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DA > Cardiovascular disease and Anaesthesia > Flashcards

Cardiovascular disease and Anaesthesia Flashcards

1
Q

What are the anaesthesia concerns in a patient with hypertension

A
  1. Cerebrovascular events
  2. Myocardial ischaemia/infarction/failure
  3. Renal failure
  4. End organ damage: encephalopathy
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2
Q

How does the risk of a well controlled hypertensive compare to a non-hypertensive

A

Normal risk

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3
Q

What should be done if the DBP > 120

A

Postpone elective surgery for 2 weeks

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4
Q

How long does it take for left ventricular remodelling and normalisation of the shifted auto-regulatory curve?

A

> 6 months

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5
Q

How does the intra-operative course of the anaesthetic in patients different in patients with hypertension

A

EXAGGERATED SWINGS BP can be precipitated by SNS stimulation (Intubation / Surgery), Vasodilation and blood loss

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6
Q

What is the influence of antihypertensive medications on the anaesthetic

A

Diuretics: fluid depletion and electrolyte disturbance
BB: Neg inotropy and neg chronotropy -> low CO
CCB: hypotension
ACEI: Exaggerated intra-operative hypotension and irritable airways

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7
Q

How should BP be managed intra-operatively

A

Within 25% of starting value (avoid the ‘alpine trace’)

  • pre-empt noxious stimuli (intubation)
  • adequate analgaesia
  • avoid light plane of anaesthesia
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8
Q

What is the mortality of perioperative MI

A

50%

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9
Q

Which patients with IHD can be considered to have a normal perioperative risk

A
  1. CABG within 5 years and is symptom free

2. Walk > than 2 flights of stairs without stopping

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10
Q

Which patients have moderate increased risk

A

Stable angina

Poor effort tolerance

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11
Q

Which patients are at extremely high anaesthetic risk

A 
Unstable angina
Recent MI (< 6 month)
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12
Q

How long should elective surgery be postponed for after MI

A

at least 6 months

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13
Q

Which patients should always be discussed with/referred to cardiology prior to anaesthesia

A

Patients who have a coronary artery stent

  • Big risk of stent occlusion if clopidogrel is inappropriately stopped
  • this depends on the type of stent and when it was placed
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14
Q

Summarise the perioperative management of a patient with ischaemic heart disease

A

Principle: DO everything possible to maintain autonomic stability i.e. fluctuations in BP and HR.

NB

  • Continue meds preop (BB) and provide anxiolysis
  • Use Regional
  • Avoid NSAIDS (CVEs)
  • Blunt intubation
  • Monitor closely intraop and post op
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15
Q

What are the principles for intra-operative management for a patient with aortic stenosis

A

PREVENT DECREASED SVR and keep SLOW HR

Fixed CO = SV cannot increase

  1. SVR must be maintained (If not –> hypoperfusion brain and heart)
  2. Slower HR (ensures coronary perfusion)
  3. Spinal and epidural anaesthesia are contra-indicated
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16
Q

What are the principles for intra-operative management or a patient with aortic regurgitation

A

FULL, FAST, FORWARD

(Adequate preload, 80 - 100bpm, Decrease SVR)

Reduce time for regurgitant flow
Reduce force pushing regurgitant flow

17
Q

What is the key difference between the management of AS vs AR

A

AS

  • maintain SVR to ensure perfusion heart and brain
  • Slower HR to allow time for coronary filling

AR

  • drop SVR to reduce regurgitant flow
  • faster HR to reduce time for regurgitant flow.
18
Q

What are the principles for intra-operative management of Mitral Stenosis

A

SLOW HR (Rx dysrhythmia aggressively) to keep LA pressure low

Avoid tachycardia and dysrhythmia (AF)

Increased HR –> decreased diastolic time –> diminished ventricular filling –> pulmonary oedema + reduced CO.

AF –> loss of atrial systole/’kick’ which reduces LV filling –> increased LAP –> pulmonary oedema

19
Q

What are the principles for intra-operative management of Mitral Incompetence

A

FULL, FAST, FORWARD but avoid fluid overload

Digoxin –> keep K over 4mmol/L
INR < 1.5 before surgery

20
Q

Summarise the intra-operative management of the various valvular heart lesions

A

AS - Sustain SVR | Slow HR (Perfuse coronaries/brain)
AR - ‘Rapid’ HR | Reduce SVR (Full, fast, forward)
MS - Slow HR | Sustain SVR (LAP + Pulm. Oedema)
MR - ‘Rapid’ HR | Reduce SVR (Full, fast, forward)

‘Rapid’ = R memory aid for “Regurgitant lesion” = 80 - 100 bpm.

21
Q

Describe perioperative management for patients in cardiac failure

A
  1. Postpone until out of failure if possible
  2. Rx cause of failure and optimise medical Rx
  3. Maintain preload (CVP/US/SVV/PPV/leg raise)
  4. Maintain inotropy (Avoid myocardial depressants)
    - hypoxia/hypercarbia/acidosis
  5. Reduce afterload
  6. Use regional (caution with neuraxial)
22
Q

What are the common causes of intra-operative dysrhythmias

A
  1. Pain
  2. Hypoxia
  3. Hypercapnoea
  4. Electrolytes
  5. Drugs
23
Q

Describe intra-operative management of dysrhythmia

A

ACLS algorithms

  1. Unstable: Electrical cardioversion
  2. Amiodarone 300mg over 1 hours (or 10 mins if relatively unstable)
24
Q

What should be done if a pacemaker is identified in a patient preop

A

IS THE DEVICE AN IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR PACEMAKER?
- diathermy might cause shock and lethal dysrhythmia

Obtain details:

  • date of insertion
  • indication for insertion
  • current function/dysfunction
  • last technologist visit (within 1 year is ok for elective surgery)

ECG may show pacing spikes if patient is pacing-dependent

25
Q

What type of diathermy is preferable in patients with pacemakers and what if this type of diathermy is not available

A

BIPOLAR DIATHERMY preferred

If unipolar only –> the diathermy plate must be placed as far away from the pacemaker as possible

26
Q

When are magnets used on pacemakers

A

Some pacemakers allow for a magnet to switch the pacemaker over to ‘VOO’ mode which is a fixed rate.

  • only do this if you are aware that this is the magnets effect and if the patient is hemodynamically stable

DA (50 decks)

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