Cardiac Flashcards
Aortic Stenosis
Maintain NSR
HR @ baseline - 70-90 bpm
Maintain preload
Maintain diastolic pressures (phenylephrine) to maintain CPP
Aortic Insufficiency
Slight Tachycardia (90-110)
Fast Full Forward Flow
Preload Dependent
Afterload Decreased
Mitral Stenosis
Maintain NSR or rate control if in Afib - 70-90 bpm
Maintain preload
Maintain afterload - cannot compensate for afterload reduction given fixed stenotic lesion
4-6 cm2 - Normal Valve Area
1-2 cm2 - Mild - Moderate (<10)
< 1 cm2 - Severe (PG>10)
Mitral Insufficiency
Mild Tachycardia (90-110)
Increased preload (fast forward flow)
Mild Afterload decrease to promote forward flow
Hypertension DDx
Patient: existing htn, pain, anxiety, volume overload
Anesthesia Related: inadequate anesthesia, drug effects, reversal agents
Surgical Factors: stimulation, tourniquet
Equipment errors
Other: hypercarbia, hypoxia, bladder distension
Hypotension DDx
Preload: Hypovolemia/bleeding, hypocalcemia, compression on IVC
Obstructive: tamponade, tension pneumo, pHTN
Cardiogenic: rhythm probs, function issues (MI, med depressants, valve disease)
Distributive: neurogenic shock, sepsis, anaphylaxis
Inadequate ACT after heparin for CPB
Ensure working IV, no medication error. Reconfirm inadequate ACT
Consider AT3 deficiency
High platelets - PF4 inhibits heparin
AT3 concentrate treatment
FFP - has about 1u AT per mL
Heparin Induced Thrombocytopenia
5-14 days after initial heparin therapy
Antibodies to PF4 –> plt activation/aggregation
D/c heparin, start direct thrombin inhib or Factor Xa inhibitiors
CPB - bival - watch ACT, APTT
Debakey Classification Aortic Dissection
Stanford Classification Aortic Dissection
Type 1: Ascending and descending
Type 2: Ascending only
Type 3: Descending only
Type A: involving Ascending +/- descending
Type B: involving descending only
Aortic Dissection Monitors
Standard ASA (5 lead ECG for ST monitoring)
Right radial plus lower extremity arterial line
SSEP/MEPs for spinal cord ischemia
Lumbar drain for spinal cord pressure
TEE - extent of aneurysm and <3 function
PA catheter - CI and fluid monitoring.
ACLS Unstable Ventricular Tachycardia/Fibrillation
Start CPR & Call for help
Defibrillate 120-200 J Biphasic & resume compressions 2 min
Pulse check –> repeat shock –> resume compressions
Epi 1 mg q 3-5 minutes
Amiodarone 300 mg –> 150mg
Lidocaine 1-1.5 mg/kg –> 0.5-0.75 mg/kg
ACLS Hs & Ts
Hypovolemia
Hypoxia
Hydrogen Ions (Acidosis)
Hypo/hyperkalemia
Hypothermia
Tension pneumo
Tamponade
Toxins
Thrombosis - pulm/coronary
ACLS Persistent/Symptomatic Bradycardia
Atropine (1mg 3-5min)
Dopamine IV infusion
Epi IV infusion
ACLS Tachycardia
Unstable
- if narrow complex, consider adenosine 6mg–>12mg.
- Synchronized cardioversion
- Antiarrhythmic Infusion - procainamide, amiodarone, sotalol
Stable
- Narrow Complex - vagal maneuvers, adenosine, B blocks CCB, consult cards
- Wide Complex - Antiarrhythmic Infusion - Procainamide, Amiodarone (150mg), Sotalol
Venous Air Embolism
Detection sensitivity: TEE, Precordial doppler, PAC, Capnography, CO decrease, EtN2
Prevention: Avoid sitting position, minimize PEEP, maintain euvolemia
Treatment: Reverse Trendelenberg & Left lateral decub, flood surgical field/bone wax, Aspirate CVC, d/c N2O, start inotropes, fluid boluses. chest compressions may dislodge air trap
Surgery Following PCI
balloon angioplasty - 2 weeks
bare metal stent - 4-6 weeks
drug eluding stent - 12 months on DAPT
Avoiding stent thrombosis - prone in early DAPT stopping, older patients, poor CO, stent over stent, or stents in small vessels
Consider keeping patients on DAPT through surgery and or stopping just clopidogrel
RCRI Risk Predictors
Unstable coronary syndrome/ischemic heart disease
CHF hx
Cerebrovascular Disease
DM
Chronic renal failure
RCRI Risk + Surgical risk
If RCRI >/= 2 + Intermediate/high risk surgery
- METS > 4 - no further testing
- METS < 4 - stress test if changes management
Acute coronary syndrome - eval and treat
CPB - Roller vs Centrifugal Pumps
Roller - 2 roller heads which compress tubing
- higher damage to RBC, not sensitive to preload/afterload
- pulsatile blood flow
Centrifugal - rotational forces force forward flow
- sensitive to preload/afterload affecting flow
- less damage to RBC, stops if air in line
- not pulsatile
Dobutamine MOA
B1 Agonist
- Increased contractility
- Increased CO
- Minimal HR effect
B2 Agonist - vasodilation decreasing PVR
Dopamine MOA
B1 Agonist
- Inc HR/contractility –> inc CO
Renal dopamine receptors - renal vasodilation
Inhibits NE release –> vasodilates
Vasopressin MOA
V1 Receptors - Vasoconstriction
V2 Receptors - Antidiuretic - promotes water reabsorption (DI treatment)
V3 - ACTH secretion –> inc cortisol
V4 - releases vWB and Factor VIII from endothelial cells –> platelet aggregation
Preoperative Eval - Pacemakers or ICDs
Pacemakers - 12 mo, ICDs 6 mo interrogation prior to surgery
Find device type, settings, interrogation report prior
Disable any anti-tachycardia functionality to prevent discharge as a result of electrocautery
Use bipolar when possible, bovie pad placement to avoid crossing generator
Reprogram if within 15 cm of surgical field, restore device in PACU
Emergency Management of Unknown Pacing Device
Bovie pad away from generator
CXR to identify PM/ICD
Place external defibrillation pads on the patient
Apply magnet to PM and see what happens to rate/rhythm
Immediate device interrogation intra and or post op
