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CSC Prep > Ch. 3&4 Cardiac Surgery & Complications > Flashcards

Ch. 3&4 Cardiac Surgery & Complications Flashcards

1
Q

On-Pump CABG (ONCAB)
* What type of incision
* Key difference between ONCAB and OPCAB
* 6 Risks
* How much heparin
* Consideration during re-warming

A
  • Median sternotomy
    *Grafts sewn while heart is arrested vs. beating
  • Risks: Aortic dissection, embolization, SIRS/inflammation, unable to wean off, Bleeding, thrombocytopenia & HIT
  • Run ACT 350 - 400 sec while on CPB
  • Consider vasodilation during re-warming from moderate hypothermia
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2
Q

Types of Sternotomy incisions
1. Median Sternotomy
2. Mini Sternotomy
3. Clamshell sternotomy
4. Hemisternotomy
5. Thoracosternotomy

A
  1. Vertical incision that runs from top to bottom of sternum
  2. Minimally invasive sternotomy that is 3-4 inches long in the middle of the sternum
  3. Also known as a bilateral thoracosternotomy, involves the sternum and provides access to thoracic cavity
  4. Smaller incision made in either upper or lower portion of sternum
  5. Provides access to thoracic cavity and can be hemiclamshell or modified
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3
Q

Cardioplegia Solution Top Components
4

A
  1. Plasmalyte - carrier fluid
  2. Potassium Chloride and/or lidocaine to arrest the heart
  3. Sod Bicarb to scavenge H+ ions and buffer pH
  4. Mannitol to prevent myocardial edema
  5. Mag sulfate
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4
Q

ONCAB Inflammatory response
* What causes this
* Inflammatory response causes release of what
* Can cause what complications

A
  • exposure to the CPB circuit, tissue trauma, protamine administration
  • High levels of CRP, release of TNF, IL6 & IL8
  • myocardial ischemia, reperfusion injury, ARDS, vasodilation
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5
Q

What is reperfusion injury

A

defined as the paradoxical exacerbation of cellular dysfunction and death, following restoration of blood flow to previously ischaemic tissues.

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6
Q

Atrial appendage closure (LAAL)
* Patient is at risk for what

A
  • Atrial fibrillation and other atrial arrhythmias
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7
Q

Sternal wires
* Sternal precautions for how long
* What do the precautions entail
* When do the wires come out

A
  • Precautions for 4-6 weeks
  • Do not lift more than 5-8 lbs or a gallon of milk, no pushing/pulling with arms, no reaching behind back or overhead, no driving
  • The wires never come out because they are permanent
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8
Q

OPCAB / MIDCAB
Off Pump / minimally invasive direct

  • How is this different than ONCAB
A
  • Grafts sewn while heart is beating
  • Receive fewer grafts
  • Higher graft re-occlusion rates and re-intervention rates
  • Higher aortic dissection rates
  • Conversion to ONCAB
  • Benefit from mild hyopthermia or normothermia, fewer transfusions, and less heparin
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9
Q

CABG Vessels go where
* SVG
* Left ITA
* Right ITA
* Advantages to ITA
* RA - often placed on what

A
  • SVG - can go several places
  • Left ITA bypass to LAD
  • Right ITA bypass to RCA
  • Advantages include only one anastomosis, reduce emboli and stroke risk
  • Often placed on CCB or diltiazem x 6 months to prevent arrhythmia
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10
Q

Radial Artery Graft
* Usually use which hand/arm
* Compressive wrap x how many hours
* what test preop
* Post-op 6 P’s

A
  • Use non-dominant hand/arm
  • Compressive wrap x 24 hours
  • Allen’s test to assess collateral circulation of ulnar artery
  • Pulse, Pain, Pallor, Parasthesia, Paralysis, Polar
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11
Q

Which drugs used Preop for CABG (3)
High risk for what

A
  1. Beta blockers to prevent POAF
  2. Statins to reduce inflammatory response
  3. Prophylactic antibiotics
  • High risk for surgical site infection, redo surgery, prolonged surgery, prolonged mechanical ventilation,
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12
Q

Immediate Postop priorities (4)
longer pump time = ?
Optimal pump time=

A
  1. Hemodynamic stability - consider causes and monitor for arrhythmias
  2. Hypothermia - during rewarming
  3. Coagulopathy - longer pump time = increased risk of bleeding
  4. Acidosis - decreased myocardial contractility

Last three are the triad of death

Optimal pump time = 180 mins/3hrs to minimize the risk of severe complications

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13
Q

Post-op Considerations - why monitor for theses
* shivering
* aspirin administration
* Post-op ischemia - chest pain

A
  • Shivering increases O2 consumption
  • Aspirin administration within 6-12 hours post-op. Hold if bleeding
  • Low threshhold for ECG
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14
Q

Hyperflycemia management post surgery

  • what level do we shoot for
  • always know what before administering insulin
A
  • 140-180 mg/dL, may opt for tighter control 110-140
  • Always know their potassium level
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15
Q

Malignant hyperthermia
* Definition
* Signs/symptoms
* Treatment

A
  • Sever metabolic state due to a reaction to anesthetics. Calcium is released from muscles
  • Symptoms include hyperthermia, tachycardia, rigors/muscle spasms which can develop into rhabdomyolysis, may see metabolic acidosis
  • Dantrolene 2.5 mg/kg IV
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16
Q

What is Pulsus paradoxus and what does it indicate

A
  • High variability in blood pressure during inhalation/exhalation would indicate that they would be responsive to fluid or that we need to optimize preload
  • Can be a sign of Cardiac tamponade or restrictive pericarditis
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17
Q

Classic signs of RV failure (4)

A
  1. Tachycardia & hypotension
  2. Decreased CO/SV
  3. High right preload (RA), normal or low left heart preload
  4. RV dilation (on echo or TEE)
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18
Q

Treatment of RV failure (4)

A
  1. Optimize RV preload with fluid
  2. Improve contractility (dobutamine/milrinone)
  3. RV afterload reduction (iNO, Epoprostenol, pulm vasodilation)
  4. Mechanical circulatory support (right impella or RVAD)
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19
Q

Vasoplegia
* Definition
* Hemodynamics
* Treatment

A
  • Massive systemic vasodilation due to inflammatory response or cytokine/chemokine release in the setting of hyperdynamic state (High CI)
  • CI increased, SVR decreased, Hypotension
  • Treat with fluid optimization, vasopressors, methylene blue (increased BP and SVR)
20
Q

Low Cardiac Output Syndrome (LCOS)
* Definition
* Hemodynamics
* Signs/symptoms
* Treatment

A
  • This is LV failure, Decreased CI <2
  • Hypotension, Decreased CO CI SV, Increawsed SVR, Increased PAD/PAOP, Decreased SvO2 d/t increased demand
  • Increasing lactate >2, oliguria, mottling, cold/clammy skin, decreased LOC, shock
  • Inotropes (milrinone, dobutamine, epi low dose), IABP or impella, Afterload reduction, vasopressors, diuretic if fluid overloaded, fluid only in inadequate preload, minimize fever and WOB
21
Q

Cardiac Tamponade
* Definition
* % of people with pericardial effusion after surgery
* Symptoms
* Beck’s Triad

A
  • Compression of the heart due to fluid accumulation within the pericardium
  • POD2 ~85% have some degree of pericardial effusion
  • Beck’s Triad
    1. Elevated CVP w/JVD
    2. Hypotension with narrow pulse pressure
    3. muffled heart sounds
  • SOB, tachycardia, sudden drop in CT output, equilization of intracardiac pressures, pulsus paradoxus, cardiac arrest
22
Q

Treatment of Cardiac Tamponade

A
  • Pericardiocentesis
  • Suction the chest tubes
  • Resternotomy if unable to clear drainage
  • Locate and control source of bleeding
23
Q

Who is at greatest risk for post-operative myocardial ischemia

A
  • Female
  • Age >70
  • Diabetes
  • PVD
  • Emergent or redo surgery
  • Poor protection during CPB w cardioplegia
  • Coronary embolism
  • incomplete revascularization
  • coronary spasm
  • EF<35%
  • Pre op MI
24
Q

Pos-op Treatment of MI
2 things

A

Aspirin + p2Y12 inhibitor

25
Q

Treatment for VT with a pulse (5)
What to watch out for

A
  1. Amiodarone 150 mg over 10 mins
  2. Amio 1mg/min x 6 hours, then 0.5 mg/min x 18 hours
  3. Procainamide
  4. Sotalol
  5. Lidocaine
  • Watch out for prolonged Qt and torsades
26
Q

Open chest from the OR
* Why is the sternum sometimes left open
* Positioning postop
* Treatment to work toward closure
* How long do they stay open

A
  • Left open to avoid myocardial compression d/t myocardial edema, bleeding, low CO, tamponade, VAD placement
  • Suipine position only
  • Aggressive diuresis, CRRT?,
  • Close within 2-5 days d/t high risk for sternal infection
27
Q

Causes of Post-op ischemia
5

A
  1. Graft failure
  2. coronary embolism
  3. Poor protection during CPB (didn’t reduct heart’s O2 demand enough)
  4. incomplete revascularization
  5. coronary artery vasospasm
28
Q

STEMI
* What symptoms are significant (3)
* Hallmark signs of STEMI
* Treatment and time goal

A
  1. > 1 mm in limb leads
  2. > 2 mm precordial leads
  3. new BBB
    * Hallmark signs: SOB, diaphoresis, cardiac biomarkers increasing
    * PCI iitreatment door to balloon time goal 90 minutes, Aspirin, notroglycerin, morphine, supplemental O2, consider P2Y12 inhibitor like plavix
29
Q

Aspirin treatment in STEMI
* Whats special about this med
* Initial dose
* action

A
  • This is the 1st med prioritized in ACS
  • initial dose 325 mg chewed, then 81 mg indefinitely
  • inhibits platelet aggregation
30
Q

Nitroglycerin treatment in STEMI
* Action
* Initial dose
* Side effects
* caution

A
  • Potent vasodilator and venodilator which reduces preload and ventricular wall tension. This decreased myocardial O2 consumption
  • Sublingual spray or IV - sublingual 0.4 mg Q5 min x3 then assess for IV NTG
  • Monitor for hypotension, headache is common
  • Do not give to patients with right ventricular infarction. Nitro drops preload
31
Q

Morphine
* initial dose
* action
* avoid in

A
  • Small incremental doses: 1-2 mg IV q 5-15 min if CP unrelieved by NTG
  • Potent analgesic and anxiolytic which reduces preload and mild afterload reduction. Decreases workload of the heart.
  • Avoid in RV MI because it reduces preload
32
Q

Oxygen
* Avoid hyperoxygenation above what amount and why

A

Avoid oxygenation >96% because hyperoxemia likely perpetuates oxidative injury after MI. Hyperoxemia can increase infarct size

33
Q

Retroperitoneal bleed & Hematoma
* What causes risk for this
* Signs
* Treatment

A
  • Femoral arterial approach in any procedure
  • Tachycardia, hypotension, very fluid responsive, back pain, groin pain, fl;ank ecchymosis (late sign), Grey turner sign which is discoloration of the flank
  • Stay CBC, coags if applicable, may medically manage with pressure or surgical repair, percutaneous intervention with balloon tamponade, fluids and transfusion
34
Q

What does each wave represent?
* P wave
* PR interval
* QRS
* T wave
* QT interval

A
  • Atrial depolarization
  • AV conduction time (0.12-.20 sec)
  • Ventricular depolarization (.06-0.10 sec)
  • Ventricular repolarization
  • Ventricular repolarization time
35
Q

Q waves present in contiguous leads is indicative of:
Abnormal if:

A
  • myocardial necrosis
  • basically if they are abnormal looking
36
Q

12 Lead ECG Review - show changes in what leads
1. Inferior Wall MI
2. Anterior/septal
3. Lateral
4. Posterior
5. Right ventricle

A
  1. II, III, aVF
  2. V1-V4
  3. I, aVL, V5 - V6
  4. Posterior leads V7 - V9
  5. V2R - V4R
37
Q

12 Lead ECG Arteries Affected
1. Inferior wall
2. Anterior/septal
3. Lateral
4. Posterior
5. Right ventricle

A
  1. RCA or L Circumflex
  2. LAD/Left Main
  3. L Circumflex LAD
  4. L Circumflex, RCA
  5. Proximal RCA
38
Q

Which lead would best indicate right ventricular infarction?

A

V1, V2R - V4R

39
Q

Aneurysm definition and locations
* Thoracic (TAAA)
* Abdominal (AAA)
* Aortic dissection
* Rupture

Symptoms of aneurysm

A

Aneurysm: permanent localized dilation of aorta 1.5 times diameter
* Above Diaphragm
* Below Diaphragm
* Tear in the inner lining of the aorta
* complete tear through all 3 layers of the aorta

Patients often describe “ripping” chest pain radiating to the back

40
Q

Thoracic Aneurysm
* Who is at risk (2)
* treatment
* symptoms of dissection

A
  • HTN, smoking
  • Prevent rupture or dissection with BP control, HR reduction
  • BP difference >25 mmHg between left and right arm, Sudden severe pain, shortness of breath, may have muffled heart sounds, tachycardia
41
Q

Type A dissection vs. Type B dissection

A
  • Type A is a proximal tear of the ascending aorta +/- arch and/or valve. This is life threatening and requires emergent surgery to repair/replace
  • Type B iis a descending tear that can extend to the abdominal aorta. May need suirgery depending on location and organs affected
42
Q

Ascending TAA
* At risk for
* symptoms
* Diagnosis

A
  • At risk for aortic regurgitation/insufficiency
  • Diastolic murmur because blood is flowing back out of aneurysm during diastole, widened pulse pressure when valve is affected
  • Diagnosed with Stat CT scan, consider TEE
43
Q

Descending TAA
* Treatment

A
  • medical management
  • If dissected administer vasodilators to keep BP controlled
  • Endovascular stentingi
44
Q

Post-op TAAA & TEVAR
* Abbreviation
* Treatment
* Risks (2)

A
  • Thoraco-abdominal aortic aneurysm
  • Thoracic endovascular aortic repair
  • Aorta cross-clamping can lead to spinal cord ischemia/infarction, paraplegia incidence not insignificant in surgical repair
45
Q

Lumbar Drain usage

Spinal cord perfusion pressure
* Equation for this
* Goal for CSF pressure
* CSF drain for how long
* Avoid what
* SCPP goal, Map goal

A
  • Map - Lumbar CSF pressure = SCPP
  • CSF goal <10 mmHg
  • CSF drain 2 - 3 days
  • Avoid rapid drainage of CSF
  • Keep MAP>80, SCPP >70
46
Q

Abdominal Aneurysm
* Pulsation where
* % mortality risk
* treatment
* Signs of rupture

A
  • Pulsation in the abdomen
  • > 90% mortality risk
  • Control hypertension and surgical repair
  • Signs include hypotension, tachycardia, shock
47
Q
A

CSC Prep (8 decks)

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