Carotid stenting

Specialties Neuro

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Not sure if this is the right category to ask this question. In our facility, the cardiologists are doing carotid stenting because the radiologists don't care to take it on. The cardiologists are accustomed to vessel intervention (PTCAs), so they won by default. After the procedure, with femoral sheath in place, the patient must lay flat until the sheath is safely removed and the vessel is stable before allowing the patient to sit up. In the meantime, we have orders to maintain the BP >100syst. We have noticed that many of these patients drop their BP after the procedure and we have to start Dopamine. Almost all of these patients are on beta-blockers that they take in the AM before coming in. Then the docs wonder why the BP drops after they've mucked around with those baroreceptors :confused: Anybody else have similar problems and how do you manage it? I've suggested numerous times that they tell the patients to not take the beta-blocker that AM before the procedure, but nobody seems to be listening.

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Not sure if this is the right category to ask this question. In our facility, the cardiologists are doing carotid stenting because the radiologists don't care to take it on. The cardiologists are accustomed to vessel intervention (PTCAs), so they won by default. After the procedure, with femoral sheath in place, the patient must lay flat until the sheath is safely removed and the vessel is stable before allowing the patient to sit up. In the meantime, we have orders to maintain the BP >100syst. We have noticed that many of these patients drop their BP after the procedure and we have to start Dopamine. Almost all of these patients are on beta-blockers that they take in the AM before coming in. Then the docs wonder why the BP drops after they've mucked around with those baroreceptors :confused: Anybody else have similar problems and how do you manage it? I've suggested numerous times that they tell the patients to not take the beta-blocker that AM before the procedure, but nobody seems to be listening.

Recent studies have shown that overall perioperative morbidity and mortality decreases with the administration of beta blockers to patients undergoing intermediate to high-risk procedures. Patients with carotid disease typically do not have disease in only their carotids...usually involves their coronaries, etc. Heart rate increases are the most oxygen-consuming change in hemodynamics - this is why we encourage patients to take their beta blockers prior to the procedure, and if the patients are not on beta blockers, we often start them a day or two before surgery. I don't know how our postop PACU nurses manage carotid stents, but intraop we use phenylephrine boluses and occasionally an infusion. Perhaps your patients are not adequately volume loaded after the procedure also. Is this a possibility?

I would think that dopamine may not be the best choice because of its ability to increase the heart rate. Do your patients often become tachycardic after the procedure? And do your cardiologists inject the sinuses with lidocaine?

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Recent studies have shown that overall perioperative morbidity and mortality decreases with the administration of beta blockers to patients undergoing intermediate to high-risk procedures. Patients with carotid disease typically do not have disease in only their carotids...usually involves their coronaries, etc. Heart rate increases are the most oxygen-consuming change in hemodynamics - this is why we encourage patients to take their beta blockers prior to the procedure, and if the patients are not on beta blockers, we often start them a day or two before surgery. I don't know how our postop PACU nurses manage carotid stents, but intraop we use phenylephrine boluses and occasionally an infusion. Perhaps your patients are not adequately volume loaded after the procedure also. Is this a possibility?

I would think that dopamine may not be the best choice because of its ability to increase the heart rate. Do your patients often become tachycardic after the procedure? And do your cardiologists inject the sinuses with lidocaine?

Thanks for your response. The lady I took care of the other day had 3 liters of NS on board and I still had to start Dopamine. I'm not sure what all they do during the procedure (i.e. Lido) and we (the CICU) handle the patients post-op because we're the ones who can pull sheaths. I know about using the beta blockers to prevent vagal stimulation, but wouldn't it be easier to give IV Lopressor if their BP shoots up after the procedure, if their beta blocker is held? No, I rarely see tachycardia (probably because they take their meds). I'll have to ask about using Neo in the cath lab.

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Not sure if this is the right place to ask, but looking for input on carotid stent care. Where do most of the carotid stent patients go post op at different facilities? Currently ours go to the ICU but we are bursting at the seams with patients so looking for the best practice for this population. would love to hear from anybody out there what their practice is.

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Specializes in CCU/CVU/ICU.
Not sure if this is the right place to ask, but looking for input on carotid stent care. Where do most of the carotid stent patients go post op at different facilities? Currently ours go to the ICU but we are bursting at the seams with patients so looking for the best practice for this population. would love to hear from anybody out there what their practice is.

Ours come to ICU/CCU also. This may change at some point as these patients typically do very well.

The big problem is that because the carotids get ballooned, the procedure can 'stretch' the barrow-receptors (did i spell that right?). It's not uncommon to see these patients experience vagal-type reactions...most notably bradycardia. We have standing orders for these patients to start vasopressors (neosynephrine, etc.) in such cases. I think this is the primary reason (at my facility) they come to ICU...as it is standard for anyone on pressors to be in ICU.

And...i totally understand your frustration...as they, for the most part, do so well...and seem to just be occupying valuable ICU beds.

If it were up to me...they'd go to a stepdown/IMCU...

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