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Anesthesiology > Cardiac Anesthesia > Flashcards

Cardiac Anesthesia Flashcards

1
Q

What questions are important in pre-op before placing the TEE probe?

A

Dysphagia, swallowing problems, esophageal surgery, h/o esophageal obstruction, h/o EGD (and results)

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2
Q

What do you need to consent the patient for?

A

GA, arterial line, central venous line, +/- PA catheter, TEE, post-op ICU stay / intubation

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3
Q

What do you need to present in your plan?

A
  1. Induction (+HR/BP goals)
  2. Cannulation plan (“Full/Ao/RA” format)
  3. Graft plan (radial/LIMA/RIMA/BIMA/SVG)
  4. TEE?
  5. Airway
  6. Access (TLC vs. cordis)
  7. Blood products
  8. Other
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4
Q

What conditions is etomidate useful for?

A

Low EF (very) or severe stenotic valvular disease

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5
Q

What lines do you need to prepare at bedside?

A

1) Bolus line –> Cordis side port or brown port of TLC (1L NS on half-walrus tubing attached to Go4)
2) VIP line –> VIP of PA or white port of TLC (1L NS on microdrip w/ Go4)
3) 4-channel Alaris pump w/ Amicar (7.5g x 30min, then 1.25g/h) + 3 others

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6
Q

What premixed bags should you have ready?

A

1) Phenylepi 320mcg/cc
2) Epi 16mcg/cc
3) Norepi 32mcg/cc
4) NTG 40mcg/cc

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7
Q

What do you need for access?

A

A-line, PA line, TLC or Cordis kits

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8
Q

Before sternotomy, what do you need to give?

A

1000mcg fentanyl to minimize hemodynamic shifts

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9
Q

What do you need to do with sternal saw?

A

Hold ventilation

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10
Q

3min after giving heparin, what do you do?

A

Draw ACT (+compare to baseline)

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11
Q

Before aortic cannulation, what must you reduce SBP to?

A

90-100

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12
Q

Before CPB… what do you need to do for fluids

A

Empty urine + record IVF

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13
Q

Once on CPB, what do you need to do? (13)

A

1) Turn off ventilation
2) Remove pulse ox
3) Place machine on CPB mode
4) Stop all infusions (except Amicar, insulin)
5) Record times for “CPB on”, “aortic x-clamp on”
6) Prepare transport items for ICU
7) Maintain pressure 50-70
8) Monitor BIS
9) Monitor urine output
10) Hang pressors/inotropes + have boluses ready
11) Give rewarming drugs to perfusionist
12) Set up labels/paperwork/tubes for post-CPB labs (CBC, Coags/Fibrinogen, ACT/ABG)
13) Set up propofol GTT for ICU transfer

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14
Q

What is the protamine test dose?

A

1cc (10mg)

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15
Q

What are the side effects of protamine?

A

Hypotension, pulm HTN, anaphylaxis

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16
Q

How fast should you give protamine?

A

1-2cc q 1-2min

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17
Q

What should you give in sign-out?

A
  • ICU pause to confirm patient and procedure
    • Brief HPI (co-morbidities, functional status, ALL/Med)
    • Airway (easy or not, i.e. Does anesthesia need to be there for extubation?)
    • Last dose antibiotics, neuromuscular blockage reversal
  • Brief operative course
    • Induction/pre CPB - any problems?
  • Coming off CPB – pressors, arrhythmias/defib, underlying rhythm/pacer settings, new ekg changes/regional wall motion abn, post-op EF, etc.)
    • Current drips
    • Access
    • Ins/outs
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18
Q

What antibiotics are generally needed for a VAD?

A

Vancomycin - based on weight
Ciprofloxacin - 400mg
Fluconazole - 200mg

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19
Q

Amicar dosing

A

7.5g load over 30min, 1.25g/h infusion after until after CPB

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20
Q

Amiodarone dosing to break VF/VT

A

150-300mg IV

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21
Q

Amiodarone dosing for infusion

A

150mg over 10min, drip 1-2mg/min of 720mg/150cc D5W (12.5cc/hr)

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22
Q

Dexmedetomidine dosing

A

1mcg/kg load over 10-30min, 0.3-0.7mcg/kg/hr infusion

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23
Q

Dobutamine dosing

A

1mg/cc @ 2-10mcg/kg/min

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24
Q

Dopamine dosing for D1 action

A

1-3mcg/kg/min of 1600mcg/cc

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25
Q

Dopamine dosing for B1/B2 action

A

3-10mcg/kg/min

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26
Q

Dopamine dosing for alpha action

A

> 10mcg/kg/min

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27
Q

Epinephrine dosing for beta action only

A

1-3mcg/min of 16mcg/cc (4mg/250cc)

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28
Q

Epi dosing for beta>alpha

A

3-10mcg/min

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29
Q

Epi dosing for alpha = beta

A

> 10mcg/min

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30
Q

Esmolol dosing

A

5-10mg bolus, 50-200mcg/kg/min infusion

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31
Q

Insulin dosing

A

1 unit/cc, check BG every 30min

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32
Q

Lopressor (B1) dosing

A

5mg q5-15min

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33
Q

Labetalol dosing

A

5-10mg bolus, up to 300mg/max

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34
Q

Milrinone dosing

A

50mcg/kg load, 0.25-0.75mcg/kg/min infusion

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35
Q

Nitroglycerin dosing

A

10-200mcg/min

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36
Q

Nitroprusside dosing

A

0.1-10mcg/kg/min

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37
Q

Norepi dosing

A

1-30mcg/min to effect

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38
Q

Propranolol dosing

A

0.5-1mg

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39
Q

Propofol dosing

A

0.5-1mg bolus

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40
Q

Vasopressin dosing

A

0.01-0.1U/min

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41
Q

What is a normal ACT?

A

80-160s

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42
Q

What is the ACT goal?

A

> 350-450s (depends on location)

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43
Q

Why is the aorta cannulated first?

A

The aorta is cannulated first so that if there is a significant event (e.g. a tear during insertion of the venous cannula or a malignant arrhythmia) there is a way to deliver volume into the arterial circulation and maintain perfusion to the patient while CPB is being established.

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44
Q

What is “Testing the line”?

A

“Testing the line” means that the perfusionist checks the pressure required to move fluid through the arterial side of the circuit and into the aorta. If this pressure is too high, it may be a sign that the cannula is not in the lumen of the aorta, which could lead to an aortic dissection when CPB is initiated. To “test the line,” the perfusionist transfuses 50-100cc of fluid at 1L/min into the arterial cannula. There is a pressure gauge on the arterial line from which the perfusionist reads the pressure.

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45
Q

What is the purpose of the aortic X-clamp?

A

The aortic cross clamp goes on to effectively separate the systemic and coronary circulations. The reason for this is that the cardioplegia is administered into and needs to stay within the coronary circulation in order to stop the heart. If the cross clamp was not present, the systemic flow would also go through the coronaries and wash out any of the cardioplegia, making it impossible to stop the heart. REMEMBER: Once the aortic xclamp is on, the myocardium is rendered ischemic.

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46
Q

In what two ways may cardioplegia be administered?

A

Cardioplegia is given either anterograde (down the coronary arteries via a small cannula that is placed in the aortic root between the aortic valve and the cross clamp) or retrograde (via the coronary sinus).

47
Q

What are the necessary steps for stopping CPB?

A

In order to adequately perform the cardiac output, the heart must have an acceptable rate, rhythm, and contractility. Afterload, electrolytes, and temperature must be normalized.

48
Q

When is it safe to give all protamine?

A

When ALL cannulations removed

49
Q

When should you use a PA catheter?

A

These measurements are helpful when faced with poor left ventricular function, valvular disease, recent MI, ARDS, massive trauma, major vascular surgeries, or when there is a critical need to accurately assess the intravascular fluid volume or the response to blood pressure interventions.

50
Q

When should you use a CVP?

A

Used in any case when there is the need to closely monitor the intravascular volume status or there is a need to evaluate right ventricular function.

51
Q

When should you use an a-line?

A

o Used in any case where wide swings in blood pressure are expected, where tight control of blood pressure is needed, in cardiopulmonary bypass cases, or when there will be the need for multiple blood gas analyses.

52
Q

When should you do a TEE?

A

Used to evaluate regional wall motion abnormalities indicative of myocardial ischemia, to evaluate stroke volume/ejection fraction, to evaluate cardiac valvular function, to look for intracardiac air, to monitor changes in cardiac function, or to evaluate adequacy of intravascular fluid volume.

53
Q

What is the FRC in a normal person?

A

3L

54
Q

What is the purpose of pre-oxygenation?

A

To replace nitrogen with oxygen in FRC, giving 3-6min extra of apnea

55
Q

With 4 twitches and spontaneous breathing, the patient may still have ___% of NMJ-R blocked

A

75% of the NMJ receptors occupied by the blocking agent.

56
Q

How can you test recovery from NMJ blockade?

A

ability of the patient to maintain a head lift, leg lift or handgrip strength for > 5 seconds.

57
Q

When is the patient ready to extubate?

A
  1. adequately recovered from the effects of the neuromuscular blocking agents
  2. is able to breathe on his own
  3. is able to follow commands
  4. demonstrates purposeful movements
  5. can protect his airway
58
Q

What physiological parameters are used to assess readiness for extubation?

A
  • RR > 8 & 5 cc/kg
  • TV/RR > 10
  • PaO2 > 65-70 mmHg on FiO2
59
Q

All inhalational agents are broncho_____, except for _____ which can precipitate _____

A

Dilators; desflurane; bronchospasm

60
Q

Inhaled anesthetics ___ TV and ____ RR

A

Decrease; increase

61
Q

Inhalational anesthetics are eliminated by ____ except for _____

A

Ventilation; halothane

62
Q

T/F: Nitrous can trigger MH

A

False

63
Q

Halothane: Pros

A

Cheap, nonirritating so can be used for inhalation induction

64
Q

Halothane: Cons

A

Long time to onset/offset, Significant Myocardial Depression, Sensitizes myocardium to catecholamines, Association with Hepatitis

65
Q

Isoflurane: Pros

A

Cheap, excellent renal, hepatic, coronary, and cerebral blood flow preservation

66
Q

Isoflurane: Cons

A

Long time to onset/offset, irritating so cannot be used for inhalation induction

67
Q

Desflurane: Pros

A

Extremely rapid onset/offset

68
Q

Desflurane: Cons

A

Expensive, Stimulates catecholamine release, Possibly increases postoperative nausea and vomiting, Requires special active-temperature controlled vaporizer due to high vapor pressure, Irritating so cannot be used for inhalation induction

69
Q

Sevoflurane: Pros

A

nonirritating so can be used for inhalation induction. Extremely rapid onset/offset.

70
Q

Sevoflurane: Cons

A

Expensive. Due to risk of “compound A” exposure must be used at flows > 2 L/min. Theoretical potential for renal toxicity from inorganic fluoride metabolites.

71
Q

Nitrous: Pros

A

Decreases volatile anesthetic requirement, Dirt cheap, Less myocardial depression than volatile agents

72
Q

Nitrous: Cons

A

Diffuses freely into gas filled spaces (bowel, pneumothorax, middle ear, eye, Decreases Fi02, Increases pulmonary vascular resistance

73
Q

What drug is preferred for neurosurgery cases, and why?

A

Thiopental: decrease ICP by decrease in cerebral oxygen consumption.

74
Q

Thiopental: Cons

A

Myocardial depression, Vasodilation, Histamine release, Can precipitate porphyria in susceptible patients

75
Q

What is the induction dose of propofol in adults?

A

1.5 to 2.5 mg/kg

76
Q

What is the maintenance dose of propofol in adults?

A

100 to 200 micrograms/kg/min

77
Q

What is the induction dose of propofol in kids?

A

2.5 to 3.5 mg/kg over 20 to 30 seconds

78
Q

What is the maintenance dose of propofol in kids?

A

125 to 300 mcg/kg/min.

79
Q

What are the cons of etomidate?

A

Pain on injection, Adrenal suppression (? significance if used only for induction), Myoclonus, Nausea/Vomiting

80
Q

Induction dose of ketamine in adults?

A

Induction dose of 1 to 2 mg/kg in adults.

81
Q

Dosing of dexmedetomidine?

A

It is generally given as a loading dose of 0.5-1 mcg/kg over 10 minutes, followed by an infusion of 0.2 to 0.7 mcg/kg/hr.

82
Q

Dosing of midazolam?

A

Midazolam (Versed) induction dose of 0.1 to 0.2 mg/kg and infusion rates of 0.25 to 1 microgram/kg per minute.

83
Q

How are ester local anesthetics metabolized?

A

plasma esterases

84
Q

What does metabolism of ester local anesthetics produce?

A

PABA (allergen)

85
Q

How many “i”s are in the name of an ester anesthetic?

A

1

86
Q

How are amide local anesthetics metabolized?

A

Metabolized by hepatic enzymes.

87
Q

How many “is” are in the name of an amide anesthetic?

A

2

88
Q

Who should avoid morphine?

A

Renal patients - long acting & renally excreted → active metabolite has opiate properties, therefore beware in renal failure

89
Q

Who should avoid meperidine?

A

Someone on MAO-Is, cardiac patients, and renal disease

90
Q

Sufentanil is ____x potency of morphine

A

1000

91
Q

Who should avoid succinylcholine?

A

MH, hyperK, burns, crush injury, spinal cord injury, muscular dystrophy or disuse syndromes

92
Q

Characteristics of pancurionium?

A

Slow onset, long duration, tachycardia due to vagolytic effect

93
Q

Characteristics of cisatracurium?

A

Slow onset, intermediate duration, Hoffman (nonenzymatic) elimination so attractive choice in liver/renal disease.

94
Q

Characteristics of rocuronium?

A

Fastest onset of nondepolarizers making it useful for rapid sequence induction, intermediate duration.

95
Q

What are MACs of major anesthetics?

A 
Nitrous - 104
Desflurane - 6
Sevo - 2.2
Iso - 1.5
Halo - 0.8
96
Q

In general, high MAC implies…

A

Fast onset, low potency

97
Q

Allowable blood loss equation

A

ABL = BV x (Hcts - Hct-t)/(Hct/s)

Hcts = starting Hct 
Hct-t = threshold Hct for transfusion
BV = 50cc/kg for F, 60cc/kg for M, 80cc/kg infants, 90cc/kg neonates
98
Q

Shortcut for 4-2-1 rule for IVF calculation

A

40 + weight in kg for anyone over 20kg

99
Q

Fluid deficit

A

NPO time x maintenance

100
Q

EBL replacement

A

1: 1 colloid
3: 1 crystalloid

101
Q

When does infarction risk stabilize post-MI?

A

Infarction risk stabilizes at 5-6% after 6 months

102
Q

What is the periop MI mortality rate?

A

mortality 20-50%

103
Q

If no prior MI, what is perioperative risk of MI?

A

0.13%

104
Q

What are strict C/I to surgery?

A

MI

105
Q

Sx of MH?

A

increased HR, increased breath rate, increased etCO2 (most sensitive), unstable BP, cyanosis, coca-cola colored urine

106
Q

Confirming dx of MH?

A

Confirm diagnosis by large difference between venous CO2 and arterial CO2

107
Q

Labs of MH?

A

Respiratory and metabolic acidosis, hypoxia, hyperkalemia, hypercalcemia, high myoglobin, high CPK, myoglobinuria

108
Q

Tx of MH? (10 steps)

A

1 - Call for help
2 - Stop volatile anesthetic
3 – 100% O2
4 – Manually hyperventilate
5 – Switch to a clean breathing circuit
6 – Stop surgery, maintain on sedative-hypnotic anesthesia
7 – Dantrolene 2.5mg/kg (mixed with sterile water) q 10 minutes to max dose of 10mg/kg. Maintenance dose at 1mg/kg q 6hrs for 72 hours.
8 – Correct metabolic acidosis with NaCHO3 1-2mg/kg, Correct high K+
9 – Cool patient with iced IV NS, and cold fluids in gastric lavage, in peritoneal or thoracic cavity if open, and PR
10 – Maintain urine output with mannitol or lasix. Do not use CCB’

109
Q

Mechanism of local anesthetics

A

decrease permeability to Na ions, binds to Na channel in inactivated state, no threshold potential reached, affects rapid firing nerves first, myelinated&raquo_space;> unmyelinated

110
Q

C/I to local?

A

hypersensitivity, severe heart block, WPW syndrome

111
Q

Toxicity signs of local?

A
  • Cardio – decreased phase IV depolarization, increased PR, wide QRS
  • Pulmonary – phrenic/intercostal nerve paralysis
  • CNS – dizziness, circumoral numbness, tinnitus, blurred vision, excitatory signs → CNS depression
  • Muscle – toxic injected IM
  • Lidocaine known to decrease coagulation
112
Q

What is Mendelssohn’s Syndrome?

A

o Aspiration pneumonia secondary to aspiration of gastric contents

113
Q

S/Sx of aspiration PNA?

A

dyspnea, tachypnea, increased HR, wheezing, CXR with lower lobe infiltrates, hypoxia

114
Q

Essential pre-op room check

A

Suction Airway Machine Pharmacy Monitors

Anesthesiology (2 decks)

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