22 CARDIOVASCULAR DISEASE Flashcards
1
Q
- What percent of adult patients undergoing surgery are estimated to have, or be at
risk for, coronary artery disease?
A
2
Q
- What are some components of a routine preoperative cardiac evaluation? What are
some more specialized methods of cardiac evaluation? What is the ultimate
purpose of a preoperative cardiac evaluation?
A
3
Q
- What are some important aspects of the preoperative history taken from patients
with coronary artery disease with respect to their cardiac status?
A
4
Q
- What are some coexisting noncardiac diseases that are frequently present in
patients with coronary artery disease?
A
5
Q
- By what percent can a major coronary artery be stenosed in an asymptomatic
patient?
A
6
Q
- What is the best indicator for a patient’s cardiac reserve?
A
7
Q
- When is angina pectoris considered “stable”?
A
8
Q
- When is angina pectoris considered “unstable”? What is the clinical implication of
unstable angina?
A
9
Q
- What is it likely an indication of when dyspnea follows the onset of angina
pectoris?
A
10
Q
- How does angina pectoris due to spasm of the coronary arteries differ from classic
angina pectoris?
A
11
Q
- What is silent myocardial ischemia?
A
12
Q
- What is the most common symptom of angina in men and women?
A
13
Q
- Approximately what percent of myocardial ischemic episodes are not associated
with angina pectoris? Approximately what percent of myocardial infarctions are
not associated with angina pectoris?
A
14
Q
- Is hypertension or tachycardia more likely to result in myocardial ischemia in the
patient with coronary artery disease? What is the physiologic explanation for this?
A
15
Q
- What is the basis for the common recommendation that elective surgery be delayed
until 6 months or more after a prior myocardial infarction?
A
16
Q
- What is the approximate incidence of perioperative myocardial infarction 6
months after a myocardial infarction? What is the approximate incidence of
perioperative myocardial infarction in patients who have not had a prior
myocardial infarction?
A
17
Q
- What time period after surgery do most perioperative myocardial infarctions
occur?
A
18
Q
- What are some cardiac medications that patients with coronary artery disease are
likely to be taking? What is the recommendation regarding the patient’s
preoperative medicine regimen with regard to their regular cardiac medicines?
A
19
Q
- What information can be gained from a preoperative electrocardiogram?
A
20
Q
- How might myocardial ischemia appear on the electrocardiogram?
A
21
Q
- Complete the following table:
A
22
Q
- Name some determinants of myocardial oxygen requirements and delivery.
A
23
Q
- What are some intraoperative goals for the anesthesiologist in an attempt to
decrease the risk of myocardial ischemia in patients at risk?
A
24
Q
- What is the difference between risk stratification and risk reduction?
A
25
Q
- What are the risks of recent percutaneous coronary angioplasty in surgical patients
and how do they differ with bare metal versus drug eluting stents?
A
26
Q
- What are two potential benefits of administering premedication preoperatively to
patients with coronary artery disease?
A
27
Q
- How should anesthesia be induced in patients at risk for myocardial ischemia?
A
28
Q
- Why is there an increased risk of myocardial ischemia during direct laryngoscopy?
What are some things the anesthesiologist may do during this time to minimize this
risk?
A
29
Q
- What are some methods of maintenance of anesthesia that may be employed by the
anesthesiologist for the patient with coronary artery disease?
A
30
Q
- What is coronary artery steal syndrome? What is its clinical significance?
A
31
Q
- What is a concern regarding the administration of a regional anesthetic to patients
with coronary artery disease?
A
32
Q
- What are some considerations an anesthesiologist should take when selecting a
neuromuscular blocking drug for patients with coronary artery disease? What is
unique about pancuronium in this situation?
A
33
Q
- How should neuromuscular blockade be reversed in patients with coronary artery
disease?
A
34
Q
- What are some factors that influence the intensity of intraoperative monitoring by
the anesthesiologist?
A
35
Q
- When might an intraoperative pulmonary artery catheter be useful? What
information does it provide?
A
36
Q
- What is some information that may be provided by an intraoperative
transesophageal echocardiogram?
A
37
Q
- What are some treatment options when myocardial ischemia is detected
intraoperatively?
A
38
Q
- What is the problem with decreases in body temperature that may occur
intraoperatively in patients with coronary artery disease?
A
39
Q
- Why is it important to monitor heart rate in the patient with coronary artery
disease?
A
40
Q
- What information can be gained from Doppler echocardiography in patients with
valvular heart disease?
A
41
Q
- How should anesthetic drugs and neuromuscular blocking drugs be selected for the
patient with valvular heart disease?
A
42
Q
- What is mitral stenosis? How does it affect left atrial and pulmonary venous
pressures? At what chronic left atrial pressure is an increase in pulmonary vascular
resistance likely to be seen?42. When is it important to administer antibiotics to patients with known valvular
heart disease?
A
43
Q
- What is mitral stenosis? How does it affect left atrial and pulmonary venous
pressures? At what chronic left atrial pressure is an increase in pulmonary vascular
resistance likely to be seen?
A
44
Q
- What is the most common cause of mitral stenosis? How does it present?
A
45
Q
- Why are patients with mitral stenosis at an increased risk of atrial fibrillation?
A
46
Q
- Why are patients with mitral stenosis at an increased risk of thrombus formation in
the left atrium?
A
47
Q
- What are some anesthetic considerations for patients with mitral stenosis?
A
48
Q
- How can the maintenance of anesthesia be achieved in patients with mitral
stenosis?
A
49
Q
- How might the adequacy of intravascular fluid replacement be monitored in
patients with mitral stenosis? Why is this important?
A
50
Q
- Why might the mechanical support of ventilation be required postoperatively in
patients with mitral stenosis?
A
51
Q
- What is mitral regurgitation? How is mitral regurgitation reflected on the
recording of pulmonary artery occlusion pressure tracings?
A
52
Q
- What is the most common cause of mitral regurgitation? What other pathologic
process is often present under these circumstances? What are some other causes of
mitral regurgitation?
A
53
Q
- What are some anesthetic considerations for patients with mitral regurgitation?
A
54
Q
- How can the maintenance of anesthesia be achieved in patients with mitral
regurgitation?
A
55
Q
- What is aortic stenosis? How is the severity of aortic stenosis estimated? What is
considered to be hemodynamically significant aortic stenosis?
A
56
Q
- Name at least two causes of aortic stenosis. What is the natural course of aortic
stenosis?
A
57
Q
- Why might patients with aortic stenosis have angina pectoris despite the absence
of coronary artery disease?
A
58
Q
- How is aortic stenosis diagnosed on cardiac auscultation? Why is it
important for the anesthesiologist to rule out aortic stenosis by auscultation
preoperatively?
A
59
Q
- What are some anesthetic considerations for the patient with aortic stenosis?
A
60
Q
- What would result from tachycardia, bradycardia, or decreases in systemic
vascular resistance in the patient with aortic stenosis?
A
61
Q
- How can the maintenance of anesthesia be achieved in patients with aortic
stenosis?
A
62
Q
- How should the intravascular fluid status be managed intraoperatively in patients
with aortic stenosis?
A
63
Q
- In patients with chronic aortic stenosis, why might the pulmonary artery occlusion
pressure not be reflective of the left ventricular end-diastolic volume?
A
64
Q
- How effective are external cardiac compressions in patients with aortic stenosis
during cardiopulmonary arrest?
A
65
Q
- What is aortic regurgitation? What is the effect of chronic aortic regurgitation on
the left ventricle?
A
66
Q
- What is acute aortic regurgitation most likely due to? What is chronic aortic
regurgitation most likely due to?
A
67
Q
- Why might a patient with aortic regurgitation have angina pectoris despite the
absence of coronary artery disease?
A
68
Q
- What are the goals for the anesthetic management of aortic regurgitation?
The anesthetic management of aortic regurgitation resembles the anesthetic
management for which other valvular disease?
A
69
Q
- What is mitral valve prolapse? What percent of the adult population is estimated
to have mitral valve prolapse?
A
70
Q
- What are some other conditions associated with mitral valve prolapse?
A
71
Q
- What symptoms do most patients with mitral valve prolapse have?
A
72
Q
- What are some potential complications of mitral valve prolapse?
A
73
Q
- What is the goal of the maintenance of anesthesia in patients with mitral valve
prolapse? How should the intravascular fluid volume status be managed in patients
with mitral valve prolapse?
A
74
Q
- What is the potential problem with regional anesthesia in patients with mitral
valve prolapse?
A
75
Q
- What are some tools available to the clinician for the diagnosis of disturbances in
cardiac conduction and rhythm?
A
76
Q
- What are some types of conduction defects? Are conduction defects above or
below the atrioventricular node usually permanent?
A
77
Q
- Is the placement of a prophylactic artificial cardiac pacemaker before surgery
indicated in a patient with a bifascicular block? Why or why not? What is the
theoretical concern?
A
78
Q
- How is third-degree atrioventricular heart block treated? What are the various
methods by which this can be accomplished? How can third-degree heart
block be treated pharmacologically?
A
79
Q
- What is sick sinus syndrome? How does it present? How is it treated?
A
80
Q
- What are ventricular premature beats? What are the hallmark features of a
ventricular premature beat on an electrocardiogram?
A
81
Q
- When do premature ventricular beats warrant treatment? How are they treated
under these circumstances?
A
82
Q
- What may be some causes of ventricular premature beats?
A
83
Q
- When is ventricular tachycardia diagnosed? How can it be treated?
A
84
Q
- What are preexcitation syndromes?
A
85
Q
- What is Wolff-Parkinson-White (WPW) syndrome? What is the incidence of WPW
syndrome in the general population? How is it characterized on the
electrocardiogram?
A
86
Q
- What is the most common cardiac dysrhythmia associated with WPW syndrome?
How can it be treated?
A
87
Q
- What is the goal of the anesthetic management of a patient with WPW syndrome?
A
88
Q
- What are the various methods by which paroxysmal atrial tachycardia or
fibrillation may be treated in the perioperative period in patients with WPW
syndrome?
A
89
Q
- What is prolonged QT interval syndrome? What adverse events are associated with
a prolonged QT interval? How can they be treated pharmacologically?
A
90
Q
- What is a congenital cause of prolonged QT interval syndrome? How is a stellate
ganglion block thought to work for this?
A
91
Q
- What is the goal of the anesthetic management of a patient with a chronically
prolonged QT interval?
A
92
Q
- What should be included in the preoperative evaluation of the patient with an
artificial cardiac pacemaker? - How should the pacemaker b
A
93
Q
- How should the pacemaker be evaluated by the anesthesiologist preoperatively?
A
94
Q
- What intraoperative monitoring is important in a patient with an artificial cardiac
pacemaker?
A
95
Q
- What can occur if the ground plate for electrocautery is placed too near the pulse
generator of the artificial cardiac pacemaker?
A
96
Q
- How is the selection of drugs or anesthetic techniques altered by the presence of an
artificial cardiac pacemaker in a patient?
A
97
Q
- Why should a magnet be kept in the operating room intraoperatively for a patient
with an artificial cardiac pacemaker undergoing anesthesia?
A
98
Q
- What are some causes of temporary pacemaker malfunction? When is placement of
a pulmonary artery catheter in a patient with an artificial cardiac pacemaker a risk?
A
99
Q
- What is the definition of essential hypertension? What is the benefit of the
long-term treatment of patients with essential hypertension?
A
100
Q
- What should be included in the preoperative evaluation of a patient with essential
hypertension?
A
101
Q
- How should blood pressure medications be managed in the perioperative period in
the patient with essential hypertension?
A
102
Q
- What other medical problems are frequently seen in patients with essential
hypertension? Approximately what percent of patients with peripheral vascular
disease can be assumed to have 50% or greater stenosis of one or more coronary
arteries even in the absence of symptoms?
A
103
Q
- How is the curve for the autoregulation of cerebral blood flow altered in patients
with essential hypertension?
A
104
Q
- What is the value of treating essential hypertension in patients before an elective
procedure?
A
105
Q
- How do patients with essential hypertension frequently respond physiologically to
the induction of anesthesia with intravenous medications? Why is this thought
to occur?
A
106
Q
- How do patients with essential hypertension frequently respond physiologically to
direct laryngoscopy? What are these patients at risk of during this time? How
can this response be attenuated?
A
107
Q
- What is the goal for the anesthetic management of patients with essential
hypertension?
A
108
Q
- How can the maintenance of anesthesia in patients with essential hypertension be
achieved?
A
109
Q
- How might intraoperative hypotension be managed by the anesthesiologist in
patients with essential hypertension?
A
110
Q
- What is the potential problem with regional anesthesia in patients with essential
hypertension?
A
111
Q
- How frequently does hypertension occur in the early postoperative period in
patients with essential hypertension? How can it be managed?
A
112
Q
- What is the correlation between congestive heart failure and postoperative
morbidity? What does this suggest for the patient scheduled for elective surgery
in the presence of congestive heart failure?
A
113
Q
- What is the goal of the anesthetic management of patients with congestive heart
failure who are undergoing urgent or emergent surgery? What medicines may
be useful to achieve this?
A
114
Q
- How does positive-pressure ventilation of the lungs affect patients in congestive
heart failure?
A
115
Q
- For major surgery in patients with congestive heart failure, what monitoring may
be necessary?
A
116
Q
- For peripheral surgery in patients with congestive heart failure, can regional
anesthesia be selected as an anesthetic option?
A
117
Q
- What is another name for hypertrophic cardiomyopathy? What pathophysiology
defines hypertrophic cardiomyopathy? What is the stroke volume in patients
with hypertrophic cardiomyopathy?
A
118
Q
- What is the goal of the anesthetic management of patients with hypertrophic
cardiomyopathy?
A
119
Q
- How can intraoperative hypotension be treated in patients with hypertrophic
cardiomyopathy?
A
120
Q
- How can intraoperative hypertension be treated in patients with hypertrophic
cardiomyopathy?
A
121
Q
- What is the problem with using b agonists for the treatment of hypotension or
using nitrates for the treatment of hypertension in patients with hypertrophic
cardiomyopathy?
A
122
Q
- What is cor pulmonale?
A
123
Q
- What are some signs and symptoms associated with cor pulmonale?
A
124
Q
- What are some treatment methods for cor pulmonale?
A
125
Q
- What is the recommendation for the patient with cor pulmonale who is scheduled
for an elective surgical procedure?
A
126
Q
- What is the goal of the anesthetic management of patients with cor pulmonale?
How can this be achieved?
A
127
Q
- What is the advantage of monitoring pulmonary artery pressure during surgery in
patients with cor pulmonale?
A
128
Q
- What is cardiac tamponade?
A
129
Q
- Name some manifestations of cardiac tamponade.
A
130
Q
- What is the treatment for cardiac tamponade? What are some temporizing
measures for patients with cardiac tamponade awaiting definitive treatment?
A
131
Q
- What is the goal of the anesthetic management of cardiac tamponade?
A
132
Q
- What effect can the induction of anesthesia and positive-pressure ventilation of
the lungs have on patients with cardiac tamponade?
A
133
Q
- What is the recommendation for anesthesia in patients with cardiac tamponade?
A
134
Q
- What pharmacologic agents may be useful in patients with cardiac tamponade?
A
135
Q
- What is the most frequent cause of aortic aneurysms? Do most aortic aneurysms
involve the thoracic or abdominal aorta?
A
136
Q
- What is a dissecting aneurysm?
A
137
Q
- When is elective resection of an abdominal aortic aneurysm recommended?
A
138
Q
- What are some medical problems frequently associated with aortic aneurysms?
A
139
Q
- What is the goal of the anesthetic management of patients undergoing resection of
an abdominal aortic aneurysm? What monitoring is warranted in these
procedures?
A
140
Q
- When are patients with coronary artery disease especially at risk of myocardial
ischemia during surgery for resection of an aortic aneurysm?
A
141
Q
- How should intraoperative fluids be managed during surgery for resection of an
aortic aneurysm?
A
142
Q
- Why does hypotension frequently accompany unclamping of the abdominal aorta
during surgery for the resection of an aortic aneurysm? What are some methods for
minimizing the hypotension?
A
143
Q
- What are some concerns regarding renal function in patients undergoing aortic
aneurysm repair?
A
144
Q
- What are some concerns regarding spinal cord function in patients undergoing
aortic aneurysm repair?
A
145
Q
- How is blood drained from the venae cavae during cardiopulmonary bypass?
A
146
Q
- What are two different types of pumps that are used to return blood to the arterial
system during cardiopulmonary bypass? Which results in less trauma to blood?
A
147
Q
- How is blood kept from entering the heart from the superior and inferior venae
cavae during cardiopulmonary bypass for mitral valve or intracardiac surgery?
A
148
Q
- Under what conditions does the aorta need to be cross-clamped distal to the aortic
valve and proximal to the inflow cannula during cardiopulmonary bypass?
A
149
Q
- What is the required cardiac index delivered by the roller pump on the
cardiopulmonary bypass machine dependent upon? What approximate cardiac
index is usually sufficient?
A
150
Q
- What is the required cardiac index delivered by the roller pump on the
cardiopulmonary bypass machine dependent upon? What approximate cardiac
index is usually sufficient?
A
151
Q
- What is the advantage of low flows during cardiopulmonary bypass?
A
152
Q
- What are two different types of oxygenators that are used to oxygenate blood that
is returning to the arterial system during cardiopulmonary bypass?
A
153
Q
- What is the advantage of a bubble oxygenator? What is the disadvantage of a
bubble oxygenator?
A
154
Q
- What is the advantage of a membrane oxygenator? What is the disadvantage of
a membrane oxygenator?
A
155
Q
- How can the patient’s body be heated or cooled by the cardiopulmonary bypass
machine?
A
156
Q
- How is blood loss from the field recirculated to the patient during cardiopulmonary
bypass?
A
157
Q
- What is a problem with the cardiotomy suction used during cardiopulmonary
bypass?
A
158
Q
- Why might the left ventricle need a vent during cardiopulmonary bypass?
How might this be achieved?
A
159
Q
- How are systemic emboli from cellular debris prevented from occurring during
cardiopulmonary bypass?
A
160
Q
- What does priming of the cardiopulmonary bypass system refer to? What is the
cardiopulmonary bypass system primed with?
A
161
Q
- What is the patient’s hematocrit maintained at during cardiopulmonary bypass?
Why is it important to hemodilute the patient’s blood during cardiopulmonary
bypass?
A
162
Q
- Why is it important to remove all air from the cardiopulmonary bypass system
during cardiopulmonary bypass?
A
163
Q
- Why is heparin-induced anticoagulation of the patient’s blood necessary during
cardiopulmonary bypass? What dose of heparin is usually administered? How is
the adequacy of anticoagulation confirmed?
A
164
Q
- What are some explanations for the low mean arterial pressure often seen after the
institution of cardiopulmonary bypass? What blood pressure is typically
considered acceptable?
A
165
Q
- Why does blood pressure slowly rise spontaneously after some time on
cardiopulmonary bypass?
A
166
Q
- What are the dangers of hypertension while on cardiopulmonary bypass? How can
hypertension under these circumstances be treated?
A
167
Q
- What are some methods by which the adequacy of tissue perfusion during
cardiopulmonary bypass can be evaluated?
A
168
Q
- Why is diuresis induced during cardiopulmonary bypass?
A
169
Q
- What may be the cause of an increasing central venous pressure with or without
facial edema while on cardiopulmonary bypass? How can this be confirmed?
A
170
Q
- What may be the cause of increasing abdominal distention while on
cardiopulmonary bypass?
A
171
Q
- What are some complications of extracorporeal circulatory support or
cardiopulmonary bypass?
A
172
Q
- How should ventilation of the lungs be managed during cardiopulmonary
bypass?
A
173
Q
- What is the goal of myocardial preservation during cardiopulmonary bypass?
What are some methods by which this can be achieved?
A
174
Q
- What is the oxygen consumption of a normally contracting heart at 30 C? What is
the oxygen consumption of a fibrillating heart at 22 C? What is the oxygen
consumption of an electromechanically quiet heart at 22 C?
A
175
Q
- How is the effectiveness of cold cardioplegia of the heart measured?
A
176
Q
- What are two potential negative effects of intramyocardial hyperkalemia due to
cold cardioplegia after cardiopulmonary bypass? How can they be treated?
A
177
Q
- What are two potential sources for systemic hyperkalemia during
cardiopulmonary bypass? How can the hyperkalemia be treated if it were to persist
at the conclusion of cardiopulmonary bypass?
A
178
Q
- Why might supplemental intravenous anesthetics be administered during
cardiopulmonary bypass?
A
179
Q
- Why might supplemental neuromuscular blocking drugs be administered during
cardiopulmonary bypass?
A
180
Q
- Is supplemental anesthesia routinely required during rewarming after the
conclusion of cardiopulmonary bypass?
A
181
Q
- What conditions in the patient must be present for cardiopulmonary bypass to be
discontinued?
A
182
Q
- When are the aortic and vena cava cannulae removed after cardiopulmonary bypass?
A
183
Q
- What are some potential problems associated with persistent hypothermia after
cardiopulmonary bypass?
A
184
Q
- What special precautions must be taken before discontinuing cardiopulmonary
bypass in patients who have had the left side of the heart opened, as during valve
replacement surgery? What is the potential risk?
A
185
Q
- For each of the following situations, please complete the diagnosis and appropriate
therapy
A
186
Q
- Why might a patient have posterior papillary muscle dysfunction after
cardiopulmonary bypass? How would this be manifest on the pulmonary artery
occlusion pressure tracing?
A
187
Q
- What is a mechanical addition to the pharmacologic support of cardiac output in
patients with a poor cardiac output after cardiopulmonary bypass? How does it
work? What physiologic alterations may interfere with its efficacy?
A
188
Q
- When is protamine administered after cardiopulmonary bypass? Why?
A
189
Q
- What are some possible side effects of protamine administration?
A
190
Q
- What does the perfusionist do with blood and fluid that remains in the
cardiopulmonary bypass circuit after cardiopulmonary bypass?
A
191
Q
- Why might there be a gradient between central aortic and radial artery blood
pressures in the early period after cardiopulmonary bypass? How long can this
effect persist?
A
