How are postoperative bleeding and respiratory complications of carotid endarterectomy (CEA) treated?

Updated: Oct 24, 2019
  • Author: Sonia Nhieu, MD; Chief Editor: Sheela Pai Cole, MD  more...
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Answer

Answer

After CEA, tracheal reintubation for airway protection in the setting of emergency hematoma evacuation may be challenging because of the distortion of the airway structures by the hematoma itself and by postoperative airway edema. In a large retrospective study from the Mayo Clinic College of Medicine, tracheal tube placement proved difficult in 40% of patients returning to the OR for hematoma evacuation, despite the absence of a history of difficult airway management for CEA earlier. [17]

Although CEA is an increasingly routine procedure, recognition of the risk factors for development of wound hematomas is nevertheless important for identifying patients who warrant closer postoperative monitoring in an ICU setting.

The laryngeal mask airway offers certain theoretical advantages, [18] but the lack of data supporting its use or the use of video laryngoscopy makes it difficult to compare these approaches with direct laryngoscopy and fiberoptic techniques. Each airway management technique has its own clinical and anatomic advantages and challenges. Accordingly, there is no standard approach.

If the patient is stable, it is reasonable to proceed with awake fiberoptic intubation to maintain spontaneous ventilation. However, if fiberoptic intubation is unsuccessful or the patient is unstable, the results from Shakespeare et al suggest that direct laryngoscopy with possible decompression of the trachea is likely to result in success. [17]

Direct laryngoscopy may be done with the patient awake after topical anesthesia or after induction of general anesthesia. However, it is important to remember that induction of anesthesia coupled with inability to intubate a patient with compromised physiologic reserve results in a life-threatening situation.

Regardless of the method used to secure the airway, the surgeon, the nursing team, and the anesthesiologist should all be prepared for the possibility that an emergency tracheostomy may prove necessary. In patients who are closely monitored and receiving timely airway assessment and management, this measure is rarely required. [17]


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