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S5 - Principles III - Test 3 > Cardiac Anesthesia Management > Flashcards

Cardiac Anesthesia Management Flashcards

1
Q

components of primary pre-op testing for cardiac surgery (5)

A
  • EKG
  • chest x-ray
  • echo
  • stress test (exercise, nuclear, stress echo)
  • heart cath
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2
Q

what things do we want to note from a pre-op EKG?

A
  • rate
  • rhythm
  • ischemic changes
  • chamber enlargement
  • conduction blocks
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3
Q

what things do we care about on a pre-op chest xray?

A
  • cardiac/mediastinal/aortic silhouette
  • pulmonary effusion
  • pulmonary congestion
  • evidence of implantation device
  • previous surgical marks
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4
Q

what things do we care about on a pre-op ECHO?

A
  • anatomic measurements and calculated values (pertinent positives)
  • valvular performance (w/ attention to stenosis and regurg of all 4 valves)
  • systolic function (graded EF and any regional wall motion abnormalities)
  • presence of effusions, air, thrombus, vegetation, or anatomicl abnormalities (PFO, ASD, etc.)
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5
Q

what things from a preop stress test do we care about?

A
  • type of test and performance summary
  • ejection fraction
  • EKG
  • uptake abnormalities
  • failure criteria
  • regional perfusion distribution report
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6
Q

what information from a pre-op heart cath do we care about?

A
  • cardiac output measurement
  • specific vessel findings and severity
  • interventions performed (previous and current)
  • an EF measurement with gradient measurements
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7
Q

which heart test do we use to help us determine if the patient has aortic stenosis?

A

echo

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8
Q

what items are a part of the basic setup for a cardiac case?

*monitoring devices only (10)

A
  • ALL REGULAR MONITORS +
  • art line
  • CVL with transducer for CVP
  • temp monitor - esophageal and bladder
  • PAC
  • neuromonitoring device (BIS)
  • cardiac output monitor
  • doppler
  • echo/TEE
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9
Q

what items are a part of the basic setup for a cardiac case?

thing that are NOT monitors or drugs

A
  • warming device - fluid warmer at minimum, forced air warmers (bypass pump most effective)
  • lab testing device - very hospital-specific
  • pacemaker
  • defibrillator with pacing
  • banked blood available
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10
Q

what labs are frequently monitored during a cardiac case?

A
  • iStat or TEG
  • ACT
  • ABG
  • electrolytes
  • h/h frequently
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11
Q

what drugs are used for cardiac procedures?

*tons

A
  • induction drugs
    • versed
    • fentanyl
    • etomidate
    • anectine
    • non-depolarizing muscle relaxant
    • lidocaine
  • heparin
  • protamine
  • vasopressors - ex. epi, neo, NTG
  • diluted pressors
  • antibiotics
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12
Q

what type of temp monitoring is used during cardiac procedures?

any lil things you wanna keep in mind about it?

A

esophageal and bladder temp

esophageal temp may not be accurate when circulation is stopped

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13
Q

what is the most effective in warming a patient having a cardiac procedure that requires CBP?

A

the bypass pump itself

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14
Q

what dose of heparin is commonly used in cardiac procedures?

A

30,000 units

30 ml of 1000u/ml concentration is common dose

or 300 units/kg, depending on which page of the same MF document you look at :)

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15
Q

key consideration with protamine

A

never open up, draw up, remove from cart, or prepare before needed

can lead to inadvertent administration and cause catastrophic and almost certainly fatal effects

never emergent med that needs to be prepared in advance

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16
Q

benefits of an available diluted pressor syringe

A
  • meds can be bolused if there’s a pump failure
  • if IV/CVL failure, boluses can be given a different route while access is re-acquired
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17
Q

at minimum, what pressors should be prepared for CV procedures?

what other meds are often added?

A

minimum: neosynephrine, calcium chloride, nitroglycerin

common to add: epinephrine, ephedrine, levophed

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18
Q

what are three potential times for awareness when the patient might need versed?

A
  • sternotomy
  • re-warming - brain starting to function
  • going on CPB - adds volume of distribution which dilutes out drug in body
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19
Q

what are the three components of BP?

A
  • HR
  • stroke volume
  • SVR
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20
Q

what factors influence stroke volume?

A

contractility and preload

~ frank says the greater the preload the greater the SV

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21
Q

what influences regional contractility?

A

ischemic factors

ex. poor blood flow from LAD to the anterior wall causing poor pumping of that area

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22
Q

what factors influence global contractility?

A

entire myocardium becoming sluggish from…

  • excess beta blocker
  • excess (anesthetic?) agent
  • hypoxia
  • acidosis
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23
Q

what factors affect cardiac output?

A

stroke volume and heart rate

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24
Q

what is the best way to assess which parameter is causing a decrease in BP in order to initiate precise therapy?

A

TEE

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25
Q

what factors often influence the decision of which pressor to use?

A
  • hospital/clinical preference
  • availablity
  • cost
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26
Q

epinephrine bolus dose

A

2-10 mcg

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27
Q

receptor effects when given the following doses of epinephrine:

  1. 01-0.03 mcg/kg/min
  2. 04-0.1 mcg/kg/min

>0.1 mcg/kg/min

A
  • 0.01-0.03: alpha: + / beta +++
  • 0.04-0.1: alpha: ++ / beta: +++
  • >0.1: alpha: +++ / beta +++
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28
Q

dose of NE and the receptor effects associated

A

0.01-0.1 mcg/kg/min

alpha +++ beta ++

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29
Q

dose of dobutamine and receptor effects associated

A

2-20 mcg/kg/min

alpha: none / beta: ++

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30
Q

bolus and infusion dose of phenylephrine and receptor effects

A

bolus: 50-200 mcg
infusion: 10-50 mcg/min
alpha: +++ / beta: none

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31
Q

milrinone bolus and infusion dose

MOA

A

bolus: 50 mcg/kg
infusion: 0.375-0.75 mcg/kg/min

MOA: phosphodiesterase inhibition

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32
Q

BP, HR, SV, CVP, PA, SVR indicators for volume therapy

A
  • BP - low
  • HR - normal-high
  • SV - low
  • CVP - low
  • PA - low
  • SVR - low
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33
Q

BP, HR, SV, CVP, PA, SVR indicators for a vasopressor

A
  • BP - low
  • HR - normal
  • SV - normal-high (high due to decreased afterload increasing EF)
  • CVP - low
  • PA - low
  • SVR - low
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34
Q

BP, HR, SV, CVP, PA, SVR indicators for an inotrope

what else must be done?

A
  • BP - low
  • HR - normal
  • SV - low
  • CVP - normal
  • PA - high
  • SVR - normal

*must also rule out ischemia

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35
Q

what would BP, HR, SV, CVP, PA, SVR look like in a patient with RV failure?

therapy indicated?

A
  • BP - low
  • HR - normal
  • SV - normal
  • CVP - high
  • PA - normal
  • SVR - normal

therapy: decrease PVR, increase inotropy, rule out RV ischemia

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36
Q

considerations for home anti-coag meds prior to CV surgery

A
  • we must know pre-op anti-coagulation meds
  • some cases will need time for the med to be metabolized away prior to surgery
  • some meds will want to be continued
  • some meds we will want to reverse
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37
Q

2 main indications for blood products during surgery

A
  • replace blood loss
  • correct coagulopathies
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38
Q

what is the standard amount of blood products to have available for a cardiac procedure?

A

minimum 2 units PRBCs reserved for the pt

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39
Q

it is “imperative” to have suction connected to what two places for a CV case?

*other than the pts suction for airway

A
  • venous reservoir of bypass machine
  • cell saver
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40
Q

methods to decrease chances of patient receiving donated PRBCs?

A

autologous donation

hemodilution

*must coordinate with blood bank team

this is stupid.

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41
Q

what is cell saver?

what does it include/not include?

A

a machine that collects, filters, and returns the RBCs lost to suction back to the patient

does not give back plasma or plts

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42
Q

if blood loss is 2.5-3 L, how many liters of RBCs are returned?

A

1 liter - no plasma plts

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43
Q

what the implication of cell saver when there are large volumes being returned to the patient?

A

it indicates significant blood loss and the potential for coagulopathy

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44
Q

what is the most common anticoagulant used in cardiac surgery?

goal of use?

A

heparin - the goal is to prevent clot formation in the bypass pump —- duh.

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45
Q

MOA of heparin?

effects?

A

MOA - potentiate the action of the endogenous antithrombin III (ATIII)

this action increases the inhibition of the clotting action of thrombin 1,000-fold

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46
Q

classic heparin dosing?

goal ACT?

A

300 units/kg

ACT > 400 within 3-5 min

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47
Q

if ACT is not at goal within 3-5 min, what should be considered?

A

patient may have heparin resistance or an ATIII deficiency

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48
Q

what to do if patient has heparin resistance?

A

give additional dose of heparin

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49
Q

what do if the patient has ATIII deficiency

A

two options…

  1. administer ATIII and then additional heparin dose — or
  2. administer FFP and then additional heparin
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50
Q

what is HIT?

what commonly administered things can cause this?

what to do if HIT history/susceptible? (truly unsure what he means here so pls help)

A
  • potentially fatal and incapacitating process caused by heparin
  • can be caused by heparin flushes and AL fluids (and obvi heparin admin for bypass)
  • careful attention to remove heparin from the supply area
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51
Q

when is protamine administered?

what will happen if administered early?

A
  • only once CPB is completely disengaged
  • administration while on bypass will cause catastrophic pump clotting and failure (Death X_X)
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52
Q

protamine dose?

MOA?

A

1 mg of protamine per 100 units of heparin administered

MOA: electrostatic binding and inactivation of heparin

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53
Q

how to administer protamine?

why?

A
  • administer slowly - decreases the likelihood of mild allergic reactions
    • some use solu-set or slow bolus
    • *though some say true anaphylaxis may occur no matter the dose amount
  • administer through PIV to reduce the severity of heparin response such as hypotension
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54
Q

possible routes of protamine administration

A
  • PIV
  • CVL
  • direct injection into the heart
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55
Q

what are the two most commonly used antifibrinolytic agents in cardiac surgery?

indication for use?

A

aminocaproic acid (Amicar)

transexamic acid (TXA)

often used to reduce post-op micro bleeding and venous oozing

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56
Q

when should antifibrinolytics be given?

A

some recommend administering after therapeutic ACT achieved to avoid heparin interference for bypass

(but they do not affect ACT 🤷🏻‍♀️)

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57
Q

formula for SVR

normal range

A

SVR = (MAP - CVP) / cardiac output x 80

normal: 700-1600 dynes

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58
Q

formula for cardiac output

normal range of cardiac index

A

CO = HR x SV

normal CI: 2-4 L/min/m2

google - cardiac output alone cannot be a reliable indicator of cardiac performance when used alone since it doesn’t take into account the patient’s size

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59
Q

formula for ejection fraction

A

EF = (EDV - ESV / EDV) x 100

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60
Q

formula for coronary perfusion pressure

A

CPP = DBP - LVEDP

fun fact per APEX that was brand new to me - can use PAOP for LVEDP

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61
Q

normal PA value

A

15-30 / 5-10

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62
Q

normal CVP

A

5-10

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63
Q

what is one of THE MOST important principles to understand for a cardiac CRNA?

A

myocardial oxygen balance

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64
Q

principle components of myocardial oxygen demand

A

wall stress

heart rate

contractility

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65
Q

principle components of myocardial oxygen supply

A

coronary blood flow

oxygen content of the perfusing blood

oxyhgb dissociation curve

oxygen extraction

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66
Q

what is the primary focus for increasing myocardial oxygen supply in the absence of anemia and with an adequate O2 content?

A

coronary blood flow

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67
Q

what section of the heart muscle is most susceptible to ischemia?

A

the subendocardium of the LV

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68
Q

EKG changes seen in patients with subendocardial ischemia

A
  • subtle ST/T wave changes
  • ST-elevation does not result from isolated subendocardial event
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69
Q

5 ways to support O2 supply/demand balance

A
  1. keep the heart “unloaded” to reduce wall tension and avoid an increase in contractility
  2. maintain afterload to ensure CPP
  3. decrease contractility unless contractility is markedly diminished (β blockers)
  4. decrease/minimize HR (β blockers)
  5. maintain adequate blood oxygenation
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70
Q

methods to keep the heart “unloaded” to reduce wall tension (3.5?)

A
  • judicious use of preload (does this mean be careful with volume? why does he have to be so damn cryptic)
  • nitroglycerin
  • morphine
  • other venous capacitance tools (?)
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71
Q

what’s a good drug to use to maintain afterload to ensure adequate CPP?

which is better for coronary perfusion - hypotension or hypertension?

A

neosynephrine

hypertension better

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72
Q

what occurs when myocardial oxygen demand exceeds supply?

A

ischemia — DEATH

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73
Q

factors impacting cardiac O2 supply

A
  • coronary artery anatomy
  • diastolic pressure
  • diastolic time
  • O2 extraction (Hgb, SaO2)
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74
Q

factors impacting cardiac O2 demand

A
  • HR
  • preload
  • afterload
  • contractility
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75
Q

chronology on patient arrival to OR

~ set up kinda things ?

idk this is stupid

A
  1. oxygen
  2. standard non-invasive monitors
  3. print EKG strip
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76
Q

pros vs cons for placing lines before induction

A

pros:

  • can see abnormal reading prior to start of procedure
  • no worry of emergent line placement

cons:

  • awk
  • can cause increased HR and possible ischemia
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77
Q

when should lines be placed for cardiac surgeries? why?

A
  • artline and PIV prior to induction CVL/PAC after
  • allows for quick monitoring of cardiac output during induction without the stress of CVL placement
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78
Q

why does Sanford think you shouldn’t place a PA/CVL under conscious sedation before cardiac surgery?

A

pt breathing under the drapes can cause hypercapnia and potential airway loss

(benefits don’t outweigh the risks)

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79
Q

after non-invasive and pre-induction monitors are in place and a securing strap is on the patient, what are the next steps taken?

A

external defibrillator pads are placed

pre-oxygenation is initiated

induction then begins

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80
Q

pros vs. cons for a high dose narcotic anesthetic technique

A

pros: smooth induction, hemodynamic stability, more than adequate blunting of stimulation
cons: risk of stiff chest syndrome, awareness, and prolonged time til extubation

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81
Q

pros vs. cons of a narcotic anesthetic technique with generous benzos

A

pros: addresses the potential for awareness (vs. narcotic only technique)
cons: can result in prolonged extubation times

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82
Q

what is a balanced anesthetic technique?

A

mixing smaller amount of different drugs to allow for faster metabolism and wake up with less side effects

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83
Q

example of common meds used for a balanced anesthetic technique to address:

initial amnesia

SNS stim/pain

ongoing amnesia

A

amnesia: midazolam

SNS stim/pain: fentanyl

ongoing amnesia/unconsciousness: inhalation agent

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84
Q

recommendations regarding muscle relaxants in CV surgical pts during induction

A

center specific

controversy over non-depolarizer vs SCh

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85
Q

induction/intubation considerations for pt needing TEE

A

patient needs true RSI without mask ventilation

air in stomach obstructs views

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86
Q

one suggested technique regarding induction and timing is:

make the induction ____, but not necessarily ____

*idk how to word this halp

A

make induction smooth, but not necessarily slow

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87
Q

how should NMBs be dosed during CV surgery?

A

depends on nerve stimulation monitoring

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88
Q

pros of using nerve stimulation monitoring during CV case

A

helps to avoid unnecessary drug dosing which facilitate timely extubation post-op

avoids unanticipated spontaneous breaths and movement intra-op

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89
Q

what changes during surgery can affect the metabolism and excretion of our anesthetic agents?

A
  • temperature
  • pH
  • organ perfusion
  • renal output
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90
Q

what factors should be considered when dosing muscle relaxants?

A

changes in volume of distribution

rewarming

circulatory arrest (meds not circulating)

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91
Q

what monitors should be implemented after induction but prior to surgery start? (7-8)

(above the standard monitors)

A
  • art line - if not already in place
  • CVL - if not already in place
  • BIS monitoring*
  • cerebral oximetry*
  • core temp - esophageal and bladder (rectal can be used instead of bladder if needed)
  • cardiac output monitor (via PAC, AL or TEE so unsure why he included)
  • PAC
  • TEE
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92
Q

what are fundamental parameters we can collect from an art line waveform that allow for fine-tuning to “the vigilant anesthetist” —- lol

A
  • pulse pressure
  • systolic pressure variation
  • hemodynamic status
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93
Q

do we want our monitor art line wave form set to optimized scale or fixed scale?

why?

A

fixed scale

to allow us to better see changes in the waveform

94
Q

why is having the art line waveform set to “optimum scale” deceptive?

A

keeps the screen full no matter the pressure - “deceiving the casual eye into thinking the pressure is actually satisfactory”

unable to appreciate systolic pressure variation

95
Q

how does bypass affect radial art line readings & why?

A

reads falsely low by 10-30 points due to hypothermia and vasoactive medications

*will return to same pressure as other sites following rewarming and reduction of vasoactive meds

96
Q

which side is preferred for radial art line cannulation?

why?

A

left - bc apparently the surgeon leans on the right arm

97
Q

reasons that some centers empirically place art lines on one side?

A
  • some cases require radial artery harvesting for implantation for coronary flow
  • the retractor may impede or occlude the subclavian artery and dampen the radial site reading

pls change if this isnt what that part means tysm

98
Q

what is one intervention the CRNA can do to help prevent/minimize positioning issues related to an art line?

*TW this is dumb as hell

A

place a wrist splint

99
Q

what are the three primary uses of a CVL?

A
  • measure CVP
  • access point for large and/or rapid volume, meds, blood and fluids
  • as an introducer for central catheters such as PAC, coronary sinus catheter, LV drain, and pacing wires
100
Q

what are the two most common sites for CVL insertion?

which of those has a big advantage/what is the advantage?

A
  • right subclavian
  • right internal jugular - easy to access, can guide catheters directly without extensive turns
101
Q

what are the implications of administering cell saver, PRBCs, and fluids without warming?

A
  • drastically decrease temp
  • prevent management of coagulopathy
  • impact metabolism
  • impair cardiac function

*so warm your fluids ladies

102
Q

BIS and cerebral oximetry —

which is used to monitor level of consciousness?

which helps determine tissue perfusion?

A

BIS = monitor LOC

cerebral oximetry = monitor tissue perfusion, esp when there is potential for brain blood flow to be compromised

103
Q

it is difficult to resume stable autonomous electrical activity below ___º C after bypass

A

34º C

104
Q

what is the primary means of cooling and warming the CV patient?

what extra device is used during re-warming?

A
  • bypass pump is main method
  • forced air warmer should be used during re-warming to assist and also maintain temp following coming off pump
105
Q

how should temp be measured in CV surgery patients?

considerations for oliguric patients?

A
  • typically measured esophageal and bladder
  • rectal can be measured instead of bladder in oliguric patients bc bladder temp may be inaccurate
106
Q

T/F: cardiac output monitors are always beneficial

A

false

“only beneficial when the user understands what data is being derived, implications of how that data is applicable, and then can take that information and introduce it into the management therapy”

107
Q

examples of derived data from a cardiac output monitor

A
  • cardiac output
  • cardiac index
  • systemic vascular resistance
  • stroke volume
  • stroke volume variation
108
Q

T/F: modern cardiac anesthesia guidelines indicate the regular use of TEE for cardiac procedures

A

true

109
Q

data that can be seen from use of a TEE

A

real-time direct data on:

  • regional and global cardiac performance
  • volume status
  • valvular status
  • intra-cardiac air
  • aortic assessment
110
Q

why are TEEs becoming standardized for cardiac anesthesia?

A
  • sensitive to abnormalities
  • direct assessment capability
  • multi-faceted evaluation properties
111
Q

does TEE directly or indirectly assess volume and contractility?

A

directly

112
Q

what are the 4 classifications for regional wall motion?

A

normal

hypokinesis

akenesis

dyskinesia

113
Q

what is the utility of a PAC?

A
  • assess right and left heart function
  • assess volume status
  • assess cardiac output
  • assess pulmonary function
  • initiation of atrial/ventricular pacing
114
Q

consideration of PAC when going on bypass

A

catheter tends to advance when on bypass - withdraw the catheter 3-5 cm to avoid inadvertent wedging

115
Q

intra-op complications from use of PAC

A
  • looping
  • RBBB

this is just based on previous lectures but I think these are more assoc. with insertion?

116
Q

what could potentially occur in a patient with known LBBB during PAC placement?

interventions?

A

RBBB can occur in conjunction with LBBB causing complete heart block

requires immediate pacing and resuscitation

117
Q

this is stupid. so on the back there’s some tips for how to stay organized if ya wanna take a look.

A
  • label your shit
  • ensure vascular access points are clearly labeled, clearly connected, functional, and secured
  • build structure so that once patient is draped you are confident what is under drapes, how to access critical points, that connections are secure, that fragile points are padded
  • know what to do at any given point for any given crisis and how to initiate emergency therapy for the airway and resuscitation
118
Q

what are the 3 “keys to success” for cardiac anesthesia

A
  1. vigilance
  2. understanding of oxygen supply and demand
  3. proficiency in pharmacologic management
119
Q

when should antibiotics be administered?

A

prior to surgical inicsion

120
Q

optimal tidal volumes for CV surgery

A

6-8 ml/kg

121
Q

optimal ETT size for CV surgery patients

A

*bigger than average for more comfortable post-op ventilation (staying intubated & going to ICU)

males: 8.0-8.5
females: 7.5-8.0

122
Q

times during procedure that it might be required to suspend ventilation?

what might result?

A

sternotomy, surgical exposure, and visualization

may result in hypoxia, hypercapnia, systemic acidosis

123
Q

what ventilation strategies may be beneficial during peri-op time for CV patient?

A
  • recruitment maneuvers
  • PEEP
  • mild hypocapnia
124
Q

what is the long ass surgical sequence for cardiac procedures?

A
  1. access the heart
  2. collect the vein/artery or other anastomosis conduit
  3. ***heparin here!
  4. enable bypass and cannulation
  5. arresting the heart
  6. grafting new conduit to coronary artery vasculature
  7. restarting heart
  8. separating from bypass
  9. reversing coagulopathy and surgical packing
  10. closure
125
Q

complication of sternal saw

what measures must we take during use?

A
  • ….lung injury
  • vent must be disengaged with APL completely open to allow deflation of lungs away from sternum
126
Q

what three vessels are typically harvested for LAD circulation?

A
  • left internal mammary artery from chest wall
  • saphenous vein
  • radial artery
127
Q

what should the CRNA consider doing during mammary artery dissection?

A

decreasing tidal volumes to avoid lung pushing into field

128
Q

implications for internal mammary artery harvesting (3)

A
  • lungs can encroach into the surgical field - minimize tidal volumes
  • left art line may be dampened if retractor for internal mammary artery dissection compresses the subclavian artery
  • be aware of preexisting subclavian stenosis - precludes the use of internal mammary artery (bc its the origin of IMA)
129
Q

what is the most common vessel to harvest?

why is it the most common?

A

saphenous vein

its the most cosmetically appealing incision sites and yields multiple pieces of vein for implantation

130
Q

T/F: saphenous vein harvesting has a high amount of stimulus and must be done after sternotomy due to the amount of drugs required to blunt stimulation

A

false - minimally stimulating and may be initiated prior to sternotomy

131
Q

considerations for radial artery harvesting

why is this important?

A

don’t put an art line in the artery to be harvested - then we’ll piss off the surgeon

also put all the other vascular access and monitors on the opposite side

*typically done on the non-dominant side

132
Q

what medication might be administered post-bypass when the radial artery is harvested?

why?

A

calcium channel blocker - to prevent vasospasm of the radial artery and creation of a pseudo-coronary occlusion

133
Q

what is the next step in the sequence of surgical events after the conduit is obtained?

A

heparin is administered for bypass

134
Q

how is heparin ususally administered?

what lab is drawn after and the timing?

A
  • heparin adminstered in central access
  • TWO LABS! - ACT and ABG drawn 3-5 min after adminstration
135
Q

where are the bypass cannulas placed?

what should we do to pts BP and why?

A

cannulas placed in ascending aorta and right atrial appendage/RA/IVC

SBP should be dropped to 90-100 to avoid wall tension on aorta during cannula insertion

136
Q

next step in sequence of events after cannulas placed?

A

cardioplegia device (needle and tubing) is inserted into the aorta

137
Q

FYI - dissection, false lumen, improper placement, etc. of the aortic cannula may result in the inability to deliver blood back to the patient

A

bc its gotta be in the real aorta ya know

138
Q

FYI - improper placement of the venous cannula can result in venous engorgement, obstructive compartments such as SVC syndrome, and increased risk for stroke and tissue damage

A

bc its gotta get out of the body ya know

139
Q

we all know that bypass means the patient has blood diverted from their heart to the pump to do the work instead

A

next

140
Q

what ventilation/volatile differences are there when the patient goes on bypass?

A

ventilation is discontinued

volatile is added by the perfusionist to the bypassed blood to maintain GA instead of being delivered into pts lungs

141
Q

what drugs are typically redosed when the patient goes on bypass?

A

amnestic

narcotic

muscle relaxant

142
Q

why are patients cooled when on bypass?

A

to reduce body and brain metabolism

143
Q

what is the purpose of an aortic cross clamp?

A

to isolate coronary blood flow

144
Q

where is the cardioplegia device placed?

A

between the aortic valve and aortic cross clamp - “aortic root”

solution flows down through the coronaries and stops the heart

145
Q

what areas of the body do not recieve oxygenated blood while on bypass?

A

ONLY the coronaries

146
Q

what temperature is the heart reduced to while stopepd?

why is it cooled?

A

usually 10-15º C

coolness decreases the metabolism & cardioplegia arrests the heart

147
Q

is systemic cooling done for systemic protection, cardiac protection, or both?

A

only systemic protection - only provides a small effect on heart

*cardiac cooling is for cardiac protection

148
Q

what is an indicator of satisfactory delivery of cardioplegia to the coronaries - aside from the obvious that the heart stops

A

decreased temperature of heart muscle distally

149
Q

what could cause an incomplete arrest and maintained metabolism after administration of cardioplegia?

whats an intervention to fix this issue?

A

abnormal coronaries

can place catheter in coronary sinus and deliver cardioplegia to the distal tissue in reverse flow

150
Q

what comes next in the sequence of events after adminstraiton of cardioplegia and arrest of the heart?

A

grafting of the coronaries

complete with proximal attachment to the aorta

151
Q

what comes next in the sequence of events after coronary grafting is complete?

A

rewarming and removal of aortic cross clamp

152
Q

what causes the heart to start beating again?

A
  • cross clamp is removed, allowing blood to flow into coronaries
  • cardioplegia is washed away and the heart rewarms
  • the heart starts itself - but no blood is moving through it
153
Q

what medications are administered after removal of the cross clamp to address hyperkalemia and reperfusion dysrhythmias?

A
  • lidocaine
  • calcium
  • magnesium
154
Q

what interventions are taken to achieve rate and contractility control after aortic cross clamp is removed?

A
  • vasoactive infusions
  • pacer
155
Q

how to reinstate ventilation after removal of cross-clamp

A

manually inflate lungs with careful recruitment to avoid overpressurizing and damaging lungs

ensure both lungs are ventilating

156
Q

how is blood put back in the heart when trying to come off bypass?

(slow or all at once?)

A

pump is partially clamped to allow blood flow into heart

pump outflow is gradually weaned as patient’s cardiac output tolerates (inotropes often used)

157
Q

what are we assessing for when using a TEE to wean off pump?

A
  • absence of intra-cardiac air
  • intra-cardiac volume
  • contractility
  • valve function (if valve procedure was done)
158
Q

when is protamine administered?

A

once the heart is pumping well and cannulas are removed

159
Q

what lab is drawn after protamine is given?

what are we looking for?

A

ACT - verifying pre-bypass coagulation

160
Q

speed of protamine adminstration?

why?

considerations?

A

administer slow since it can tank BP

have phenylephrine ready

161
Q

how is cardiac function assessed after separation from pump and protamine adminstration?

A

doppler signal

162
Q

what is the next step in the sequence of events after pump separation and verification of proper cardiac function/controlled bleeding?

A

pleural and mediastinal chest tubes placed

closure of sternum

163
Q

considerations and complications during sternal closure

A
  • manually ventilate to avoid hyperinflation and potential injury from sternal wire
  • watch airway and right heart pressures
  • chest closure could cause right heart compression and cardiac collapse
  • lung recruitment after closure is a cool thing to do
164
Q

what is required for patient transport post-op?

A
  • oxygen
  • monitoring
  • ventilation device
  • emergency meds that would allow for reintubation if necessary
  • emergency meds that can manipulate pressure and HR (need meds to raise and lower)
  • ability to institue pacing if EKG has been abnormal or if valve surgery
165
Q

goal time for extubation post-op?

benefits associated? (5)

A
  • less than 8 hours
  • shorter ICU stays
  • shorter hospital stays
  • decreased cost
  • lower infection rates
  • less complications
166
Q

suggestions for how to facilitate timely post-op extubation?

A
  • avoid post-op muscle relaxants
  • consider reversal of muscle relaxant
  • utilize short acting narcotics
  • utilize short acting sedatives (propofol/dexmedetomidine/midazolam better than lorazepam/diazepam)
167
Q

what is the average prime volume for a bypass pump?

A

1.5 L

168
Q

effects of priming the pump with crystalloid

A
  • reduced viscosity (good)
  • diluted H/H (bad)
  • decreased O2 carrying capacity (obvi bad)
  • larger Vd can dilute meds - need to redose

*pt more likely to need transfusions if crystalloid primed pump

169
Q

you think your patient has an ATIII deficiency. what can you administer to allow them to anticoagulate properly?

A
  • administer exogenous ATIII or FFP (contains ATIII)
  • then give additional heparin dose

*if low ATIII, heparin has nothing to act on

170
Q

techniques for blood conservation when patient needs procedure that requires CBP?

what are two examples he gave of patients that would benefit from these techniques?

A
  • autologous blood banking (pt will get their whole blood back vs just PRBCs with cell saver)
  • autologous hemodilution and re-transfusion
  • retrograde autologous priming (RAP) of bypass pump

good for dialysis pts that wont tolerate 1.5 L of extra fluids or Jehovah’s witness that cant accept blood

171
Q

what device is necessary to allow for cardioplegia to flow into the coronaries?

A

aortic cross clamp

172
Q

good and bad effects of cardioplegia during bypass?

A

good: stops the heart, cools the heart
bad: removes oxygen supply

173
Q

what body temperature allows for benefit of myocardial and systemic metabolism reduction and results in superior neurologic recovery?

A

28º C

174
Q

describe antegrade cardioplegia delivery

A

cardioplegia introduced into aortic root and flows through the coronary arteries in the direction of normal blood flow

175
Q

describe retrograde cardioplegia administration

when would it be useful?

A

cardioplegia introduced into coronary sinus (venous) where it flows backwards through the coronary arteries and exits into the aorta

*useful when blockage would obstruct spread of cardioplegia if given antegrade

176
Q

classic fluid management for CV surgical cases involves what three components?

A
  • calculating fluid deficits
  • hourly maintenance
  • third space losses
177
Q

how long does it take the patient’s entire blood volume to cycle through the bypass machine?

A

1 min

178
Q

current trend is to minimize crystalloids to less than what prior to bypass?

A

< 1 L

179
Q

FYI - reason for all the access is for post-op administration of blood/crystalloid/colloids but we’re limiting fluid pre-op

A

🙄

180
Q

goals for aortic valve stenosis

A
  • full preload
  • avoid tachycardia
  • maintain perfusion pressure with afterload maintenance
181
Q

goals for aortic valve regurg

A
  • full preload (may already be in overload)
  • maintain rate
  • decrease afterload
182
Q

goals for mitral stenosis

A
  • full preload
  • avoid extreme increase in afterload, but maintain
  • maintain contractility
  • avoid tachycardia
183
Q

goals for mitral valve regurg

A
  • full preload (may already be in overload)
  • decrease afterload
  • maintain rate
184
Q

what is the BIG difference in management of CABG vs aortic dissection?

A

timing - aortic dissection needs to be in OR ASAP

*mortality in ascending dissection increases 1-2% per hour after onset of symptoms

185
Q

ascending vs descending aortic dissection —

which needs surgical treatment?

which can have medical or surgical treatment?

A

ascending = surgery

descending = medical or surgical

186
Q

where does a descending aortic dissection occur?

A

distal to the L subclavian

187
Q

inital pre-surgical interventions we need to take for an aortic dissection patient (4)

A
  • avoid HTN
  • manage contractility (may be influenced by decreased coronary perfusion, dissection, or tamponade)
  • prep for circulatory arrest
  • obtain significant vascular access
188
Q

what are three ominous signs in an aortic dissection patient?

what can they indicate?

A
  • cerebral changes = diminished blood flow to brain
  • coronary symptoms = diminished blood flow to myocardium
  • changes in peripheral motor function = diminished blood flow to spinal cord
189
Q

what are the 2 indicators of severe aortic dissection progression?

A
  • cardiac tamponade
  • acute aortic valve insufficiency
190
Q

T/F: you can take your sweet ass time getting your aortic dissection patient into the OR

A

false

191
Q

minimally invasive cases:

____ invasive incision

____ invasive anesthesia

A

minimally invasive incision

maximally invasive anesthesia

192
Q

do minimally invasive procedures involve sternotomy?

A

~no~

*wow, shocking

193
Q

three approaches/procedures that can be done during a minimally invasive cardiac procedure

A
  • coronary bypass
  • valve repair
  • valve replacement
194
Q

***idk what this means***

what extra anesthesia responsibility would we have in a minimally invasive cardiac surgery?

A

facilitating the portions in a non-visualized fashion

***what***

*also have no idea what this means, must be something only DS could understand*

195
Q

difference in ventilation strategy in minimally invasive CV procedure? why?

A

one lung ventilation

to allow surgical access to the heart through the pleural space

196
Q

how is cardioplegia adminstered in a minimally invasive procedure?

A

retrograde

placement of a coronary sinus catheter via CVL

197
Q

what types of surgical catheters are used during minimally invasive procedures?

how do we verify placement?

A
  • femoral arterial cannula
  • femoral venous cannula
  • aortic endoclamp
  • pacing PA catheters

*placement verified with TEE

198
Q

do patients having a minimally invasive cardiac surgery go on bypass?

A

yep - give em heparin

199
Q

what is the premise of an off-pump CABG?

A

the coronary grafts are placed via routine sternotomy but without arresting the heart or going on cardiac bypass

200
Q

what is one component of off-pump CABG that impacts anesthesia?

how do we try to manage this?

A
  • the surgical need to stabilize heart for surgical access but in such a way that filling and ejecting is not compromised
  • often requires:
    • volume management
    • pharmacologic support
    • frequent communication with the surgeon
201
Q

EKG and TEE monitoring is recommended for off-pump CABG due to increased heart stress and risk for ischemia.

what might make these sub-optimal assessments?

A

mechanical displacement of the heart

202
Q

during off-pump CABG, what can be beneficial during periods of stress to fill the heart that impeded from natural filling?

A

fluid boluses

Trendelenburg position

203
Q

what monitoring device is “imperative” during off-pump CABG?

A

“an accurate and perfectly functioning artline”

🙄🙄🙄

204
Q

do off-pump CABG pts receive heparin?

if yes - goal ACT?

A

yep - idk why though

>300

205
Q

what is an ideal vessel for grafting in off-pump CABG?

why?

A

internal mammary artery

b/c it doesn’t require proximal anastomosis (has native blood supply)

(a vein graft from aorta to heart requires partial clamp of the aorta and increases the risk of neurologic event)

206
Q

advantage and disadvantage of off-pump CABG

A
  • advantage: the lack of bypass effects (dilution, capillary permeability, renal, inflammatory etc)
  • disadvantage: risk of ischemia from stress without the “rest” of bypass
207
Q

indications for balloon pump (3)

A
  • presence of ischemia
  • potential ischemia
  • poor cardiac output requiring augmentation
208
Q

relative contraindications for balloon pump (3)

A
  • aortic disease
  • aortic valve disease
  • surgical insult to the aorta
209
Q

how does a balloon pump work?

A
  • a balloon inflates during diastole
  • that increases proximal aortic pressure and thus coronary perfusion pressure
  • deflation just prior to systole allows the heart to have a decreased workload requirement to eject blood
210
Q

ideal placement of a balloon pump?

how to verify placement?

A

balloon tip distal to the left subclavian artery

verify with TEE or fluoroscopy

211
Q

goal of using a balloon pump?

A

improve coronary perfusion

decrease cardiac workload

*may O2 supply > O2 demand

212
Q

what do we monitor in a patient with a balloon pump?

A

distal pulses &

UOP

213
Q

diastolic goals with balloon pump

(not number, but general goal)

A

augmented diastolic pressure should exceed the unassisted systolic pressure

214
Q

what does the shaded portion represent?

A

balloon pump inflation

215
Q

what is an impella (Abiomed) device?

how does it work?

A
  • ventricular assist device
  • device sits in LV, and blood is siphoned into the pump catheter and pumped into the aorta on the distal side of the aortic valve
216
Q

who might benefit from an impella (Abiomed) device?

A

support of the LV during

  • acute MI
  • cardiogenic shock
  • post-bypass
217
Q

what is a Tandem Heart?

functional difference in it vs an impella?

A

ventricular assist device

can add an oxygenator to it unlike in the impella (aka tandem lung!!!!)

218
Q

what is a TAVR procedure?

A

transcatheter aortic valve replacement — placement of an expandable valve inside the native aortic valve

*not considered true valve replacement since native valve remains

219
Q

how is the new valve placed in a TAVR?

A
  • valve is threaded over a guidewire from either the trans-apical (of the LV) or from the distal aortic route (via femoral artery)
  • once the valve is positioned inside the native valve, rapid ventricular pacing is initiated to minimize cardiac output
  • valve is then expanded and deployed by balloon expansion and begins to function
220
Q

indication for TAVR

A

severe aortic valve stenosis

221
Q

anesthetic implications for TAVR procedure (6)

A
  • current co-morbidities
  • heparinizing
  • impaired hemodynamics
  • intra-operative TEE
  • management of complications
  • type of anesthesia

all of which may become intensive and dynamic

222
Q

what type of anesthesia technique is classically used for TAVR?

what is becoming trendy?

A

classic = GA

~*~trendy~*~ = MAC

223
Q

T/F: TAVRs are often very sucessful and potential complications are not a big deal

A

false —

“while often very successful, the complications of the surgery may be catastrophic”

true dat

224
Q

if using the transapical approach for TAVR procedure, what is the location for balloon insertion?

~ obvi apical area but be specific

A

5th intecostal space mid-clavicular line

typically where point of maximal impulse is

225
Q

what is the purpose of hypothermic circulatory arrest?

A

to way cool the body to decrease CMRO2

-to prevent exsanguination if the aorta can’t be clamped before opening it, to decrease metabolic demand and preserve tissues

226
Q

ideal time limit for circulatory arrest

A

15-20 min max

227
Q

what should the CRNA remeber & anticipate in a case where hypothermic circulatory arrest is indicated?

A

remember:

  • meds cant be given when their blood aint pumpin, so give ur drugs early
  • pad all the bony things real good
  • cold body = platelet inactivation, vasodilation (???), etc. (???)

anticipate:

  • severe vasodilation (pt 2 ???)
  • coagulopathy
  • pump failure
228
Q

pros/cons of etomidate for induction of cardiac surgeries

A

pros: hemodynamic stability
cons: adrenal suppression

229
Q

pros/cons of propofol in CV surgery

A

pros: decreased SVR
cons: avoid if cardiac frailty

230
Q

pros/cons of ketamine in CV surgery

A

increased HR and BP are both pros and cons - useful in some patients but detrimental to CAD patients

S5 - Principles III - Test 3 (3 decks)

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