Anesthesia for Vascular Surgery - Quiz 4, Part 1

Question 1

Most common cause of occlusive dz

Answer 1

Atherosclerosis

Question 2

Most common cause of occlusive dz in the lower extremity

Answer 2

Periph Vasc Dz

Question 3

Pathophys of PVD

Answer 3

1. Plaque formation
2. Thrombosis
3. Embolism from micro thrombi or atheromatous debris
4. Aneurysm formation

Question 4

Major risk factors in the pathogenesis of atherosclerosis in the peripheral vascular system

Answer 4

1. Cigarette Smoking

2. DM

Question 5

What provides alternative vast blood flow in its w occlusive dz?

Answer 5

development of collateral circulation

Question 6

From what does more than half of the mortality associated w PVD result?

Answer 6

adverse cardiac events

Question 7

How long before surgery (specifically AAA repair) should B-blockers be started to decease risk for myocardial ischemia and infarction?

Answer 7

days to weeks before surgery

Question 8

What target heart rate should B-blocker therapy be titrated to?

Answer 8

50-60 bpm

Question 9

Because of their antiinflammaory effects, statin drugs should be instituted ____ days prior to the surgical procedure

Answer 9

30 days

Question 10

T/F: Preop, the greater number of comorbidities that exist, the treater the risk of morbidity and mortality during the peri-op period.

Answer 10

True

Question 11

Typical symptoms of PVD

Answer 11

1. Claudication
2. Skin ulceration
3. Gangrene
4. Impotence

Question 12

What primarily influences the extent of the disability from PVD?

Answer 12

development of collateral blood flow

Question 13

Mortality rates of PVD are _____ times higher than the general population.

Answer 13

2-6x higher

Question 14

Primary objective of monitoring during surgery on a pt w PVD

Answer 14

Detection of myocardial ischemia

Question 15

Should MAP be kept high or low in a pt with HTN and/or angiopathy? Why?

Answer 15

Higher

these pos depend on MAP to perfuse their vital organs

Question 16

Does the range of auto regulation pressures change in an angiopathy or HTN pt?

Answer 16

Yes. Cerebral and coronary auto regulation occurs at higher than normal pressures

Question 17

Why is intraarterial BP monitoring warranted during surgery on a pt w vasc dz?

Answer 17

Dramatic fluctuations in BP can occur during anesthesia

Question 18

What should be expected in a pt with atherosclerotic occlusive dz?

Answer 18

Expect that the disease is elsewhere also, specifically in the coronary, cerebral, and renal arteries

Question 19

Why is B blocker therapy recommended in its w a high risk of myocardial ischemia and infarction?

Answer 19

1. decreases myocardial O2 demand

2. brings supply-demand system into balance

Question 20

Single most significant risk factor influencing long-term survivability in a pt who requires abd aortic reconstruction

Answer 20

Presence of underlying CAD

Question 21

Most reliable definition of coronary anatomy and the extent of CAD

Answer 21

Coronary angiography

Question 22

Reliable method for evaluating the extent of myocardial dysfx associated with CAD and for predicting coronary events after vast surgery; does not rely on exercise for detection of areas of myocardial hypoperfusion

Answer 22

Dipyridamole thallium testing

Question 23

Goal of al prep cardiac evaluation

Answer 23

ID fx cardiac limitations

Question 24

Common coexisting diseases in pts presenting for abd aortic resection

Answer 24

1. HTN
2. Heart dz
3. COPD
4. DM
5. Renal impairment
6. CAD

Question 25

T/F: postoperative admin of narcotics after vascular surgery not only provides pt comfort but also contributes to cardiac stability.

Answer 25

True

Question 26

Why are epidural opioid and local anesthetics an important component in pts recovering from vascular surgery?

Answer 26

Pain can enhance sympNS stimulation

Question 27

Risk factor most highly correlated with AAA

Answer 27

Smoking Smokers have a 5-8 fold increase in AAA incidence

Question 28

What is thought to be the primary cause of AAA in 90% of pts?

Answer 28

Atherosclerosis

Question 29

AAA Contributing factors

Answer 29

1. Atherosclerosis 2. Proteolysis of elastin and collagen within a vessel wall 3. HTN 4. Cigarette smoking 5. Genetic predisposition 6. Obesity - may mask s/s

Question 30

One of the most frequent vascular surgical procedures

Answer 30

Elective AAA repair

Question 31

Risk of rupture is very low for AAAs less than ___cm in diameter

Answer 31

<4 cm

Question 32

Risk of rupture dramatically increases for AAAs with a ____ cm or greater diameter

Answer 32

>/= 5 cm

Question 33

Criteria for AAA surgical intervention

Answer 33

- AAA >/= 5.5 cm - Ruptured AAA - 4-5 cm AAA w >0.5 cm enlargement in < 6 mo - symptomatic AAA - elective repair of AAA >/+ 5.o cm

Question 34

T/F: Age alone is not a contraindication to elective aneurysmectomy

Answer 34

True

Question 35

Contraindications to elective repair of AAA

Answer 35

1. Intractable angina pectoris 2. Recent MI 3. Severe pulm dysfx 4. Chronic renal insufficiency

Question 36

Do its with stable CAD and coronary artery stenosis of >70% who require non emergent AAA repair benefit from revascularization if B-blockade has been established?

Answer 36

No. They do not benefit.

Question 37

Most common reason for poor outcomes in non cardiac surgery

Answer 37

Peri-op MI

Question 38

What are the 2 major goals of per-op risk reduction?

Answer 38

1. Optimization of myocardial O2 supply and demand | 2. Modification of cardiac risk factors

Question 39

Hallmark pharmacologic tx for medical mgmt of AAA

Answer 39

1. B-blockers 2. Statins 3. ASA

Question 40

Most important techniques used to enhance cardiac fx during abd aortic aneurysmectomies

Answer 40

1. Pre-op fluid loading | 2. Restoration of intravasc vol

Question 41

Standard monitoring methods for AAA repair

Answer 41

ECG - leads II and V5 Pulse ox Capnography Indwelling urinary catheter

Question 42

Which has higher sensitivity and specificity in detecting myocardial ischemia, PAC or TEE?

Answer 42

TEE

Question 43

Primary method of interaction-op cardiac assessment in its undergoing surgery on the heart and aorta

Answer 43

TEE

Question 44

What occurs sooner during periods or reduced coronary blood flow, wall motion abnormalities or EKG changes?

Answer 44

Wall motion abnormalities

Question 45

Greatest risk of mortality after abd aortic reconstruction

Answer 45

Myocardial Ischemia

Question 46

The most common site for aorta cross-clamping. Why?

Answer 46

Infrarenal Most aneurysms appear below the level of the renal arteries

Question 47

How do hemodynamics change on each side of an aortic cross clamp?

Answer 47

HTN above the clamp | HoTN below the clamp

Question 48

During aortic cross clamp (AoX), what causes myocardial wall tension to increase?

Answer 48

increase in after load

Question 49

How do MAP and SVR change during AoX?

Answer 49

they both increase

Question 50

How does CO change during AoX?

Answer 50

it decreases or remains unchanged

Question 51

How does PAOP change during AoX?

Answer 51

increases or stays the same

Question 52

True or False: Infrarenal clamping always causes an increase in preload.

Answer 52

False. | It depends on splanchnic vascular tone. if blood is shifted into splanchnic circulation, preload will not increase.

Question 53

What 2 things determine if CO increases during AoX?

Answer 53

coronary flow and contractility increased coronary flow and contractility = increased CO no increase in coronary flow and contractility = decreased CO

Question 54

Synthesis of __________, which is accelerated by the application of an AoX, may be responsible for the decrease in myocardial contractility and CO that occurs.

Answer 54

Thromboxane A2

Question 55

Syndrome characterized by - decrease in BP and SVR - tachycardia - increased CO - facial flushing

Answer 55

Mesenteric traction syndrome