefits of shunting in carotid endarterectomy. The International Transcranial Doppler Collaborators . Stroke. 1992;23(11):1583-1587.

19.

Cao P. , Giordano G. , Zannetti S. , et al. Transcranial Doppler monitoring during carotid endarterectomy: is it appropriate for selecting patients in need of a shunt? J Vasc Surg. 1997;26(6): 973-979.

20.

Sloan MA Prevention of ischemic neurologic injury with intraoperative monitoring of selected cardiovascular and cerebrovascular procedures: roles of electroencephalography, somatosensory evoked potentials, transcranial Doppler, and near-infrared spectroscopy . Neurol Clin. 2006;24(4):631-645.

21.

Whiten C. , Gunning P. Carotid endarterectomy: intraoperative monitoring of cerebral perfusion. Curr Anaesth Crit Care. 2008;20(1):42-45.

22.

Moritz S. , Kasprzak P. , Arlt M. , Taeger K. , Metz C. Accuracy of cerebral monitoring in detecting cerebral ischemia during carotid endarterectomy: a comparison of transcranial Doppler sonography, near-infrared spectroscopy, stump pressure, and somatosensory evoked potentials. Anesthesiology. 2007;107(4):563-569.

23.

Guarraccino F. Cerebral monitoring during cardiovascular surgery. Curr Opin Anaesthesiol. 2008;21(1):50-54.

24.

Calligaro KD , Dougherty MJ Correlation of carotid artery stump pressure and neurological changes during 474 carotid endarterectomy performed in awake patients. J Vasc Surgery. 2005;42(4):684-689.

25.

De Castro V. , Godet G. , Mencia G. , Raux M. , Coriat P. Target-controlled infusion for remifentanil in vascular patients improves hemodynamics and decreases remifentanil requirement . Anesth Analg. 2003;96(1):33-38.

26.

Machata AM , Illievich UM , Gustorff B. , Gonano C. , Fässler K. , Spiss CK Remifentanil for tracheal tube tolerance: a case control study. Anaesthesia. 2007;62(8):796-801.

27.

Coppi G. , Moratto R. , Ragazzi G. , et al. Effectiveness and safety of carotid endoarterectomy under remifentanil . J Cardiovasc Surg (Torino). 2005;46(4):431-436.

28.

Evans WE , Hayes JP , Waltke EA , Vermilion BD Optimal cerebral monitoring during carotid endoarteriectomy: neurologic response under local anesthesia. J Vasc Surg. 1985;2(6):775-777.