Cardiac anesthesia 1 Flashcards by Hannah Garrison

1 in 3 American adults have

one or more types of CVD

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These minorities have a higher mortality rate from CAD

African Americans & Hispanics

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Evidence supports that female gender short term survival after CABG is

worse than male gender but 5 yr survival rate is better

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CABG surgical procedures include

CABG
off pump CABG
minimally invasive direct (MID)-CABG
valve replacement
heart transplant

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Preoperative evaluation includes evaluating

cardiac history
past surgical history
angina presentation
dysrythmias
past medical history
co-morbid diseases
medications

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Describe the assessment of cardiac history for the preoperative evaluation.

severity of disease/hemodynamic status
-<4 mets- cause for concern
catheterization, ECHO, & EKG reports
-what is baseline disease: low EF, high LVEDP, pulmonary HTN, valvular & congenital lesions, CHF

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Describe the assessment of past surgical history

past sternotomy (scarring around heart)
leg and groin vascular surgery
previous protamine use?

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Describe the assessment of angina presentation.

nausea, fatigue, DOE, SOB

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Frequent past medical history for patients undergoing CABG includes

TIA, CVA

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Co-morbid diseases for patients undergoing CABG includes

PVD (carotid disease), DM, HTN, COPD, renal= prepare for postop care!

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Preoperative evaluations of medications that patients take include

anticoagulants, antianginals, insulin, ACEI’s

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Preoperative cardiac testing includes

cardiac catheterization report
ECG
Echo report
hematologic studies
CXR
renal function
liver function tests
type & cross

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Patients undergoing cardiac surgery must have

PRBCs available

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Liver function tests are important because

CPB may hypo-perfuse liver

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Patients with decreased renal function have

increased post-op mortality

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Chest XRs can show

calcified aorta, cardiomegaly, and edema

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Hematologic studies include

PTT, PT, baseline ACT

-clotting studies, especially platelet number & functionality (thromboelastogram:TEG)

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Describe how anesthetist may use ECG & cardiac catheterization reports

cardiac cath- locate blockages

ECG: recent MI (intraop MIs= 50% mortality)

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The echo report can show

EF, valve function, wall abnormalities, calcified aorta, atrial thrombus (No CVA!)

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These drugs should be continued until the operative day:

antiarrhythmics
Ca+ channel blockers
beta blockers
nitrates

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Cardiac anesthesia goals include

decrease cardiac oxygen utilization
maintain oxygen supply
anticoagulation
maintain BP in target range

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Describe methods that may be used to decrease cardiac oxygen utilization.

anesthesia
hypothermia
electrical silence, cardioplegia use
empty cardiac chambers, specifically the LV: no LV distension!

Describe methods used to maintain the oxygen supply.

maximize oxygen carrying capacity & flow

hemodilution and acceptable perfusion pressure & flow

Describe the effects of hypotension and hypertension.

hypotension= decreased organ perfusion
hypertension= disrupts myocardial balance

Myocardial protection strategies include

cardioplegia induced asystole hypothermia hemodilution

Hemodilution is not really a protection strategy but flow

increases due to decreased blood viscosity

Describe how hypothermia allows for myocardial protection

alters platelet function & reduces fibrin enzyme function inhibits initiation of thrombin formation reduces metabolic demands and increases tolerance to ischemia

Describe how cardioplegia induced asystole protects the heart.

electrical and mechanical activity ceases potassium given continuously during cross clamping must be able to cross clamp aorta: calcification/clots already present? blood versus clear prime hyperkalemia is an issue with renal patients

The order of events for CABG includes:

``` pre-op prep monitors lines induction wait incision drop lungs sternotomy surgical dissection cannulation on-bypass off bypass dry up: give protamine close chest to ICU ```

Monitors that should be used for CABG may include

``` pulse ox TEE EKG- leads V5 & II temperature ABP- usually radial, sometimes femoral CVP-mandatory for infusion of drugs PA catheter- pts with severe LV dysfunction, pts with profound pulmonary HTN ```

Transesophageal can be used to

help to plan case interventions | helps diagnose underlying mechanisms ascribed to several scenarios

A transesophageal echo helps plan case interventions including

when to give volume start vasoactive drips re-examine graft assessment of surgical repair

A transesophageal echo can help diagnose the following mechanisms:

evaluation of ventricular filling (preload) estimation of cardiac output assessment of ventricular systolic function assessment of ventricular diastolic function valvular pathology calcified aorta cardiac tamponade atrial thrombus

Contraindications to transesophageal echo includes

``` esophageal pathology (alcoholic varices) empty stomach before placing probe ```

The pulmonary artery catheter used to be the standard monitor for cardiac surgical patients but is being

used less due to risk and use of TEE

Pulmonary artery catheters are typically placed

in the right IJ (IJ is the most direct route)

There is no evidence to suggest that PA catheters

offer additional information and have inherent risk in ICU patients

You know when the SWAN enters the pulmonary artery when the waveform shows ______________ in the PA versus RV

an INCREASED diastolic pressure

Complications of PAC include

``` ventricular arrhythmias heart block (especially in patients with preexisting LBBB) pneumothorax unintended arterial puncture valve damage hematoma/thromboembolism vascular injury perforation of thorax leading to hemothorax PA rupture blood stream infection cardiac tamponade ```

A pneumothorax is most common with a ______ approach for insertion of a PA cath

subclavian approach

The most common acute injury for Swan catheters is

unintended arterial puncture

The most common life threatening complication of CV cannulation with a Swan catheter is

cardiac tamponade

Prior to bypass, it is suggested to keep the blood pressure ______ and the heart rates between_________

within 20% of baseline pressure | HR 40-80 depending on clinical situation prior to bypass

Describe the recommendations for aortic stenosis.

Preload: maintain SVR: maintain HR: 50-80 (NSR)

Describe the recommendations for aortic regurgitation.

preload: maintain SVR: low HR: 50-80 (NSR)

Describe the recommendations for mitral stenosis.

preload: maintain SVR: maintain HR: 50-80 (NSR)

Describe the recommendations for mitral regurgitation.

Preload: maintain SVR: low HR: 50-80 (NSR)

Cardiac OR set up includes:

``` usual airway equipment/machine check pacemaker drips- vary by institution heparin & coag. monitoring capability emergency drugs PRBC available in OR ```

Describe the most common drips utilized for cardiac OR set up:

``` NTG/NTP Epinephrine/norepinephrine phenylephrine/ephedrine dopamine/dobutamine as needed antiarrhythmics (esmolol, lidocaine, mag, amiodarone) ```

Describe why epinephrine is preferred over norepinephrine.

epinephrine provides greater inotropy & chronotropy via alpha agonist

Cardiac anesthetic drugs include:

``` inhalation agent fentanyl/sufentail versed propofol/etomidate/ketamine vecuronium/rocuronium/cisatricurium succinylcholine or rocuronium if RSI antibiotic: cefazolin, vancomycin, clindamycin anti-fibrinolytics magnesium insulin drip ```

Anti-fibrinolytics are used because during CPB, large amounts of circulating TPA are found and

increased postop bleeding due to inappropriate fibrinolysis

To be effective, anti-fibrinolytics must be

started before going on CPB | include: ACA & TXA

Fibrinolysis is diagnosed via

thromboelastogram (TEG)