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Cardiac - Vascular > Cardiac Anesthesia > Flashcards

Cardiac Anesthesia Flashcards

1
Q

preop evaluation of cardiac surgical patient

A

type of procedure

echo, EKG, BMP, CBC, Coags

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

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2
Q

what are some coexisting dieases that are prevalant in cardiac patients

A

COPD, kidney disease, DM, obesity, PVD

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3
Q

discuss lead placement and rate/ischemic changes

A

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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4
Q

discuss invasive lines and cardiac sxg

A

a line, central line is standard. cvp is standard

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

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5
Q

why is having an A line standard for cardiac sxg

where is the best placement

A

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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6
Q

when is contra indicated to place a PA cath

A

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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7
Q

when does PCWP > LVEDP

PCWP<lvedp></lvedp>

A

PCWP>LVEDP: increase PEEP, incr PVR, COPD

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

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8
Q

how can the kidney get injured during cardiac sxg

best prevention

A

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

best prevention is hydration

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9
Q

discuss glucose control during cardiac anesthesia

A

goal is 80-180

delayed wound helaing, increased infection risk, gastroparesis

hyperglycemia will occur from the inflammation/stress response.

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10
Q

where does most CNS injuries come from during cardiac surgery

A

micro emboli

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

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11
Q

heparin use in cardiac surgery

MOA, dose, ACT

A

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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12
Q

Heparin and protamine

what are some reasons heparin might work? what to do

protamine dose

A

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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13
Q

what are some variables that affect clotting

A

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

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14
Q

lab data that correlates with an MI

which is the most popular and why

A

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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15
Q

Cardiac testing

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

A

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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16
Q

premedications to be concerned with for cardiac surgery

A

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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17
Q

TEE

how does it read the heart

what information does it give

A

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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18
Q

discuss the cardiac set up

A

different for every instution

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

airway equipment

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19
Q

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

A

Fentanyl 50mcg/kg, Sufentanil 10mcg/kg

Inhalation: Iso for renal protective

N20: avoid for PHTN

Induction: etomidate, versed

NMB: rocuronium

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20
Q

preincision period: discuss

A

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

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21
Q

cannulation

which side first and why

what are come complications that can occur

A

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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22
Q

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

A
  1. turn off VG 2. stop ventilation 3. turn off pressors or any drips 4. empty urine 5. pull back PA cath 5 cm
  2. put TEE into neutral 7.
23
Q

how to prepare for surgical incision

A

very painful, deep anesthetic gas or give more fentanyl

drops lungs to prepare for sternotomy

LIMA or RIMA are harvested

24
Q

what drug is given before bypass

discuss

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

A

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

25
Q

cardioplegia

how cold is the solution

when does V fib occur

what electrolyte is present

A

4 degrees celcius

occurs at 25-30 celcius

k

26
Q

why does your BP drop when starting bypass (3)

A

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

27
Q

what are the ingredients of the priming fluid

A

2000cc

Heman likes MACA

heparin, mannitol, NaHco3, albumin, corticosteroids, Abx,

28
Q

Bypass

what is the flow rate

what is the BP when to have lower/higher

A

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

29
Q

instrinsic and extrinsic pathway with CPB

discuss

A

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

30
Q

Heparin resistance

(3) reasons why this may happen

txt

A
  1. congenital defect 2. lacking ATIII 3. current dz state
    trxt: give more heparin
31
Q

Heparin Rebound

what are (3) reasons this occurs

A
  1. protamine cleared for heparin
  2. heparin dissociation from protein
  3. recirculation of heparin from lymphatic tissues
32
Q

Discuss HITT

A

herparin induced thrombocytopenia

IgG antibody reaction. antibodies attacking PF4

PLt drop below 100k or 50% drop

other options are agatroban(thrombin inhibitor) LMWH

33
Q

discuss the (3) types of prothrombine reactions

A

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

34
Q

MOA for protamine reactions

A

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

35
Q

who is at risk for protamine reactions

A

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

36
Q

how to give protamine

what to do if they have a previous incident with it

how to treat protamine reaction

A

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

37
Q

Antifibrinolytics

when are they given

MOA

which one not used anymore

A

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

38
Q

what are the pharm categories of the following

aprotinin

clopidigrel (plavix)

dabigatran

A

aprotinin = serine prtease inhibitor

clopidigrel (plavix) stop 3 days prior. ADP receptor antagonist

Dabigatran: Factor Xa inhibitor

39
Q

when might you need to give prothrombin complex concentrate

A

when pt is still bleeding after warfarin

40
Q

LMWH

A

enoxaparin, Lovenox

41
Q

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

A

emboli are the biggest culprits

hypothermia to decrease metabolic rate

Ca channel blockers, barbituates

ABG managment

BP managment

cerebral oximetry

42
Q

fluid managment goals for cardiac surgery

A

give 1.0 - 1.5L fluids total

replace blood loss with colloids, cell saver or PRBC

DONT FOLLOW THE 3:1 rule

43
Q

when do we start the rewarming process

how fast can you rewarm a pt

A
  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

44
Q

discuss the rewarming process of a pt

A

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

45
Q

discuss the CVP for coming off bypass

A

cold, conduction, coagulation, cells, cardiac output, calcium

visualization, ventilation, vaporization, volume

predictors, pressors, pressure, potassium, Pacing, protamine

46
Q

termination of CPB

things that occur

A

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

47
Q

what are some devices that can aid the LV

A

IAMP, LVAD

48
Q

protamine

derived from

dose

why can a reaction occur

A

derived from salmon sperm

  1. 0mg/100 u of heparin
  2. previous exposure 2. vasectomy 3. taking NPH
49
Q

what are options if pt has a protamine reaction

A
  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
50
Q

talk about metabolic disturbances you might see during cardiac surgery

A

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

51
Q

what are some pulmonary complications that can arise

A

Aa gradient increase (normal 5-10)

atelectasis, hemothorax, pneumothorax, broncospasms,

52
Q

what happens to BP when chest is closed

A

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

53
Q
A

Cardiac - Vascular (3 decks)

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