Wake-up test decrease shunts insertion during carotid endarterectomy under general anesthesia

Objective: The use of locoregional anesthesia versus general anesthesia (GE) in carotid endarterectomy (CEA) has been a debatable issue in clinical studies for the past several years. In our study, GE with wake-up tests (WUTs) during carotid cross-clamping was used instead of stump pressure (SP) to directly assess the neurological status of the patient to determine whether shunting was needed. Our study assessed the percentage of patients under light sedation and mechanically ventilated needing shunting based on WUT compared to a systolic stump pressure (SPs) cutoff value of ≤40 mm Hg. Design: Retrospective, observational study. Setting: University hospital clinic. Participants: Three hundred fifty-one patients (American Society of Anesthesiologists physical class II-III) with carotid artery stenosis scheduled for CEA under GE. Interventions: The WUT was used to assess the neurological status in patients undergoing CEA, which involved the gradual reduction of depth of anesthesia until the patient was capable of responding to a verbal stimulus and provide full collaboration while only receiving remifentanil. A positive WUT indicated that patient was not able to carry out the order. Measurements and Main Results: Of 343 patients, 20 (5.8%) were shunted due to a positive WUT after cross-clamping in comparison to 45 patients (12.8%) based on the SPs ≤40 mm Hg criteria. Conclusion: Wake-up test can be used to directly assess the neurological status in patients undergoing CEA to determine whether shunting is required. Our results showed that less patients required shunting based on WUT compared to the SP criteria.