- Intraarterial catheter
- ECG monitoring: includes leads II and V5 for ST-T segment assessment; TEE in high-risk patients
- Midazolam (if sedation is necessary)
- Determine baseline blood pressure and heart rate from preadmission and admission (maintain hemodynamics within this range intraoperatively)
- Continue antianginal, antihypertensive and antiplatelet medications (the exception is clopidogrel, which is stopped 1–5 days preoperatively)
- Limit fluid administration to 10 mL/kg (fluid overload may contribute to postoperative hypertension)
- Avoid long-lasting opioids that can depress respiration and confound neurologic assessment (remifentanil is an alternative)
- Maintain light general anesthesia (permits EEG monitoring and blood pressure maintenance)
- Vasopressors to treat hypotension or EEG changes
- Extubation at conclusion of surgery
- Evaluate neurologic integrity in the operating room (new deficits may require noninvasive imaging, contrast angiography, and/or surgical re-exploration)
- Regional anesthesia: sensory blockade of C2–C4 dermatomes with a superficial cervical plexus block (no difference in rate of stroke, MI, or mortality after 30 days with regional vs. general anesthesia)
EEG = electroencephalography; MI = myocardial infarction; TEE = transesophageal echocardiography.