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Advanced Principles 2 > Cardiac anesthesia 2 > Flashcards

Cardiac anesthesia 2 Flashcards

1
Q

Patient preparation prior to induction includes

A

oxygen via nasal cannula (NRB facemask if respiratory distress)
evaluate need for mild sedation
line placement
baseline ABG and baseline activated clotting time
cross matched blood
place external defibrillation pads prior to induction
make sure team is rolling back

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2
Q

Evaluating the need for mild sedation includes

A

limiting or avoiding versed based on age & cognitive state preoperatively
fentanyl preferred

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3
Q

Line placement prior to induction includes

A

2 PIVs & arterial line

typically cordis & SWAN placed after induction in stable patients

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4
Q

Intraoperative preparation & positioning includes:

A 
supine with legs padded
foam head support
arms tucked at sides and padded
check lines
prep area: from sternal notch to toes
Foley (hook up bladder temperature)
fluid & under-body forced air warmer
rapid infuser (Belmont or "Level-1")
drips spiked and ready to go
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5
Q

The prep area includes

A

sternal notch to toes

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6
Q

The best place to measure temperature is

A

bladder temp

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7
Q

Describe the use of propofol as an induction agent.

A

use safely in patients with ischemic & valvular heart disease
biggest challenge is hypotension

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8
Q

Describe the use of etomidate as an induction agent.

A

may be less likely to cause hypotension than propofol

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9
Q

Describe the use of ketamine as an induction agent.

A

CV effects are advantageous

biggest challenge is CV stimulation

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10
Q

Avoid ________ during induction and on CPB!!!

A

N2O

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11
Q

Volatile anesthetics produce dose dependent

A

global cardiac depression

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12
Q

The negative effects of volatile anesthetics are due to

A

alterations in intracellular Ca++

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13
Q

Volatile anesthetics are responsible for sensitizing the myocardium to the effects of _____ in varying degrees

A

EPI

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14
Q

Volatile anesthetics may prevent or facilitate _______ during myocardial ischemia or infarction

A

atrial or ventricular arrhytmias

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15
Q

The perfusionist has a vaporizer on the bypass machine

A

and thus you should turn off your vaporizer

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16
Q

Volatile anesthetics produce weak coronary

A

artery dilation and depresses baroreceptor reflex control of arterial pressure

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17
Q

Pre-incision hypotension considerations include

A

lack of stimulation
systemic pressure support
risks involved with vasoconstrictors
recall rare at this point, unless severe hypotension occurs in the face of purely opioid technique

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18
Q

For induction it is important to proceed

A

slowly and know your plan

it is not the drug but the way it is given that is important

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19
Q

The induction technique may include

A

either high versus low dose narcotics work

use propofol or other induction agent with low dose narcotics

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20
Q

If you anticipate a difficult airway, do not hesitate to

A

do an awake intubation

-a well planned, well topicalized patient provides the smoothest induction

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21
Q

Post induction tasks include

A 
central line (if not placed pre-op)
OG then TEE
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22
Q

Veins that are harvested include

A

arterial and saphenous veins

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23
Q

Incision time to bypass is intense

A

surgical stimuli

hypertension may develop- deepen anesthetic, vasoactive agents- NTG/NTP

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24
Q

_______ can be significant with incision

A

bleeding

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25
Q

Considerations for incision include

A

identifying and localizing ischemia

drop the lungs for sternotomy

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26
Q

Prior to bypass, the patient should be

A

anticoagulated with heparin

27
Q

Heparin works by

A

binding to antithrombin III and potentiates its natural anticoagulant properties

28
Q

Heparin should be administered via

A

CVP or directly into RA

29
Q

The dosing of heparin is

A

weight based dosing at 300-400 units/kg- wait 3-5 minutes for ACT

30
Q

Normal ACT & CPB ACT:

A

Normal is 130 secs or less (80-120)

ACT of >400-450 for bypass

31
Q

With heparinization, _________ can decrease

A

SVR & BP can decrease by 10-20%

32
Q

Special circumstances in which heparin should not be used includes

A

ATIII deficiency- pt unresponsive to heparin; FFP can be given or thrombate III
heparin-induced thrombocytopenia, antiplatelet, antibodies which lead to platelet aggregation and potentially life threatening thromboembolic events

33
Q

The ACT needs to be

A

> 400 to go on CPB

-give heparin BEFORE any cannulas are placed

34
Q

Cannulation of the aorta (arterial) and RA (venous) considerations include

A

must drop the pts BP for aortic cannulation (systolic <90)
BP might drop and/or arrhythmias can occur while placing venous cannula
the perfusionist can give fluids via the arterial line

35
Q

Pre bypass and post heparinization medications include

A

medicate patient with midazolam and fentanyl

36
Q

If BP is too high during cannulation of the aorta,

A

aortic dissection can occur

37
Q

Cannulation of the coronary sinus for retrograde cardioplegia includes

A

similar effects to cannulation of the aorta & RA with a drop in BP

38
Q

Frequently encountered problems on bypass include

A 
arrhythmias
heart failure
hypertension
hypotension
heart failure
bleeding :sternotomy lacerates RV or aorta
39
Q

Hypertension during _______ is most concerning

A

aortic cannulation d/t risk of aortic dissection

40
Q

Hypotension prior to bypass may be treated with

A

volume through aortic line via pump

41
Q

Arrhythmias are usually related to

A

cardiac manipulation and cannulation

-may be the first sign of myocardial ischemia

42
Q

Transitioning to bypass involves the perfusionist opening

A

venous clamp and allowing blood to drain passively into venous reservoir which immediately begins to cool patient

43
Q

When the patients goes to bypass, the arterial line

A

tracing goes flat but ECG is still present

44
Q

Prior to going on bypass pull back

A

2-3 cm on PAC so it is no longer in pulmonary artery and won’t cause obstruction

45
Q

When transitioning to bypass, look for

A

head for swelling- indicate proper placement of venous catheter
check pupils & BIS–> thrombus

46
Q

Drugs to consider when transitioning to CPB include

A

give muscle relaxant to prevent shivering or if mixed venous gas is going down (70-80 is desired)
give amnestic drug
close down fluids

47
Q

CVP on bypass should be

A

0-5 possibly even negative

48
Q

______ will decrease on bypass but a marked decrease is concerning

A

Cerebral oximetry

49
Q

For adults, the CPB machine is primed with

A

1500-2500 mL of balanced electrolyte solution

50
Q

Albumin, heparin, mannitol, and NaHCO3- is often added to

A

increase osmolality, reduce edema, and promote diuresis

51
Q

The CPB machine causes significant

A

hemodilution and a decrease in oxygen carrying capacity occurs

52
Q

Typically a hematocrit of _____ is acceptable when patients are on bypass

A

20%

53
Q

Hemodilution is associated with

A

decreased viscosity, decreased SVR, and promotes blood flow to tissues

54
Q

Describe the path of cardiopulmonary bypass.

A

arterial inflow–> filter–> flow meter–> oxygenator–> heat exchanger–> pump–> bubble detector–> reservoir–> SVO2–> venous return line

55
Q

Cardioplegia is

A

cold- at 4 degrees C

contains K+- 26 mEq/L

56
Q

The potassium in cardioplegia causes

A

depolarization of the heart

57
Q

The cold for cardioplegia reduces

A

metabolism of the heart

vfib occurs at 25-30 degrees C

58
Q

Retrograde cardioplegia is infused via

A

the coronary sinus

59
Q

Issues related to CPB include

A 
hypotension
renal ischemia
CVA
air emobli introduced into CPB system
thromboyctopenia 
increased inflammatory response
altered post-op mental state "pump-head"
60
Q

Renal ischemia related to CPB occurs due to

A

hypo-perfusion and/or hemodilution

61
Q

A CVA while on CPB occurs from

A

thrombus in CPB system (clot or foreign object)

62
Q

Hypotension on CPB is related to

A

decreased SVR

63
Q

________ failure is mot common after bypass

A

kidney

64
Q

Cardiac surgery inflammatory response is a result of

A

surgical factors
perfusion factors
pharmacology
& technological

Advanced Principles 2 (42 decks)

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