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Anesthesia Practice > AP 3 Test 1 > Flashcards

AP 3 Test 1 Flashcards

1
Q

Mechanism by which volatile anesthetics depress cardiac contractility

A

Decreases the entry of Ca2+ into cardiac muscle cells during depolarization

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2
Q

Mechanism by which nitrous oxide depresses cardiac contractility

A

Dose dependent reduction in availability of intracellular Ca2+ available during contraction

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3
Q

Mechanism by which local anesthetics depress cardiac contractility

A

Dose dependent reduction in Ca2+ influx and release

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4
Q

Why does acidosis depress cardiac contractility

A

Blocks slow calcium channels

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5
Q

Mechanism by which phosphodiesterase inhibitors increase cardiac contractility

A

Prevent breakdown of cAMP which allows for recruitment of open Ca2+ channels

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6
Q

Mechanism by which Digitalis increases cardiac contractility

A

Increases intracellular Ca2+ concentration

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7
Q

How do hypocalcemia, beta blockers, and calcium channel blockers affect the effects of anesthesia on cardiac function

A

They all potentiate anesthetic-induced cardiac depression

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8
Q

Major cardiovascular control center that is the primary regulator of heart rate and BP

A

Medulla

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9
Q

Region of the brain that regulates cardiovascular response to changes in temperature

A

Hypothalamus

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10
Q

Region of the brain that adjusts cardiac reaction to a variety of emotional states

A

Cerebral cortex

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11
Q

Parasympathetic fibers primarily innervate what region of the heart

A

Atria

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12
Q

Acetylcholine acts on which receptors in the heart to produce negative effects

A

M2 - negative chronotropy, inotropy, dromotropy (conduction velocity of AV node)

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13
Q

What region of the spinal cord contains the cardiac sympathetic fibers

A

T1-T4

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14
Q

What is the primary neurotransmitter/receptor pair that has positive chronotropic, dromotropic, and inotropic effects on the heart

A

Norepinephrine acting on beta 1 receptors (sympathetic NS)

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15
Q

Location of B2 receptors in the heart

A

Primarily in atria

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16
Q

Effect of activating B2 receptors in the heart

A

Increase HR, lesser increase in contractility

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17
Q

What causes the increase in heart rate due to inspiration

A

The vagal fibers in the lungs get stretched and activated - this stretch sends an inhibitory signal to the cardioinhibitory center in the medulla and allows for an unopposed sympathetic increase in HR

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18
Q

Receptors that mediate baroreceptor reflex

A

Pressoreceptors in the aortic arch and carotid arteries

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19
Q

Afferent nerves of baroreceptor reflex

A
  • Hering

- Vagus

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20
Q

Most important determinant of myocardial blood flow

A

Myocardial oxygen demand

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21
Q

Percentage of oxygen requirements dedicated to pressure work

A

64%

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22
Q

The myocardium usually extracts __% of oxygen in arterial blood

A

65

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23
Q

Most other body tissues other than the myocardium extract __% of oxygen in arterial blood

A

25

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24
Q

Why does a fast heart rate cause a decrease in coronary filling?

A

It decreases the time in diastole, which is when coronary filling occurs

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25
Q

How does low aortic diastolic pressure affect coronary filling pressure

A

Decrease

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26
Q

How does increased LVEDP affect coronary filling pressure

A

Decrease

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27
Q

Equation for Coronary Perfusion Pressure

A

Arterial diastolic pressure-LVEDP

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28
Q

Main factor that affects CaO2

A

Hemoglobin concentration

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29
Q

Why does aortic stenosis and regurgitation decrease CaO2

A

They both worsen the blood flow into the coronary arteries

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30
Q

What are common causes of decreased coronary vessel diameter and thus decreased oxygen uptake

A
  • Blockage
  • Artherosclerotic plaque
  • Coronary vasospasm
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31
Q

What factors contribute to increased wall tension thus increased oxygen demand

A
  • Increased preload
  • Increased BP
  • Increased afterload
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32
Q

Cardiac index calculation

A

CI=CO/BSA

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33
Q

Normal range for cardiac index

A

2.5-4.2 L/min/m^2

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34
Q

Normal mixed venous oxygen saturation

A

65-73%

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35
Q

Byproduct of anaerobic metabolism used to indirectly assess cardiac output

A

Lactic acid

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36
Q

In the absence of hypoxia or severe anemia, what measurement is the best determination of the adequacy of cardiac output

A

Mixed venous oxygen saturation

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37
Q

What law states the physical relationship between wall tension and internal pressure within a circular structure

A

Law of LaPlace

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38
Q

What is the Frank-Starling Law

A

The greater the end diastolic volume, the greater the force of muscular contractions thus increasing stroke volume

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39
Q

Physiology behind Frank-Starling Law

A

When there is an increased end diastolic volume, there is increased stretch in the heart wall which increases the affinity of troponin C for calcium - this causes a greater number of cross-bridges to form within the muscle fibers thus increasing contractile force

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40
Q

3 primary factors that regulate stroke volume

A

1) Preload
2) Afterload
3) Contractility

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41
Q

Another term for end-diastolic volume

A

Preload

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42
Q

What is preload dependent on

A

Ventricular filling

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43
Q

3 factors that influence preload

A

1) Venous return
2) Heart rate
3) Heart rhythm

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44
Q

Ventricular filling progressively becomes impaired at a heart rate above…

A

120bpm in adults

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45
Q

Atrial arrhythmias can reduce ventricular filling by what percentage?

A

20-30%

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46
Q

Atrial arrhythmia that causes an absent atrial kick

A

A-fib

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47
Q

Atrial arrhythmia that causes an ineffective atrial kick

A

A-flutter

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48
Q

Atrial arrhythmia that causes loss of atrial kick due to altered timing of atrial contraction

A

Junctional rhythm

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49
Q

What measurement is useful to monitor TRENDS in preload and volume

A

CVP

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50
Q

Normal range for CVP

A

2-8mmHg

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51
Q

End diastolic pressure in the right atrium is nearly equal to what other measurement

A

CVP

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52
Q

What fraction of estimated blood volume is in the venous system

A

2/3

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53
Q

How does gravity affect CVP

A

It redistributes ~500cc of blood from the intrathoracic vessels into the veins of the lower limbs, which reduces CVP and stroke volume

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54
Q

How does venoconstriction in response to exercise, shock or hemorrhage affect CVP

A

Increase

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55
Q

Under normal conditions, pulmonary capillary wedge pressure is indicative of what other pressure

A

Left atrial pressure

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56
Q

Assuming normal left ventricular compliance, left ventricular end diastolic pressure is equal to what

A

Left ventricular end diastolic volume

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57
Q

Under what condition can LVEDP be used as a measure of preload

A

Only if the relationship between ventricular volume and pressure (i.e. ventricular compliance) is constant

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58
Q

Left ventricular conditions that cause abnormal compliance during early diastole

A
  • Hypertrophy
  • Ischemia
  • Asynchrony
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59
Q

Left ventricular conditions that cause abnormal compliance during late diastole

A

Fibrosis

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60
Q

SVR calculation

A

80 x [(MAP-CVP)/CO]

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61
Q

Normal range for SVR

A

900-1500 dyne x s/cm^5

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62
Q

PVR calculation

A

80 x [(PAP-LAP)/CO]

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63
Q

Normal range for PVR

A

50-150 dyne x s/cm^5

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64
Q

What branch of the nervous system has the most important effect on cardiac contractility

A

Sympathetic nervous system

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65
Q

Most common physiologic states that depress myocardial contractility

A

1) Anoxia - lack of O2
2) Acidosis - increased H+
3) Low catecholamine stores
4) Loss of functioning muscle mass - due to ischemia or infarction

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66
Q

Influence of parasympathetic system on cardiac function

A

Negative chronotropy (decrease HR)

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67
Q

Influences of sympathetic system on cardiac function

A
  • Positive chronotropy

- Positive inotropy

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68
Q

Influence of high arterial pressure on cardiac output

A

Lowers cardiac output bc it lowers stroke volume

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69
Q

Influence of high preload (filling pressure) on cardiac output

A

Increases cardiac output bc it increases stroke volume via Starling’s Law mechanism

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70
Q

Why does stenosis of AV valves reduce stroke volume

A

Because ventricular preload/filling is decreased due to the stenotic valves

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71
Q

Why does stenosis of semilunar valves reduce stroke volume

A

Because ventricular afterload is increased

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72
Q

Define angina

A

Myocardial ischemia which usually manifests as chest pain

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73
Q

Most common cause of angina

A

Coronary Artery Disease

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74
Q

Causes of angina

A
  • CAD
  • Vasospasm
  • Low cardiac output states (anemia, hypotensive, heart failure)
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75
Q

Cardiovascular states that increase oxygen demand

A

1) Tachycardia
2) HTN aka high afterload
3) Increased contractility

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76
Q

Cardiovascular states that decrease oxygen supply

A

1) Anemia
2) Hypoxemia
3) CAD
4) Vasospasm
5) Hypotension

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77
Q

What is stable angina

A

Angina that occurs with exertion because the diseased coronary artery is maximally vasodilated

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78
Q

Treatments for stable angina

A

Rest or vasodilators

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79
Q

What is unstable angina

A

Angina that has increased in frequency, severity, or duration or occurs at rest

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80
Q

Which type of angina is considered an acute coronary syndrome?

A

Unstable angina

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81
Q

What is CAD

A

Atherosclerotic plaque build up in coronary arteries, limiting blood flow to myocardium

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82
Q

What is the leading cause of death in the US

A

CAD

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83
Q

Risk factors for CAD

A

1) Male
2) Hypertension
3) Hypercholesterolemia
4) Diabetes
5) Obesity
6) Family history
7) Tobacco use

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84
Q

Treatment options for CAD

A
  • Lifestyle changes i.e. diet
  • Medical therapy
  • PCI
  • CABG
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85
Q

Medical therapies available for CAD treatment

A
  • Beta blockers
  • Ca2+ channel blockers
  • Nitrates
  • ACE inhibitors
  • ASA/anti-platelets
  • Statins
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86
Q

How do we assess functional status and physical exams to ensure a patient with CAD is optimized for surgery?

A

Assess METs

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87
Q

What pertinent information should be pulled from history and records of a patient with CAD to ensure they are optimized for surgery

A

1) Recent PCI/stent placement
2) Dual anti-platelet therapy
3) Prior revascularization
4) Significant comorbidities (HTN, DM, CKD, PAD, hyperlipidemia)

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88
Q

A patient with a previous bare metal stent placement is required to be on dual anti-platelet therapy (aspirin + plavix) for how long after placement?

A

4-6 weeks

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89
Q

A patient with a previous drug alluding stent placement is required to be on dual anti-platelet therapy (aspirin + plavix) for how long after placement?

A

12 months

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90
Q

What is the goal for anesthetic management of a patient with CAD?

A

Maximize favorable oxygen supply and demand relationship

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91
Q

How will cardiac enzyme levels be affected if a patient has a myocardial infarction?

A

The injured myocardium will release enzymes (i.e. troponin) into the bloodstream so these levels will be elevated after an MI

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92
Q

What comorbidity alters the clearance of cardiac enzymes, thus can falsely indicate an MI?

A

ESRD

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93
Q

Which type of MI is marked by ST elevation?

A

Transmural MI - affects the epicardium, myocardium, and endocardium

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94
Q

A transmural MI is usually secondary to what occurrence?

A

An obstruction in a major coronary artery

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95
Q

Which type of MI is marked by ST depression?

A

Subendocardial MI

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96
Q

What test is used perioperatively to assess for wall motion abnormality?

A

TEE

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97
Q

What is the basic definition of heart failure?

A

Inability of the heart to provide adequate cardiac output to maintain the needs of the body

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98
Q

Normal values for cardiac index

A

2-2.5

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99
Q

Most frequent etiology of heart failure

A

Ischemic (prior MIs, prior CABG, etc)

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100
Q

What valvular heart disorders most often cause heart failure?

A
  • Aortic and mitral regurgitation

- Aortic and mitral stenosis

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101
Q

Which etiology of heart failure are patients normally born with?

A

Non-compaction

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102
Q

Which type of heart failure is most common - systolic or diastolic?

A

Systolic

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103
Q

A patient is considered as having a severely low ejection fraction if it is below –%

A

25

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104
Q

Patients with what comorbidity most commonly have diastolic heart failure?

A

Hypertensive patients due to the impaired relaxation leading to impaired filling

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105
Q

Class I Heart Failure

A

Symptoms of heart failure only at activity levels that would limit normal individuals

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106
Q

Class II Heart Failure

A

Symptoms with ordinary exertion

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107
Q

Class III Heart Failure

A

Symptoms with less than ordinary exertion

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108
Q

Class IV Heart Failure

A

Symptoms at rest

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109
Q

Are most LVADs currently implanted pulsatile or continuous flow?

A

Continuous flow

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110
Q

Should inotrope dependent patients with heart failure continue or discontinue these meds perioperatively?

A

Continue

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111
Q

Heart failure patients that are on maximal pharmacologic therapy and still need extra assistance often have what device implanted?

A

Intra-aortic balloon pump (IABP)

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112
Q

How can you monitor BP in a patient with an LVAD?

A

A-line

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113
Q

What are the 2 major functions of an IABP?

A
  • Increase perfusion pressure thus coronary blood flow

- Decrease afterload

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114
Q

IABPs are “counterpulsatile” - what does this mean?

A

They deflate in systole and inflate in diastole to augment diastole and force blood into the coronary arteries

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115
Q

Patients with complete heart block, AV block, or symptomatic bradycardia most likely have which cardiac device?

A

Pacemaker

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116
Q

Category in position I of pacemaker description

A

Chambers PACED

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117
Q

Category in position II of pacemaker description

A

Chambers SENSED

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118
Q

Category in position III of pacemaker description

A

Response to sensing

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119
Q

Category in position IV of pacemaker description

A

Rate modulation

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120
Q

A patient with which type of pacemaker is completely pacemaker dependent?

A

DOO

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121
Q

An automatic implantable cardioverter defibrillator (AICD) has what capabilities?

A
  • Pacing
  • Anti-tachycardia pacing
  • Defibrillating
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122
Q

For which patients is an AICD indicated?

A

Patients with certain cardiomyopathies, low EF, history of malignant arrhythmia

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123
Q

Cardiac resynchronization therapy-dual chamber (CRT-D) is indicated for which patients?

A

Patients with a significant conduction delay and ineffective systole due to one or both ventricles pumping out of sync with the rest of the heart

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124
Q

If a patient has an AAIR pacemaker, what setting might we want to discontinue during surgery?

A

Rate modulation

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125
Q

Monopolar electrocautery during surgery can lead to what phenomena in a patient with a pacemaker

A

Oversensing - the pacemaker will sense the electrocautery as a native rhythm so it won’t pace the patient’s heart when it actually needs it

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126
Q

What is the most common class of medications that patients with cardiac issues are on?

A

Beta blockers

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127
Q

Cardiac effects from calcium channel blockers

A
  • Decreases SVR

- Vasodilation

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128
Q

Calcium channel blockers can cause what reflex?

A

Reflex tachycardia - not good for patients with compromised oxygen flow

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129
Q

An ultra-short acting IV calcium channel blocker that acts to decrease SVR

A

Clevidipine

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130
Q

Calcium channel blocker used in patients with subarachnoid hemorrhage to prevent cerebral vasospasm

A

Nimodipine

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131
Q

Cardiac effects of nitrates

A

Causes smooth muscle relaxation which decreases preload and afterload and dilates coronary arteries

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132
Q

What is the caution for extended use of nitrates

A

Tachyphylaxis

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133
Q

Cardiac effects of ACE inhibitors

A

Decreases afterload

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134
Q

Contraindications to ACE inhibitors

A

Angioedema

135
Q

MOA of aspirin (ASA)

A

Inhibits thromboxane and exerts an anti-platelet effect

136
Q

How soon before surgery should Plavix (clopidogrel) be discontinued?

137
Q

MOA of Statins

A

Inhibits HMG-CoA reductase and blocks production of cholesterol in the liver

138
Q

Risk of statins

139
Q

Pacemakers can be classified based on…

A

location of the leads

140
Q

Where are the leads in a dual chamber pacemaker

A

Right atrium and right ventricle

141
Q

Where are the leads in a biventricular or CRT pacemaker

A

Right and left ventricle (and right atrium)

142
Q

Most pacemaker leads are placed __________. What are the other alternatives to this?

A

Most are placed transvenously. They can also be placed epicardial, transcutaneous, or transesophageal

143
Q

Indications for permanent pacemaker therapy (5)

A

1) Symptomatic disease of SA node
2) Symptomatic disease of AV node
3) Long QT syndrome
4) Hypertrophic obstructive cardiomyopathy
5) Dilated cardiomyopathy

144
Q

Temporary pacemakers are often placed for…(2)

A

1) Hemodynamic instability from electrophysiologic source

2) Post cardiac surgery

145
Q

Most commonly encountered pacemaker mode

A

DDD (dual pacing, dual sensing, dual response to sensed beat)

146
Q

What is a “dual” response to a sensed beat?

A

The pacemaker will be inhibited (I) when a native beat is sensed, and will trigger (T) a beat when needed

147
Q

If a pacemaker is asynchronously pacing, what mode is it in?

A

DOO (dual pacing of atria and ventricle, no sensing)

148
Q

What pacemaker mode is often used during electrocautery to prevent the bovie from causing asystole?

149
Q

What is the main reason we should use caution when a patient has a pacemaker in DOO mode?

A

They are at risk for R on T phenomena which can lead to v-tach or Torsades

150
Q

What is “pacemaker threshold”

A

The ability of the myocardium to respond to the pacemaker

151
Q

What factors raise pacemaker threshold and make it more difficult to pace?

A
  • Hypokalemia
  • Hypocarbia
  • Hypoxia
  • Hyperglycemia
  • Beta blockers
  • Rest/sleep
152
Q

What factors lower pacemaker threshold and make it easier to pace?

A
  • Hyperkalemia
  • Hypercarbia
  • Hyperoxia
  • Stress (increased levels of catecholamines)
153
Q

What leads are involved in a biventricular pacemaker?

A

Right atria, right ventricle, left ventricle

154
Q

What is another name for a biventricular pacemaker

A

Cardiac resynchronization therapy (CRT)

155
Q

What is the benefit of CRT

A

Allows for the pacing of both ventricles simultaneously to improve cardiac output

156
Q

What is often seen on an EKG of a patient with a biventricular pacemaker

A

2 spikes immediately preceding QRS complex

157
Q

What is CRT-P

A

CRT with only pacing capabilities

158
Q

What is CRT-D

A

CRT with defibrillation capabilities

159
Q

Are patients with biventricular pacemakers pacemaker dependent?

160
Q

What patients are approved for CRT

A

Patients with…

1) Class I-Class IV heart failure
2) EF less than 50%
3) QRS greater than 130ms
4) AV block that requires pacing

161
Q

What is Micra? What patients could benefit from Micra?

A 
Leadless RV pacer that is MRI compatible. 
Used for patients with...
1) Permanent a-fib
2) High grade block
3) Symptomatic AV block
162
Q

Where are the lead placed in an Internal Cardioverter Defibrillator (ICD)

A

Right ventricle and/or right atrium

163
Q

What electrical activity does an ICD measure?

A

The R-R interval and categorizes the rate as too slow, too fast, or normal

164
Q

If an ICD detects a high number of short R-R intervals within a set time, what will it do?

A

It will initiate an anti-tachycardic event (rapid pacing or a shock)

165
Q

If an ICD detects a high number of long R-R intervals within a set time, what will it do?

A

Trigger antibradycardic therapy

166
Q

How can you differentiate an ICD from a pacemaker using an X-ray?

A

An ICD has a thick coil used for defibrillation in the right ventricle

167
Q

Indications for ICD placement (6)

A

1) Significant v-tach or v-fib
2) EF less than 35%
3) Post-MI EF less than 30%
4) Hypertrophic cardiomyopathy
5) Brugada syndrome
6) Long QT syndrome

168
Q

How do subcutaneous ICDs respond to v-tach

A

Terminates v-tach only via defibrillation, no rapid pacing capabilities

169
Q

Subcutaneous ICDs are not suitable for which patients? (3)

A

1) Patients with primary v tach
2) Patients who need CRT
3) Patients who respond to rapid pacing

170
Q

Advantages of subcutaneous ICD

A

Avoid the vascular system thus avoid…

  • Vein thrombosis/stenosis
  • Lead failure
  • Infection
171
Q

Disadvantages of subcutaneous ICD

A
  • Larger
  • Shorter battery life
  • Limited long term evaluation
172
Q

How do subcutaneous ICDs respond to magnets?

A

Temporarily disabled

173
Q

Source of 99% of OR EMI

174
Q

Which bovies produce EMI?

175
Q

Sources other than bovies that cause EMI

A
  • Therapeutic radiation
  • Lithotripsy
  • RF ablation
  • TENS unit
  • ECT
176
Q

Effects of EMI on an ICD

A

It can trigger the ICD to deliver antitachycardic therapy inappropriately

177
Q

Effects of EMI on pacemakers

A
  • Can lead to oversensing which can cause a period of asystole
  • Increased rate modulation
178
Q

What is noise reversion?

A

When a pacemaker triggers asynchronous pacing in response to repetitive sensing at a high rate

179
Q

Procedures at high risk for EMI

A
  • Major surgeries above umbilicus with bovie use
  • Radiofrequency ablation
  • Lithotripsy
  • TURP/hysteroscopy
  • MRI
180
Q

Which procedure at risk for EMI poses the greatest risk to pacemaker devices?

A

Therapeutic radiation

181
Q

Methods to minimize EMI

A
  • Place bovie grounding pad 15-25cm away from device
  • Ensure bovie path does not cross the pulse generator or leads
  • Try to avoid unipolar bovie
  • Use bovie in short bursts less than 5 seconds
182
Q

Risks of placing a magnet on pacemakers

A
  • R on T phenomenon
  • V-tach/v-fib
  • Decreased cardiac output
183
Q

What capabilities of an ICD is turned off with magnet placement?

A

Antitachycardic detection/therapy

184
Q

If a patients ICD is turned off with a magnet, what are the protocols until the ICD is turned back on?

A

Patient must have continuous EKG monitoring and defibrillation equipment readily available

185
Q

If defibrillation is necessary in a patient with an ICD, how should the pads be oriented?

A

In an anterior-posterior direction to avoid direct current to the device

186
Q

What function of the ICD is not affected by magnet placement?

A

Antibradycardic

187
Q

What does it mean if no tones are heard when a magnet is placed on a Boston Scientific ICD

A

Either the magnet is not correctly placed or the magnet mode is not enabled - the ICD is still functional

188
Q

What does it mean if a Boston Scientific ICD produces a tone that is synchronous with the patients QRS when a magnet is in place?

A

The ICD is temporarily disabled but will resume normal therapy with magnet removal

189
Q

What tone is heard when a magnet is placed properly on a Medtronic ICD?

A

A constant tone for 10-30 seconds

190
Q

What does it mean if a pulsing or alternating high/low tone is coming from a Medtronic ICD?

A

Device malfunction

191
Q

What happens when a magnet is placed on a combined ICD/Pacemaker

A
  • Antitachycardic function is disabled on ICD

- NO effect on pacemaker

192
Q

All ICDs should be interrogated within __ months of an elective surgical procedure

193
Q

All pacemakers should be interrogated within __ months of an elective surgical procedure

194
Q

Guidelines for a patient with a pacemaker having a low EMI risk surgery

A

Prophylactic placement not necessary

195
Q

Guidelines for a patient with an ICD having a low EMI risk surgery

A

Consider prophylactic magnet placement

196
Q

Guidelines for a patient with a pacer/ICD combo having a low EMI risk surgery

A

Consider prophylactic magnet placement

197
Q

Guidelines for a pacer-dependent patient having a high EMI risk surgery

A
  • Consider magnet placement if rapid asynchronous pacing is available
  • Limit bovie to short bursts
198
Q

Risks of a pacer-dependent patient having a high EMI risk surgery

A

Oversensing and asystole

199
Q

Guidelines for a non-pacemaker dependent patient with a pacemaker having a high EMI risk surgery

A

Prophylactic magnet placement not necessary

200
Q

Guidelines for a patient with an ICD having a high EMI risk surgery

A

Place magnet and have continuous access to defibrillator

201
Q

Guidelines for a patient with an ICD/pacemaker combo having a high EMI risk surgery

A
  • Magnet can be placed to disable ICD
  • Use bovie in short bursts
  • Place pacemaker in asynchronous mode if necessary
202
Q

Which patients should be evaluated by the Electrophysiology Service immediately postoperatively before leaving a cardiac monitored unit (4)

A

1) Any device that was programmed off
2) Any patient that required external defibrillation or CPR
3) Any patient having cardiothoracic or major vascular surgery
4) Any emergency surgery with EMI above umbilicus

203
Q

Any patient exposed to monopolar electrocautery should be evaluated within __ month(s) of the procedure

204
Q

What are the recommendations when surgery must proceed but an implantable cardiac device is not known?

A
  • Obtain EKG to determine if the patient is pacemaker dependent
  • Stat chest X ray to determine if there is an ICD coil or to identify the device
205
Q

Incidence of Congenital Heart Disease

A

8 in 1,000 live births

206
Q

What percentages of CHD patients survive into adulthood

207
Q

Most frequent Congenital Heart Disease

A

Ventricular septal defect

208
Q

The majority of congenital cardiac shunts are…

A

Left to right

209
Q

How do left to right shunts affect pulmonary blood flow?

210
Q

Patients with left to right shunts are at risk of developing…

A

CHF because of a VOLUME overloaded ventricle

211
Q

What Congenital Heart Disease is a right to left shunt

A

Tetralogy of Fallot

212
Q

How does Tetralogy of Fallot (right to left shunt) affect pulmonary blood flow

213
Q

Patients with a right to left shunt have a ______ overloaded ventricle

214
Q

Large ventricular septal defects cause early…

215
Q

Manifestations of CHF as a result of ventricular septal defect

A
  • Poor growth
  • Tachypnea
  • Sweating with feeding
216
Q

Delayed treatment of ventricular septal defect results in increasing…

217
Q

Consequence of late or no repair of ventricular septal defect

A

Eisenmenger’s with cyanosis and polycythemia. basically, the increasing pulmonary vascular resistance from untreated VSD turns into pulmonary hypertension, which turns the previously left-to-right shunt into a right-to-left shunt which shunts deoxygenated blood over to the left heart to be pumped throughout the body and causes cyanosis

218
Q

How does pulmonary vascular resistance change as we age?

A

It starts out very high in the womb and steadily decreases as we age due to arborization

219
Q

What is atrioventricular canal defect?

A

When the heart contains 1 large, elongated valve instead of 4 separated chambers. This causes mixing of blood at atrial and ventricular levels

220
Q

AV canal defect is commonly associated with what genetic disorder

A

Trisomy 21 (Down syndrome)

221
Q

What is involved in the repair of AV canal defect

A

Closing the atrial and ventricular septal defects and making 2 AV valves from the one large one

222
Q

What can occur with late or inadequate repair of AV canal defect

A

Elevated PVR

223
Q

What four issues are involved in Tetralogy of Fallot?

A

1) Ventricular septal defect
2) Pulmonary stenosis
3) Overriding aorta
4) Right ventricular hypertrophy

224
Q

What does the repair of Tetralogy of Fallot involve?

A

Closing the ventricular septal defect and relieving the pulmonary stenosis

225
Q

Pulmonary stenosis in Tetralogy of Fallot can occur at what 3 levels?

A
  • Infundibular (muscular)
  • Valve
  • Supravalvar
226
Q

What can be caused by a transannular patch in patients with Tetralogy of Fallot?

A

It will cause free pulmonary insufficiency which can lead to right ventricular dilation, tricuspid regurgitation, and right heart failure

227
Q

Why is phenylephrine a great drug to use for kids with Tetralogy of Fallot?

A

Dropping their SVR causes more blood to bypass the lungs, so phenylephrine helps by increasing SVR and allowing as much blood as possible to get to the lungs and improve O2 saturation

228
Q

What is Transposition of Great Arteries?

A

Pulmonary artery and aorta are switched in location, so there are 2 separate circulations and deoxygenated blood gets pumped throughout the body

229
Q

What surgical placement may be required to treat Transposition of Great Arteries?

A

Balloon septostomy

230
Q

What surgery is being used to treat Transposition of Great Arteries in the recent era?

A

Arterial switch

231
Q

What late problems can occur after an atrial switch (early era surgery) to treat Transposition of Great Arteries?

A
  • CHF if right ventricle can’t sustain systemic afterload

- SVT, a-fib/flutter due to extensive atrial suture lines

232
Q

What is the “Achilles heel” of the arterial switch procedure to treat Transposition of Great Arteries?

A

Coronary artery transfer

233
Q

Late problems from an arterial switch procedure to treat Transposition of Great Arteries

A
  • Supravalve stenosis of aorta or PA
  • Aortic valve insufficiency
  • Coronary ostial stenosis
234
Q

What is the 1st procedure done to treat a right sided single ventricle lesion?

A

Blalock-Taussing shunt. This redirects blood from the subclavian or carotid artery to the pulmonary artery to help increase blood flow to the lungs

235
Q

What is the 1st procedure done to treat a left sided single ventricle lesion?

A

Norwood series - a 3 stage procedure to create a new functional systemic circuit

236
Q

What is the 2nd stage of treatment used for both right and left side single ventricle lesions?

A

Glenn anastamos - a connection between the superior vena cava and the right main pulmonary artery to increase pulmonary blood flow

237
Q

What is the ultimate result of treatment for single ventricle lesions?

A

Fontan - diverts the blood from the right atrium to the pulmonary arteries without passing through a right ventricle

238
Q

What is necessary for a successful Fontan?

A
  • Good ventricular function since blood is pushed through both circulations by only one ventricle
  • Low PVR
239
Q

Calculation for transpulmonary gradient

A

Pulmonary artery pressure - Left atrial pressure

240
Q

Causes for failure of a Fontan procedure

A

Reduction of ventricular function –> expansion of vascular volume –> increased LVEDP –> increased LA pressure –> increased PA pressure –> increased CVP –> edema, hepatic congestion, protein losing enteropathy

241
Q

Symptoms of Fontan failure

A
  • Fatigue
  • Headache
  • Swelling
242
Q

What should be avoided during inhaled induction of a patient with a CHD?

A

Avoid overdose because that will decrease blood pressure thus pulmonary blood flow

243
Q

Monitors other than standard ASA that are often used for a patient with a CHD

A
  • Arterial line

- BIS

244
Q

The lowest PVR exists at what lung volume?

A

Functional residual capacity

245
Q

Are most cases of SBE attributable to invasive procedures?

246
Q

Cardiac conditions requiring prophylaxis for SBE

A

1) Prosthetic cardiac valve
2) Previous SBE infection
3) Congenital Heart Disease (unrepaired, repaired within last 6 months, or repaired with residual defects)
4) Cardiac transplantation with valvulopathy

247
Q

What dental procedures should SBE prophylaxis be used for?

A

Any dental procedures with bleeding potential (i.e. gums, mucosa)

248
Q

What surgical procedures is SBE prophylaxis REQUIRED for?

A

1) Tonsillectomy/adenoidectomy
2) Any involving respiratory mucosa (sinus)
3) Rigid bronchoscopy
4) Infected skin or tissue

249
Q

Oral antibiotic order for SBE prophylaxis

A

Amoxicillin one hour before surgery

250
Q

IV antibiotic order for SBE prophylaxis

A

Ampicillin 30 minutes before

251
Q

Oral antibiotics available for penicillin allergic patients for SBE prophylaxis

A

-Clindamycin
-Cephalexin
-Azithromycin
-Clarithromycin
Take 1 hour before

252
Q

IV antibiotics available for penicillin allergic patients for SBE prophylaxis

A

-Clindamycin
-Cefazolin
-Ceftriaxone
Take 30 min before

253
Q

Is SBE prophylaxis required for a 2 year old s/p BT shunt for BMT and adenoidectomy?

A

Yes - at risk patient and at risk procedure

254
Q

Is SBE prophylaxis required for a 10 year old for cysto and ureteral reimplantation?

A

No - neither patient nor surgery is high risk for SBE

255
Q

Is SBE prophylaxis required for a 4 year old with a small VSD and murmur having a dilation of esophageal stricture s/p TEF repair?

A

No - neither patient nor surgery is high risk for SBE

256
Q

Why should NM blockade reversal with neostigmine/glycopyrrolate be avoided in a cardiac transplant?

A

It can cause asystole due to increased levels of Ach

257
Q

You are on CPB and the Hgb is 7. Which of these would lead you to transfuse?

A. Temp 32C
B. MVO2 80
C. Reservoir volume 200ml
D. MAP 65

A

C Reservoir volume 200ml

258
Q 
Which monitor is the most important for CPB?
A. ECG
B. A line
C. Temp
D. BIS
259
Q

How does venous blood flow into a CPB reservoir?

A

Gravity drainage

260
Q

When should the heat exchanger cool the patient?

A

While they are on CPB

261
Q

When should the heat exchanger warm the patient?

A

As the surgeons are finishing the operation and the patient is about to come off CPB

262
Q

What surgeries is left heart bypass used for?

A

Descending aortic surgeries

263
Q

Where does blood flow out of during left heart bypass?

A

Left atrium

264
Q

Where is blood reinfused during left heart bypass?

A

Femoral artery

265
Q

What functions of CPB are not available during left heart bypass?

A

Oxygenator, some have heater/cooler

266
Q

What monitor would not be useful if the patient was on left heart bypass with the subclavian included?

A

Left radial arterial line

267
Q

Alternatives to left heart bypass

A
  • Clamp and sew

- DHCA (deep hypothermic cardiac arrest)

268
Q

Patients in respiratory failure would be on what type of ECMO?

269
Q

Patients in heart failure would be on what type of ECMO?

270
Q

What additional care is needed for ECMO?

A
  • Systemic heparinization

- Significant ICU care

271
Q

If you are using a right axillary cannula for CPB, where must you put your aline to ensure adequate perfusion?

A

Left radial or femoral

272
Q

Why should you rewarm patients slowly when coming off CPB?

A

For brain protection - evidence shows that if you over -warm the brain the risk of stroke doubles

273
Q

A vent may be used for a patient with what valvular disorder?

A

Aortic regurgitation to drain the heart if it is getting too full

274
Q

What are the functions of a tack?

A

Inserts into the aorta and allows cardioplegia and de-airing at the end of the procedure

275
Q

Functions of ECG monitoring during CPB

A

Allows assessment of ischemia and asystole

276
Q

Why is hypothermia used during CPB?

A

To improve tolerance of prolonged non-pulsatile blood flow and decrease ischemic injury to brain, heart, and kidneys

277
Q

The target hypothermic temperature used for CPB is related to what?

A

Expected duration of procedure

278
Q

Temperature goal when mild/tepid hypothermia is used

279
Q

Temperature goal when moderate hypothermia is used

280
Q

Temperature goal when DHCA is used

281
Q

What part of the body is most sensitive to ischemic insult?

A

Central nervous system

282
Q

What does the cerebral oximeter give us an indication of?

A

The oxygenation in the frontal lobe of the brain

283
Q

Why do we monitor PA pressures on CPB?

A

To assess how full the heart is getting. For ex, if the PA mean is above 10 on CPB, it is either wedged or there is too much volume in the heart and it needs to be drained

284
Q

What is the perfusionist administering in their fluids that would cause us to expect reasonable diuresis in patients on CPB?

285
Q

How often are labs and ACTs checked while the patient is on CPB?

A

Every 30 minutes

286
Q

Important labs to assess while on CPB

A
  • Lactate
  • Glucose
  • Acid-base status
  • Potassium
287
Q

Which lab, important during CPB, is a global indicator of perfusion

288
Q

Why is insulin a standard drip for cardiac operations?

A

The glucose tends to be very high in these patients because the operations are so stressful on the body

289
Q

What is the best intravascular volume estimator that we have during CPB?

A

Volume in the CPB reservoir

290
Q

MOA of Heparin

A

Inhibits thrombin via antithrombin III

291
Q

If a patient with HIT must have surgery, what are some heparin alternatives?

A
  • Lepirudin
  • Argatroban
  • LMWH
  • Danaparoid
  • Ancrod
292
Q

If a patient on CPB is coagulopathic, how do we redose heparin?

A

On a time basis

293
Q

Normal ACT values

294
Q

ACT values adequate to go on CPB

295
Q

ACT is affected by what components?

A
  • Temperature
  • Platelet function
  • Hemodilution
296
Q

Where is the most common placement of an arterial cannula used for CPB?

A

Ascending aorta, distal to the PA

297
Q

What location of arterial cannulation for CPB poses an increased risk of stroke?

A

Femoral artery

298
Q

Where can venous cannulas used for CPB be placed?

A

In any large vein that will allow gravity drainage of blood to the reservoir

299
Q

What is bicaval cannulation?

A

2 separate cannulas in the SVC and IVC used when maximal drainage of the heart is needed

300
Q

Common placement of venous cannulas for minimally invasive procedures or repeat sternotomies

A

SVC via RIJ or femoral

301
Q

Where is a vent typically placed

A

In the right upper pulmonary vein and down into the left atrium

302
Q

Function of a vent during CPG

A

Removes blood that accumulates in the heart to prevent distention injury

303
Q

Flow of antegrade cardioplegia

A

Normal direction - ascending aorta –> coronary arteries

304
Q

Flow of retrograde cardioplegia

A

Coronary sinus –> coronary veins –> aorta

305
Q

What determines the choice of antegrade vs retrograde cardioplegia

A
  • Surgical procedure

- Patient ventricular function status

306
Q

Why is infusion pressure measured during retrograde cardioplegia?

A

To prevent overinflation and injury to the coronary sinus

307
Q

How is infusion pressure of retrograde cardioplegia measured

A

With the CVP transducer monitor

308
Q

Where is temperature measured during CPB?

A
  • Nasopharyngeal
  • Bladder
  • PA
  • Arterial inflow
  • Venous return
309
Q

Why is temperature measured in so many places during CPB?

A

To ensure temperature change is equally distributed and to monitor speed of temp changes

310
Q

What pressors are used to maintain MAP during CPB? Why?

A

Phenylephrine and vasopressin because they don’t have beta effects

311
Q

The hemoglobin trends as low as __ during most procedures with CPB

312
Q

What procedures use axillary cannulation for CPB?

A

Major aortic surgeries such as…

  • Aortic dissections
  • Aneurysms
  • Arch procedures
313
Q

When weaning from CPB, what component of the CPB circuit decreases as the patient’s blood pressure increases

A

Arterial inflow rate

314
Q

What is the first line alpha agent used to increase SVR when weaning from CPB?

A

Norepinephrine

315
Q

Why is phenylephrine usually not used when weaning a patient off CPB?

A

Because we don’t want strictly unopposed alpha agonism and too large of an increase in SVR

316
Q

What are the indications for using phenylephrine when weaning a patient off CPB?

A
  • Dilated cardiomyopathy

- Systolic anterior motion of mitral valve

317
Q

What inotrope do we use when weaning patients off CPB if we also need chronotropy?

A

Epinephrine

318
Q

What inotrope would we use to wean patients off CPB if they had a high SVR and poor heart function?

319
Q

What patients would need inhaled Flonan/NO when weaning off CPB?

A

Patients with pulmonary hypertension and right heart failure

320
Q

Functions of an intra-aortic balloon pump

A
  • Augment myocardial perfusion
  • Increase coronary blood flow during diastole
  • Unload left ventricle during systole
  • Improve systemic perfusion
321
Q

Effects of intra-aortic balloon pump during inflation

A
  • Increase diastolic pressure
  • Increase O2 supply
  • Increase systemic perfusion pressure
  • Increase baroreceptor response
  • Decrease sympathetic stimulation
322
Q

Effects of intra-aortic balloon pump during deflation

A
  • Reduce aortic systolic pressure
  • Reduce duration of isovolemic contraction
  • Increases SV/EF
323
Q

Effect of intra-aortic balloon pump on lactate use

324
Q

Effect of intra-aortic balloon pump on arterial distensibility

325
Q

Indications for intra-aortic balloon pump

A
  • Cardiogenic shock
  • Failure to wean from CPB
  • Pre-op stabilization
  • Cardiac support during coronary angiography
  • Bridge to transplant
326
Q

Contraindications to an intra-aortic balloon pump

A
  • Aortic insufficiency
  • Dissecting descending aortic aneurysm
  • Severe atherosclerosis
  • AAA
  • Trauma
327
Q

How does protamine reverse heparin

A

Via acid/base mechanism

328
Q

Hallmarks of protamine reaction

A
  • Pulmonary HTN

- Systemic hypotension

329
Q

What are the only blood products that can be given during CPB?

330
Q

What lab studies are beneficial when managing coagulation? (5)

A
  • Antithrombin III level
  • Platelet count
  • Fibrinogen
  • INR
  • TEG
331
Q

Most common valve repair done without CPB

A

Aortic valve repair

332
Q

Example of an aortic surgery that can be done without CPB

A

TEVAR (Thoracic Endovascular Aortic Repair)

333
Q

What blood product can be used as a source of antithrombin III

334
Q

What is the most important component used to predict failure of weaning from CPB

A

Type of surgical procedure

Anesthesia Practice (9 decks)

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