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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
What joule dosage is used on the internal defibrillator paddles?
20 - 30 joules
26
What is our BP goal around decannulation time?
90 - 100 sBP
27
When are antibiotics typically redosed in CV surgery?
Decannulation **Dependent on drug and bypass time**.
28
What should be done prior to restarting the patient on the ventilator after cardiopulmonary bypass?
Alveolar recruitment
29
What is the dose of protamine for CPB reversal?
1mg/kg
30
How is protamine best administered?
IV Piggyback
31
What should be held as the chest is wired shut?
Respirations
32
What specific type of pump is most often used in adult CPB?
Roller pump
33
What are the most important characteristics of a centrifugal roller pump?
- Pressure limited - Higher prime volume
34
What priming solution is most often used for a CPB pump?
Crystalloid typically
35
What is the typical priming volume for a CPB pump?
1500 - 2500 mLs
36
What additive may be included in a CPB circuit dependent on specific patient factors?
- Albumin - PRBCs - Electrolytes - Mannitol - Heparin
37
What hematocrit would be expected for a patient on CPB? Why?
Low HCT expected (17 - 25%) **This is due to dilutionary effects from the pump prime**.
38
What two things are used for myocardial protection during cardiac surgery?
- Cold, **Hyperkalemic** Cardioplegia - Systemic Hypothermia
39
Where is cardioplegia administered in: Antegrade? Retrograde?
- Antegrade = Aortic root - Retrograde = Coronary sinus - On occasion a graft may also be used
40
What is the most common lung injury due to CPB?
Pump Lung (Acute Lung Injury)
41
What are the characteristics of pump lung?
- Diffuse congestion & edema - Hemorrhagic atelectasis
42
What is the main CNS complication of CPB?
"Pump Head" - Stroke is also a major risk
43
What is the cause of Pump Head?
- Small emboli - Hypotension
44
What is the major GI complication of CPB to watch out for?
Mesenteric Infarction
45
What are the possible causes of CPB induced mesenteric infarction?
- Emboli - Hypoperfusion - HIT
46
What is the urine output goal for cardiac surgery?
1 mL/kg/hr
47
What factors will increase the risk of acute renal injury post cardiac surgery?
- Pump time (non-pulsatile time) - Excessive blood loss - DM - Vasopressor usage - Advanced age
48
What anti-fibrinolytic has replaced aprotinin?
Cyclokapron
49
Cyclokapron may increase risk of bleeding if administered more than ____ hours prior to surgery.
3 hours
50
What drug will work as a hemostatic agent in cases of extreme fibrinolysis?
Cyclokapron
51
What is the dose of cyclokapron for cardiac surgery?
10mg/kg bolus 1-2 mg/kg/hr infusion
52
What is the generic name of cyclokapron?
Tranexamic Acid
53
Off pump CABG's (OPCAB) are most successful with a normal _____.
EF
54
How are vessels grafted differently in OPCAB surgeries?
Grafts sewn **proximally first** and **distally second**.
55
How often are ACT's checked during OPCAB?
every 20 min
56
What major anesthetic issues should be considered in cardiac transplantation?
- Denervated heart - Immunosuppressant effects - CAD
57
What is the major consequence of denervated heart in a cardiac transplant patient?
SNS > PSNS due to lack of vagal input *HR higher, atropine & glyco won't work, etc.*
58
What sensory capability is lost by a patient who has a heart transplant?
No sensory ability **CAD w/o angina!!!**
59
Immunosuppressants must be discontinued during the perioperative period in transplant patients. T/F?
False. **Immunosuppressants must be continued**.
60
What should occur in regards to preload and vasodilation with cardiac transplant patients?
- Maintain preload - Avoid vasodilation
61
What two echocardiogram views are commonly used in cardiac surgery?
- Transverse 4-chamber - Transgastric short axis
62
What are contraindications to TEE?
- Esophageal stricture - Esophageal mass - Esophageal varices - Zencker's Diverticulum - S/P radiation to the neck - Recent gastric bypass surgery
63
What view is depicted below?
Aortic Valve Short Axis view
64
What view is depicted below?
4-chamber view
65
What view is depicted below?
Transgastric Short Axis
66
What view is depicted below?
Left Atrial Appendage view
67
What view is depicted below?
Ascending Aorta Short Axis
68
What are the characteristics of a bioprosthetic valve?
- Bovine or porcine - 10 - 15 year duration - Lower clotting potential
69
What are the characteristics of metal valves?
- Metal or carbon alloy - Last 20 - 30 years - Highly thrombogenic
70
What are risk factors for mitral stenosis?
- Female - Rheumatic fever - RA - SLE
71
How quickly does mitral stenosis occur?
Slowly (20 - 30 years)
72
What is a normal mitral valve opening?
4 - 6 cm²
73
At what surface area does an obstruction of LV filling occur with mitral stenosis patients?
MV area ≈ 1.5 cm²
74
What type of murmur is heard in mitral stenosis?
Diastolic murmur at apex
75
What s/s of mitral stenosis are common?
- DOE - Orthopnea - PND - A-fib - Embolism
76
What EKG changes are seen in mitral stenosis patients?
- Broad notched p-waves - LAE on EKG - A-fib
77
What is the medical treatment of mitral stenosis?
- Maintain NSR - Diuretics (↓ LAP) - Anticoagulation
78
What are the surgical treatment option for mitral stenosis?
- Balloon Valvulotomy - Commissurotomy - Replacement
79
What are our anesthetic goals for mitral stenosis patients?
- Prevent/treat pulmonary edema - Prevent/treat Afib - Avoid ↑ CVP - Avoid ↓ SVR
80
Stenosis generally requires ____________ of normal parameters.
**Maintenance** of normal parameters (normal BP, normal HR, etc)
81
What are common causes of mitral regurgitation?
- Endocarditis - MV prolapse - LV hypertrophy - Papillary muscle dysfunction - SLE - RA - Ankylosing spondylitis - Carcinoid syndrome
82
A regurgitant fraction of ________ is considered severe mitral regurgitation.
greater than 0.6
83
What factors contribute to the degree of regurgitation of a mitral valve?
- MV orifice size - HR - Pressure gradients
84
What type of murmur is heard with mitral regurgitation?
Holosystolic apical murmur radiating to axilla
85
What EKG changes are seen with MR?
LAE & LVH on EKG *Overall left axis deviation*.
86
What two hemodynamic changes should be avoided in mitral regurgitation?
- Bradycardia - ↑ SVR
87
What hemodynamic parameters would indicate the need for mitral valve replacement for regurgitation?
- EF < 30% - Right SV > 65mL
88
Is repair or replacement preferred for mitral regurgitation? Why?
Repair is preferred
89
What HR should be maintained in mitral regurgitation?
normal to slightly high
90
The phrase "Forward, Fast, & Full" describes the anesthetic goals for what valvular pathology?
Mitral Regurgitation
91
What induction agent might be best for MR?
Etomidate (minimal cardiac depression & SNS activity)
92
Why might VAA's be good for severe MR?
VAA will ↓ SVR
93
Aortic stenosis will occur earlier in life if the valve is ______.
bicuspid
94
What is the normal valvular surface area of the aortic valve?
2.5 - 3.5 cm²
95
At what surface area is aortic stenosis considered severe?
< 0.8 cm²
96
What are the s/s of aortic stenosis?
- Angina - Syncope - DOE - Left axis deviation
97
What murmur is heard with aortic stenosis?
Systolic murmur that radiates to the neck
98
The murmur heard from aortic stenosis may sound like what other pathologic condiditon?
Carotid bruit
99
What murmur is heard with aortic regurgitation?
Diastolic murmur at the right sternal border
100
What s/s are seen with aortic regurgitation?
- Widened pulse pressure - LV dysfunction - Fatigue/Dyspnea/Coronary ischemia - Left axis deviation
101
Warfarin and direct thrombin inhibitors should be discontinued _____ days preop.
3 - 5 days
102
How long must warfarin be held prior to starting neuraxial anesthesia?
5 days
103
How long must lovenox be held prior to neuraxial anesthesia?
12 - 24 hours
104
How long must apixaban, rivaroxaban, etc be held prior to neuraxial anesthesia?
3 days
105
How long must Clopidogrel (Plavix) be held prior to starting neuraxial anesthesia?
5 - 7 days

Advanced Principles C (11 decks)

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