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N934 Adv Principles Fa 21 > Cardiac Anesthesia Part 1 continued and Part 2 > Flashcards

Cardiac Anesthesia Part 1 continued and Part 2 Flashcards

1
Q

what are the beneficial effects of mannitol as part of the pump prime solution

A

acts as an O2 free radical scavenger and a diuretic

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2
Q

what does hemodilution mean in relation to catecholamines

A

it also means a decrease in catecholamines

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3
Q

define the blood salvage strategy

A

mix the patients autologous blood with the prime solution

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4
Q

what does the LV vent do

A

drains thesbian veins

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5
Q

where does anterograde cardioplegia catheter go?

A

in the aortic root and sits proximal to cross clamp

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6
Q

where does retrograde cardioplegia catheter go?

A

coronary sinus

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7
Q

which comes first, cardiac arrest or cross clamp?

A

heart is arrested in diastole then cross clamp is applied. this is to ensure cardioplegia goes to the heart

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8
Q

what is long pump time associated with (neuro)

A

postoperative cognitive disorder

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9
Q

what are risks associated with postoperative renal dysfunction after bypass (6)

A

age, preexisting CKD, long pump time (>1h), DM1, nephrotoxic agents, vascular pathology

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10
Q

there is an activation of what and an increase in these two things on bypass

A

activation of extrinsic and intrinsic pathways

increase in angiotensin and free O2 radicals

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11
Q

when do you start re warming the patient

A

after seeing the last distal graft in. turn on warming blanket at this time

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12
Q

how long does it take to re warm a patient safely

A

30-40 minutes or about 1 degree celsius q3-5 minutes

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13
Q

where do you want to keep the BG to prevent infection

A

<200

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14
Q

how many joules for defibrillation after removal of cross clamp?

A

10-30 joules ( you may dial this in)

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15
Q

when do you start to turn on fluids and pressors while coming off of bypass

A

after lung reinflation (and de airing maneuvers), before cross clamp removal

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16
Q

what is an acceptable HCT while coming off pump

A

25-28

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17
Q

what do you give to decrease K

A

500mg CaCl

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18
Q

what do you give to prevent arrhythmias and decrease risk of afib

A

2-4g magnesium

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19
Q

special considerations if they did an internal mammary artery (/thoracic artery) to LAD while coming off bypass?

A

when inflating lungs, you can overstretch anastomosis easily. be aware

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20
Q

complications to aortic cross clamp (3)

A

hemorrhage (at cannulation site)
dislodgement of atheromas (clots)
aortic dissection

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21
Q

what do ST changes tell you as you are unclamping the aortic cross clamp?

A

tells the surgeon to look at the TEE for infarct versus air

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22
Q

when is the patient at the most risk for recall during CPB surgery

A

graft harvest, sternotomy, rewarming

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23
Q

dont give protamine until

A

all catheters are out. you want to make sure you do NOT have to go back on bypass

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24
Q

if the cardiac output is decreased but the blood pressure is ok, what would you consider

A

after load reduction or inotrope

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25
Q

how slowly do you give protamine

A

over 20-30 minutes

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26
Q

which ACT number would alert you that they need protamine

A

> 150

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27
Q

type 1 reaction from protamine

A

histamine release. slow the protamine, give volume, give neo/ephedrine PRN

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28
Q

type 2 reaction from protamine

A

IgE mediated, more like anaphylaxis but “not too problematic”. bronchoconstriction can occur

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29
Q

type 3 reaction from protamine

A

heparin protamine complex that lodges in pulmonary circulation. bad. not good.

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30
Q

do you give protamine via CVC or PIV

A

always PIV, never CVC

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31
Q

if you see a drop in BP during chest closure, what should you consider administering

A

an inotrope

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32
Q

typical heart transplant recipient picture

A 
NYHA functional class IV with a predicted life expectancy <12 months
EF <20%
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33
Q

most common indication for a heart transplant

A

idiopathic cardiomyopathy

34
Q

contraindications to receiving a heart transplant

A

> 70 years old, chronic renal dysfunction, obesity

35
Q

how is the anesthetic management timed for a transplant recipient

A

timed so CPB initiated when heart is available

36
Q

what to look for pre op with heart transplant recipients

A

VAD, IABP, ICD, inotropic drug infusions

37
Q

what type of induction, standard versus RSI for the transplant recipient?

A

RSI, considered full stomach since you “never know when youre receiving a heart”.
you want smooth rapid control of airway but do slow administration of medications

38
Q

goal before heart arrives

A

get patient on CPB as fast as possible

39
Q

when do you place lines on a heart recipient

A

before induction

40
Q

maintain these three things to maintain CO for a heart recipient

A

HR and intravascular volume maintenance.

avoid a decrease in SVR

41
Q

what do these patients take for an immunosuppressant protocol

A

high dose steroid and immunosuppressant drug

42
Q

most common reason for inability to wean from CPB

A

right hear failure

43
Q

medications you need to anticipate requiring for heart transplant

A

isoproterenol, epinephrine, phosphodiesterase inhibitors (milrinone), nitric oxide, inhaled prostaglandins

44
Q

vasopressin in relation to SVR and PVR

A

preserves SVR without effect of PVR

45
Q

post heart transplant HR

A

faster due to loss of parasympathetic tone

46
Q

which receptors do you need to target for a post heart transplant patient to see an effect

A

need direct action on myocardial adrenergic receptors. basically make sure all of your drugs are direct acting

47
Q

what are post heart transplant patients dependent on

A

volume (preload)

48
Q

does the frank starling mechanism still apply post heart transplant to a denervated heart

A

yes

49
Q

what are these heart transplant patients at risk for and how do they present

A

accelerated atherosclerotic disease. they dont have angina but will get arrhythmias

50
Q

will you see bradycardia from fentanyl and anticholinergics in a denervated heart

A

no

51
Q

are all reflexes post transplant gone?

A

no, some reflexes will be maintained

52
Q

describe an off pump CABG (OPCAB)

A

immobilization of the heart by compression and/or suction of vessels theyre looking to treat

53
Q

how to prevent hypotension and reduced coronary perfusion during an OPCAB

A

volume load
head down
pressors
-theres alot of hemodynamic changes with this approach so youre doing alot of utilization of these three mechanisms during this approach

54
Q

what to consider as a negative effect of suction during OPCAB

A

can compromise native coronary artery flow

55
Q

monitors and equipment to have during OPCAB

A

still use TEE

have bypass on standby

56
Q

do you do heparin during OPCAB

A

may use low dose heparin

57
Q

do you still do a sternotomy for an OPCAB

A

yes

58
Q

describe a minimally invasive direct coronary bypass (MIDCAB)

A

grafting of single vessel ex) LIMA to LAD

59
Q

what is the surgical approach to a MIDCAB

A

you can do this alot of ways including left anterior thoracotomy incision requiring one lung ventilation or even a Da Vinci approach

60
Q

ventilation strategy for a MIDCAB?

A

lung isolation with double lumen ETT

61
Q

is a MIDCAB an on pump case?

A

no, off pump for this case

62
Q

MIDCAB HR, preload, Vt considerations

A

decrease HR to decrease VO2
increase preload
decrease Vt if not OLV

63
Q

what medication should you have available for a MDICAB?

A

heparin

64
Q

what should you have on the patient during a MIDCAB

A

defibrillation pads (and bypass on standby)

65
Q

describe the surgical approach to a minimally invasive aortic and mitral valve replacement

A

can either do parasternal, thoracoscopy, partial hemisternotomy

66
Q

where does the bypass insert on a patient receiving a minimally invasive aortic/ mitral valve replacement

A

femoral artery/femoral vein. there is apparently decreased bleeding related to this approach

67
Q

access for a mini AVR and MVR procedure?

A

CVC

68
Q

ventilation for a mini AVR and MVR procedure?

A

OLV/ DLT for lung isolation

69
Q

two things to have on patient during mini AVR and MVR

A

transvenous pacers placed and tested

defibrillator pads

70
Q

where else can a TAVR/TAVI be done

A

EP

71
Q

approach to a TAVR/TAVI?

A

femoral artery or transapical (apex of LV)

72
Q

anesthesia technique for TAVR/TAVI

A

can do IV sedation but usually GETA

73
Q

access for a TAVR/TAVI?

A

large bore PIV, aline, CVC

may need fluoro to put in lines

74
Q

TTE or TEE for TAVR/TAVI?

A

TEE if GETA, TTE if IV sedation

75
Q

what should you have on the patient getting TAVR/TAVI

A

defibrillator pads

76
Q

medications to have on standby during TAVR/TAVI

A

pressors

77
Q

blood consideration strategies in cardiac surgery include (6)

A 
antifibrinolytic drugs
minimizing hemodilution
cell saver
retrograde priming of pump
normovolemic hemodilution
use of POC testing to support transfusion
78
Q

platelet function is altered by these three things during cardiac bypass surgery

A

hemodilution
hypothermia
contact with CPB circuit

79
Q

right ventricular dysfunction or failure may occur after CPB because of

A

inadequate myocardial protection or

inadequate revascularization with resultant RV ischemia

80
Q

approaches to reduce inflammatory response during cardiac surgery

A

modification of surgical and perfusion techniques
circuit components
pharmacological strategies

81
Q

even after uncomplicated cardiac surgery, a midline sternotomy (or thoracotomy) causes a significant reduction in these 3 pulmonary components

A

TLC, VC and FEV

N934 Adv Principles Fa 21 (23 decks)

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