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Sp: Methods 1 > 12. On/Off Pump Management > Flashcards

12. On/Off Pump Management Flashcards

1
Q

cardiac induction drug options

A
  1. higher versed/fentanyl
  2. etomidate
  3. smaller propofol dose w/bag mask induction
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2
Q

versed cardiac induction dose

A

5mg

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3
Q

fentanyl cardiac induction dose

A

250mcg

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4
Q

why would etomidate be considered for cardiac induction?

A

produces less hypotension

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5
Q

when is intubation indicated during cardiac induction

A

once induction drugs have lowered BP to level that will prevent excessive HTN (under 100 systolic)

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6
Q

BOBCAT

A

Baseline labs/ACT
OG insertion/removal
BIS monitor
Central line
Amicar
TEE

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7
Q

Amicar bolus for cardiac surgery

A

liberty: 5g
lukes: 10g

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8
Q

Amicar infusion

A

1g/hr

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9
Q

why is amicar used for cardiac surgery

A

antifibrinolytic used to counteract bypass blood damage
decrease post op bleeding

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10
Q

amicar alternative

A

TXA

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11
Q

most sensitive detection of interoperative ischemia

A

RMWA is 4x more sensitive than ECG ST segment

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12
Q

TEE functions (7)

A
  1. show valve function
  2. EF
  3. chamber size
  4. contractility
  5. RWMA
  6. PAP
  7. estimate CO
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13
Q

what procedure is the saphenous vein harvested in

A

CABG

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14
Q

anesthesia tasks during sternal incision and sternotomy

A

turn off ventilator
remove breathing bag
avoid HTN
- give fentanyl
- NTG

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15
Q

what drugs help avoid HTN during sternotomy

A

fentanyl
NTG

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16
Q

what happens to intrathoracic pressure during sternal retraction

A

incr ITP
==decr venous return
==decr CO
==decr BP

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17
Q

what procedure is the LIMA harvested in

A

CABG

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18
Q

anesthesia tasks during LIMA harvesting

A

decr tidal volume to keep lungs out of surgeon’s view
incr RR to preserve MV

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19
Q

is there significant stimulation during LIMA harvesting

A

no

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20
Q

what might happen when the pericardium is opened?

A

vagal response

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21
Q

pericardium nerves are derived from

A

vagus
phrenic

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22
Q

is the pericardium closed at the end of surgery

A

no - closing the pericardium causes incr risk of tamponade

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23
Q

when do you give heparin

A

prior to aortic cannulation

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24
Q

what lab do you check after giving heparin? how long after?

A

ACT is checked 3 mins after giving heparin

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25
Q

how much blood is needed for ACT

A

1mL

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26
Q

what ACT is pt ready for bypass

A

> 450s

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27
Q

aortic cannulation an lead to

A

possible aortic dissection

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28
Q

what is cannulated first, arterial or venous?

A

arterial

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29
Q

anesthesia tasks during aortic cannulation

A

lower SBP to 90-100mmHg
(decr risk of dissection)

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30
Q

where is venous cannulation done?

A

right atrial appendage

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31
Q

when is the pt considered “on pump”

A

once venous cannulation occurs and the venous reservoir is open

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32
Q

anesthesia tasks when pt starts bypass

A
  1. vent off
  2. vaporizer off
  3. empty foley (pre-bypass urine)
  4. monitor in “bypass” mode
  5. put vasoactive infusions in stanby
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33
Q

what infusions do we keep on during bypass

A

amicar
insulin

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34
Q

optimal MAP for pts on bypass

A

78mmHg

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35
Q

antegrade CP catheter placement

A

aortic root

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36
Q

when is strain on the heart minimized

A

when heart is empty

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37
Q

CP is given after

A

the cross clamp is placed

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38
Q

when is CP re-dosed

A

every 20-30 mins

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39
Q

what indicates that the surgeon is almost done repairing the heart

A

when the perfusionist begins to rewarm the pt

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40
Q

what risk increases during rewarming

A

risk for awareness increases during rewarming

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41
Q

hypothermia ______ MAC

A

hypothermia decreases MAC
(provides anesthetic effects)

42
Q

drugs given during rewarming

A
  1. versed
  2. antiarrhythmics
    • magnesium
    • amiodarone
    • lidocaine
43
Q

magnesium rewarming dose

A

2g

44
Q

amidarone rewarming dose

A

150 mg over 10 mins

45
Q

why are antiarrhythmics given during rewarming?

A

decr chance of fibrillation
incr conversion rate if heart goes into fibrillation

46
Q

first step to start coming off bypass

A

perfusionist refills heart with blood by partially closing venous reservoir

47
Q

before the cross clamp is removed, what does the surgeon do?

A

looks for and removes any air bubbles in heart

48
Q

how does the heart start beating again?

A

the cross clamp is removed
blood from arterial cannula washes CP out of the heart

49
Q

what rhythms does the heart typically go into after CP washout?

A
  1. bradycardia
  2. Vtach/Vfib
50
Q

are we worried about Vtach/Vfib post-cross clamp removal?

A

not really - the heart is still on bypass so it is still perfused

51
Q

treatment for heart in Vfib/Vtach after bypass

A

10-20J defibrillation by surgeon

52
Q

2 ways to help kick start the heart?

A

give inotropes
epicardial pacing wires

53
Q

what inotropes?

A

calcium (1g)
epi
milrinone

54
Q

pacing rate

A

80-100 bpm

55
Q

pacing capture

A

20mA

56
Q

what should you titrate pacing current to?

A

10% higher than where capture is regained

57
Q

anesthesia tasks once the heart is beating in sinus

A

vent ON
Iso ON

58
Q

when is the venous reservoir closed

A

when the pt is back on the ventilator

59
Q

when is the venous cannula removed

A

after the venous reservoir is closed

60
Q

when is the aortic cannula removed

A

after heparin is reversed with protamine

61
Q

why do the surgeons wait to remove the aortic cannula?

A

precautionary action in case of protamine adverse reaction

62
Q

primary agent to reverse heparin

A

protamine

63
Q

what drug can be given if pt is bleeding more than expected after protamine?

A

DDAVP (desmopressin)

64
Q

DDAVP mechanism

A

triggers clotting factor release
promotes coagulation

65
Q

DDAVP side effect

A

profound hypotension

66
Q

DDAVP should be administered

A

SLOWLY

67
Q

when is cell saver blood given?

A

after protamine

68
Q

are pts extubated in OR after cardiac surgery?

A

NO

69
Q

sedation during transport options

A
  1. propofol - 20-50mcg/kg/min
  2. precedex
70
Q

when do you start transport sedation

A

prior to chest closure

71
Q

items to take during transfer to ICU

A
  1. vasoactive meds for BP control
  2. laryngoscope
  3. ambu mask
72
Q

redo sternotomy risk

A

uncontrollable hemorrhage

73
Q

redo sternotomy prep

A
  1. blood in room w/blood tubing
  2. place defib pads before induction
  3. gentle hand ventilation
74
Q

is a redo sternotomy faster or slower than primary sternotomy

A

slower

75
Q

post-op bleeding in chest tube: normal

A

0.5-1 mL/kg/hr

76
Q

post-op bleeding in chest tube that requires immediate surgical intervention

A

8-10 mL/kg/hr

77
Q

ischemic heart causes:

A

coronary artery blockage
less perfusion during bypass

78
Q

reperfusion refers to

A
  1. occluded coronary artery opening
    OR
  2. re-establishment of perfusion after bypass
79
Q

causes of reperfusion injury

A
  1. hypercalcemia
  2. prolonged ischemia period
80
Q

when should Ca be administered during bypass

A

15 mins after cross clamp release

81
Q

what protects against reperfusion injury?

A

volatile agents

82
Q

which is more protective against reperfusion: TIVA or VA?

A

VA is more protective than a TIVA with propofol

83
Q

can you use nitrous during bypass

A

NO

84
Q

nitrous effects during bypass

A
  1. air bubble expansion
  2. incr PVR
  3. incr PAP
  4. worse RH output
85
Q

off pump advantages (4)

A
  1. faster recovery/shorter hospitalization
  2. decr post-op neuro deficits
  3. incr renal/pulm/cardiac protection
  4. mx physiologic perfusion
86
Q

off pump disadvantages

A
  1. higher HD instability
  2. poor distal anastamosis
    • incr risk of reocclusion/thrombosis
  3. undervascularization
  4. difficult for surgeon/steep learning curve
87
Q

long term off pump CABG impacts

A

decr graft patency
incr need for revascularization
decr long term survival

88
Q

prevent hypotension during off pump CABG

A

give fluid bolus prior to lifting heart
2 L crystalloid
500mL 5% albumin

89
Q

arrythmia prevention during off pump CABG

A

prior to lifting heart give:
amidarone (150mg)
Mg (1-2g)

90
Q

inotropic support during off pump CABG

A

prior to lifting heart give:
Ca (1g)

91
Q

optimal BP for distal anastamosis during off pump CABG

A

MAP 90-100 mmHg

92
Q

optimal BP for proximal anastamosis during off pump CABG

A

SBP < 100mmHg

93
Q

do you give amicar during off pump CABG

A

yes - same dose

94
Q

which is sewn first: distal or proximal

A

Distal first

95
Q

do you give heparin during off pump CABG

A

yes - dose may differ

96
Q

more stenotic vessels

A

better collateral circulation
less hypotension

97
Q

less stenotic vessedl

A

poor collateral circulation
more hypotension

98
Q

options if off pump fails

A
  1. full bypass and arrest heart
  2. partial bypass
99
Q

benefits to partial bypass

A
  1. hypotension is less likely
  2. better myocardial protection
    • less O2 demand
100
Q
A

Sp: Methods 1 (15 decks)

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