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Anestesiologia - Pontos ME1 ME2 + Miller > 42 Marcapasso e CDI > Flashcards

42 Marcapasso e CDI Flashcards

1
Q

A patient is considered to be pacemaker dependent if:

A

Sintomas importantes ou PCR assim que o MP for interrompido

It is important to establish if the patient is pacemaker- dependent, which is defined as the absence of a perfusing rhythm without pacing.

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2
Q

Most pacemakers have the capability of varying the pacing rate.

  • De quais maneiras isso ocorre? (2)
A
  • Nivel de atividade e movimento do corpo
  • Ritmo respiratorio ou volume
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3
Q

The pacing capture threshold is the ___1___ and is determined by ___2___, ___3___, and ___4___.

A
  1. minimum electrical energy needed to consistently capture the heart outside of the refractory period
  2. the intrinsic excitability of the myocardium
  3. the current density at the electrode-tissue interface
  4. the duration of the electric pulse.
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4
Q

O que significam as posições dos códigos de designação dos Marcapassos?

A
  1. Camara estimulada
  2. Camara detectada
  3. Resposta a deteccao
  4. Modulacao de ritmo
  5. Estimulacao multisítio
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5
Q

O que a designacao DDDR de um marcapasso significa e qual a principal indicação?

A
  • Estimula AV,
  • Detecto AV,
  • inibe ou estimula resposta a um evento
  • sensor capaz de alterar a frequencia conforme demandas metabólicas percebidas
  • (Posição V omitida, ou seja, sem estimulação multissítio)

Pp indicacao: Sick Sinus Syndrome e/ou bloqueio de ramo

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6
Q

Por que o modo DDIR é comum em pacientes com Taquiarritmias Supraventriculares?

A
  • O MP detecta ambos A+V, mas nao vai estimular o ventrículo em uma frequencia idêntica se TSV
  • A resposta a uma frequencia rapida no atrio leva a inibicao do estimulo ventricular (por isso a letra “i” na terceira designacao)
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7
Q

Qual a vantagem do modo DOO no intraop?

A
  • Modo assincrono ou sem detecção
  • A+V colocados em uma frequencia pre-determinada, independente da frequencia e ritmo subjacente

Evita que o MP ententa o eletrocauterio monopolar como conducao cardiaca.

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8
Q

Principais indicacoes de CDI (2)

A
  • Prevencao primaria ou secundaria de PCR
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9
Q

Quais as 4 funções principais dos CDIs?

A
  • Detectam atividade elétrica atrial ou ventricular
  • Classifica o sinal em “zonas cardíacas” programadas diversas
  • Entrega terapia para interromper TV ou Fibrilacao
  • Todos os CDI sao MP bradicardia
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10
Q

There are several methods by which ICDs discrimi- nate between SVT and VT.

A
  • Camara unica: utilizam intervalos de tempo V-V e morfologia QRS
  • Duas Camaras: intervalo de tempo A-A e camara de inicio
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11
Q

ICDs terminate ventricular arrhythmias by: (2)

A
  • Antitachycardiac pacing (ATP)
  • Defibrillation
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12
Q

Como funcionam os seguintes marca-passos?

  1. AAI
  2. DDDR
  3. VVIRV
  4. DOO
A
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13
Q

In contrast to pharmacologic means of improving systolic function, CRT improves:

A

Cardiac performance with reductions rather than with increases in myocardial metabolic demand.

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14
Q

CRT has been shown to improve mitral regurgitation (MR) and New York Heart Association (NYHA) function class because of

A

Reverse ventricular remodeling over time.

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15
Q

Standard indications for CRT are (3)

A
  • FEVE < 35% com QRS > 120ms
  • Ritmo sinusal
  • NYHA III ou IV apos otimizacao de terapia medicamentosa
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16
Q

Qual a anormalidade de condução mais comum em pacientes que necessitam de TRC?

A

VRE

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17
Q

Approximately 30% of patients meeting selection criteria for CRT do not respond to biven- tricular pacing. Risk factors for failure to respond to CRT include (4)

A
  • Cardiomiopatia isquemica
  • TV sustentada
  • Reg Mitral grave
  • Dilatacao de VE
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18
Q

For patients with a pace- maker, they should have an interrogation report within the last 12 months; patients with an ICD or CRT should have a report within the previous 6 months.

  • Por que ocorre essa diferenca no tempo?
A

Comorbidades cardiovasculares gerais nas populações de pacientes

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19
Q

Worsening cardiovascular function might negatively impact CIED performance. The preopera- tive evaluation begins with general considerations, such as: (6)

A
  • Definir o tipo de dispositivo
  • Indicacao do CIED
  • Historia + EF focados
  • ECG
  • Contactar equipe do CIED - se visita recente, o paciente traz uma nota detalhada
  • Fabricante
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20
Q

Although DDD pacing of both atrium and ventricle in a dual-chamber pacemaker maintains atrioventricular (AV) synchrony, it creates RV-LV dys- synchrony and LV-LV dyssynchrony because ___1___. Preserved synchrony optimizes stroke volume, which is desirable during the perioperative environment.

A
  1. Pacing begins in the right ventricle and crosses the septum before activating the LV lateral wall
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21
Q

Occasionally, patients present for elective surgery without CIED team communication. In this subset of patients, there are several options:

A
  • Rx Torax

Chest radiographs can identify pacemakers versus ICDs, due to the increased thick- ness of the shocking coil in ICDs. Chest radiographs can also identify CRT devices due to the lead in the coronary sinus. With some training, the manufacturer can also be identi- fied via chest radiograph.

  • Ligar para o fabricante
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22
Q

Qual tempo de longevidade de bateria ideal para cirurgia?

A

3 meses

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23
Q

Pacemaker dependence can be established by the CIED team preoperatively.

  • Como isto é feito?
A

They can decrease the pacing rate in a stepwise fashion to search for intrinsic electrical activity. If no intrinsic rate is present around 40 to 45 beats/min or the patient develops symptoms, the patient may be considered pacemaker-dependent.

Some patients who are not pacemaker-dependent may become pacemaker-dependent in the perioperative period due to SA and AV nodal blocking agents; there- fore, it is important to be prepared to address this clinical scenario.

24
Q

Although there are several potential sources of Electro Magnetic Interference, the most commonly encountered source is:

A
  • Monopolar electrocautery

Monopolar electrocautery is the most frequently used type of electrocautery because it has both cutting as well as coagulation capabilities. Monopolar electrocautery creates a current that passes from the probe to the tissue and returns through the patient to the return pad to create an electrical circuit.

Bipolar electrocautery is usually not a concern25; the electrical current field is small and limited to the two poles at the end of the electrode. Unfortunately, bipolar is less frequently used compared with monopolar electrocautery and is usually reserved for neurosurgery, ophthalmology, and head and neck proce- dures.

25
It is important to note that it is not only the **___1___** that is critical to proper CIED function, but it is also the location of the **___2___** that is critical to avoid CIED malfunction.
1. location of monopolar electrocautery 2. grounding pad
26
The HRS/ASA Expert Consensus Statement suggests that due to the decreased likelihood of EMI-related interference seen when surgery is **___1___**, the patient should proceed to surgery with no magnet application to the device or reprogramming
1. below the umbilicus *This assumes that the mono-polar electrocautery grounding pad or return pad is also placed below the level of the umbilicus*
27
For procedures above the umbilicus with no EMI from the surgical procedure, the patient may also proceed for surgery:
* Without routine magnet use or device reprogramming.
28
Efeito de ímã em um Marcapasso
Induz modo assíncrono
29
Efeito de ímã no CDI
inibe detecção de ritmo taquicárdico, prevenindo a terapia (choque) *However, it does not change the mode of the underlying pacemaker. Therefore, a magnet placed over an ICD will not induce asynchronous mode in the underlying pacemaker.*
30
Qual a melhor maneira de prevenir um "reset" do CIED?
* Deixar Interferencia Eletromagnetica o mais longe possivel do gerador de pulso, idealmente > 15cm
31
No manejo intraoperatorio de CIED, qual a primeira consideração a ser feita?
* A Interferencia Electromagnética é acima do umbigo?
32
Qual a 2ª e 3ª perguntas a serem feitas conforme o algoritmo de
2. MP x CDI 3. Paciente é dependente de MP?
33
Paciente em uso de CIED, cirurgia acima do umbigo, dependentes do marcapasso, e com necessidade de eletrocauterio monopolizar na regiao de 15cm do gerador - qual a conduta em relacao ao CDI?
* Reprogramar para modo assincrono * Para evitar o estimulo do eletrocauterio como funcao cardiaca intrinseca
34
Quais as possiveis consequências deletérias de reprogramar o MP para modo assíncrono no intraop?
* Underpacing e colapso hemodinámica em pacientes dependentes do marcapasso
35
Whether the prescription plan is reprogramming or magnet application, the **___1___** features of the device should be disabled.
* Rate responsive
36
The rate response is the fourth letter in the 2002 NAPSE guidelines and refers to **___1___**. Rate response sensors commonly use **___2___** to increase rate, and both may be affected intraoperatively.
1. increasing the heart rate above the lower rate limit when the patient has increased metabolic demand (e.g., exercise) 2. minute ventilation or thoracic impedance
37
Patients with ICDs who are pacemaker dependent with close EMI to the generator are a special group that must have their devices **___1___**. Magnet application is not a reasonable strategy in these patients, since the magnet **___2___**.
1. Reprogrammed 2. Will not make the pacemaker asynchronous.
38
Qual o melhor monitor que indica que o marcapasso esta capturando e criando DC?
* Oximetria de pulso pletismografica
39
Qual o cuidado ao colocar Acesso Venoso Central ou Cateter de Arteria Pulmonar em paciente com CIED?
* Se recente, 1-2meses,risco de deslocamento
40
No manejo pos-op, quais os principais motivos para decidir a disposição do paciente? (2)
* Gravidade * Curso operatorio *There does not need to be escalation of postoperative disposition based on the presence of a CIED alone.*
41
Identifying patients who need CIED interrogation prior to discharge avoids lapses in communication in the postoperative period. Most patients with CIEDs do not require routine interrogation following surgery; however, there are notable exceptions.
* Consulta ambulatorial em 1 mes de pos-op para todos é razoavel * Terapia traquiarritmica desligada * Procedimentos hemodinamicos grandes * Cardioversao, Desfibrilacao e radicato terapeutica intraop
42
Principais informacoes para obter em cirurgia de emergencia para paciente com CIED (4)
* Tipo de dispositivo * Dependencia de marcapasso * Risco de interferencia eletromagnetica * Funcao de ímã
43
Como encontrar informacoes do tipo de dispositivo em paciente que nao apresenta Carteira, Historico medico ou anotações da equipe de CIED?
* Raio-x de torax
44
During an emergency procedure, it is important to establish whether the patient is **___1___**. In the absence of a CIED note, a **___2___** can be examined to look for **___3___**.
1. pacemaker dependent 2. 12-lead ECG or rhythm strip 3. pacemaker spikes
45
If the majority of QRS complexes are preceded by a pacing spike, the patient should be treated as **___1___**.
1. pacemaker dependent.
46
For pacemaker patients who are pacemaker dependent, it is reasonable to use a **___1___** for surgeries requiring EMI above the umbilicus.
1. Magnet
47
However, it is important to remember that a minority of pacemakers will have the magnet function turned off. Therefore, the anesthesiologist should monitor the **___1___** to ensure that there is no oversensing of the EMI leading to a lack of pacing in pacemaker-dependent patients, even when the magnet is applied to the device.
1. pulse oximeter
48
For patients who are not pacemaker dependent, it is reasonable to have a **___1___** available in case the patient requires **___2___**.
1. magnet 2. asynchronous pacing.
49
For patients with ICDs, **___1___** should be placed on the patient during emergency procedures. **___2___** application should be applied for cases with EMI above the level of the umbilicus. Since this will not render the pacemaker asynchronous, if monopolar EMI is used above the umbilicus, it is critical for the surgeon to use **___3___** of monopolar electrocautery to avoid pacemaker oversensing.
1. Defibrillator pads 2. Magnet 3. Short bursts (<5 seconds)
50
Quais os cuidados a serem tomados com CIED que necessitam de Cardioversao Elétrica? (2)
* Modelos antigos Unipolares - perda de captura quando os pads foram colocados nas orientações anterior e lateral. * Modelos novos Bipolares - nao alteram com CVE
51
Quais os cuidados a serem tomados com CIED que necessitam de Ablacao por Radiofrequência? (2)
* Complicacoes sao incomuns * Evitar contato do cateter de ablação com o gerador de pulso e leads, mantendo o caminho da corrente de radiofrequência o mais longe possivel
52
Quais os cuidados a serem tomados com CIED que necessitam de Litotripsia por ondas de choque extracorporea (2)
* Distancia de 15cm do dispositivo a area de tratamento * Contraindicacao do procedimento a CIEDs abdominais
53
Quais os cuidados a serem tomados com CIED que necessitam de Radiacao? (2)
* Afeta a funcao se direcionada ao gerador de pulso * Manter dose acumulada < 5 Gy
54
Quais os cuidados a serem tomados com CIED que necessitam de Eletroconvulsoterapia (2)
* Se curta < 5s, sem alteracoes hemodinamicas * Se prolongada, colocar em modo assíncrono e a funcao antitaquiarritmia desativada *There are no reports of direct damage to the CIED; however, the concern is pacemaker oversensing of the electric current leading to underpacing in pacemaker-dependent patients.*
55
Quais os cuidados a serem tomados com CIED que necessitam de Endoscopia (2)
* Apenas se utilizar eletrocauterio, seguir guidelines de EMI risk

Anestesiologia - Pontos ME1 ME2 + Miller (118 decks)

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