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Advanced Principles C > Cardiovascular Anesthesia Pt. II (Exam III) > Flashcards

Cardiovascular Anesthesia Pt. II (Exam III) Flashcards

1
Q

When is the highest risk of mortality from a surgery after an MI?

A

Within the 1st 30 days after the MI

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2
Q

When should an arterial line be placed for cardiac surgery?

A

Preoperatively (preop area or pre-induction)

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3
Q

What drug is necessary prior to cardiac surgery in the preop area?

A

Versed

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4
Q

How should an initial reading with the cerebral oximeter be measured?

A

Baseline measurement at room air

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5
Q

What four factors result in our cerebral oximeter reading?

A
  • MAP
  • FiO₂
  • Hgb
  • EtCO₂
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6
Q

What is the most important thing during sternal incision?

A

Lungs need to be down

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7
Q

What possible complication can occur doing a redo sternotomy on someone who had previous heart surgery years ago?

A

Pericardium can be adhered to sternum and at risk of being cut by the saw.

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8
Q

What changes should be made from a first time steronotomy to a redo sternotomy?

A

2ⁿᵈ Sternotomy needs:

  • Blood in room
  • Bypass primed and on field
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9
Q

What should be done as the pericardium is opened?

A
  • Assess color of pericardial fluid (should be straw-colored)
  • ↓ lung volumes as pericardium is tacked.
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10
Q

Systolic BP must not exceed _______ mmHg as we cannulate.

A

90 - 100 mmHg

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11
Q

What is the bypass dose of heparin?

A

3mg/kg
or
300units/kg

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12
Q

What is the ideal body weight dosage of heparin for cardiopulmonary bypass?

A

Trick question. Heparin for bypass is dosed on actual body weight.

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13
Q

ACT must be greater than ______ to go on bypass.

A

400

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14
Q

When is ACT drawn after heparin administration?

A

3 - 5 minutes

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15
Q

What should an ACT be for off-pump heart surgeries?

A

300 - 350 is acceptable

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16
Q

If a repeated dose of heparin does not achieve an ACT of 400 or greater, what should be considered?

A

ATIII deficiency (consider giving FFP or ATIII directly)

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17
Q

How often must cardioplegia solution be administered to maintain cardiac arrest?

A

Every 20 - 30 min

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18
Q

CMRO₂ will decrease __% for every 1°C drop in temperature.

A

7%

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19
Q

What is the temperature goal in cardiac surgery?

A

32°C

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20
Q

Where are bypass grafts sewn first? Why is this?

A

Distally

Done so that warming can begin.

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21
Q

What is our target temperature during re-warming?

A

35.5 - 37°C

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22
Q

When should postoperative sedation start being considered during a cardiac operation?

A

During re-warming.

Versed, Precedex, Propofol…

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23
Q

What aortic clamp is used to allow partial flow whilst sewing on proximal grafts?

A

Partial occluder clamp

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24
Q

What cannot be maintained if a patient is cold coming off bypass?

A

Stable rhythm

Cold = V-fib.

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25
Q

What joule dosage is used on the internal defibrillator paddles?

A

20 - 30 joules

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26
Q

What is our BP goal around decannulation time?

A

90 - 100 sBP

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27
Q

When are antibiotics typically redosed in CV surgery?

A

Decannulation

Dependent on drug and bypass time.

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28
Q

What should be done prior to restarting the patient on the ventilator after cardiopulmonary bypass?

A

Alveolar recruitment

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29
Q

What is the dose of protamine for CPB reversal?

A

1mg/kg

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30
Q

How is protamine best administered?

A

IV Piggyback

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31
Q

What should be held as the chest is wired shut?

A

Respirations

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32
Q

What specific type of pump is most often used in adult CPB?

A

Roller pump

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33
Q

What are the most important characteristics of a centrifugal roller pump?

A
  • Pressure limited
  • Higher prime volume
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34
Q

What priming solution is most often used for a CPB pump?

A

Crystalloid typically

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35
Q

What is the typical priming volume for a CPB pump?

A

1500 - 2500 mLs

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36
Q

What additive may be included in a CPB circuit dependent on specific patient factors?

A
  • Albumin
  • PRBCs
  • Electrolytes
  • Mannitol
  • Heparin
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37
Q

What hematocrit would be expected for a patient on CPB? Why?

A

Low HCT expected (17 - 25%)

This is due to dilutionary effects from the pump prime.

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38
Q

What two things are used for myocardial protection during cardiac surgery?

A
  • Cold, Hyperkalemic Cardioplegia
  • Systemic Hypothermia
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39
Q

Where is cardioplegia administered in:

Antegrade?
Retrograde?

A
  • Antegrade = Aortic root
  • Retrograde = Coronary sinus
  • On occasion a graft may also be used
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40
Q

What is the most common lung injury due to CPB?

A

Pump Lung (Acute Lung Injury)

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41
Q

What are the characteristics of pump lung?

A
  • Diffuse congestion & edema
  • Hemorrhagic atelectasis
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42
Q

What is the main CNS complication of CPB?

A

“Pump Head”

  • Stroke is also a major risk
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43
Q

What is the cause of Pump Head?

A
  • Small emboli
  • Hypotension
44
Q

What is the major GI complication of CPB to watch out for?

A

Mesenteric Infarction

45
Q

What are the possible causes of CPB induced mesenteric infarction?

A
  • Emboli
  • Hypoperfusion
  • HIT
46
Q

What is the urine output goal for cardiac surgery?

A

1 mL/kg/hr

47
Q

What factors will increase the risk of acute renal injury post cardiac surgery?

A
  • Pump time (non-pulsatile time)
  • Excessive blood loss
  • DM
  • Vasopressor usage
  • Advanced age
48
Q

What anti-fibrinolytic has replaced aprotinin?

A

Cyclokapron

49
Q

Cyclokapron may increase risk of bleeding if administered more than ____ hours prior to surgery.

50
Q

What drug will work as a hemostatic agent in cases of extreme fibrinolysis?

A

Cyclokapron

51
Q

What is the dose of cyclokapron for cardiac surgery?

A

10mg/kg bolus
1-2 mg/kg/hr infusion

52
Q

What is the generic name of cyclokapron?

A

Tranexamic Acid

53
Q

Off pump CABG’s (OPCAB) are most successful with a normal _____.

54
Q

How are vessels grafted differently in OPCAB surgeries?

A

Grafts sewn proximally first and distally second.

55
Q

How often are ACT’s checked during OPCAB?

A

every 20 min

56
Q

What major anesthetic issues should be considered in cardiac transplantation?

A
  • Denervated heart
  • Immunosuppressant effects
  • CAD
57
Q

What is the major consequence of denervated heart in a cardiac transplant patient?

A

SNS > PSNS due to lack of vagal input

HR higher, atropine & glyco won’t work, etc.

58
Q

What sensory capability is lost by a patient who has a heart transplant?

A

No sensory ability

CAD w/o angina!!!

59
Q

Immunosuppressants must be discontinued during the perioperative period in transplant patients. T/F?

A

False. Immunosuppressants must be continued.

60
Q

What should occur in regards to preload and vasodilation with cardiac transplant patients?

A
  • Maintain preload
  • Avoid vasodilation
61
Q

What two echocardiogram views are commonly used in cardiac surgery?

A
  • Transverse 4-chamber
  • Transgastric short axis
62
Q

What are contraindications to TEE?

A
  • Esophageal stricture
  • Esophageal mass
  • Esophageal varices
  • Zencker’s Diverticulum
  • S/P radiation to the neck
  • Recent gastric bypass surgery
63
Q

What view is depicted below?

A

Aortic Valve Short Axis view

64
Q

What view is depicted below?

A

4-chamber view

65
Q

What view is depicted below?

A

Transgastric Short Axis

66
Q

What view is depicted below?

A

Left Atrial Appendage view

67
Q

What view is depicted below?

A

Ascending Aorta Short Axis

68
Q

What are the characteristics of a bioprosthetic valve?

A
  • Bovine or porcine
  • 10 - 15 year duration
  • Lower clotting potential
69
Q

What are the characteristics of metal valves?

A
  • Metal or carbon alloy
  • Last 20 - 30 years
  • Highly thrombogenic
70
Q

What are risk factors for mitral stenosis?

A
  • Female
  • Rheumatic fever
  • RA
  • SLE
71
Q

How quickly does mitral stenosis occur?

A

Slowly (20 - 30 years)

72
Q

What is a normal mitral valve opening?

A

4 - 6 cm²

73
Q

At what surface area does an obstruction of LV filling occur with mitral stenosis patients?

A

MV area ≈ 1.5 cm²

74
Q

What type of murmur is heard in mitral stenosis?

A

Diastolic murmur at apex

75
Q

What s/s of mitral stenosis are common?

A
  • DOE
  • Orthopnea
  • PND
  • A-fib
  • Embolism
76
Q

What EKG changes are seen in mitral stenosis patients?

A
  • Broad notched p-waves
  • LAE on EKG
  • A-fib
77
Q

What is the medical treatment of mitral stenosis?

A
  • Maintain NSR
  • Diuretics (↓ LAP)
  • Anticoagulation
78
Q

What are the surgical treatment option for mitral stenosis?

A
  • Balloon Valvulotomy
  • Commissurotomy
  • Replacement
79
Q

What are our anesthetic goals for mitral stenosis patients?

A
  • Prevent/treat pulmonary edema
  • Prevent/treat Afib
  • Avoid ↑ CVP
  • Avoid ↓ SVR
80
Q

Stenosis generally requires ____________ of normal parameters.

A

Maintenance of normal parameters (normal BP, normal HR, etc)

81
Q

What are common causes of mitral regurgitation?

A
  • Endocarditis
  • MV prolapse
  • LV hypertrophy
  • Papillary muscle dysfunction
  • SLE
  • RA
  • Ankylosing spondylitis
  • Carcinoid syndrome
82
Q

A regurgitant fraction of ________ is considered severe mitral regurgitation.

A

greater than 0.6

83
Q

What factors contribute to the degree of regurgitation of a mitral valve?

A
  • MV orifice size
  • HR
  • Pressure gradients
84
Q

What type of murmur is heard with mitral regurgitation?

A

Holosystolic apical murmur radiating to axilla

85
Q

What EKG changes are seen with MR?

A

LAE & LVH on EKG

Overall left axis deviation.

86
Q

What two hemodynamic changes should be avoided in mitral regurgitation?

A
  • Bradycardia
  • ↑ SVR
87
Q

What hemodynamic parameters would indicate the need for mitral valve replacement for regurgitation?

A
  • EF < 30%
  • Right SV > 65mL
88
Q

Is repair or replacement preferred for mitral regurgitation? Why?

A

Repair is preferred

89
Q

What HR should be maintained in mitral regurgitation?

A

normal to slightly high

90
Q

The phrase “Forward, Fast, & Full” describes the anesthetic goals for what valvular pathology?

A

Mitral Regurgitation

91
Q

What induction agent might be best for MR?

A

Etomidate (minimal cardiac depression & SNS activity)

92
Q

Why might VAA’s be good for severe MR?

A

VAA will ↓ SVR

93
Q

Aortic stenosis will occur earlier in life if the valve is ______.

94
Q

What is the normal valvular surface area of the aortic valve?

A

2.5 - 3.5 cm²

95
Q

At what surface area is aortic stenosis considered severe?

A

< 0.8 cm²

96
Q

What are the s/s of aortic stenosis?

A
  • Angina
  • Syncope
  • DOE
  • Left axis deviation
97
Q

What murmur is heard with aortic stenosis?

A

Systolic murmur that radiates to the neck

98
Q

The murmur heard from aortic stenosis may sound like what other pathologic condiditon?

A

Carotid bruit

99
Q

What murmur is heard with aortic regurgitation?

A

Diastolic murmur at the right sternal border

100
Q

What s/s are seen with aortic regurgitation?

A
  • Widened pulse pressure
  • LV dysfunction
  • Fatigue/Dyspnea/Coronary ischemia
  • Left axis deviation
101
Q

Warfarin and direct thrombin inhibitors should be discontinued _____ days preop.

A

3 - 5 days

102
Q

How long must warfarin be held prior to starting neuraxial anesthesia?

103
Q

How long must lovenox be held prior to neuraxial anesthesia?

A

12 - 24 hours

104
Q

How long must apixaban, rivaroxaban, etc be held prior to neuraxial anesthesia?

105
Q

How long must Clopidogrel (Plavix) be held prior to starting neuraxial anesthesia?

A

5 - 7 days

Advanced Principles C (11 decks)

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