CARDIAC3 HTN

Question 0

WHATS THE PREVALENCE AND CHARACTERISTICS OF HTN?

Answer 0

1/5 AMERICANS.
25% OF GEN POP.
HIGHER IN AFRICAN AMERICANS.
USUALLY ASYMPTOMATIC. ACCELERATES ONSET OF ATHEROSCELEROTIC CHANGES IN ART VESSELS OF TARGET ORGANS.

Question 1

WHAT IS HTN?

Answer 1

SUSTAINED 140/90 INDEPENDENT OF KNOWN CAUSE.

Question 2

RISK FACTORS FOR HTN?

Answer 2

SMOKER, HIGH CHOLESTEROL, DM, AGE > 60, POST MENUPAUSAL WOMEN, MEN, FAMILY HX OF CVD.

Question 3

WHAT ARE HEMODYNAMIC EFFECTS OF HTN?

Answer 3

INCREASED SVR, CO…DECREASED INTRAVASCULAR VOL., EXAGGERATED PRESSOR RESPONSE, EDEMA.

Question 4

DO PT ADAPT TO HIGH BP?

Answer 4

YES SO THEY REQUIRE HIGH BP TO MAINTAIN CBF. INTRAOP YOU MUST BE MORE AGGRESSIVE WITH THEM….GIVE THEM PRESSORS.

Question 5

ARE HTN PT VOL DEPLEATED?

Answer 5

YES. THIER VOL IS REDUCED AND DISTRIBUTED CENTRALLY. THEY ARE VERY SUCCEPTIBLE TO DILATION OF VESSELS ….THIS WILL SIG DECREASE VENOUS RETURN.

Question 6

HOW DO DIURETICS WORK?

Answer 6

DECREASE PERIPH. VASCULAR RESISTANCE BY REDUCING PLASMA AND EXTRACELLULAR FLUID.
REDUCES CO DUE TO REDUCTION IN PRELOAD.
REDUCE SVR WITH LONG TERM USE.
ACT ON KIDNEY TO EXCRETE NA AND WATER IN URINE.

Question 7

HOW DO ACE INHIBITORS WORK?

Answer 7

PREVENT CONVERSION OF ANGIOT. 1 TO 2. THIS CAUSES ART DILATION, ATTENUATION OF SNS/RELEASE OF NE. REDUCTION IN ALDOSTERONE SECRETION.
SIDE EFFECT: ANGIOEDEMA….PT TO OR FOR TRACH.

Question 8

WHAT ARE ALPHA 2 AGONISTS?

Answer 8

THE ACCENTUATE THE NEGATIVE FEEDBACK OF ALPHA 2…WHICH INHIBITS RELEASE OF NE.

Question 9

WHAT ARE ALPHA 1 BLOCKERS?

Answer 9

COMPETATIVE ANTAGONISTS TO NE ON SMOOTH MUSCLE RELEASED BY SNS.

Question 10

WHAT ARE BETA BLOCKERS?

Answer 10

DRUGS THAT BIND TO BETA ADRENOCEPTORS AND THEREBY BLOCK THE BINDING OF NE AND E. THEYRE SYMPATHOLYTIC DRUGS. IF YOU BLOCK B1 YOU: DECR HEART FOC, HR AND RENIN SECRETION.
IF YOU BLOCK B2 YOU INCRE AIRWAY RESISTANCE, AND VASCULAR RESISTANCE.

Question 11

WHAT ARE B BLOCKERS USED FOR?

Answer 11

HTN, ANGINA, MI ARRHYTHMIAS, CHF.

Question 12

WHAT ARE CALCIUM ANTAGONISTS?

Answer 12

BLOCKS CA INFLUX. PRIMARILY EFFECT ART RESISTANCE VESSELS WITH ONLY MIMIMAL EFFECTS ON VENOUS CAPACITANCE VESSELS.
THEY: RELAX SMOOTH MUSCLE, VASODILATE, SLOW HR, REDUCE PERIPHERAL RESISTANCE; PRESERVE CO.

Question 13

WHAT ARE DIRECT VASODILATORS?

Answer 13

ACT DIRECTLY ON SMOOTH MUSCLE. MIMIC NITROUS OXIDE.

Question 14

WHAT REFLEX DOES TEH RHEOS SYSTEM BLOCK?

Answer 14

BARORECEPTOR. FOR HTN UNRESPONSIVE TO MEDICAL THERAPY.

Question 15

WHAT ARE ANESTHETIC CONSIDERATIONS FOR INSERTION OF RHEOS SYSTEM?

Answer 15

NO N2O. HAVE VASOPRESSOR READY (EPHEDRINE OR DA TO TX HYPOTENSION PERIOP) ALPHA AGONISTS SHOULD BE AVOIDED UNTIL MAPPING IS COMPLETE. CONT BETA BLOCERS. NARCS OK. PROPOFOL OK FOR INDUCTION NO BOLUSES DURING PROCEDURE.

Question 16

WHY DOES SURGERY PLACE THE CV PT AT RISK?

Answer 16

RELEASE OF KININS, HYPERCOAGULABILITY, ENDOTHELIAL DYSFUNCTION, PLAQUE INSTABILITY, HEMODYNAMIC CHANGES, SNS STIM DUE TO PAIN.

Question 17

WHAT BP WOULD MAKE YOU CANCEL ELECTIVE SURGERY?

Answer 17

DIASTOLIC > 110

Question 18

WHAT IS THE BEST GENERAL POLICY REGARDING BLOOD PRESSURE PERIOP?

Answer 18

FIND OUT WHERE THE PT LIVES AND TRY TO KEEP THEM THERE. IDEALLY YOU WANT PT < 160/100 PREOP.

Question 19

WHAT IF YOUR PT HAS TAKEN AND MAO INHIBITOR?

Answer 19

CANCEL THE SURGERY. MAO’S MUST BE DISCONTINUED 2 WKS PRIOR TO SURGERY.

Question 20

SHOULD ACE INHIBITORS BE CONTINUED?

Answer 20

YES

Question 21

SHOULD DIURETICS BE CONTINUED?

Answer 21

NO. COMBINATION DRUGS LIKE HYDROCHLOROTHIAZIDES CAN BE CONTINUED THOUGH.

Question 22

WHAT ARE THINGS YOU SHOULD THINK OF PERIOP WITH A CARDIAC PT?

Answer 22

PREVENT INCREASE IN SNS, MAINTAIN HR, PRESERVE CORONARY PERFUSION (BLOOD PRESSURE), OPTIMIZE CONTRACTILITY WITHOUT INCREASING WORKLOAD TO DECR. O2 DEMAND.
DECREASE VA DOSE, PROPOFOL, BARBITUATE DOSE FOR INDUCTION. ETOMIDATE IS MOST CV STABLE DRUG FOR INDUCTION. FENT AND NARCS ARE CV NEUTRAL.

Question 23

WHAT ARE CONSIDERATIONS DURINGLARYNGOSCOPY AND MAINTENANCE?

Answer 23

LIMIT LARYNGOSCOPY TIME AND GIVE LIDOCAINE 1.5MG/KG. USE FENT.
ALL VA REDUCE MYOCARDIAL O2 DEMAND.
N2O IS OK TO USE EXCEPT IN PTS WITH MARKEDLY INCREASED PULMONARY VASCULAR RESISTANCE. CONSIDER PAVULON FOR MR BECAUSE IT OFFSETS THE DEC INOTROPY AND HR OF VA. REPLACE BLOOD WITH BLOOD TO MAINTAIN HGB.

Question 24

IF YOU ARE DOING REGIONAL ON CHF PT HOW DO YOU PRELOAD THEM?

Answer 24

CONSIDER HESPAN.

Question 25

WHAT DO YOU DO IF CARDIAC PT BECOMES HYPOTENSIVE PERIOP?

Answer 25

GIVE VOL, REDUCE VA, TREAT WITH EPHEDRINE OR NEO. IF THOSE DONT WORK TRY VASOPRESSIN .5-1 UNIT BOLUS INFUSION .03U/MIN (CAREFUL IF RENAL DISEASE)
IF HYPOTENSIVE AND NOT RESPONSIVE TO ANYTHING TRY METHLENE BLUE (IF NOT ON SSRI) 1-2MG/KG OVER 10-20 MIN FOLLOWED BY INFUSION OF .25MG/KG/HR FOR 48-72 HRS.

Question 26

HOW DO YOU WANT TO EMERGE THE PT?

Answer 26

SMOOTHLY!…….
1MG MS AFTER PT BACK BREATHING FOR PAIN.
DEEP EXTUBATION IF APPROPRIATE.
CONSIDER BB DURING EXTUBATION.