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The role of the anesthesiologist as a perioperative consultant requires a thorough knowledge of current guidelines, a deep understanding of perioperative risk associated with various noncardiac surgeries in order to follow an evidence-based approach to perioperative management. This chapter presents a case study of a 76-year-old male was scheduled for a right carotid endarterectomies (CEA) under general anesthesia after an episode of transient monocular blindness (amaurosis fugax) prompted a duplex ultrasound of the carotid vessels. Preoperative laboratory work-up was significant for a hematocrit of 33 and a serum creatinine of 1.6 mg/dL. The vascular surgeon consulted the anesthesia team for preoperative evaluation. The classification of cardiac risk in noncardiac surgery is based on the incidence of cardiac death and nonfatal myocardial infarction. Patients undergoing vascular surgery have a high incidence of concomitant coronary artery disease and cardiac causes are the most common causes of morbidity and mortality after CEA.
Intraoperative neurologic monitoring has been the subject of intense research for many years, the goal being to accurately identify intraoperative cerebral ischemia, and predict which patients may benefit from intraoperative shunting. This chapter presents a case study of a 73-year-old male scheduled for a right carotid endarterectomy (CEA) under general anesthesia. The patient experienced delayed emergence and displayed signs of a left hemiparesis. A diffusion-weighted magnetic resonance imaging confirmed the presence of a right-sided ischemic stroke in the middle cerebral artery (MCA) territory. For patients undergoing CEA under general anesthesia a number of monitoring modalities exist: monitors of cerebral hemodynamics, monitors of cerebral oxygenation and metabolism, and monitors of electrophysiologic parameters. None of the monitoring modalities commonly used for CEA under general anesthesia have been shown to either reliably identify or prevent cerebral ischemia or stroke, nor predict which patients may benefit from shunt placement.