Clinical Guideline for the Management of Post-Carotid Endarterectomy (CEA) Hypertension Summary. Blood pressure lability is common in the first 12-24 hours post-operatively and it is standard care for CEA patient to be place on monitored setting with an arterial line in place. Manipulation of the carotid bulb during carotid endarterectomy can result in haemodynamic instability Intraoperatively and in the early post-operative period. Adequate cerebral perfusion pressure should be maintained during periods of hemodynamic instability to avoid low cerebral blood flow and cerebral ischaemia. Hypertension should be avoided as it may increase the likelihood of neck haematoma or suture line disruption. Continue patient’s normal antihypertensive medication. BP Medications Place NG tube if patient unable to swallow.

BP Goal

Systolic blood pressure to be maintained as specified by anaesthetist.

BP Monitoring

Blood pressure to be monitored continuously for 4 hours post operatively in recovery.

If 2 successive BP greater than specified – nursing staff to alert doctor Assess patient to exclude pain, urinary retention or other causes of hypertension, if all excluded / treated and hypertension persists Is the Patient able to swallow

Yes

No

Start Labetalol or Isoket intravenously

Start oral Antihypertensive by mouth or NG tube

If patient has symptoms of severe headache or seizure & uncontrolled hypertension – this is an EMERGENCY. Control hypertension with iv labetalol or isoket, start phenytoin for seizure control, consider stat dose of dexamethasone 8mg iv – Contact Vascular Consultant and ITU Clinical Guideline Template

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1. Aim/Purpose of this Guideline 1.1. To support medical and nursing staff in providing appropriate care for patients following carotid artery surgery.

2. The Guidance 2.1. Blood pressure lability is common in the first 12-24 hours post operatively and it is standard care for CEA patients to be placed on monitored setting with an arterial line in place. 2.2. Manipulation of the carotid bulb during carotid endarterectomy can result in haemodynamic instability Intraoperatively and in the early post-operative period. Adequate cerebral perfusion pressure should be maintained during periods of hemodynamic instability to avoid low cerebral blood flow and cerebral ischaemia. Hypertension should be avoided as it may increase the likelihood of neck haematoma or suture line disruption. 2.3. BP Medications – Please continue patient’s normal antihypertensive medication. Place NG tube if patient is unable to swallow. 2.4. BP Goal – Systolic blood pressure should be maintained as specified by anaesthetist, (see chart). These BP parameters should be specified in the postoperative instruction on the operation note, on the anaesthetic chart, or the postoperative observations chart. 2.5. BP Monitoring – Monitor blood pressure continuously for 4 hours post operatively in recovery, if stable remove arterial line. Then monitor BP every 30 minutes for 4 hours, then hourly for 4 hours. If stable then monitor BP 4 hourly thereafter (see chart). 2.6. If 2 successive BP greater than specified – nursing staff to alert doctor: 2.6.1. Assess patient to exclude pain, urinary retention or other causes of hypertension. 2.6.2.

If all excluded / treated and hypertension persists:

1) If patient able to swallow start oral antihypertensive by mouth or NG tube (see below). 2) If patient unable to swallow start labetolol or isoket intravenously (see below). 3) If patient has symptoms of severe headache or seizure and uncontrolled hypertension – this is an emergency. Control hypertension with iv labetolol or isoket, start phenytoin for seizure control, consider stat dose of dexamethasone 8mg iv, contact vascular consultant and ITU (see below).

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2.7. Oral Antihypertensive Therapy: 1st Line: 1st Line: 2nd Line: 3rd Line: 4th Line:

Start amlodipine 5mg od (long acting Ca antagonist) Start Lisinopril 2.5mg od if younger than 55 and renal function allows. Add either calcium channel blocker or ACE Add diuretic Bendroflumethiazide 2.5mg od Add b- Blocker Atenolol 25mg od or a-blocker Doxazocin 1mg od

2.8. Intravenous Therapy First Line: LABETALOL 100mg Labetalol in 20mls of 0.9% Saline. (i.e. 5mg per ml) Give 10mg (2ml) boluses slowly every two minutes up to 100mg (i.e. 20mls given over 20 minutes) If BP remains elevated after 20 minutes, move to second line agent. If BP reduces and does not rebound, continue regular BP observations. If BP reduces but increases again, start infusion at 50-100mg per hour, titrating dose to BP. Ensure patient is on BP monitor with BP check at least every 15 minutes while unstable. 2.9. Intravenous Therapy Second Line ISOKET (Isosorbide Dinitrate) Use if history of asthma, heart failure or heart block 25mg ISOKET in 50mls 0.9% Sodium Chloride (i.e. 1mg per ml) Start infusion at 4mls/hr (2mg/hr), increasing rate to 20mls/hr (10mg/hr), titrated to BP. Ensure patient is BP monitor with BP check at least every 15 minutes while unstable. 2.10.Hyperperfusion Syndrome Occurs in 1-3% of patients post CEA and is due to impaired autoregulation of cerebral blood flow. Symptoms are ipsilateral headache, focal seizures and intracerebral haemorrhage. It is more likely to occur after revascularisation of high grade carotid stenosis. Best prevention is good blood pressure management. Management Start iv Labetolol or ISOKET BP treatment IMMEDIATELY (see above. If seizure start Phenytoin (loading dose 20mg/kg at 100-150mg/min) and administer Dexamethasone 8mg iv stat. Surgical SHO must: Initiate treatment, Admit patient. Contact on call vascular surgeon. Contact ITU team to arrange ITU transfer for invasive BP monitoring Consider arranging CT brain scan Patient remains in ITU for a minimum of 6 further hours to minimise rebound hypertension. For advice: contact Stroke Physician during working hours via switch contact on call medical registrar out of hours via switch

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3. Monitoring compliance and effectiveness Element to be monitored Lead

All

Tool

Casenote and record review prior to patient discharge.

Frequency

Post-operative care of every CEA patient should be reviewed on ward round.

Vascular ward round

Due to rarity of events would only report when patient care deviates from protocol, and would share this in real time with vascular team and any others involved in patients care. Reporting Vascular audit group. arrangements Acting on Vascular Audit Lead recommendations and Lead(s) Required actions will be identified and completed in a specified timeframe. Change in Required changes to practice will be identified and actioned within practice and 6 weeks. A lead member of the team will be identified to take each lessons to be change forward where appropriate. Lessons will be shared with all shared the relevant stakeholders.

4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website.

4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. We thank Leicester Vascular Surgical Unit for permission to use their guidelines and adapt.

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Appendix 1. Governance Information Document Title

Clinical Guideline for the Management of Post Carotid Endarterectomy (CEA) Hypertension

Date Issued/Approved:

29th April 2016

Date Valid From:

29th April 2016

Date Valid To:

29th April 2019

Directorate / Department responsible (author/owner):

Mr Ken Woodburn MD FRCSG(gen) Consultant Vascular & Endovascular Surgeon

Contact details:

01872 25 2925

Brief summary of contents

To support medical and nursing staff in providing appropriate care for patients following carotid artery surgery. Carotid surgery, blood pressure control, hypertension. RCHT PCH CFT KCCG 

Suggested Keywords: Target Audience Executive Director responsible for Policy:

Medical Director

Date revised: This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Signature of Executive Director giving approval Publication Location (refer to Policy on Policies – Approvals and Ratification): Document Library Folder/Sub Folder

29th April 2016 Clinical Guideline for the Management of Post Carotid Endarterectomy (CEA) Hypertension Surgical Divisional Governance Group Duncan Bliss Not Required {Original Copy Signed} Name: {Original Copy Signed} Internet & Intranet Clinical / Vascular

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 Intranet Only

Links to key external standards

None British National Formulary 2012 Mohler, ER. Fairman AM. Carotid Endartectomy. UpToDate.

Related Documents: National Institute for Health. NICE Clinical Guideline 127. Clinical Management of Primary Hypertension in Adults. NICE. August 2011. No

Training Need Identified? Version Control Table Date

20/02/13

29/04/16

Version No

V1.0

V2.0

Summary of Changes

Changes Made by (Name and Job Title)

Initial Issue

Mr Ken Woodburn MD FRCSG(gen), Consultant Vascular & Endovascular Surgeon

Re format into new template

Cathy Edwards Divisional Audit & Governance

All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager.

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Appendix 2. Initial Equality Impact Assessment Form Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): Clinical Guideline for the Management of Post Carotid Endarterectomy (CEA) Hypertension Directorate and service area: Vascular Is this a new or existing Policy? Existing Surgery Name of individual completing Telephone: 01872 25 2925 assessment: Ken Woodburn 1. Policy Aim* To ensure appropriate management of hypertension following carotid Who is the strategy / surgery. policy / proposal / service function aimed at? 2. Policy Objectives* Ensure a standardised escalating therapeutic regime is followed as agreed by physicians, anaesthetists and surgeons involved in care of patients with carotid disease. 3. Policy – intended A&E, Ward nursing and medical staff have immediate access to Outcomes* information to assist in care of post-CEA patients with hypertension 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy?

Casenote review at hospital discharge

Patients

No

b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Age Sex (male, female, trans-

Yes

No X X

Rationale for Assessment / Existing Evidence

gender / gender reassignment) Clinical Guideline Template

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Race / Ethnic communities /groups Disability -

X X

Learning disability, physical disability, sensory impairment and mental health problems

Religion / other beliefs

X

Marriage and civil partnership Pregnancy and maternity Sexual Orientation,

X X X

Bisexual, Gay, heterosexual, Lesbian

You will need to continue to a full Equality Impact Assessment if the following have been highlighted:  You have ticked “Yes” in any column above and  No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or  Major service redesign or development No 8. Please indicate if a full equality analysis is recommended. Yes X

9. If you are not recommending a Full Impact assessment please explain why. No negative impact identified. Signature of policy developer / lead manager / director Ken Woodburn Names and signatures of members carrying out the Screening Assessment

Date of completion and submission 06.03.13

1. 2.

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust’s web site. Signed _______________ Date ________________

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