Cardiac Disease Flashcards
Only require standard monitoring
Early cardiac eval
Antibiotic prophylaxis during l&d
For congenital heart disease
4 major defects with ToF
- RV outflow obstruction
- VSD
- RV hypertrophy
- overriding aorta
Anesthetic goals with TOF
Maintain SVR to prevent increased RL shunt (phenylephrine)
Maintain venous return - high filling pressures that improve RV output and pulmonary blood flow
Preferred anesthetic with ToF
Epidural analgesia
Spinals do not maintain SVR and want to maintain intravascular volume
What does ToF look like repaired?
Asymptomatic
VSD closed
Widening pulmonary outflow tract
Small VSD may recur or hypertrophy of outflow tract
VSD and ASD (left to right shunts) repaired =
No problem
T or F small asymptomatic VSD and ASD tolerate labor
T
What does pain do to VSD/ASD
Increases SVR increasing L to R shunt and causing pulmonary hypertension
What anesthetic management is preferred for VSD/ASD
Epidural decreases SVR and decreases L to R shunt
Slowly to prevent rapid decrease in SVR causing a R to L shunt, cyanosis, hypoxemia
VSD/ASD all have…
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
What is seen in large VSD/ASD
Pulmonary HTN and increased pulmonary blood flow
Anesthetic management for large VSD/ASD
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)
Development of eisenmenger’s syndrome
- 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
Eisenmenger syndrome becomes _____ to ______
Acyanotic to cyanotic
Eisenmenger’s effects on pregnancy
Don’t tolerate pregnancy well
Decreased SVR may increase shunt
Decreased FRC and increased O2 consumption exacerbates hypoxemia
Compromised O2 to fetus
Anesthetic management for eisenmenger’s syndrome
Regional to decrease catecholamines Supplemental O2 Pulse ox, a-line CVP for maintenance of preload PAC not recommended, difficult insertion and pulmonary HTN
Regional management considerations in ES
Epidural, CS, CSE
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
Why is epidural preferred for ES
Prevent sudden drop in svr
Slow epidural level
Avoid chloro
Why is single shot spinal not recommended for ES
Precipitous hemodynamic changes
GETA considerations for ES
- 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
PP goals with ES
Risks of mortality still persist
ICU for 24-48 hours
Prophylactic anticoag
AS usually results from
Congenital bicuspid valve or rheumatic heart disease
What are the recommendations for moderate to severe AS in pregnancy
Replacement before conception
With cardiac changes happen with pregnancy and AS
Increased CO, O2 consumption
Decreased SVR
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
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
Analgesia for L&D AS
Slow titration of epidural Phenylephrine over ephedrine Intrathecal opioids CSE Continuous spinal same as ES Invasive monitors
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
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)
AS PP concerns
Increased CO = decompensation
Careful Fluid management
Analgesia to avoid tachycardia
Invasive monitoring 24 hours post op
Most common cause of chronic AI
Rheumatic heart disease
Endocarditis can also cause it
AI characteristics
LV volume overload from regurg
LV hypertrophy and dilation; function declines
Pulmonary edema
Changes occur over many years with chronic insufficiency - asymptomatic
Mild/moderate AI and pregnancy
Beneficial
Decreased SVR improving forward SV
Increased HR less time for diastolic filling and smaller EDV
Severe AI and pregnancy
Decline in LV function
Extensive management
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
Most common lesion associated with RHD
MS
T or F first symptoms of MS occur in pregnancy bc precipitation of CV changes of pregnancy
T
Why do you want to avoid increased CO/HR in MS
Pulmonary edema
Cardiology management of MS
BB to maintain slow HR
A-fib detrimental, aggressive therapy of dig BB and cardioversion
Mild/moderate MS and pregnancy
Tolerates labor well
Invasive monitoring not warranted
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
Regional considerations with MS
Epidural preferred Analgesia Dense block for instrument assisted CSE, epidural, CS Phenylephrine > ephedrine
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
PP for MS
Monitor for 24 hours
Continue epidural - increased preload associated with resolution of sympathectomy will not coincide with pp increased preload
What causes mitral insufficiency
RHD and MV prolapse
What is seen in mitral insufficiency
Dilation of LA and increased LAP
MI has an increased risk of what during pregnancy
A. Fib
Incidence of pulmonary edema and pulmonary HTN is higher or lower than with stenosis
Lower
T or F decreased SVR and increased HR are advantageous to MI patients
T
Most MI patients tolerate pregnancy well T or F
T
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
CS considerations for mitral insufficiency patients
Epidural
Ephedrine
GA decreases afterload and slightly increases HR, avoid myocardial depressants
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
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
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)
Peripartum cardiomyopathy risk factors
Advanced maternal age Multiparity Obesity Multiple gestation Pre-eclampsia Chronic HTN African american
Etiology for peripartum cardiomyopathy
Unknown
Myocarditis
Abnormal immune response to pregnancy
Maladaptive responses to hemodynamic stresses of pregnancy
S/S of peripartum cardiomyopathy
LV failure
Fatigue, orthopnea, pedal edema, cardiomegaly, pulmonary edema, increased LVEDV, decreased EF
Medical OB management for cardiomyopathy
Preload optimization Afterload reduction Increased contractility If stable - induction of labor recommended Acute cardiac decompensation = CS
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
