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Advanced Anesthesia II > Cardiac > Flashcards

Cardiac Flashcards

1
Q

What are you looking for on an echo?

A

EF, valve function, wall abnormalities, calcified aorta (think cannulation), atrial thrombus (think CVA)

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2
Q

an intraop MI for a cardiac surgery patient

A

50 % mortality

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3
Q

what are you looking for on a CXR?

A

-calcified aorta, cardiomegaly, edema

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4
Q

What are comorbid conditions commonly seen w/cardiac patients?

A

PVD (carotid?), DM, HTN, COPD, renal (this one increase post-op mortality)

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5
Q

What do you continue until DOS?

A

antiarrhythmics, CCBs, BB, nitrates

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6
Q

Baseline Labs (4)

A

PT, PTT, ACT
Platelet # & function (TEG)
Renal + Liver function
T&C (4 units PRBCs)

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7
Q

Four cardiac anesthesia goals

A

decrease MVO2
maintain oxygen
anticoagulation
BP managment

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8
Q

How do we decrease MVO2?

A

anesthesia, hypothermia, electrical silence w/cardioplegia, empty cardiac chambers (esp. LV)

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9
Q

how do we Maintain oxygen supply

A

Maximize oxygen carrying capacity + flow

Hemodilution and acceptable perfusion pressure

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10
Q

Three myocardial protection strategies

A

cardioplegia
hypothermia
hemodilution - increases flow by decreasing viscosity

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11
Q

Cardioplegia induced asystole

A

all electrical & mechanical activity ceases

  • Potassium given continuously during cross clamping
  • May be primed w/blood versus clear prime
  • Hyperkalemia is a risk w/renal patients
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12
Q

The effects of hypothermia

A
  1. Alters platelet function and reduces fibrin enzyme function
  2. Inhibits initiation of thrombin formation
  3. Reduces metabolic demands and increases tolerance to ischemia
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13
Q

Name the CABG order of events

A 
o	Monitors, Lines, Induction
o	Wait (no stimulation)
o	Incision
o	Drop Lungs
o	Sternotomy
o	Surgical dissection (minimal stimulation)
o	Cannulation
o	On-Bypass
o	Off Bypass
o	Dry up – Give protamine
o	Close Chest
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14
Q

What monitors do you need? (4)

A

pulse ox on ear or nose
pacemaker
TEE
Swanz Ganz

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15
Q

What does TEE do?

A

o Helps diagnose underlying mechanisms ascribed to multiple scenarios
o Evaluates preload (ventricular filling) do we give volume?
o Estimates CO
o Assess ventricular systolic function + ventricular diastolic function
o Valvular pathology, calcified aorta
o Cardiac tamponade
o Atrial thrombus
o Air in the heart
o Re-examine graft

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16
Q

TEE C/I

A

esophageal varices, full stomach

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17
Q

Swanz Ganz

A

Placed in the right IJ via cordis

  • Swan has entered PA when DBP increases compared to RV
  • 15-30/0-8 (RV)
  • 15-30/5 – 15 (PA)
  • 10 (wedge)
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18
Q

Complications w/Swan

A
  • Ventricular arrhythmias
  • Heart block (esp. if pre-existing LBBB) b/c you don’t want to interfere with the Bundle of His on the right
  • Pneumothorax (esp. with subclavian)
  • Arterial puncture (most common acute injury)
  • Hematoma/thromboemboli
  • Vascular injury (localized hematoma, minor, & most common)
  • Valve damage (rare – can happen if balloon is not down when pulling)
  • PA rupture
  • Perforation of thorax leading to hemothorax (BAD)
  • Cardiac tamponade (most common life-threatening complication of CV cannulation)
  • Blood stream infection
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19
Q

Nitro gtt

A
  • Nitro primed plugged into central line
  • (25 mg in 250 mL bottle = 100 mcg/mL) runs at 0.2 – 1.5 mcg/kg/m OR 5 – 200 mcg/m; titrate Q3-5 minutes
  • MOA: venous dilator > arterial dilator; relaxes peripheral VSM by donating an NO group. Reduces cardiac oxygen demand by decreasing preload. Dilates CA and improves collateral flow to ischemic regions to help prevent vasospasm.
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20
Q

Epi > NE

A
  • Epinephrine affects alpha, beta1, and beta 2.
  • Use 1: 1,000 (1 mg/mL) in 1 mL ampule and add 1 – 4 ampules into a 250 mL bag of NS. (4 mcg – 16 mcg/mL)
  • Dosing: 1 – 16 mcg/min
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21
Q

Phenylephrine

A

Neo gtt primed 10 mg/250 mL NS = 40 mcg/mL plugged into central line

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22
Q

Dopamine

A

1 - 20 mcg/kg/m

Renal 1-5 * Cardiac 2 – 10 * VC 10 – 20

gtt primed (esp. if EF < 40%) use for coming off pump

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23
Q

Dobutamine

A

2.5 – 20 mcg/kg/m

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24
Q

Antiarrhythmics

A

esmolol, lidocaine, magnesium, amiodarone

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25
Q

esmolol + mg dosing

A

Esmolol – SVT (0.5 – 1 mg/kg over 1 minute); 50 – 250 mcg/kg/m

Magnesium 2 – 4 grams (give after aortic clamp, good membrane stabilizer)

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26
Q

Heparin

A

30 – 50 K units in a 60 cc syringe (1,000U/mL or 10 mg/cc) (dose = 300 units/kg)

DOA: 150 minutes

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27
Q

protamine

A

(10 mg/mL) in a 30 cc syringe (10 mg of protamine for every 1,000 units of heparin)

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28
Q

Why do we give TXA?

A

We use the TEG to monitor fibrinolysis b/c large amounts of circulating tPA are found during CPB leading to increased post-op bleeding. This is due to inappropriate fibrinolysis. Drugs exist to inhibit the binding of plasminogen to fibrin (a step in the fibrinolytic pathway). To be effective must be started prior to going on CPB.

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29
Q

Calcium Chloride

A

(100 mg/mL) in a 10 cc syringe

500 mg dose for hyperkalemia

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30
Q

Pre-Induction Patient Prep

A 
NC
\+/- mild sedation (fent.)
PIV x2
A-Line
Baselinee: ABG, ACT, T&C
Defibb pads
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31
Q

Propofol

A

safe in patients with ischemic and valvular heart disease; biggest challenge is hypotension
o 50 mg increments at a time; note there will be a slow circ time

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32
Q

what IA do you avoid

A

nitrous

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33
Q

post-induction (4 actions)

A

central line
OG
TEE
tuck arms

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34
Q

VA

A

produce dose dependent global cardiac depression. Alters the intracellular calcium and sensitizes the myocardium to the effects of epinephrine

o Prevent or facilitate atrial or ventricular arrhythmias during myocardial ischemia or infarction
o Produce weak coronary artery dilation and depresses baroreceptor reflex control of arterial pressure
o Usually, isoflurane is used by the perfusionist, no desflurane b/c tachycardia

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35
Q

Pre-Incision

A
  • Hypotension d/t lack of stimulation. There are risks involved if you use vasoconstrictions.
  • Recall is rare at this point unless severe hypotension occurs in the face of purely opioid technique
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36
Q

Incision

A
  • Intense surgical stimulation = HTN
    o Deepen anesthetic, NTG/NTP
  • Handling of the heart by the surgeon to identify and localize ischemia (arrhythmias + hypotension common)
  • Significant bleeding
  • Drop lungs for sternotomy (actually d/c from the circuit)
  • Arterial & saphenous veins are harvested
  • Once the chest is open, you will see RV on the screen. The LV is behind the heart (unable to see)
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37
Q

Pre-Bypass HD

A

keep the blood pressure +/- 20% of baseline pressure. HR 40 – 80

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38
Q

Heparin MOA

A

Pre-Bypass

MOA: binds to antithrombin III and potentiates its natural anticoagulant properties (1000x)

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39
Q

Heparin dosing + onset

A

300 – 400 units/kg

– wait 3-5 minutes for activated clotting time (ACT)

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40
Q

ACT & Heparin

A

Normal ACT = < 130 (80 – 120)

CPB ACT > 400 – 450

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41
Q

Heparin ADR

A
  • SVR & BP can drop by 20%
  • AT III deficiency patient unresponsive to heparin, give FFP or thrombate III
  • HIT – antiplatelet antibodies which leads to platelet aggregation and potentially life-threatening thromboembolic events (platelet < 100,000). This is r/t being exposed to heparin before**
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42
Q

Name a few things you need to do BEFORE cannulas in

A
  • Heparin must be given
  • Medicate w/midazolam + fentanyl.
  • Dump foley for fresh UO
  • The patient is passively cooling in the OR, be sure to avoid atrial fibrillation w/cooling because of LV swelling
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43
Q

Name some frequently encountered problems pre-bypass

A
  • Arrhythmias r/t cardiac manipulation and cannulation. This may be the first sign of MI (watch your ST segments)
  • HTN: especially during aortic cannulation
  • HoTN: volume or pressors through aortic line
  • Heart failure
  • Bleeding: sternotomy lacerates RV or aorta
44
Q

Arterial cannulation

A
  • aorta
  • Drop the BP for aortic cannulation (SBP < 90) to avoid dissection. This is done first so the perfusionist can give volume if needed.
  • NTG or nipride to drop the BP
  • Be looking at TEE for calcium or plaques b/c you need to notify surgeon of this
45
Q

Venous cannulation

A

BP will drop &/or arrhythmias will occur when placing

46
Q

Coronary sinus cannulation

A

Will see a drop in BP. This is for retrograde cardioplegia

47
Q

what is an LV vent for

A

to drain the thebesian and bronchial veins so the heart does not swell.

48
Q

Where is anterograde catheter?

A

proximal to cross clamp

also place a retrograde one (in coronary sinus) if anterograde is not enough!

49
Q

Surgeon says… go on bypass.. then what? (6)

A

The perfusionist will open the venous clamp and blood drains passively into venous reservoir

  • cool patient
  • Arterial tracing goes flat – but EKG still present
  • Pull back PAC 2 – 3 cm so it is not in PA (don’t want it to lodge, obstruct, or puncture).
  • Look at head to ensure there is no swelling (this would indicate venous catheter is improperly placed).
  • Check pupils & BIS
50
Q

Heart is empty - now what?

A

stop the ventilator. They may say ‘we are at full flow, stop the ventilator’

  • Stop the fluids.
  • Stop IA.

*Perfusionist runs IA, phenylephrine, nitroglycerin

51
Q

What is full flow

A

*Full flow = 2.5 – 3 L/m or 50 – 60 mL/kg

52
Q

Goals during CPB

A
  • CVP 0 – 5 or (-)
  • MAP 65 – 70 (unless it’s a valvular case, then 50 – 60 is ok)
  • SVO2 70 – 80% (if there is a major decrease, give more paralytic)… Ensure no shivering
  • Provide amnesia with versed
  • Cerebral Oximetry will decrease once on CPB, but a major drop (i.e., 80 - 20) is concerning as it may indicate cannula malposition
53
Q

CPB priming

A

1500 – 2500 mL of balanced electrolyte solution.
-Albumin, heparin, mannitol (diuresis & free radical scavenging), and bicarbonate is added to increase osmolality, reduce edema, and promote diuresis

+/- corticosteroid and blood products

  • Once venous is cannulated, aspirate blood, prime w/blood + solution
  • Dilution of catecholamines will occur with priming
54
Q

Ideal Hct

A

20%

  • Hemodilution is associated w/decreased viscosity, decreased SVR, and promotion of blood flow to tissues
  • A decrease in viscosity = increase in flow (be mindful there is already an increase in viscosity d/t cooling)
55
Q

how often is abg/act drawn?

A

q30m by perfusionist

56
Q

cardioplegia solution

A

*4 degrees C (reduces metabolism of the heart, V-Fibb occurs at 25 – 30 degrees C)
-Contains K+ to depolarize the heart (26 mEq/L)
o Glucose 43.9 gm/L
o Mannitol 12.5 gm/L
o Sodium bicarbonate 2.67 mEq/L
o Solu-Medrol (methylprednisolone sodium succinate) 1 g/L
o Normosol-R

pH 7.6
mOsm = 480

57
Q

how do we ensure cardioplegia solution does not leak into circulation?

A

Once the patient arrests, the perfusionist drops the flow, the surgeon cross-clamps the aorta.

58
Q

Complications r/t CPB

A

o Hypotension r/t decreased SVR and heart handling
o Renal ischemia from hypo-perfusion and hemodilution (A decrease in UO is not indicative of renal injury postop)
o CVA from thrombus in CPB system, air emboli
o Thrombocytopenia
o Increased inflammatory response (Extrinsic and intrinsic coagulation pathways are activated)
o Pump-head

59
Q

risks for postop renal damage

A

CBP > 1 hour, pre-existing renal disease, increased age

60
Q

ways to protect brain during CPB

A

hypothermia, blood gas management, adequate BP, cerebral oximetry, BIS.

Biggest culprit = emboli!!

61
Q

how to help w/SIRS

A

Stress response is evident w/increased catecholamines, AT II, and free radicals

Statins may help

62
Q

Re-warming

A

HIGH RECALL RISK d/t vasodilation and hypotension

63
Q

when do you start warming?

A 
the surgeon is sewing the last distal graft
OR 
PRIOR TO AORTIC CROSS-CLAMP REMOVAL
OR 
WHEN KNOTS ARE BEING TIED DOWN
64
Q

how long to re-warm

A

30 – 40 minutes to rewarm b/c damage may occur if it is done too quickly.
o 1 degree Celsius Q3-5 minutes

65
Q

Preparation for Coming off Bypass

A 
Core temperature > 35C (target = 37C)
Correct labs (ABG, K+, Acid-Base, Hct)
o	High K+ = 500 mg CaCl
o	Magnesium = 2 – 4 g (prevent a-fibb)
o	Hct = 20 – 25% goal
o	Cell Saver
o	Blood sugar < 200 
-	Inflate lungs (de-airing maneuvers)
o	Position changes
o	Manual ventilation
-	Removal of cross clamp and hot shot given (warm cardioplegia – K+ to restart the heart)
-	Defibrillation if heart does not res-start at 10 – 30J with sterile pads
-	Heart rate: pace at 80 – 90
o	Usually v-paced b/c atrial wires are harder to remove
66
Q

what is termed off-bypass

A

When the pump comes off and the venous cannula is clamped

67
Q

off-bypass.. now what?

A
  • Measure CO, watch TEE, PA, A-Line
  • Monitor SVO2: increased demand? Decreased delivery?
  • Shivering? Paralyze
  • Turn on the ventilation, manually recruit? Just be careful b/c internal mammary graft (aka internal thoracic graft) will rupture… thus keep PIP < 30 mmHg
  • IVF + VA
68
Q

CPB ADRs

A
  • Prolonged cross-clamp time significantly correlates w/major postoperative morbidity
  • When the cross clamp comes off, reperfusion may paradoxically cause myocardial damage and limit the extent of recovery.
  • Complications include hemorrhage at CPB, dislodgement of clots, and aortic dissection
  • ST elevation may be indicative of air in the heart. Notify surgeon. Examine TEE.
69
Q

post CBP assessment

A

o Contractility: look at the heart, how is it filling? How is it beating? We need adequate contractility to come off bypass.
o Inspect for bleeding
o Systemic pressure in relation to PA pressure

70
Q

when can you give protamine?

A
  • WHEN ALL CATHETERS OUT + PATIENT IS STABLE + SURGEON SAYS ITS OKAY … you can give protamine SLOWLY through PIV
71
Q

protamine dosing

A

1mg/100U of heparin or 2 – 4 mg/kg

if ACT > 150 give

72
Q

protamine half life

A

30 - 60 m (shorter than heparin BTW)

73
Q

what is protamine

A

composed of multiple low molecular weight proteins that are derived from salmon sperm. It is able to neutralize and reverse effects of heparin, so heparin cannot form a complex with AT III.

-Has anticoagulant effects at levels 2 – 3 x normal reversal dose (weak anticoagulant at normal levels)

74
Q

protamine ADR

A

 Type I reaction = histamine release resulting in hypotension (just give volume & VP)
 Type II reaction = IgE (anaphylactoid)
 Type III reaction = lodging in pulmonary circulation resulting in pulmonary HTN

75
Q

chest closed..

A
  • When the chest is closed, the heart is squished and hypotension ensues. The team may have to open back up if patient does not tolerate it.
    o Low CO and high BP – maybe inotrope? Milrinone?
76
Q

Post CPB Challenges

A
  • Recall + neurocognitive changes (emboli?)
  • Bleeding d/t loss of clotting factors, fibrinolysis, thrombocytopenia, surgical blood loss, vessel trauma, metabolic byproducts
  • Organ hypo-perfusion
  • Non-pulsatile blood flow, emboli, thrombi
  • Systemic inflammation response
  • Residual hypothermia
  • Remember, extended CPB and cross-clamp time makes it hard to wean off CPB
77
Q

Reperfusion interventions

A
  • Spend time paying back by re-perfusing the empty heart at adequate perfusion pressure (20 – 30 minutes). This allows the heart time to recover by washing out metabolic products.
  • Consider IABP if long clamp time.
  • Correct metabolic abnormalities.
78
Q

what do you need for transport

A
  • Ambu bag, oxygen tank
  • EKG, a-line
  • Emergency drugs = epinephrine, paralytic, propofol, dex drip
  • Once you move the patient to the other bed, check breath sounds
  • The surgical table is sterile until we leave the room
  • Once in ICU, attach to ventilator and re-check breath sounds
  • Oxygen stays at 100% until first ABG
79
Q

HD for Aortic & Mitral Stenosis

A

maintain preload + SVR; HR 50 – 80 (lower = better)

80
Q

HD Aortic & Mitral Regurgitation

A

maintain preload; drop SVR; HR 50 – 80 (higher = better)

81
Q

Highest rates of recall

A
  1. Graft harvest
  2. Sternotomy
  3. Re-warming
82
Q

Heart transplant recipient considerations

A

Priority status, ABO, Body size match, Distance from donor site (b/c only lasts 4 – 6 hours)

83
Q

selection for recipients

A

o Typical recipient = NYHA Class IV with a predicted life expectancy < 12 months, EF < 25%
o Usually has a VAD
o Most common indication: idiopathic cardiomyopathy

84
Q

Contraindications for the recipient for heart transplant

A

o > 70 years old
o Chronic renal dysfunction
o Obesity

85
Q

heart transplant patient induction

A

RSI b/c full stomach

  • Lines prior to induction.
  • smooth, rapid control of airway
  • Slow administration of medications
  • Maintain HR and intravascular volume
  • Avoid a drop in SVR
86
Q

intraop heart transplant

A

adhere to immunosuppression protocol; high dose steroid & immunosuppressant drug

  • Gtts: DIRECT ACTING AGENTS!! (Isoproterenol, epinephrine, phosphodiesterase inhibitors (milrinone), nitric oxide, inhaled prostaglandins)
  • Vasopressin preserves SVR w/o effecting PVR
87
Q

Inability to wean from CPB for heart tx sx

A

(likely right heart failure)

88
Q

Post Heart Transplant

A

Denervation of donor heart during retrieval
(why we need direct acting agents on myocardial adrenergic receptors)
o Loss of PSNS = faster resting HR
(Still reverse w/neo & glyco)
o Direct acting vasoactive agents (inotropes and vasoconstrictors)
o Volume dependent (preload dependent); Frank Starling mechanism still functions
o Accelerated atherosclerotic disease = no angina s/s (arrhythmia is indicative of ischemia)

89
Q

how is an off pump CABG done?

A
  • Immobilization of the heart by compression &/or suction
  • a sternotomy is still done
  • The bypass is on standby in the room
  • If the suction is placed on the RV, be mindful the RV is very thin walled and can compress the native coronary flow.
  • TEE & heparin are still used
90
Q

how to prevent hypotension and reduced coronary artery perfusion during off pump cabg

A

o Volume load
o Head down
o Vasopressors

91
Q

Minimally Invasive Direct Coronary Artery Bypass

A
  • Grafting of a single vessel; LIMA to LAD
  • Robotic off pump case with bypass on standby
  • Left anterior thoracotomy incision
  • OLV
    -heparin oh ya
    !!Defibb pads prior to draping!!
92
Q

Other techniques for Minimally Invasive Direct Coronary Artery Bypass

A

right thoracotomy, parasternal, CBP through femoral artery + veins

93
Q

HD for minimally invasive direct coronary artery bypass

A

o Keep HR low to keep MVO2 low
o Increase preload
o Drop TV if not isolating one lung

94
Q

Mini AVR & MVR Procedures

A
  • DLT for lung isolation
  • Femoral cannulation
  • Transvenous pacing – placed & tested
  • Pads on
  • Central venous access
95
Q

TAVR/TAVI

A
  • Femoral artery or transapical (apex of left ventricle)
96
Q

TAVR technique

A
  • Anesthetic Technique: IVA or GETA
    o Large bore IV
    o A-Line
    o Central access
97
Q

TAVR monitors

A

o TEE (GA) or TTE (transthoracic echo)
o External defibrillator pads (R2 pads)
o Fluro for lines
o Pump on standby

98
Q

TAVR risks

A

stroke, RF, cardiac rupture, tamponade

99
Q

what are blood conservation strategies for cardiac surgery

A

o Antifibrinolytic drugs
o Cell saver, POC testing to support transfusion
o Minimize hemodilution (normovolemic hemodilution)
o Retrograde priming of pump w/autologous blood

100
Q

Platelet function is lost/altered by:

A

Hemodilution, hypothermia, contact w/CPB circuit

101
Q

why does RV dysfunction or failure occur post CPB

A

because of inadequate myocardial protection or inadequate revascularization w/resultant right ventricular ischemia

102
Q

How to reduce the inflammatory response w/cardiac surgery

A

o Modification of surgical and perfusion techniques
o Circuit components
o Pharmacological strategies

103
Q

causes of CNS insults

A

micro emboli, hypoperfusion, and SIRS

but < 2% now yay

104
Q

post op renal dysfunction risks

A

o T1DM
o Renal insufficiency
o Vascular pathology
o Nephrotoxic agents

105
Q

ADR of sternotomy

A

a significant reduction in TLC, VS, and FEV

Advanced Anesthesia II (9 decks)

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