Sharon Butler, RN

Carotid endarterectomy: Care in the OR

The registered nurse who will be cir- culating during a carotid endarterec- tomy can participate in preoperative teaching by helping the patient under- stand what will happen to him in the operating room. The preoperative as- sessment also helps the nurse by provid- ing data to use in planning and carrying out an intraoperative nursing care plan.

In the assessment, she establishes rapport with the patient and family, ex- plains operative events, and answers questions. She reinforces what the physician has already told the patient, making sure he has a clear understand- ing of the surgery, reason for surgery, and results of surgery. The patient needs to know

where his incision will be what preoperative care he will re- ceive (such as shave, enema, sleep- ing medications, preoperative medications, and any diagnostic studies) how long he must go without eating and drinking what time surgery will be, what time his family should be there, where the family will wait, and ap- proximate time for surgery

.events that will happen in the operating room (transfer to OR bed; temperature in operating room;

Sharon Butler, RN, is a private scrub nurse at the Phoenix (Ariz) Heart and Lung Associa- tion. She is a graduate of Aultman Hospital School of Nursing, Canton, Ohio.

routine preparations such as intra- venous infusions, blood pressure, and electrocardiogram; and how he will be anesthesized) postoperative information (such as where he will awaken, medications for pain control, if he will have a drain, dressings, and sore throat from endotracheal tube) that valuables such as jewelry, glasses, contact lenses, dentures, and hair pieces, etc, must be left for safekeeping, that no makeup or nail polish can be worn, and that a hos- pital gown must be worn.

This information is intended to put the patient at ease, reduce anxieties, and help him to know what is expected of him.

Data from the preoperative assess- ment are a means of individualizing the patient's preparation for his surgery and establishing a nursing care plan.' They also help the nurse prepare other members of the operating room team for special problems of the case such as pa- tient disabilities and allergies. Knowl- edge about the surgical procedure, its indications, and the anatomy involved enables the nurse to be better prepared and anticipate the needs of the OR team.

In the operating room, the nurse first puts the patient at ease. After introduc- ing herself (if she did not do the preop- erative assessment on the unit), the nurse verifies who the patient is, what surgery he is having, and who the sur-

42 AORN Journal, July 1980, V0132, No 1

geon is. She also does a nursing assess- ment, especially if no other OR nurse did a preoperative interview. According to the SELF-PACING technique, as- sessment of the patient’s individual needs includes:

Social (communication problems and impaired senses)

Elimination (urinary status, exer- cise, the patient’s normal activities of daily living)

Liquids and Food status

Pain (personal hygiene or posture needs)

Aeration Circulation needs Integument (condition of skin) Neuromuscular status General condition.

The nurse checks the chart and the operative permit for routine items such as date and time signed, surgical proce- dure, and surgeon. It is important to make sure the permit was witnessed and the proper site of surgery is on the permit. The nurse checks that all physi- cians’ orders were carried out and re- views the history and physical. She notes any other cardiovascular prob- lems, drug allergies, and other medical or surgical problems. She checks that all valuables have been removed. If the patient had carotid arteriograms, they should be with the patient for the sur- geon to refer to.

In safely transferring the cardiovas- cular patient to the OR bed, it is impor- tant to avoid sudden changes of posi- tion, prolonged immobilization, hypo- tension, or fluid overloading. These

Fig 1. An oblique incision about 4 inches long is made along the skin folds of the neck, parallel to the sternocleidomastoid muscle. The carotid sheath is opened, and the common, internal, and external carotid arteries are identified.

AORN Journal, July 1980, Vol3.2, No 1 43

could precipitate a myocardial infarc- tion or cerebral stroke. Heparin, pro- tamine, hypertensive and hypotensive medications, narcotics (if necessary), and all necessary anesthetics should be available.

For this surgery, most surgeons pre- fer general anesthetics, using endo- tracheal tubes, leaving the operative site accessible. The endotracheal tube is also beneficial in case of hematoma, which could cause ventilation problems. Adequate blood pressure must be main- tained during arterial occlusion to the brain to prevent postoperative neuro- logical problems.

After the patient is asleep, the nurse prepares him for surgery. She tucks his free arm (making sure there are no pressure points to cause nerve damage) and places the cautery pad in a safe, well-padded area (usually the but- tocks). If hair is on the incision site, she may need to extend the shaved area and tape excess hair or cap off the neck. The operative site is prepared with an ap- propriate germicidal agent, using a light touch to avoid dislodging ather- omatous plaques in the carotid artery.

If the patient is to have electroen- cephalograms, arteriograms, or stump- flow measurements during the surgery,

Fig 3. Some surgeons introduce

an arterial shunt, which permits blood

flow to the intracranial portion of

the internal carotid artery. This enables

the surgeon to do the endatierectomy

around it.

Fig 2. A linear arteriotomy is made from the common carotid to the internal carotid.

44 AORN Journal, July 1980, Vol32, No 1

the nurse can also help prepare for that. She checks for correct dosages of al.1 medications on the operative fielid (heparin, contrast media for arterio- grams, local aneathetic if used to control blood pressure, or any others). She is responsible for any graft materials used, shunts, if used, and setting the stopcock during carotid occlusion. She also takes care of the arterial plaque specimen. Throughout the procedure, the OR nurse protects the patient and monitors aseptic technique.

The surgery begins with an oblique incision about 4 inches long along the skin folds of the neck, parallel to the

sternocleidomastoid muscle, beginning medially at the lower end and posteri- orly under the lobe of the ear (Fig 1). Knowing the incision site enables the nurse to shave and prepare the area adequately. In this highly vascular area, important nerves need to be iden- tified and preserved. The great auricu- lar and XI1 cranial nerves are present. After identifying the nerves, the sur- geon continues dissecting down to the carotid sheath. He identifies the com- mon facial vein, which runs across the carotid artery, and divides it. The carotid sheath is opened, and the com- mon, internal, and external carotid ar-

Fig 4. The built-up plaque is peeled off the intima of the artery.

Fig 5. The surgeon washes out the

arteriotomy site.

AORN Journal, July 1980, Vol32, No 1 45

Fig 6. The surgeon closes the

arteriotomy incision.

Fig 7. In some cases, a venous patch is used to reconstruct the vessel.

teries are identified and mobilized. At this time, the surgeon encircles the three vessels with umbilical tapes to control excess bleeding.

The carotid sinus nerve is also iden- tified (running in the upper portion of the incision). This nerve is sometimes divided to prevent bradycardia or hy- potension caused by its stimulation. Some surgeons use a nerve block here, injecting a local anesthetic. Heparin is given to prevent blood clotting when the arteries are clamped. Next, the three arteries are clamped with vascular clamps (or bulldogs), and a linear ar- teriotomy is made from the common carotid to the internal carotid (Fig 2).

Some surgeons introduce an arterial shunt, a Silastic tube smaller than the lumen of the vessel, into the internal carotid. Umbilical tapes (or clamps) are tightened around the vessel and shunt to prevent leakage. The shunt is in- serted into the common carotid, and a tape or clamp is tightened around it (Fig 3). The shunt permits blood flow to the intracranial portion of the internal carotid artery and bypasses the nar- rowed portion of the artery. This en- ables the surgeon to do the endarterec- tomy around it.

The endarterectomy is performed. Using a blunt dissector, the built-up plaque is peeled off the intima of the

46 AORN Journal, July 1980, Vol32, No 1

artery (Fig 4). The surgeon washes out the arteriotomy site and begins closing it with a vascular suture (Figs 5 and 6). In some cases, a venous patch or Dacron graft is used in reconstructing the ves- sel so there will be no compensation in the artery’s diameter or blood flow (Fi.g 7).

When the arterial closure is complet’e, the shunt is removed and vascular clamps (or bulldogs) are reapplied until the suture is tied and bleeding is con- trolled. At this time, the heparin is reversed with protamine, and small bleeders are ligated. The incision is closed-the muscular layer first, sub- cutaneous layer next, and then the skim.

Neurologic deficits sometimes occur during this procedure due to cerebral emboli, from small plaques in the artery tearing loose, or cerebral ischemia, from hypotension, intracerebral thrombosis, or inadequate cerebral protection.2 To avoid this, some surgeons use the shunt, check the internal carotid stump pres- sure, and monitor the patient with the electroencephalograph. Complicatioins of recovery and related nursing care will be discussed in the next article.

Well-informed perioperative nursing care is a key to protecting the patient, individualizing care, and assisting in a smooth, efficient procedure. The OR nurse can prepare for this role by learn- ing about the surgical procedure, patr- ticipating in preoperative assessments, and reviewing her responsibilities for sound OR nursing technique. 0 Notes

1. Mark L Phippen, “Perioperative nurses use pa- tient teaching conference,” AORN Journal 29 (May 1979) 1046. 2. Jesse E Thompson, C M Talkington, “Carotid

endarterectorny,” Annals of Surgery 184 (July 1976) 7.

Suggested reading Javid, Manucher; Taylor, Charles. “Neurosurgical

experience with carotid endarterectorny at Uni- versity Hospitals (1 954-1 976).” Wisconsin Medi- cal Journal 77 (July 1978) 65-67.

Marbach, Linda. “The perioperative role: A practical approach.” AORN Journal 29 (March 1979) 639- 646.

Rob, C. Vascular Surgery, Operative Surgery Series, 3rd ed. (Woburn, Mass: Buttersworths,

Smith, Dorothy; Germain, Carol P. Care ofthe Adult Patient, 3rd ed. (Philadelphia: J B Lippincott,

Stanton, Paul E, Jr; McCluskey, David A, Jr; Lamus, Pano A. “Carotid endalterectorny.” The American Surgeon 44 (October 1978) 670-673.

1976) 54-61.

1970) 207-235.

Runners cautioned about risks of heat stroke Summer’s sun brings out more than 30 million runners and joggers, but it also brings the risk of heat stroke for these health enthusiasts.

well-known rules for training, heat acclimatization, taking plenty of fluids, and diet, says a communication in the May 16 Journal of the American Medical Association.

In scheduled long distance runs, it is important for the first aid center to have facilities for rapid cooling of all heat injury patients without delay, says John R Sutton, MD, of McMaster University, Hamilton, Ontario. Rapid cooling minimizes the chances of serious injury from heat stroke, which can include kidney damage and blood clots, says Dr Sutton.

Running in the early morning or after sundown on hot summer days will reduce the risk of heat stroke. Reducing speed and distance of running on hot, humid days will also help.

The casual weekend jogger probably will not run a risk of heat stroke, unless he is in poor physical condition. Those beginning to run again after a winter of inactivity are advised to start with long walks and begin running slowly and gradually.

Runners should pay close attention to the

AORN Journal, July 1980, Vol32, NO 1 47