Cardiac Surgical Patient

Question 1

Risks of anesthesia and the heart

Answer 1

decreased SVR and decreased SV

Question 2

Induction of general anesthesia lowers systemic arterial pressures by __ to __% BUT tracheal intubation increases BP by __ to ___ mmHg

Answer 2

20 to 30 % / 20-30mmHg

Question 3

Many anesthetic agents lower cardiac output by ___ %

Answer 3

15%

Question 4

The initial history, physical exam and ECG assessment should focus on identification of potentially serious cardiac disorders. In addition to identifying the presence of pre-existing manifested heart disease, it is essential to define disease _____, _____ and ____ _____

Answer 4

severity, stability and prior therapy

Question 5

______ ________ is best assessed by asking what kind of activity they can perfrom/tolerate

Answer 5

functional capacity

Question 6

Other factors that help determine cardiac risk include

Answer 6

functional capacity, age, co-morbid conditions (DM, PVD, chronic pulm dz)

Question 7

Vascular procedures and prolonged, complicated thoracic, abdominal, and head and neck procedures are considered ____ _____

Answer 7

high risk

Question 8

The presence of anemia may also place a patient at ________ perioperative risk

Answer 8

higher

Question 9

In addition to the presence of CAD and CHF, a history of cerebrovascular disease, preoperative elevated creatinine greater than 2 mg/dL, insulin treatment for DM and high-risk surgery have all been associated with increased _____ ______

Answer 9

cardiac morbidity

Question 10

The cornerstone of preoperative cardiac evaluation includes

Answer 10

review of history, physical examination, diagnostic tests, knowledge of the planned surgical procedure

Question 11

_______ alone is not a risk factor

Answer 11

angina

Question 12

Signs of CHF

Answer 12

JVD, pedal edema, decreased cap refill, displaced apical impulse, S3, S4, presence of murmurs, pulmonary edema

Question 13

S3 Gallop

Answer 13

increased LVEDP

Question 14

Displaced apical impulse

Answer 14

cardiomegaly

Question 15

S4

Answer 15

decreased compliance

Question 16

One MET represents what?

Answer 16

the oxygen consumption of a resting adult (3.5ml/kg/min)

Question 17

The MET is defined as the ratio of a person’s working metabolic rate relative to the ___ ____ ____

Answer 17

resting metabolic rate

Question 18

In the revised cardiac risk index by Lee, ______ _____ was not independently associated with risk

Answer 18

functional status

Question 19

If patient’s reduce exertion because of cardiac symptoms but still meet a 4-MET threshold, clinicians will ________ risk

Answer 19

underestimate

Question 20

Non cardiac functional limitations (back pain, knee pain) may cause provider to falsely __________ cardiac risk

Answer 20

overestimate

Question 21

Light work around the house like dusting or washing dishes

Answer 21

4 MET

Question 22

Climb a flight of stairs or walk up a hill, walk on level ground at 4-6mph, run a short distance

Answer 22

4 MET

Question 23

Participate in strenuous activites like swimming, tennis, football, basketball or skiing

Answer 23

10 METs

Question 24

Less than 4METs

Answer 24

poor

Question 25

4-7 METS

Answer 25

moderate

Question 26

Great than 7-10 METs

Answer 26

Good

Question 27

If someone was coming in for a TAVR, how many METS do you suppose they have?

Answer 27

4 METS

Question 28

If can get to 85% of max HR then they will be ____ risk

Answer 28

low

Question 29

Measurements on a treadmill inducing ischemia at low-level exercise (<5 MET) or HR < 100/min identfies a ____ _____ group, whereas the achievement of more than 7 MET or HR > 130/min without ischemia identifies a _____ ____ group

Answer 29

high risk / low risk

Question 30

The presence of abnormalities such as ___ ____ and non ____ ____ have been shown to correlate with adverse postoperative cardiac events

Answer 30

Q waves / sinus rhythm

Question 31

What can alter an ECG tracing?

Answer 31

metabolic and electrolyte disturbances, medications, intracranial disease and pulmonary disease

Question 32

Conduction disturbances like RBBB or First-degree AVB may lead to concern but usually do not justify _____ _____

Answer 32

further workup

Question 33

Willl someone with first degree AVB or RBBB go to the OR

Answer 33

yes

Question 34

New LBBB or block beyond first degree will require ____ ____ and surgery likely to be _______

Answer 34

further workup / cancelled

Question 35

What is the gold-standard for risk index?

Answer 35

ACC/AHA

Question 36

used for assessment of the patient's overall physical status and to predict morbidity and mortality

Answer 36

ASA

Question 37

used for risk stratification of medical patients with angina, but they have been adapted for use in surgical patients

Answer 37

NHYA/CCS

Question 38

MAJOR Clincal predictors of Increased perioperative cardiovascular risk (MI, HF, Death)

Answer 38

Unstable coronary syndromes, acute or recent MI with evidence of important ischemic risk by clinical symptoms or noninvasive study, unstable or severe angina, decompensated heart failure, significant arrhythmias, high grade AV block, symptomatic ventricular arrhythmias in the presence of underlying CAD, supraventricular arrhythmias with uncontrolled ventricular rate, severe valvular dz

Question 39

INTERMEDIATE clinical predictors of increased perioperative cardiovascular risk

Answer 39

mild angina, history of MI, pathologic Q waves, compensated or Prior CHF, DM, Renal insufficiency (CKD)

Question 40

Example of intermediate

Answer 40

on metoprolol, takes nitrates on occasion, on ACE/ARB, diabetes, creat 1.5-2.1

Question 41

MINOR clinical predictors or increased perioperative cardiovascular risk

Answer 41

advanced age, abnormal ECG (LVH, LBBB, ST-T abnormalities), rhythm other than sinus, low functional capacity, history of stroke, uncontrolled HTN

Question 42

High risk surgical risk

Answer 42

>5% risk of perioperative death or MI; ex: emergent major surgery, peripheral vascular or aortic surgery, prolonged surgery involving excessive loss of blodd

Question 43

Moderate surgical risk

Answer 43

1-5% risk of perioperative death or MI; ex: carotid endarterectomy, urologic, orthopedic, uncomplicated abdominal, head, neck and thoracic operations

Question 44

Low risk surgical risk

Answer 44

<1% risk of perioperative death or MI; ex: cataract removal, endoscopy, superficial procedure, cosmetic procedures, and breast surgery

Question 45

Review algorithm on slides

Answer 45

31-35

Question 46

Indications for preoperative cardiac testing

Answer 46

patients with intermediate clinical predictors, prognositc assessment of patients undergoing evaluation for suspected or proved CAD, evaluation of patients with a change in clinical status, evaluation of adequacy of medical treatment, prognostic assessment after an acute coronary syndrome

Question 47

Noninvasive cardiac tests

Answer 47

transthoracic echo, exercise stress test, exercise tests and pharamacologic tests, adenosine stress test, ambulatory ECG monitoring

Question 48

Review slides 40 and 41

Answer 48

regarding class and risk