Cardiovascular Flashcards
What is the Etiologu and Diagnosis of Acute Pericarditis?
When do they occur?
When does it worsen?
What is the treatment for Acute Pericarditis?
Medications
What is reserved for cases that don’t respon to conventional treatment?
This is an accumulation of pericardial fluid in the perdicardial sac
normally 15 - 100 ml of fluids
What are the S/S of a patient that has cardiac tamponade?
mild to severe that occurs gradually.
What are the s/s of chronic cardiac tamponade?
Signs:
- tachycardia
- JVD
- hepatomegaly
- peripheral edema
- CVP almost always increased
- Tamponade may be the cause of low cardiac output post cardiac surgery
Tamponade can happen chronically,
as cardiac tamponade progresses there will be equalization of pressure –
Equalization of pressures:
Equalization of LA pressures with RV end diastolic pressure –> impaired diastolic filling pressure of the heart –> decrease stroke volume –> decrease CO
How do we diagnose tamponade?
What is a difinitive measure?
How do we treat tamponade?
Recommendations for pericardiocentesis procedure
No general anesthesia if pericadiocentesis is the plan.
Recommendation: very acute severe cardiac tamponade
Light sedation –
local anesthetic
**hand holding
—> sometimes tamponade is severe enough that patient will arrest if put on GA
What is chronic constrictive pericarditis
What is the definitive treatment of Chronic Constrictive pericarditis
When do you expect hemodynamic improvement?
surgical removal of constricting pericardium (pericardial stripping)
– expect improvement in 3 months (its slow)
What is the anesthetic management of Constrictive Pericarditis
what are the hemodynamic changes that you want minimized?
**heavy handed on opiods**
*tend to be long cases**
What is a most serious aneurysm?
what are we concerned about?
dilation to all 3 layers if an artery
50 % increase in diameter
-
Where do most dissection commonly happens?
What are the factors in aneurysmal disease?
What are Causes of dissection?
most commonly happens in the thorax in the ascending aorta
What are the factors in aneurysmal disease?
- Atherosclerosis (80%)
- HTN
- Older age
- Male sex
- Family Hx of aneurysmal disease
- Smoking
Causes:
– Blunt trauma, cocaine use, iatrogenic dissection d/t aortic cannulation, systemic HTN, chronic dissection (17%)
most common symptom of aneurysm
back pain
Thoracuc Aortic Aneursym Inherited disorders
Thoracoabdominal Aneurysm Classifications
Type 2 crosses the diaphragm
Type 3 also crosses
Type 4 below diaphragm
DeBakey Classification
What are S.S of TAA
often asymptomatic
S/S of TAA
dissecting**
What is the mechanism of cardiac tamponade in TAA
Cardiac Tamponade in TAA:
Retrogade dissection of sinus of valsava in the pericardial space
—> major cause of death
How di we diagnose TAA?
Type A Dissection
what is the mortality?
Type B Dissection
where is it?
what is the mortality?
when do we repair TAA?
What is the single most determinant of paraplegia and renal failure?
duration of aortic cross clamping
clamp and sew technique**
What are Unique Risk for Surgery
What artery greatly affects the chances of paraplegia?
Artery of Adamkiewicz
What are the Hemodynamic Responses to X - Clamping
Thoracic aortic clamping and unclamp-
ing are associated with severe hemodynamic and homeostatic disturbances in virtually all organ systems owing to decrease in blood low distal to the X-clamp and substantial increase in blood low above the level of aortic occlusion.
Increased systemic vascular resis-
tance (SVR), decreased cardiac output (CO), and no change in heart rate are common. The level of X-clamp is critical to the nature of hemodynamic change: minimal with infrarenal X-clamp, and dramatic with intrathoracic X-clamp.
What are the hemodynamic Responses to Unclamping
Gradual release of cross clamp?
Gradual release of the aortic clamp is recommended to allow time for volume replacement and to slow the washout of the vasoactive and cardiodepressant mediators from ischemic tissues
Anesthetic Management of TAA
What is renal protection for Thoracic Surgery?
Renal Protection (4 C LR with 25 g mannitol/L directly into renal artery by surgeon)
Post - Operative Management TAA
Postoperative Management. Amelioration of pain is essential for patient comfort and to facil-
itate coughing and maneuvers designed to prevent atelectasis. If neuraxial analgesia is used dur-
ing the immediate postoperative period, opioids are preferred over local anesthetics to prevent
masking of anterior spinal artery syndrome (LOSS OF MOTOR FUNCTION, PAIN AND TEMP SENSATION AND HYPOTENSION). Patients recovering from thoracic aortic aneurysm
resection are at risk of developing cardiac, pulmonary, and renal failure during the immediate
postoperative period. Systemic hypertension may require treatment with drugs such as nitroglycerin, nitroprusside, hydralazine, and labetalol.
Mechanism/ cause of Abdominal Aortic Aneurysm
Treatment and Evaluation of AAA
PreOperative Evaluation of AAA
Preoperative Evaluation. Coexisting medical conditions, especially coronary artery disease,
COPD, and renal dysfunction, are important to identify preoperatively. Myocardial ischemia
or infarction is responsible for most postoperative deaths ater elective abdominal aortic aneu-
rysm resection. Preoperative evaluation of cardiac function might include stress testing with
or without echocardiography or radionuclide imaging. Severe reductions in vital capacity and
forced expiratory volume in 1 second and abnormal renal function signiicantly increase the
risk of elective aneurysm repair.
Ruptured AAA
Where does ruptured AA seen often?
Management of Ruptured AA
Managament of Anesthesia
Management of Anesthesia
Monitoring
Volume
Induction and Maintenance
Where is hypotension from AA
central hypovolemia
Postoperative Management and Complications
Postoperative Management
-
Analgesia. Adequate analgesia from use of either neuraxial opioids or patient-controlled
analgesia is very important in facilitating early tracheal extubation. -
Systemic Hypertension. Systemic hypertension is common during the postoperative period
and may be more likely in patients with preoperative hypertension.
Time of Spinal cord injury
12 hrs to 21 days
Endovascular Aortic Repair Aortic Aneurysm
Management of Endovascular Repair
- GA or regional anesthesia
- A-line, Foley
- Possible convert to open
- Large bore IVs
- Maintain Evolemia and normotension
- Spinal Drain for thoracic cases
Carotid Artery Disease and Stroke
most are ischemic
Risk Factors that are Associated with Stroke
Circle of Willis
which of these areteries are unpaired?
1 Anterior Communicating Artery
2 Anterior Cerebral Artery
2 Posterior Communicating Arteries
Where does carotid stenosis most commonly occur and why?
bifurcation of the internal and external carotid arteries because of turbulent flow.
What are the treatment of Stroke?
tPa recommendation?
Interventional neuroradiology?
FDA –> w/in 3 hours of stroke
American Heart –> within 4 hours of stroke onset
Interventional Neuroradiology -> up to 8.5 hours
What is Carotid Endarterectomy (CEA)
PreOp Evaluation for CEA
WHAT IS A MAJOR MORBIDITY AND MORTALITY IN THESE PATIENTS?
Preoperative MI
What should you be careful with in management of CEA?
- careful control of HR, BP, pain, and stress response
- Regional or general anesthesia
- BP control is important
- Elevated BP during X- clamping is warranted
- But elevated BP after surgery may predispose to hematoma formation
- Normocarbia is recommended
- A- line , possibly (not usually necessary)
- Monitoring for cerebral ischemia, hypoperfusion, and cerebral emboli
- EEG, SSEP, Transcranial doppler, shunt placement
Anesthetic Management of CEA
vagal responses is possible during manipulation
Cerebral monitoring for CEA
What does GA do for CEA?
***SEVERE VAGAL response**
**barbs and propofol prior to cross clamping**
Post- Operative Management of CEA
How much Nipride?
How much Nitro?
How do you treat carotid sinus sensitivity?
0.5 mcg/kg/min
Nitro - 5 mcg/min
What are the complications of CEA?
Rucurrent laryngeal nerve –> vocal cord paralysis
Peripheral Vascular Disease
What are the medical therapy for PAD
how about surgical?
Anesthesia Management for surgical repainf of PAD
WHEN do you do epidural?
an hour before
What is Reynaud;s Phenomenon?
Who is more affected?
What are the secondary causes?
crank bair hugger
** give midaz for anxiety
PVD
Virchow’s triad
What is the recommendation for DVT
should be on before you start GA
Systemic Vasculitis
Takayasu’s arteritis
Anesthesia Management**
Takayasu’s arteritis is an idiopathic, progressive occlusive vasculitis that
causes narrowing, thrombosis, or aneurysms of systemic and pulmonary arteries. It is diag-
nosed deinitively based on contrast angiography.
Treatment is Corticosteroids. Anticoagulation may be indicated in some patients.
Takayasau’s Arteritis
Treatment
noninvasive blood pressure monitoring may not be accurate because of subclavian and brachial artery stenosis
Temporal (Giant Cell) Arteritis
- Temporal arteritis is inlammation of the arteries of the head and neck, manifesting as headache, scalp tenderness, or jaw claudication. Prompt initiation of treatment with corticosteroids is indicated in patients with visual symptoms to prevent blindness. Evidence of arteritis on a biopsy specimen of the temporal artery is present in approximately 90% of patients.
Kawasaki’s Syndrome
s/s
treatment
Kawasaki’s syndrome (mucocutaneous lymph node syndrome) occurs primarily in children and manifests as fever, conjunctivitis, inlammation of the mucous membranes, swollen erythematous hands and feet, truncal rash, and cervical lymphadenopathy and
vasculitis.
Tx: Treatment consists of γ-globulin and aspirin.
Management of Anesthesia. With regard to anesthesia, the possibility of intraoperative
myocardial ischemia must be considered.
Thromboangiitis Obliterans (Buerger’s Disease)
young man’s disease
Wegener’s Granulomatosis
Wegener’s granulomatosis is characterized by formation of necrotizing granulomas in inlamed blood vessels in multiple organ systems
-
Treatment. Treatment with cyclophosphamide can produce remissions in approximately
90% of patients. -
Management of Anesthesia. In patients with Wegener’s granulomatosis, management of
anesthesia requires an appreciation of the widespread organ system involvement of this disease. Immunosuppression results from cyclophosphamide treatment. Avoidance of trauma during laryngoscopy is important because bleeding from granulomas and dislodgment of friable ulcerated tissue can occur. A smaller than expected endotracheal tube may be required if the glottic opening is narrowed by granulomatous changes. Arteritis involving peripheral vessels may interfere with placement of an indwelling arterial catheter to moni- tor blood pressure or may limit the frequency of arterial punctures to obtain samples for blood gas analysis.
***becareful with blood pressure and RENAL PERFUSION**
Polyarteritis Nodosa
Polyarteritis nodosa most oten occurs in women, often in association
with hepatitis B antigenemia and allergic reactions to drugs. Renal failure is the most common
cause of death.
-
Diagnosis. The diagnosis depends on histologic evidence of vasculitis on biopsy and dem-
onstration of characteristic aneurysms on arteriography. -
Treatment. Treatment usually includes corticosteroids and cyclophosphamide, removal of
ofending drugs, and treatment of underlying diseases such as cancer. -
Management of Anesthesia. In patients with polyarteritis nodosa, management of anes-
thesia should take into consideration the likelihood of co-existing renal disease, cardiac disease, and systemic hypertension. Supplemental corticosteroids may be indicated.
