Cardiovascular pathophysiology 3 Flashcards
Identify the anesthetic considerations for constrictive pericarditis (Select 2).
a. Kussmaul’s sign is usually present
b. it is most commonly caused by a virus
c. afterload should be reduced
d. bradycardia should be avoided
a. Kussmaul’s sign is usually present
d. bradycardia should be avoided
The _______ surrounds the heart.
Pericardium
What three conditions affect the pericardium?
acute pericarditis
constrictive pericarditis
cardiac tamponade
Acute pericarditis is usually the result of
inflammation
Acute pericarditis does not _______________ unless inflammation leads to constrictive pericarditis or cardiac tamponade.
reduce diastolic filling
Constrictive pericarditis is caused by
fibrosis or any condition where the pericardium becomes thicker
Treatment for constrictive pericarditis is
pericardiotomy
Anesthetic considerations for constrictive pericarditis include
avoiding bradycardia, preserving contractility, and maintaining afterload
The pericardium is composed of
two layers: the visceral layer is attached to the myocardium
the parietal layer is anchored in the mediastinum
The most common cause of acute pericarditis is
infection (viral)
S/S of constrictive pericarditis includes
Kussmaul’s sign- JVD during inspiration
Pulsus paradoxus (decreased SBP > 10 mmHg during inspiration)
Increased venous pressure–> distended neck veins, hepatomegaly, ascites, peripheral edema
atrial dysrhythmias
pericardial knock
The most common complication of pericardiotomy is
hemorrhage and dysrhythmias
Treatment for acute pericarditis is
it usually resolves spontaneously
drugs are given to relieve pain
Symptoms of acute pericarditis include
pericardial friction rub
ST elevation with normal enzymes
fever
acute chest pain with pleural component
Identify the components of Beck’s triad (select 3).
a. increased pulmonary artery occlusion pressure
b. hypotension
c. tachycardia
d. jugular vein distension
e. muffled heart tones
f. mill wheel murmur
b. hypotension
d. jugular vein distension
e. muffled heart tones
Pericardial effusion is the
accumulation of fluid inside the pericardial sac
Pericardial effusion is not _______________ and seldom requires __________
an emergency; intervention
_______ is the best method of diagnosis for pericardial effusion
TEE
What is the difference between pericardial effusion and cardiac tamponade?
cardiac tamponade also results from fluid accumulation inside the pericardium, however the pericardial pressure is high enough to compress the myocardium
Clinical presentation of cardiac tamponade includes
Beck’s triad
pulsus paradoxus
Kussmaul’s sign
reduced EKG voltage
Describe Beck’s triad.
fluid accumulation in the pericardial sac–> muffled heart tones
decreased venous return to the right heart–> jugular venous distension
decreased stroke volume–> hypotension
What is Kussmaul’s sign?
JVD on inspiration
increased CVP
A patient with blunt chest trauma presents for pericardiocentesis. He exhibits jugular venous distension and Kussmaul’s sign. What is the best induction agent for this patient?
a. propofol
b. etomidate
c. ketamine
d. midazolam
C. Ketamine
Surgical management of cardiac tamponade includes
pericardiocentesis (needle aspiration)
pericardiostomy
What type of anesthetic is preferred for cardiac tamponade surgery?
local anesthesia over GA (d/t better hemodynamic stability)
If GA is required for cardiac tamponade, what drugs should be used?
drugs that preserve myocardial function:
ketamine
nitrous oxide
benzodiazepines
opioids
What should be done in regards to heart rhythm, preload, afterload, and contractility with cardiac tamponade?
maintain NSR
preload
afterload
& contractility
What kind of ventilation is preferred with cardiac tamponade surgery?
spontaneous ventilation over PPV
What are the three approaches to pericardiostomy?
subxiphoid
thoracoscopic
thoracotomy
Complications of pericardiostomy and pericardiocentesis include
pneumothorax
re-accumulation of pericardial fluid
puncture of the coronary vessels or myocardium
A patient present to the preoperative clinic with a previous history of infective endocarditis. Which procedure puts this patient at the HIGHEST risk of an adverse outcome?
a. cystoscopy
b. colonoscopy
c. dental implant
d. coronary stent placement
c. dental implant
Infective endocarditis is typically a
bacterial infection of the heart valves and endocardium
Antibiotic prophylaxis against endocarditis is NOT required for
mitral valve prolapse
CABG
or coronary stent placement
IV antibiotics for IE prophylaxis cinlude
ampicillin
cefazolin
ceftriaxone
clindamycin
The current ACC/AHA guidelines advocate for antibiotic prophylaxis only if the patient is
at higher risk of developing IE- risk is a function of patient and surgery related factors
Patient-factors that increase risk for infective endocarditis include
history of IE, prosthetic heart valve, and certain congenital heart defects
repaired congenital heart defect if the repair is <6 months old
unrepaired cyanotic congenital heart disease
heart transplant with valvuloplasty
repaired CHD with residual defects that have impaired endothelization at the graft site
Surgery-related factors that increase risk for infective endocarditis includ
“dirty” procedures such as dental procedures with gingival manipulation, certain respiratory procedures, and biopsies of infected lesions
Which intervention is MOST likely to precipitate hemodynamic instability in the patient with obstructive hypertrophic cardiomyopathy?
a. esmolol
b. nitroglycerin
c. phenylephrine
d. 500 mL 0.9% NaCl bolus
b. nitroglycerin
_______________ is the most common cause of sudden cardiac death in young athletes.
Hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy leads to _____________ during systole.
left ventricular outflow tract obstruction
Causes of left ventricular outflow tract obstruction include
congenital hypertrophy of the interventricular septum
systolic anterior motion of the anterior leaflet of the mitral valve
Common conditions that worse LVOT include
decreased preload
increased contractility
decreased afterload
Key treatments for worsening LVOT include
beta-blockers
calcium channel blockers
fluids
phenylephrine
What are all the names for hypertrophic cardiomyopathy?
obstructive hypertrophic cardiomyopathy
hypertrophic obstructive cardiomyopathy
asymmetric septal hypertrophy
idiopathic hypertrophic subaortic stenosis
What are the three determinants of blood flow through the LVOT?
systolic LV volume
the force of LV contraction
the transmural pressure gradient
Conditions that distend the LVOT are _____________, while things that narrow the LVOT are
good; bad
What will narrow the LVOT?
decreased systolic volume
increased contractility
decreased transmural pressure
Surgical options for LVOT include
mitral valve replacement (can reduce SAM)
septal myomectomy removes a portion of the septum and improves the transmural pressure gradient
alcohol injection into the septal perforator arteries causes ischemic injury to the septum and improves the transmural pressure gradient
