N201 Peripheral Perfusion

• Peripheral arterial disease


  Blockages in the arteries of the extremities
• Claudication


  • Pain with movement especially when walking
• Peripheral arterial disease


  • May develop skin ulcers and require surgery to bypass the blockage
• Risks of peripheral arterial disease

  • HTN
  • Diabetes
  • Hyperlipidemia
  • Poor eating habits
  • Sedentary lifestyle
  • Smoke
• Ankle brachial index


  A simple non-invasive diagnostic test for peripheral arterial disease
• Ischemic muscle pain


  Occurs with exercise, resolves with rest, reproducible (not a one off)
• Ischemic muscle pain


  Limb is starved of oxygenated blood flow – elevation of limb increases pain
• Pain in the thigh


  Blockages is higher up in the femoral artery
• Pain in the buttocks or groin

  Blockage is in the aorta
• Pain in the calf muscle


  Common sign of peripheral arterial disease because atherosclerotic plaque often begins in the arteries furthest from the heart
• Paresthesia


  Often described as pins and needles in the toes/feet and results from nerve ischemia
• Pallor


  Depended on rubor (redness in a dependent position) and pallor or blanching of the for with elevation are 2 very common signs of peripheral arterial disease
• Paralysis


  Seen more when earlier symptoms are ignored and as patient becomes inactive because the muscles atrophy
• Poikilithermia (Polar)


  Cold skin (later sign of peripheral arterial disease) meaning there is a significant occlusion and risk of total occlusion
• If the vessel that supplied the limb occludes completely

  The distal portion will turn white and feel cold, this is acute arterial ischemia and requires surgical intervention within 12-24 hours
• Diagnostics for peripheral arterial disease

  • Screening: physical exam, ABI (ankle brachial index)
  • Diagnosis: Doppler ultrasonography, angiography, MRI
• Goal of interprofessional care for peripheral arterial disease

  • Risk factor modification
  • Medication therapy (any lipid lowering medications)
  • Exercise therapy
  • Nutritional therapy
  • Complementary and alternative therapies
  • Interventional radiological catheter-based procedures
  • Surgical interventions
• Goals of treatment for peripheral arterial disease

  • Increase activity tolerance
  • Relief pain
  • Increase tolerance
  • Ensure skin is healthy and intact
• When CRP is elevated


  Means there is inflammation
• Surgical treatments for peripheral arterial disease

  • Balloon angioplasty
  • Arterial bypass
• Medical treatments for peripheral arterial disease

  • Anticoagulant
  • Antiplatelet (prevent platelets forming)
  • Lipid lowering agents
• Lipid lowering agents


  Reduce the risks of new or worsening symptoms of intermittent claudication and reduce the risk of MI, stroke, and death by 30%
• Antihypertensive drug therapy


  • Thiazide diuretics
  • Beta adrenergic blockers
  • ACE inhibitors
  • Calcium channel blockers
• Thiazide diuretics


  Inhibits NaCl reabsorption in distal tubule allowing for Na excretion. Thus, water to decrease BP
• Beta adrenergic blockers


  Reduce BP by blocking effects of epinephrine thus lowers HR & blocks vasoconstriction
• ACE inhibitors


  Reduces BP by inhibiting conversions of angiotensin 1 to 2 which vasoconstricts thus allows for improved perfusion
• Calcium channel blockers


  Blocks movements of Ca into cells thus causing vasodilation and decrease systemic vascular resistance (SVR)
• Glyburide


  Do not use with type 1 diabetes
• Aneurysms


  Outpouching or weakening in the wall of arteries
• Locations of aneurysms


  • Thoracic aorta
  • Abdominal aorta
  • Renal artery
  • Popliteal artery
  • Cerebral artery
• Aneurysms


  • Primarily asymptomatic until rupture – usually found in routine examination
• Signs and symptoms of ruptured aneurysm

  • Diaphoresis
  • Pallor
  • Hypotension
  • Weakness
  • Tachycardia
  • Periumbilical pain
• Types of aneurysms


  • Saccular
  • Fusiform
  • False aneurysm
• Diagnostic tests for aneurysms

  • Chest / abdominal X-rays
  • ECG
  • Echo
  • US
  • CT (2D or 3D)
  • MRI
  • Angiography
• EVAR


  Repairs via femoral groin incision with guide wire to the aneurysm where a synthetic stent graft is deployed
• Open AAA repair


  Through the abdominal wall/incision where the aorta is clamped and then opened. Then stent graft is sutured in place, aorta wall closed, and abdominal wall sutured closed
• Post-op care priorities


  • Assessment of BP, urine, output/renal perfusion and peripheral pulses
  • Antiplatelet medications as orders and BP meds
  • Monitor for S&S of aneurysm rupture
• Phlebitis


  Inflammation of vein near the surface of the skin
• VTE


  Thrombus formation due to inflammation of vein, it is a spectrum of pathology from DVT – pulmonary embolism
• Virchow's Triad


  • Hypercoagulability
  • Vascular damage
  • Circulatory stasis