Cardiac anesthesia Part 2 Flashcards
Priority status for heart transplant is given to:
- ABO compatibility
- body size match
- Distance from donor center
From retrieval to reimplementation, a heart is good for
4 to 6 hours
The typical heart transplant recipient is
NYHA functional class IV with a predicted life expectancy of <12 months. EF <20%
The most common indication for heart transplant is
idiopathic cardiomyopathy
Contraindications for the recipient to receive a heart transplant include
greater than 70 year old
chronic renal dysfunction
obesity
Anesthetic management for heart transplantation is timed so
CPB is initiated when the heart is available
Pre op considerations for heart transplantation includes
VAD, IABP, IC, inotropic drug infusions
The goal of heart transplantation management is to
go on CPB as fast as possible
Induction considerations for heart transplant include
considered full stomach
lines prior to induction
smooth rapid control of airway
slow administration of medications
Anesthetic management for heart transplantation includese:
maintain HR & intravascular volume, avoid decrease in SVR
adhere to immunosuppression protocol; high dose steroid & immunosuppressant drug
The most common reason for inability to wean from CPB is
right heart failure
Drugs that should be available for heart transplantation includes
isoproterenol, epinephrine, phosphodiesterase inhibitors (milrinone), nitric oxide, inhaled prostaglandins
________ may be used for heart transplantation to preserve SVR without effect on PVR
Vasopressin
After heart transplant, patients may still be prone to
accelerated atherosclerotic disease–> no angina
arrhythmias may be a sign of disease
After heart transplant, patients are ________ as a result of _______
volume dependent (preload dependent) as a result of denervation of donor heart during retrieval -Frank Starling mechanism still functions
Loss of parasympathetic tone post heart transplant results in
faster resting heart rate
-requires direct action on myocardial adrenergic receptors
After heart transplant, the CRNA should have
direct acting vasoactive agents, both inotropes and vasoconstrictors available for HR, BP, & CO control
Off pump CABG is
immobilization of the heart by compression and/or suction
The goal of off pump CABG is to
prevent hypotension and reduced coronary artery perfusion by
- volume load
- head down
- pressors
Minimally invasive direct coronary artery bypass is grafting of
single vessel; LIMA to LAD
Minimally invasive direct coronary artery bypass includes
lung isolation with double lumen endobronchial tube
off pump case
left anterior thoracotomy incision
Procedure notes for mini AVR & MVR procedures include
DLT for lung isolation femoral cannulation transvenous pacing- placed and tested pads on central venous access
The approach for a TAVR/TAVI includes
femoral artery or transapical (apex of left ventricle)
Essential components for TAVR/TAVI include:
IV sedation or GETA large bore IV, art line, central access TEE or TTE (transthoracic echo) external defibrillator pads (R2 pads) vasopressors
Complications of TAVR/TAVI include
strokes
cardiac tamponade
rupture
renal dysfunction
Platelet function is lost or altered by
hemodilution, hypothermia, and contact with CPB circuit
No single anesthetic “recipe” is suitable for
all patients undergoing coronary artery bypass graft; consider underlying pathology
Blood conservation strategies in cardiac surgery include
antifibrinolytic drugs, minimizing hemodilution, cell saver, retrograde priming of pump, normovolemic hemodilution, use of POC testing to support transfusion
__________ hemostatic pathway(s) are activated
extrinsic & intrinsic
_________ may occur after CBP because of inadequate myocardial protection or inadequate revascularization with resultant right ventricular ischemia
right ventricular dysfunction or failure
Numerous clinical approaches have been show to measurably reduce the inflammatory response in cardiac surgical patients including
modification of surgical & perfusion techniques
circuit components
pharmacologic strategies
Even after uncomplicated cardiac surgery, a midline sternotomy (or thoracotomy) causes a significant reduction in
total lung capacity, vital capacity, and forced expiratory volume
-will need to use Incentive spirometer
CNS insults have decreased to <2% and causes include
micro-emboli
cerebral hypoperfusion
SIRs
The following increase the risk of postop renal dysfunction
renal insufficiency
DM type I
vascular pathology
nephrotoxic agents
Randomized trails comparing off-pump CABG with on-pump CABG have
not found convincing or consistent evidence to support one approach over another
