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Cardiac Anesthesia Flashcards

0
Q

Prophylaxis of infective endocarditis

A

Dental procedures in

  1. Prosthetic cardiac valves
  2. Previous IE
  3. Several types of congenital heart disease (CHD)
  4. Cardiac transplantation recipients who developed valvulopathy
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1
Q

Hypothermia

A
  1. Plt sequestered reversibly in portal circulation
  2. Plt # back to normal w/I 1 hr
  3. Plt function & life span normal
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2
Q

Energy for one MET

A

One MET=energy expended during 1 min at rest = 3.5 ml oxygen/kg/min

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3
Q

CHD w/ right to left intracardiac shunt

A
  1. Tetralogy of Fallot
  2. Eisenmenger’s syndrome
  3. Ebstein’s malformation of tricuspid valve
  4. Pulmonary atresia w/ VSD
  5. Tricuspid atresia
  6. PFO
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4
Q

ECG

A
  1. examing more than one lead is important
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5
Q

PAC migration (922 ?)

A
  1. common (3-5 cm distally) withdrawal 3-5 cm before bypass

2. wedge position—>increase in PAP (r/o inadequate ventricular venting–>PAP w/o change after withdraw

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6
Q

malposition of aortic cannula

A

unilateral facial blanching

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7
Q

malposition of venous cannula

A
  1. too far into SVC (obstruction of R innominate vein) or
    IVC (abd distention)
  2. facial or scleral edema (bulging sclerae) or poor blood return to bypass circuit
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8
Q

transposition of great vessels

A
  1. failure of truncus arteriosus to rotate–>aorta from RV, PA from LV
  2. induction: volatile—->slow; IV—>faster—>decrease dose
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9
Q

Fontan procedure

A
  1. anastomosis: RA appendage—>PA
  2. tricuspid atresia, pulmonary stenosis, pulmonary artery atresia; hypoplastic left heart syndrome (–>increase PBF–>prepare convert RV to systemic ventricle)
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10
Q

metabolic rate in CPB

A

Each degree Celsius decrease—>5 to 8% decline

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11
Q

Itra-aortic balloon pump (IABP)

A
  1. Inflation immediately after closure of aortic valve (diastole)—>increase DBP & coronary BF
  2. Deflating just before ventricular systole—> Reduce aortic pressure and afterload—>enhance LV EF, reduce wall tension & VO2
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12
Q

Afterload reduction beneficial

A
  1. AI
  2. MV
  3. CHF
  4. PDA
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13
Q

Protamine

A
  1. From sperm of fish (certain)
  2. basic
  3. specific antagonist of heparin
  4. 1.3 mg/100 U of heparin
  5. Can bind plt & coagulation factors—>anticoagulant
  6. Allergy: NPH insulin
  7. Hypotension
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14
Q

Primary determinants of myocardial O2 consumption, from most to least important

A

HR>afterload>preload

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15
Q

Plusus paradoxus

A
  1. Pulsus paradoxus: inspiratory fall in SBP>10 mmHg<—cardiac tamponade
  2. occasionally: severe airway obstruction, RV infaction
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16
Q

pulsus parvus vs pulsus tardus

A
  1. Pulsus parvus: diminished pulse
  2. Pulsus tardus: delayed upstroke
    3, In AS
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17
Q

Pulsus alternans

A
  1. alternating smaller and larger pulse waves

2. severe LV dysfunction

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18
Q

Bisferiens pulse

A
  1. pulse waveform w/ 2 systolic peaks

2. AVR

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19
Q

ETT drugs

A

ALONE: Atropine, Lidocanine, Oxygen, Naloxone, Epinephrine (Vasopressin may be)

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20
Q

MAP

A

MAP = DBP +1/3 (SBP-DBP)

= 1/3 SBP + 2/3 DBP

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21
Q

Amiodarone

A
  1. structure similar to thyroxine—>hypo or hyperthyroidism
  2. prolong AP w/o change resting potential: atrial & ventrical muscle
    3 Effective: recurrent SVT & VT, WPW syndrome
  3. anti-adrenergic effect—>bradycardia, hypoTN–>may be atropine-resistant—->isoproterenol or temporary pacer
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22
Q

SVR

A

SVR=(MAP-CVP)/COx80
1. MAP & CVP: mmHg
2. CO: L/min
(1 wood = 80 dynes/sec/cm-5)

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24
Q

dobutamine

A

predominantly beta 1-agonist

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25
Q

beta 1 vs beta 2 stimulation

A 
Beta 1 stimulation 
    1. heat: HR, contractility, conduction velocity
    2. release of fatty acids
Beta 2
    1. vascular, rennin sectetion
    2. airway
    3. uterine relaxation
    4. glycogenolysis, gluconeogenesis
alpha: intestinal and urinary bladder-sphincter tone
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26
Q

hypertrophic cardiomyopathy–anesthesia

A
  1. goal: reduce gradient across LV outflow obstruction
    2.avoid inotrope, reducing preload or afterload
    3 halothane: direct myocardial depressant, not decrease SVR—>ideal
  2. If hypotension—>phenyephrine
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27
Q

wide complex tachycardia—>unstable

A
  1. presumed: ventricular tachycardia (VT)
  2. medical emergency
  3. synchronized cardioversion
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28
Q

Romano-Ward syndrome

A
  1. congenital
  2. prolong QT interval
  3. If plus congenital deafness–>Jervell-Lange-Nielsen syndrome
  4. etiology: likely imbalance: R & L sympathetic system
  5. L stellate ganglion block—>shorten of QT—>surgical gangionectomy
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29
Q

VAD

A
  1. Axiao = continuous, non-pulsatile
  2. NIBP not accurate—> A-line
  3. SPO2 may not work
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30
Q

Normal person, ?% CO is dependent on atrial kick

A

20 to 30 %

but pathologic —>higher, e.g. AS

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31
Q

Tetralogy of Fallot (1 yo) –GA

A
  1. Goal: maintain SVR

2. Ketamine 3 to 4 mg/kg IM or 1 to 2 mg/kg for induction

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32
Q

MS

A
  1. rheumatic fever in childhood (almost exclusively)
  2. LV: ‘protected’=unloaded,
  3. LA: decrease compliance & function—>pulmonary—>RV
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33
Q

PAC–> V wave on wedge pressure tracing

A

ischemia of posterior wall of LV & posterior leaflet of MV—>prolapse–>retrograde flow into LA–>V wave (can be earlier than ST depression (–>nitroglycerin)

34
Q

Wide complex tachycardia of undetermined origin

A

If stable—>amiodarone 150 mg IV over 10 min—>repeat prn till 2.2 g over 24 hrs

35
Q

amount of contisol

A
  1. normal: 15 - 20 mg/day

2. Max stress: 75 - 150 mg/day

36
Q

pace maker

A
  1. stimulation threshold: increased by hypokalemia & respiratory alkalosis; vasa versa—>vulnerable to VF
  2. decrease in HR >10%—>faterry failure–>cancel elective surgery–>evaluate
  3. Anesthesia: ECG moniotor, emergency equipment(e.g, defibrillator, magnet), durgs (atropine, isoproterenol)
37
Q

Fick equation

A
  1. Q=VO2/(CaO2-CvO2)
  2. CaO2=1.36 HgB x SaO2 + 0.003xPaO2
  3. CvO2=1.36 HgB x SvO2 + 0.003xPvO2
  4. VO2 = 4 ml/kg <—-O2 consumption
38
Q

Normal resting myocardial O2 consumption

A

Normal: 8 - 10 ml/100g/min—->2 in firillating heat @ 22 Celsus degree

39
Q

AS

A
  1. angina
  2. syncope
  3. CHF
    Note: new Af—>electrical cardioversion
40
Q

Prussure

A 
RA: 3-8mmHg
RV: 15-30/3-8 mmHg
LA: 4-10 mmHg
LV: 100-120/3-12 mmHg
PA: 15-30/4-12 mmHg
41
Q

PEEP

A
    • pressure to exhalation valve @ end of expiratory
  2. FIO2>0.5—>PEEP—>reduce O2 toxicity
  3. Expand collapsed but perfused alveoli–>decrease V/Q
  4. Decreased CO, pulmonary barotrauma (i.e., tension pneumothorax, pneumomediastinum, s.c. emphysema), increased extravascular lung water, redistribution of pulmonary BF5
  5. If abrupt deterioration of SPO2 & CV fx—>suspect baratrauma–>CXR; tension pneumo–>chest tube
42
Q

coronary artery BF

A
  1. Resting coronary artery BF: 75ml/100g/min–> 225 to 250 ml/min–>4 to 5% CO
  2. Resting myocardial O2 consumption: 8 to 10ml/100g/min—>10% total body O2 consumption
43
Q

Pulmonary artery rupture associated with PAC

A
  1. rare
  2. hallmark: hemoptysis: may be minimal or copious
  3. Try to separate lungs: DLETT
  4. Atheromatous: not risk<—minimal or absent in middle or distal PA where tip of PAC is
44
Q

Protamine reaction

A
  1. Diabetics taking NPH or PZI insulin, but not regular insulin
  2. seafood allergy
  3. vasectomy: Antibody to spermatozoa
45
Q

heparin vs protamine

A
  1. 100 u heparin = 1.3 mg protamine
  2. basic protamine vs acidic heparin
  3. t1/2 of heparin = 1.5 hrs at 37 cesuls degree
46
Q

cardiac perfusion

A
  1. LV: during diastole–>increase HR–>decrease

2. RV: diastole and systole

47
Q

thromboelastogram

A
  1. viscoelastometer measuring viscoelastic properties of blood during clot formation
  2. R value=reaction time: NL 7.5 to 15 mins
  3. K value reflecting clot formation time: NL 3 to 6 mins
  4. MA=max amplitude (max clot strength rate of clot destruction=fibrinolysis): -5 mm
48
Q

170 micrometer filter

A

1 .present in standard blood administration sets

  1. filtration of possible clots
  2. Used for: Plt, FFP, Cryoprecipitate, pRBC, and granulocyte concentrate transfusion
49
Q

Adenosine

A
  1. SVT: 6 mg IV–>repeat if needed 1-2 min later 12mg
  2. Including WPW syrdrome (unless AF w/ wide complex WPW occurs—>increase HR)
  3. Dipyridamole or CVC: initial dose 3mg
  4. Methylxanthine (caffeine, theophylline, amrinone)–>competitive antagonist to adenosine–>increase dose
50
Q

body temperature measurement

A
  1. PA, distal esophagus, tympanic membrane, or nasopharynx–>reliable even during rapid thermal perturbations such as CPB
  2. oral, axillary, rectal, urinary bladder–>reasonably except during extreme thermal perturbation
  3. In CPB pt measuring temp of both bladder and PA is helpful in determing likelihood of recooling after CPB
51
Q

best intraop TEE view for monitoring myocardial ischemia

A
  1. transgastric mid-papillary short axis view

2. supplied by all 3 major coronary ateries

52
Q

sodium bicarbonate–>adverse effects

A
  1. plasma hyperosmolality
  2. paradoxic cerebral spinal fluid acidosis
  3. hypernatremia
  4. hypercarbia
53
Q

hypercyanotic ‘tet spells’ in TOF

A
  1. mechanism unknow: spasm of infundibular or decrease of SVR
  2. mgt: phenylephrine, esmolol or IV fluid (morphine).
54
Q

sildenafil (Viagra)

A
  1. inhibit PDE5 —inhibit breakdown of cGMP
  2. Milrinone: inhibit PDE3
  3. NTG & hydralazine: direct acting smooth muscle relaxants
55
Q

Dural antiplatelet (ASA+clopidogrel)

A
  1. DES: mim 1 yr before stopping prior to elective surgery

2. BMS: 1 month

56
Q

HIT (heparin induced thrombocytopenia)

A
  1. type I: nonimmune: heparin bind to plt–>short life–>modest decrease: transient–>insignificant clinically
  2. type II: immume: ab to complex of heparin and a a PF4–>bind to endothelial cell–>thrombin productin–>thrombocytopenia (>50 reduction of plt) & V/A thrombosis (direct thrombin inhibitor: hirudin, leirudin, bivalirudin or argatroban
57
Q

clopidogrel

A
  1. noncompetitively and irreversibly inhibiting P2Y12 —>action is life long of plt–>no reverse drug
  2. Platelet transfusion can reverse
58
Q

port access robotic surgery

A
  1. less invasive for coronary artery revascularization

2. mini-thoracotomy–>OLV–>hypoxia

59
Q

carina vs bronchoscope

A
  1. bronchoscope–two branch points: ‘real’ carina—> (L or R) two branch points: L upper lobe & lower lobe or RUL or RML—>3 lumens
60
Q

hypoxia in OLV

A
  1. check position of DLT and correction of poor hemodynamics
  2. adding CPAP to non-dependent lung
  3. adding PEEP to dependent lung
  4. having surgeon clamp PA to lung about to remove
  5. Intermittent inflation of non-dependent lung w/ O2
61
Q

transplanted heart

A
  1. denervated–>intrinsic HR 110
  2. bradycardia(25%): eventually developed—>atropine no effect
  3. Effective: glucagon, isoproterenol, epinephrine, norepinephrine (no reflex bradycardia), pacer
62
Q

WPW syndrome w/ AVNRT (AV nodal reentrant tachycardia)

A
  1. bundle of Kent: connet atria with ventricle w/o passing AV node
  2. orthodromic: >90%, narrow complex, can use everything mentioned below
  3. antidromic: travel via accessary pathway, worse, but Can use procainamide or electrical cardioversion
63
Q

DDD-R reprogrammed to asynchronous (DOO) mode during surgery

A
  1. VOO or DOO–>R on T likely if native HR >programmed HR or PVC or PAC
  2. try Esmolol to decrease HR
64
Q

Milrinone vs amrione (inamrinone)

A
  1. PDE 3 inhibitor—>increase CAMP —>positive inotropic and vasodilation
  2. Amrinone —>thrombocytopenia, but NOT milrinone
65
Q

SVR vs PVR

A

SVR = (MAP - CVP )/CO

PVR = (PAmean - LA pressure)/CO

66
Q

type of -tropy

A
  1. chronotropy: HR
  2. dromotropy: conduction
  3. inotropy: force & velocity of ventricular contration
  4. lusitropy: myocardial relaxation
  5. bathmotropy: muscular excitation to stimulus
67
Q

adrenergic receptors vs ach-receptors

A 
alpha 1 (a, b, c)
alpha 2 (a, b, c)
beta 1, 2, 3
M1-
M2-heart
M3-coronary circulation
M4-
M5-
(M1, 3, 5: Gq/11-->PLC-->DAG; M2, 4-->Gi/o--> (-) AC
(M2 receptors can couple to K+ channels and influence the activity of calcium channels, If current, phospholipase A2, phospholipase D, and tyrosine kinases)
68
Q

Bainbride reflex

A

stretch receptors in RA &cavoatrial juntin

69
Q

Bezold-Jarisch reflex

A
  1. vagal reflex

2. noxious ventricular stimuli

70
Q

oculocardiac reflex

A

eye surgery

71
Q

baroreceptor reflex

A

maintaining BP

72
Q

SvO2 decrease vs increase

A
  1. Normal: 60-80%
  2. Decrease: Hypoxemia, low CO, anemia, increased oxygen consumption
  3. Increase: decreased oxygen consumption (e.g. cyanide toxicity), elevation in CO, normalization of hemoglobin, improvement in oxygenation
73
Q

Ketamine

A
  1. Return to full orientation takes approximately 15-20 minutes after a typical induction dose of 2-2.5 mg/kg
  2. active metabolite for ketamine: nonketamine
  3. The safe use of ketamine in pregnancy has not been established, and such use is not recommended.
74
Q

milrinone vs amrinone

A
  1. Phosphodiesterase III inhibitors–>increase cAMP in cardiac & smooth muscle–>+inotropic & vasodilation (A & V)
  2. amrinone: throbocytophenia
75
Q

SIRS vs sepsis

A 
SIRS needs 2 or more: 
1. T>38 or 90
3. R>20 or PaCO2> 32
4. WBC >12,000 or 10% immature (band) forms
Sepsis = SIRS + documented infection
76
Q

Distance from RA of PAC

A
  1. RIJ: 20-25 cm (but RV: 30 - 35 cm; PA: 40 - 45 cm; wedge: 45 - 55 cm)
  2. LIJ, LEJ, REJ: add 5 to 10 cm
  3. Feoral: add 15cm
  4. 30 to 35 cn from antecubital veins
77
Q

pulmonary hypertension

A
  1. mean PA >25 at rest or >30 mmHg w/ exercise
  2. Epoprostenol = prostacyclin (PGI2); alprostadil (PGE1): central IV or inhale
  3. O2
  4. nitric oxide (NO): inhaled (1-80 ppm, typicl 20-40 ppm
  5. Milrinone: also inotropic, ? inhale
  6. inhaled volatile anesthetics
    NOTE: nitrous oxide increase PA resistence
78
Q

PVR as a function of lung volume is the least at ?

A

functional residual capacity (FRC)

79
Q

Least likely to cause unfaovorable hemodynamic changes in MS ?
ketamine, remifentanil, pancuronium, desflurane, nitrous oxide

A

Remifentanil

80
Q

torsades de pointes (twisting of the points)

A
  1. can be induced by: drugs (e.g., quinidine, procainamide, phenothiazines like droperidol), electrolyte abnormalities (hypokalemia, hypomagnesemia), ACS
  2. If prolonged QT present: shortening QT is time permits: overdrive atrial or ventricular pacing (more definitive), MgSO4 (1st line emergency), isoproterenol (past)
  3. If no prolonged QT: std drugs for VT
  4. hemodynamically unstable–>unsynchronized shock

Anesthesia (11 decks)

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