Perioperative management of carotid endarterectomy: A survey of clinicians' backgrounds and practices

Abstract

Objective To examine current trends in anesthetic practice for management of carotid endarterectomy (CEA) and how practice may differ by groups of practitioners. Design An online survey was sent to the Society of Cardiovascular Anesthesiologists and Society of Neuroscience, Anesthesiology, and Critical Care e-mail list servers. Responses were voluntary. Setting Academic medical centers and community-based hospitals providing perioperative care for a CEA in the United States and abroad. Participants Anesthesiologists who provide perioperative care for patients undergoing a CEA. Interventions None Measurements and Main Results Of 664 responders (13% response rate), most (66%) had subspecialty training in cardiovascular anesthesiology, had been in practice more than 10 years (68%), and practiced in the United States (US, 81%). About 75% of responders considered general anesthesia as a preferable technique for CA, and about 89% of responders provided it in real life, independent of subspecialty training. The most preferable intraoperative neuromonitoring was cerebral oximetry (28%), followed by EEG (24%), and having an awake patient (23%). Neuroprotection was not considered by 33% of responders, and upon conclusion of a case, 59% preferred an awake patient for extubation, while 15% preferred a deep extubation. Neuroanesthesiologists and non-US responders more often risk stratify patients for perioperative cerebral hyperperfusion syndrome, compared with cardiac anesthesiologists and US responders (p = 0.004 and p<0.005, respectively). Additionally, reported management strategies vary substantially from anesthetic practice 20 years ago. Conclusions Although there are areas of perioperative management in which there seems to be agreement for the CEA, there are also areas of divergent practice that could represent potential for improvement in overall outcomes. There are many potential reasons to explain divergence in practice by location or subspecialty training, but it remains unclear what the "best practice" may be. Future studies examining outcomes after carotid endarterectomy should include perioperative anesthetic management strategies to help delineate "best practice." © 2014 Elsevier Inc.