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Advanced Principles 2 > Cardiac anesthesia 1 > Flashcards

Cardiac anesthesia 1 Flashcards

1
Q

1 in 3 American adults have

A

one or more types of CVD

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2
Q

These minorities have a higher mortality rate from CAD

A

African Americans & Hispanics

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3
Q

Evidence supports that female gender short term survival after CABG is

A

worse than male gender but 5 yr survival rate is better

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4
Q

CABG surgical procedures include

A 
CABG
off pump CABG
minimally invasive direct (MID)-CABG
valve replacement
heart transplant
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5
Q

Preoperative evaluation includes evaluating

A 
cardiac history
past surgical history
angina presentation
dysrythmias
past medical history
co-morbid diseases
medications
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6
Q

Describe the assessment of cardiac history for the preoperative evaluation.

A

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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7
Q

Describe the assessment of past surgical history

A

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

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8
Q

Describe the assessment of angina presentation.

A

nausea, fatigue, DOE, SOB

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9
Q

Frequent past medical history for patients undergoing CABG includes

A

TIA, CVA

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10
Q

Co-morbid diseases for patients undergoing CABG includes

A

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

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11
Q

Preoperative evaluations of medications that patients take include

A

anticoagulants, antianginals, insulin, ACEI’s

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12
Q

Preoperative cardiac testing includes

A 
cardiac catheterization report
ECG
Echo report
hematologic studies
CXR
renal function
liver function tests
type & cross
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13
Q

Patients undergoing cardiac surgery must have

A

PRBCs available

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14
Q

Liver function tests are important because

A

CPB may hypo-perfuse liver

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15
Q

Patients with decreased renal function have

A

increased post-op mortality

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16
Q

Chest XRs can show

A

calcified aorta, cardiomegaly, and edema

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17
Q

Hematologic studies include

A

PTT, PT, baseline ACT

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

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18
Q

Describe how anesthetist may use ECG & cardiac catheterization reports

A

cardiac cath- locate blockages

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

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19
Q

The echo report can show

A

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

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20
Q

These drugs should be continued until the operative day:

A

antiarrhythmics
Ca+ channel blockers
beta blockers
nitrates

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21
Q

Cardiac anesthesia goals include

A

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

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22
Q

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

A

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

23
Q

Describe methods used to maintain the oxygen supply.

A

maximize oxygen carrying capacity & flow

hemodilution and acceptable perfusion pressure & flow

24
Q

Describe the effects of hypotension and hypertension.

A 
hypotension= decreased organ perfusion
hypertension= disrupts myocardial balance
25
Q

Myocardial protection strategies include

A

cardioplegia induced asystole
hypothermia
hemodilution

26
Q

Hemodilution is not really a protection strategy but flow

A

increases due to decreased blood viscosity

27
Q

Describe how hypothermia allows for myocardial protection

A

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

28
Q

Describe how cardioplegia induced asystole protects the heart.

A

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

29
Q

The order of events for CABG includes:

A 
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
30
Q

Monitors that should be used for CABG may include

A 
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
31
Q

Transesophageal can be used to

A

help to plan case interventions

helps diagnose underlying mechanisms ascribed to several scenarios

32
Q

A transesophageal echo helps plan case interventions including

A

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

33
Q

A transesophageal echo can help diagnose the following mechanisms:

A

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

34
Q

Contraindications to transesophageal echo includes

A 
esophageal pathology (alcoholic varices)
empty stomach before placing probe
35
Q

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

A

used less due to risk and use of TEE

36
Q

Pulmonary artery catheters are typically placed

A

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

37
Q

There is no evidence to suggest that PA catheters

A

offer additional information and have inherent risk in ICU patients

38
Q

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

A

an INCREASED diastolic pressure

39
Q

Complications of PAC include

A 
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
40
Q

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

A

subclavian approach

41
Q

The most common acute injury for Swan catheters is

A

unintended arterial puncture

42
Q

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

A

cardiac tamponade

43
Q

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

A

within 20% of baseline pressure

HR 40-80 depending on clinical situation prior to bypass

44
Q

Describe the recommendations for aortic stenosis.

A

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

45
Q

Describe the recommendations for aortic regurgitation.

A

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

46
Q

Describe the recommendations for mitral stenosis.

A

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

47
Q

Describe the recommendations for mitral regurgitation.

A

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

48
Q

Cardiac OR set up includes:

A 
usual airway equipment/machine check
pacemaker
drips- vary by institution
heparin & coag. monitoring capability 
emergency drugs
PRBC available in OR
49
Q

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

A 
NTG/NTP
Epinephrine/norepinephrine
phenylephrine/ephedrine
dopamine/dobutamine as needed
antiarrhythmics (esmolol, lidocaine, mag, amiodarone)
50
Q

Describe why epinephrine is preferred over norepinephrine.

A

epinephrine provides greater inotropy & chronotropy via alpha agonist

51
Q

Cardiac anesthetic drugs include:

A 
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
52
Q

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

A

increased postop bleeding due to inappropriate fibrinolysis

53
Q

To be effective, anti-fibrinolytics must be

A

started before going on CPB

include: ACA & TXA

54
Q

Fibrinolysis is diagnosed via

A

thromboelastogram (TEG)

Advanced Principles 2 (42 decks)

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