Cardiac Anesthesia Flashcards by Joshua Guevara

preop evaluation of cardiac surgical patient

type of procedure

echo, EKG, BMP, CBC, Coags

symptoms: syncope, DOE, arhythmias, EKG changes, exercise tolerance

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what are some coexisting dieases that are prevalant in cardiac patients

COPD, kidney disease, DM, obesity, PVD

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discuss lead placement and rate/ischemic changes

V5 gives you 75% detection of ischemia. add lead II you get 80% detection. if you add V4 you get 100% detection.

lead II is for rate changes

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discuss invasive lines and cardiac sxg

a line, central line is standard. cvp is standard

and PA cath: PHTN, RV failure, regurg problems.

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why is having an A line standard for cardiac sxg

where is the best placement

blood pressure swing, possible for high blood loss, vasopressors, tight control on pressure during cannulation. HTN, CAD, PVD

gives us the ability to draw ABGs

dominant hand, may take a radial artery graft from the non dominant hand

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when is contra indicated to place a PA cath

when there is a mass in the RA or LV. also tetrology of fallot

TOF (overriding aorta, aortic stneosis, ventral septal defect, RV hypertrophy

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when does PCWP > LVEDP

PCWP<lvedp></lvedp>

PCWP>LVEDP: increase PEEP, incr PVR, COPD

PCWP<lvedp: noncompliant lv aortic regurg lvedp>25mmhg </lvedp:>

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how can the kidney get injured during cardiac sxg

best prevention

hypotension, reperfusion injury, NSAIDS, sulfa drugs, radioactive dyes

best prevention is hydration

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discuss glucose control during cardiac anesthesia

goal is 80-180

delayed wound helaing, increased infection risk, gastroparesis

hyperglycemia will occur from the inflammation/stress response.

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where does most CNS injuries come from during cardiac surgery

micro emboli

hypoperfusion injuries, emboli, inflammation, hypotension, air, aortic plaque

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heparin use in cardiac surgery

MOA, dose, ACT

heparin

MOA: works on antithrombin III, factors 2 and 10

only 1/3 of the heparin dose contains the pentasaccharide molecule. which is needed. thats why we give so much

400u/kg after the first ACt is drawn

Gial of ACT is 400-500

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Heparin and protamine

what are some reasons heparin might work? what to do

protamine dose

may not work: hemodiluted, HITT, long term heparin usage, AT III deficiency

give more heparin, FFP, thrombate

protamine is the reversal 1.0 - 1.3mg per 100u heparin

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what are some variables that affect clotting

temperature(cold), hemodilution, cell saver, plt inhibitor, thrombocytopenic

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lab data that correlates with an MI

which is the most popular and why

acute MI: 1. at 1.5 days tropinin peaks. at 12 hrs. myoglobin and CKMB isoforms show

unstable angina: at 24 hrs tropnin will peak

tropnin is the most sensitive and specific. it reflects microscopic zones in the myocadium

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Cardiac testing

what are some cadiac specifc tests that can be run and what do they tell you

EKG: ischmic and rate changes

TEE: valvular pathology, hemodynamics, filling pressures, bleeding

chest CX: cardiomegaly, pulm edema, atelectasis, pleural effusions

cardiac cath: EF, LVEDP, CI

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premedications to be concerned with for cardiac surgery

BB take day of

stop AceI day of

plavix (p2Y12 inhibitor) stop 3 days before

aspirin: dont take day of surgery (increase mediastinal bleeding) need more transfusion

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TEE

how does it read the heart

what information does it give

2.5 - 7.5 Mhz through intermittent pulses

preload, hypotnesion, CO, EF, valvular problems, lesions, bleeding, emboli, LVAD placement, placement of surgical repairs

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discuss the cardiac set up

different for every instution

blood tubing, vasopressors, vasodilators, narcotics, bair hugger, celebral oxyemetry, PRBCs, pacemaker

airway equipment

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what are some anesthetic agents that can be used during cardiac surgery

Fentanyl 50mcg/kg, Sufentanil 10mcg/kg

Inhalation: Iso for renal protective

N20: avoid for PHTN

Induction: etomidate, versed

NMB: rocuronium

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preincision period: discuss

not much going on until sternum cut, careful with BP. keep around 100 systolic

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cannulation

which side first and why

what are come complications that can occur

Aorta first, so you can give back blood if needed

Aorta: dissection, bleeding, hypotension, introduction of air into vasculature, loosen of emboli

venous side: bleeding, hypotension, dysrythmias

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what does anesthesia need to do when CPB is being started (6)

turn off VG 2. stop ventilation 3. turn off pressors or any drips 4. empty urine 5. pull back PA cath 5 cm
put TEE into neutral 7.

how to prepare for surgical incision

very painful, deep anesthetic gas or give more fentanyl

drops lungs to prepare for sternotomy

LIMA or RIMA are harvested

what drug is given before bypass

discuss

what happens when giving heparin or protamine too fast, why may it not work

herparin given to prevent intrinsic and extrinsic clotting

give 300-400u/kg to get ACT > 480

herparin acts on ATIII and factor 2, 10

give too fast —> hypotension

heparin administration might not work bc 1. long term heparin treatment 2. HITT 3. ATIII deficient (FFP or thrombate) 4. hemodilution

cardioplegia how cold is the solution when does V fib occur what electrolyte is present

4 degrees celcius occurs at 25-30 celcius k

why does your BP drop when starting bypass (3)

the priming fluid cuases hemodilution ---\> less catecholamines. rapid cooling of the heart, brain, and liver cross clamping of aorta to prevent cardioplegia to rest of body

what are the ingredients of the priming fluid

2000cc Heman likes MACA heparin, mannitol, NaHco3, albumin, corticosteroids, Abx,

Bypass what is the flow rate what is the BP when to have lower/higher

flow is 50-60mls/kg MAP 50-60 mmhg normal is having the BP in the 50s, if stroke pt and needing higher perfusion then raise MAP

instrinsic and extrinsic pathway with CPB discuss

instrinic: blood contacts plastic tubing---\> 12, 11, 10,5, 2, 1 extrinisic: cut the vessel during cannula---\> TF activates endothelial and monocyte activity---\> 7,10,2,1

Heparin resistance (3) reasons why this may happen txt

1. congenital defect 2. lacking ATIII 3. current dz state trxt: give more heparin

Heparin Rebound what are (3) reasons this occurs

1. protamine cleared for heparin 2. heparin dissociation from protein 3. recirculation of heparin from lymphatic tissues

Discuss HITT

herparin induced thrombocytopenia IgG antibody reaction. antibodies attacking PF4 PLt drop below 100k or 50% drop other options are agatroban(thrombin inhibitor) LMWH

discuss the (3) types of prothrombine reactions

Type 1: mild reaction. low BP. filling pressure and airway pressures are normal Type 2: moderate to severe hypotension. Anylphylactic reaction or allergic (IgE) or (IgG). might see bronchcoconstrx Type 3: extreme hypotension. pulmonary compromised, RV fialure, increased PAP

MOA for protamine reactions

endothelial cells will release NO, mast cell degranulation, and histamine release

who is at risk for protamine reactions

ppl taking NPH, previous vasectomy, or previosu exposure to protamine

how to give protamine what to do if they have a previous incident with it how to treat protamine reaction

give it slowly over 5 min couple of options: 1. dont rechallange pt with protamine 2. wait for heparin to wear off 3. can try giving heparinase or PF4 treat with fluids and pressors (phenyl, ephedrine). if severe may need to be placed back on CPB

Antifibrinolytics when are they given MOA which one not used anymore

they are given before we go on pump (CPB). Amicar and TXA they bind to the lysine sites of plasmin aprotinin not used anymore, d/t creatinine rise post CPB

what are the pharm categories of the following aprotinin clopidigrel (plavix) dabigatran

aprotinin = serine prtease inhibitor clopidigrel (plavix) stop 3 days prior. ADP receptor antagonist Dabigatran: Factor Xa inhibitor

when might you need to give prothrombin complex concentrate

when pt is still bleeding after warfarin

LMWH

enoxaparin, Lovenox

what are something that we try and give cerebral protection during cardiac surgery

emboli are the biggest culprits hypothermia to decrease metabolic rate Ca channel blockers, barbituates ABG managment BP managment cerebral oximetry

fluid managment goals for cardiac surgery

give 1.0 - 1.5L fluids total replace blood loss with colloids, cell saver or PRBC DONT FOLLOW THE 3:1 rule

when do we start the rewarming process how fast can you rewarm a pt

1. when the last anastamotic site is being closed 2. when all the salves are sutured in and the notes are being tied down rewarm them 1 degree Q 5min

discuss the rewarming process of a pt

1 degree every 3 -5 minutes. can take up to 50 minutes to rewarm might see a drop in SVR from vasodilation to prevent shivering and recall. give versed and rocuronium the gradient between arterial and venous blood should remain between 10 degrees. if not, at risk of an air embolism

discuss the CVP for coming off bypass

cold, conduction, coagulation, cells, cardiac output, calcium visualization, ventilation, vaporization, volume predictors, pressors, pressure, potassium, Pacing, protamine

termination of CPB things that occur

start by venous clamp removed first. then aortic clamp removed can use TEE to check filling pressures and monitor LV desired pessure is 95-125 mmhg

what are some devices that can aid the LV

IAMP, LVAD

protamine derived from dose why can a reaction occur

derived from salmon sperm 1. 0mg/100 u of heparin 1. previous exposure 2. vasectomy 3. taking NPH

what are options if pt has a protamine reaction

1. dont rechallenge them w protamine 2. wait for heparin is dissapate and dont reverse it 3. try the procedure off pump 4. PF4 or herparinase

talk about metabolic disturbances you might see during cardiac surgery

hypokalemia: from priming fluids, replace hyperkalemia: from cardioplegia. 10u of insulin and amp of D50 hypocalcemia: from multipke blood products and citrate ingredient

what are some pulmonary complications that can arise

Aa gradient increase (normal 5-10) atelectasis, hemothorax, pneumothorax, broncospasms,

what happens to BP when chest is closed

BP drops from impeeding on the blood flow return back to the heart may see hypotension from hypovolemia during closure if vessels get kinked may see ischemic injury