Variation in perioperative cerebral and hemodynamic monitoring during carotid endarterectomy.

Abstract

OBJECTIVE\nHemodynamic disturbances cause half of the perioperative strokes following carotid endarterectomy (CEA). Guidelines strongly recommend strict pre- and postoperative blood pressure (BP) monitoring in CEA patients, but do not provide firm practical recommendations. Although in the Netherlands 50 centres perform CEA, no national protocol on perioperative hemodynamic and cerebral monitoring exists. To assess current monitoring policies of all Dutch CEA-centres, a national survey was conducted.\n\n\nMETHODS\nBetween May and July 2017 all 50 Dutch CEA-centres were invited to complete a 42-question survey addressing perioperative hemodynamic and cerebral monitoring during CEA. Non-responders received a reminder after one and two months. By November 2017 the survey was completed by all centres.\n\n\nRESULTS\nPreoperative baseline BP was based on a single bilateral BP-measurement at the outpatient-clinic in the majority of centres (n=28). In 43 centres (86%) pre-operative monitoring (transcranial Doppler (TCD,n=6), electroencephalography (EEG,n=11), or TCD+EEG (n=26)) was performed as a baseline reference. Intraoperatively, large diversity for type of anaesthesia (general:45 vs local (LA):5) and target systolic BP (>100mmHg - 160mmHg (n=12), based on preoperative outpatient-clinic or admission BP (n=18), other (n=20)) was reported. Intraoperative cerebral monitoring included EEG+TCD (n=28), EEG alone (n=13), clinical neurological examination with LA (n=5), near-infrared spectroscopy with stump pressure (n=1), and none due to standard shunting (n=3). Postoperatively, significant variation was reported in standard duration of admission at a recovery or high-care unit (range 3-48hours, mean:12h), maximum accepted systolic BP (range >100mmHg - 180mmHg (n=32)), postoperative cerebral monitoring (standard TCD(n=16), TCD on indication(n=5) or none(n=24)) and in timing of postoperative cerebral monitoring (range directly postoperative - 24h postoperative; median 3h).\n\n\nCONCLUSIONS\nIn Dutch centres performing CEA the perioperative hemodynamic and cerebral monitoring policies are widely diverse. Diverse policies may theoretically lead to over- or under treatment. The results of this national audit may serve as the baseline dataset for development of a standardised and detailed (inter)national protocol on perioperative hemodynamic and cerebral monitoring during CEA.