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Neurologic checks done frequently according to policy should include arousability, orientation, strength of hand grasp, shoulder shrug, fluency of speech, position of the tongue (which should be midline), and facial symmetry at rest and with movement is critical. Cranial nerves may be injured during surgery either from nerve retraction or from clamping, also causing hoarseness and voice fatigue; these deficits are usually transient, resolving over a period of months. Hypoglossal nerve injury causes weakness of the tongue on the ipsilateral side, dysphagia, and difficulty speaking and chewing; injury to mandibular branch of the facial nerve causes numbness of the ipsilateral face and lip.

• Monitor the drain output. A Jackson Pratt or other drain may be inserted postoperatively, and any increase in output should be reported promptly as it indicates bleeding in the operative area requiring return to the OR. Low-molecular-weight Dextran (LMD) is a glucose polymer that may be infused for the first 24 hours postoperatively to decrease platelet aggregation leading to oozing in the operative area. Also, monitor the dressing for drainage.
• Monitor the operative site for neck swelling and hematoma. Approximately 2 to 5% of patients undergoing CEA will develop a hematoma. A large hematoma requires evacuation and control of bleeding sites. Dysphagia, change in voice, tracheal deviation, and stridor are late signs of bleeding at the operative site.
• Control of blood pressure is essential. Blood pressure is often labile after CEA. If untreated, hypertension can lead to postoperative stroke and/or myocardial infarction (MI). The systolic blood pressure should be kept between 120 and 160 mmHg. In a patient with uncontrolled hypertension preoperatively, the upper limit is used to prevent hypoperfusion, leading to watershed infarction. Nipride and beta-blockers are commonly used. Hydralazine (apresoline) IV should be used with caution as it can produce sudden hypotension that could lead to a cerebral infarction. Hypotension, if untreated, can lead to watershed infarction.
• Control tachycardia. Causes of tachycardia include hypoxia, pain, and hypovolemia. Each should be considered and treated separately. Perioperative beta blockade is commonly used. If untreated, tachycardia can lead to myocardial ischemia and infarction. Myocardial infarction is responsible for 25 to 50% of all deaths after CEA. Positioning the head of the bed, it should be elevated 30 to 45° to decrease edema, improve venous return, and facilitate deep breathing.