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Cardiac Disease Flashcards

1
Q

Only require standard monitoring
Early cardiac eval
Antibiotic prophylaxis during l&d

A

For congenital heart disease

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2
Q

4 major defects with ToF

A
  • RV outflow obstruction
  • VSD
  • RV hypertrophy
  • overriding aorta
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3
Q

Anesthetic goals with TOF

A

Maintain SVR to prevent increased RL shunt (phenylephrine)

Maintain venous return - high filling pressures that improve RV output and pulmonary blood flow

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4
Q

Preferred anesthetic with ToF

A

Epidural analgesia

Spinals do not maintain SVR and want to maintain intravascular volume

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5
Q

What does ToF look like repaired?

A

Asymptomatic
VSD closed
Widening pulmonary outflow tract
Small VSD may recur or hypertrophy of outflow tract

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6
Q

VSD and ASD (left to right shunts) repaired =

A

No problem

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7
Q

T or F small asymptomatic VSD and ASD tolerate labor

A

T

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8
Q

What does pain do to VSD/ASD

A

Increases SVR increasing L to R shunt and causing pulmonary hypertension

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9
Q

What anesthetic management is preferred for VSD/ASD

A

Epidural decreases SVR and decreases L to R shunt

Slowly to prevent rapid decrease in SVR causing a R to L shunt, cyanosis, hypoxemia

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10
Q

VSD/ASD all have…

A

Increased risk of systemic emboli
All air out of IV lines (LOR with air should not be used with epidural)
Mild hypoxemia leads to increased PVR thus R to L shunting
Supplemental O2

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11
Q

What is seen in large VSD/ASD

A

Pulmonary HTN and increased pulmonary blood flow

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12
Q

Anesthetic management for large VSD/ASD

A

A-line, PAC
Avoid HR increase and increase/decrease SVR and PVR
Pain control
Titrate epidural slowly
CSE only with intrathecal opioids (minimizes decrease in SVR)

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13
Q

Development of eisenmenger’s syndrome

A
  • chronic pulmonary overload from uncorrected L to R shunt = Pulm HTN
  • initially shunt is bidirectional, SVR and PVR determine direction
  • pulmonary HTN irreversible, shunt flow reverses
  • R to L shunt, PAP exceed systemic
  • hypoxia
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14
Q

Eisenmenger syndrome becomes _____ to ______

A

Acyanotic to cyanotic

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15
Q

Eisenmenger’s effects on pregnancy

A

Don’t tolerate pregnancy well
Decreased SVR may increase shunt
Decreased FRC and increased O2 consumption exacerbates hypoxemia
Compromised O2 to fetus

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16
Q

Anesthetic management for eisenmenger’s syndrome

A 
Regional to decrease catecholamines
Supplemental O2
Pulse ox, a-line
CVP for maintenance of preload
PAC not recommended, difficult insertion and pulmonary HTN
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17
Q

Regional management considerations in ES

Epidural, CS, CSE

A

Epidural - higher concentrations of LA and used for labor, some motor block to prevent pushing and straining that will increase workload of heart
CS - intrathecal opioid dosing 1st stage, minimizes hemodynamic changes, small doses of LA in stage 2, high incidence of PDPH
CSE- adequate analgesia with minimal hemodynamic effects, intrathecal opioids then small doses or dilute doses of LA ropi or bupi via epidural, continuous monitoring, phenylephrine infusions to treat SVR

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18
Q

Why is epidural preferred for ES

A

Prevent sudden drop in svr
Slow epidural level
Avoid chloro

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19
Q

Why is single shot spinal not recommended for ES

A

Precipitous hemodynamic changes

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20
Q

GETA considerations for ES

A
  • decreased venous return with PPV problematic
  • slow induction (no RSI) high dose opioids for cardiac stability
  • risk of aspiration takes a back seat, aspiration prophylaxis, cricoid pressure, no RSI/quick intubation
  • neonatal respiratory depression is a consequence of high dose opioids
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21
Q

PP goals with ES

A

Risks of mortality still persist
ICU for 24-48 hours
Prophylactic anticoag

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22
Q

AS usually results from

A

Congenital bicuspid valve or rheumatic heart disease

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23
Q

What are the recommendations for moderate to severe AS in pregnancy

A

Replacement before conception

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24
Q

With cardiac changes happen with pregnancy and AS

A

Increased CO, O2 consumption

Decreased SVR

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25
AS ob management
CO increased by increased HR (fixed SV) Tachycardia is decreasing diastolic coronary perfusion and increases myocardial O2 demand Increased CO in labor and delivery further increases risk Increased LVEDP and LV hypertrophy Decreased myocardial perfusion Decreased coronary filling during diastole and decreased perfusion to LV hypertrophy Increased risk of MI Vaginal and instrument assisted delivery preferred to avoid valsalva and pushing CS also preferred to avoid hemodynamic stress of labor
26
AS anesthetic management
NSR Tachycardia not well tolerated, fixed SV, atrial kick contributes 40% to ventricular filling and CO SVR avoid severe drops to ensure myocardial perfusion Venous return maintain EDV and LV SV A-line PAC or CVP consideration
27
Analgesia for L&D AS
``` Slow titration of epidural Phenylephrine over ephedrine Intrathecal opioids CSE Continuous spinal same as ES Invasive monitors ```
28
Regional considerations for AS
No single shot spinal Preferred is slow epidural or continuous spinal w. Invasive monitors CSE with spinal opioids and slow epidural later Phenylephrine > ephedrine
29
GA considerations for AS
Induction use etomidate, opioids, sux (slower induction, mod RSI) Inhalation decreases SVR and increases myocardial depression High dose opioids are better (infant will need resuscitation)
30
AS PP concerns
Increased CO = decompensation Careful Fluid management Analgesia to avoid tachycardia Invasive monitoring 24 hours post op
31
Most common cause of chronic AI
Rheumatic heart disease Endocarditis can also cause it
32
AI characteristics
LV volume overload from regurg LV hypertrophy and dilation; function declines Pulmonary edema Changes occur over many years with chronic insufficiency - asymptomatic
33
Mild/moderate AI and pregnancy
Beneficial Decreased SVR improving forward SV Increased HR less time for diastolic filling and smaller EDV
34
Severe AI and pregnancy
Decline in LV function | Extensive management
35
AI anesthetic management
``` Analgesia avoids pain and increased SVR Epidural ideal PAC recommended for severe Maintain preload, avoid hypotension Ephedrine! Tachy is good, brady and increased SVR are bad GA: mild/moderate tolerates RSI, severe slow induction, high dose opioids Avoid myocardial depressants ```
36
Most common lesion associated with RHD
MS
37
T or F first symptoms of MS occur in pregnancy bc precipitation of CV changes of pregnancy
T
38
Why do you want to avoid increased CO/HR in MS
Pulmonary edema
39
Cardiology management of MS
BB to maintain slow HR | A-fib detrimental, aggressive therapy of dig BB and cardioversion
40
Mild/moderate MS and pregnancy
Tolerates labor well | Invasive monitoring not warranted
41
Severe MS
PAC Avoid fluid overload increased risk of pulmonary edema Instrument assisted vaginal delivery usually planned (avoid valsalva) CSE or continuous spinal with opioids for first and low dose LA for second stage
42
Regional considerations with MS
``` Epidural preferred Analgesia Dense block for instrument assisted CSE, epidural, CS Phenylephrine > ephedrine ```
43
GA considerations with MS
RSI or high dose opioids based on ventricular function BB with RSI to avoid tachycardia and HTN Remi for hemodynamics and minimize neonatal depression Avoid large fluid intake
44
PP for MS
Monitor for 24 hours Continue epidural - increased preload associated with resolution of sympathectomy will not coincide with pp increased preload
45
What causes mitral insufficiency
RHD and MV prolapse
46
What is seen in mitral insufficiency
Dilation of LA and increased LAP
47
MI has an increased risk of what during pregnancy
A. Fib
48
Incidence of pulmonary edema and pulmonary HTN is higher or lower than with stenosis
Lower
49
T or F decreased SVR and increased HR are advantageous to MI patients
T
50
Most MI patients tolerate pregnancy well T or F
T
51
Considerations for mitral insufficiency and L&D
Epidural Avoid increased SVR and valsalva Instrument assisted delivery Decreased SVR reduces regurg, improves forward flow, decreases likelihood for pulm edema
52
CS considerations for mitral insufficiency patients
Epidural Ephedrine GA decreases afterload and slightly increases HR, avoid myocardial depressants
53
Hemodynamic goals for AS and AI
AS- normal HR and rhythm, avoid decrease in SVR, normal venous return AI: normal to mild increase in HR, avoid increase in SVR
54
Hemodynamic goals for MS and MI
MS: slow HR and SR, normal SVR, normal venous return MI: SR and normal to increase HR, avoid increase in SVR and venous return
55
Definitions for peripartum cardiomyopathy
- HF in the last month of pregnancy or within 5 months of delivery - absence of identifiable cause of HF - absence of recognizable heart disease prior to last month of pregnancy - LV dysfunction via echo (decreased EF)
56
Peripartum cardiomyopathy risk factors
``` Advanced maternal age Multiparity Obesity Multiple gestation Pre-eclampsia Chronic HTN African american ```
57
Etiology for peripartum cardiomyopathy
Unknown Myocarditis Abnormal immune response to pregnancy Maladaptive responses to hemodynamic stresses of pregnancy
58
S/S of peripartum cardiomyopathy
LV failure | Fatigue, orthopnea, pedal edema, cardiomegaly, pulmonary edema, increased LVEDV, decreased EF
59
Medical OB management for cardiomyopathy
``` Preload optimization Afterload reduction Increased contractility If stable - induction of labor recommended Acute cardiac decompensation = CS ```
60
Anesthetic management for cardiomyopathy
Invasive monitoring Vasoactive drugs Early labor analgesia to minimize cardiac stress Epidural to reduce afterload, slowly titrate CSE, CS GA high dose opioids or remi

OB (10 decks)

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