Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Anesthesia II > CV Assessment > Flashcards

CV Assessment Flashcards

1
Q

Steps of the cardiac assessment

A

1) Determine the urgency of surgery
2) Determine if the patient has an active cardiac condition
3) Determine surgical risk (risk that the surgery will further damage the heart)
4) Assess functional capacity (exercise tolerance, etc)
5) Assess clinical predictors/markers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is the goal of the pre-op cardiac assessment?

A

To identify patients with heart disease who are at high risk for perioperative morbidity or mortality or those with modifiable conditions or risks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Minor clinical predictors of increased CV risk

A 
Uncontrolled HTN
>75 years old
Abnormal EKG
Low exercise tolerance
History of CVA
Smoking
PVD
Rhythm other than NSR
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Intermediate clinical predictors of increased CV risk

A

Known CAD
Prior MI (OVER one month ago) and Q waves on EKG
Mild, stable angina
Compensated or previous LV failure/CHF
DM (both insulin dependent AND non-insulin dependent)
Chronic renal insufficiency (CR > 2.0)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

MAJOR clinical predictors of increased CV risk

A

These are major, current cardiac conditions

  • Unstable coronary syndromes (active ischmia on EKG)
  • MI within the last month
  • Severe or unstable angina
  • Decompensated CHF
  • Significant arrhythmias (arrhythmias that are symptomatic)
  • Severe valvular disease
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What valvular disease are we most concerned about when it comes to intraoperative management?

A

Aortic stenosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Special considerations for cardiac assessment of Emily Rucker

A

She is a heartless creature, and therefore does not require a pre-op cardiac assessment.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the overall mortality risk of acute MI for the average person receiving GA?

A

.3%
The risk increases if the patient is undergoing intra-thoracic or intra-abdominal surgery or for surgeries lasting longer than 3 hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Risk of periop reinfarction for those with history of prior acute MI

A

> 6 months ago = 6%
3-6 months ago = 15%
Within 3 months = 30%
Highest risk is within 30 days after acute MI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Mortality rate for perioperative reinfarction

A

50%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

ACC/AHA guidelines suggest waiting AT LEAST _______ post-MI before having elective surgery

A

4-6 weeks

This also allows us time to identify which areas of the myocardium will be most at risk during surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Surgeries with high risk of cardiac morbidity/mortality (>5% additional risk)

A

Aortic surgery (or surgery on other major vasculature)
Peripheral vascular surgery
Major emergent operations (especially for the elderly)
Prolonged procedures with major fluid shift/blood losses

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Surgeries with intermediate risk of cardiac morbidity/mortality (1-5% additional risk)

A 
Intraperitoneal
Intrathoracic
Transplant
Carotid endarterectomy
Head and neck
Major neuro / ortho cases
Endovascular aneurysm repair
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Surgeries with low risk of cardiac morbidity/mortality (<1% additional risk)

A 
Endoscopies
Superficial procedures
Biopsies
Cataract surgery
Breast surgery
GYN
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Basic components of the cardiac assessment

A

Patient history (and medication history)
Physical exam
Resting 12-lead EKG (only if indicated!!)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Who is indicated for a pre-op 12-lead EKG?

A

Patients with clinical indicators of CV disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

A 12-lead, if needed, should be done within ____days of surgery

A

30 days

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Adjunct testing that can be done for a cardiac assessment

A 
Labs
CXR
Stress test
Echo
MRI
CAT Scan
Coronary angio
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is the gold standard for visualizing coronary anatomy?

A

Coronary angiography

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Why is taking a good cardiac history important?

A

Because most of the time, history can diagnose if someone is at risk for cardiac events intra-op.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Patients with this type of angina are at a much higher risk of a cardiac event

A

Unstable angina

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What do we want to know about a patient’s angina?

A

What are the precipitating factors?
Associated symptoms?
How often does it occur? Duration of the pain? What relieves it (rest, medication, etc)?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What is the difference between stable and unstable angina?

A

Stable is predictable. Usually occurs during exercise or stress.

Unstable is unpredictable. May happen at rest or with light activity. It is a major predictor that an MI may occur soon.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Why is estrogen status of a female important to the CV history?

A

Estrogen has a protective factor against CV disease. Post-menopausal women are therefore at higher risk of a periop event.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

In the absence of lung disease, this is the most striking evidence of decreased cardiac reserve

A

decreased exercise tolerance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What is the duke activity status index?

A

A questionnaire that is able to measure functional capacity (exercise tolerance) and how much O2 demand the heart is able to tolerate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Findings of the Duke Activity Status Index and what they mean

A

1-4 METS (eating, dressing, walking around the house, dishwashing)
4-10 METS (climbing stairs, walking around the neighborhood, heavy housework, golfing, bowling, dancing)
>10 METS (strenuous sports such as swimming, tennis, running, football, basketball, etc)
Patients unable to meet a 4-MET demand are at higher cardiac risk

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Patients with this disorder may experience angina despite having healthy coronaries

A

Aortic stenosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

A spasm of this can result in angina-like pain that is also relieved by NTG

A

The esophagus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

____% of ischemic episodes in CAD occur without associated angina (are silent)

A

80%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

____% of acute MIs are silent

A

10-15%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What is Prinzmetal’s Angina?

A

Angina that occurs at rest due to coronary vasospasm.

In 85% of cases, there is a fixed, proximal lesion in a major artery
In 15% of cases, there is only spasm with no associated lesion.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Can Prinzmeta’s angina cause heart damage?

A

Yes!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Patients with Prinzmetal’s angina also tend to have higher incidence of

A

Migraines and raynaud’s disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

What do you want to know about a patient’s pacemaker / ICD?

A

Indication for insertion
Underlying heart rhythm
Type of pacemaker (demand, fixed, or radiofrequency)
The chamber paced and the chamber sensed
Effect of a magnet
Current settings and battery life
Make sure an electrophysiologist checks out the pacer/ICD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

When should a patient’s pacemaker/ICD be evaluated before surgery?

A

3-6 months before surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

When should the ICD be deactivated?

A

The day of surgery

38
Q

Why should the ICD be deactivated before surgery?

A

The ICD may detect electrical equipment of the OR as an arrhythmia and then discharge. For this reason, we turn off the ICD and place pads on the patient.

39
Q

Are pacemakers usually on a synchronous or non-synchronous mode?

A

Synchronous

40
Q

What should we have immediately available for patients with pacemakers?

A

A magnet. Most pacers can be converted to a fixed rate (asynchronous mode) by placing a magnet over the pacemaker box.
We should also have external pacing pads available.

41
Q

Where should grounding pads be placed in a patient with a pacer/ICD?

A

As far away from the pulse generator as possible

42
Q

Type of electrocautery that should be used is patients with a pacer/ICD?

A

Bipolar (as opposed to monopolar). Bipolar decreases the amount of electricity flowing through the patient.

43
Q

Where is Erb’s point?

A

Third intercostal space at the left sternal border. S2 is best auscultated here.

44
Q

Why do we listen to the lungs in CV assessment?

A

Window to the LV. CHF can cause rales, SOB, dyspnea, etc.

45
Q

HTN is defined as a BP reading over

A

140/90

46
Q

When do we treat HTN?

A

When SBP is >160 and DBP is >90.

47
Q

What do we want to give patient with uncontrolled hypertension before surgery?

A

Give a beta blocker. These may have a protective benefit.

48
Q

What do you do if a patient comes for surgery with long-standing severe HTN or uncontrolled HTN?

A

May need to delay surgery to get BP under control. Get an EKG and serum CR/BUN to look for disease states that go with chronic HTN.

49
Q

If a patient is on diuretics for HTN, what test should you get prior to surgery?

A

CHEM7

50
Q

Recommendation regarding beta blockers for those undergoing vascular surgery

A

Start beta blocker therapy 1 month prior to surgery. Starting the day of can increase risk of stroke.

51
Q

Discontinuing beta blocker therapy before surgery can cause

A

increase risk of periop CV morbidity

52
Q

What is orthopnea?

A

Dyspnea that occurs as a result of lying flat. It occurs in CHF because the supine position causes more blood to enter the central circulation, increasing pulmonary capillary pressure. And now you know!

53
Q

Heart failure can be defined as

A

abnormal contractility or relaxation of the heart

54
Q

HF can be caused by

A

HTN or ischemic heart disease

55
Q

Seeing this on EKG raises your suspicion of heart failure

A

LV hypertrophy

56
Q

The following clinical findings would make you suspicious that your patient has heart failure

A 
Orthopnea
Docturnal coughing
Fatigue
Peripheral edema
3rd or 4th heart sounds
Resting tachycardia
Rales
JVD
Ascites
LVH on EKG
57
Q

What should you do if your patient has come for elective surgery and has decompensated HF/LV function?

A

Postpone the surgery

58
Q

Work-up for a patient with HF

A 
EKG
Chem7, Cr/BUN
BNP (marker of how progressed the CHF is. Ideal level is <100)
CXR (if pulmonary edema suspected)
Echo (to measure EF)
59
Q

Should cardiac medications be continued for surgery?

A

Yes! Even anticoagulants if surgery is able to tolerate it.

60
Q

Severe aortic stenosis poses the greatest risk if valve area is less than

A

1 cm2. If the patient has symptoms, postpone the surgery.

61
Q

These types of murmurs are always pathologic and require further intervention

A

Diastolic murmurs

62
Q

Considerations for a patient with a prosthetic heart valve

A

May need to bridge anticoagulant therapy (may need to stop coumadin a week prior or can be placed on a heparin drip that can be stopped 6 hours prior to surgery)
May need subacute bacterial endocarditis prophylaxis (SBE prophylaxis)

63
Q

These arrhythmias carry the highest perioperative risk

A

SVT and ventricular arrhythmias

64
Q

This block is highly associated with CAD

A

LBBB. If this is a new block for the patient, stress testing or consultation is needed.

65
Q

Postpone a surgery for these arrhythmias

A

New or uncontrolled a-fib
V-tach
Symptomatic bradycardia
High-grade or complete HB

66
Q

These are the 3 most common cardiac meds you will see

A

Beta blockers
Statins
ACE Inhibitors

67
Q

When should antiplatelets (ASA/plavix) be discontinued?

A

7-10 days prior to sx

68
Q

When should anticoagulents (coumadin/LMWH) be discontinued?

A

3-5 days prior to sx for Coumadin (want INR < 1.5)

12 hours prior to sx for LMWH

69
Q

When should fibrinolytics (tPA, streptokinase, urokinase) be discontinued?

A

We usually cannot discontinue these

70
Q

When should we order a CXR?

A

History of CHF
Symptomatic CV disease
Older than 75

71
Q

Indications for a 12 lead EKG

A

1) Patients with known CVD, CAD, PVD having intermediate to high risk surgery
2) Patients with at least one clinical risk factor for having vascular surgery (HTN, advanced age, low exercise tolerance, hx of CVA, known arrhythmia)

72
Q

We MIGHT want to get an EKG with these patients

A

1) Having vascular surgery, but no clinical risk factors

2) Having at least one clinical risk factor and having intermediate or high risk surgery

73
Q

Lab tests you may want to consider related to comorbidities

A 
H&H
Cr/BUN
K+
Coags
ABG
74
Q

Purpose of a treadmill stress test

A

Stimulate the SNS to increase HR and BP, thereby increasing O2 demand to look for ischemic changes on EKG. We are also making sure that the HR increases appropriately and that BP doesn’t rise too much.

75
Q

Information we will receive from a treadmill stress test

A 
Duration of exercise the patient can tolerate
Max HR achieved
Time of onset of ST depression
Degree of ST depression
Time until resolution of ST
76
Q

These results on a treadmill stress test will result in a positive test (indicating presence of CAD)

A

On EKG:

  • ST depression > 2.5cm
  • ST depression occurs within 3 minutes of exercise
  • Serious ventricular arrhythmias
  • Prolonged recovery of ST change

Non-EKG signs:

  • If BP or HR increase during ST-depression
  • If hypotension occurs (ominous sign)
77
Q

Medications given for pharm stress testing

A

Dobutamine (B1 activity- pharm shout-out, Hollaaaa!) and adenosine or dipyridamole.

78
Q

Who would we give a pharm stress test to?

A

Those unable to exercise

79
Q

Process of pharm stress testing

A

Overall, we are looking for ischemia via perfusion imaging, not EKG. To do this, we give meds that will vasodilate the coronary arteries (diseased arteries are less able to dilate) and increase demand demand on the heart. We also give a gamma-emitting dye (thallium) that allows us to image the blood within the heart and lungs.

Areas with decreased perfusion (cold spots) only during times of stress shows ischemia. Spots that have a constant perfusion deficit are suggestive of an old MI. Areas of redistribution deficits are at higher risk of ischemia and infarction.

80
Q

When would we request stress testing?

A

1) Active cardiac condition
- Unstable coronary syndromes
- Unstable o severe angina
- Recent MI
- Decompensated HF
- Significant dysrhythmias
- Severe valvular disease
2) Three or more risk factors and poor functional capacity undergoing vascular surgery
3) MAYBE get it if
- At least 1-2 risk factors and poor functional capacity having intermediate risk surgery if it will change management
- At least 1-2 risk factors and good functional capacity, but having vascular surgery

81
Q

What are you looking for during a stress echo?

A

Regional abnormalities in wall motion during stress (infusion of dobutamine). This test is highly predictive of adverse cardiac events.

82
Q

When do we order a pre-op echo?

A

1) Current of prior HF (with worsening dyspnea or other change in clinical status)
2) Dyspnea of unknown origin
3) Possible aortic stenosis

83
Q

This is a gold-standard test for someone undergoing cardiac surgery

A

Coronary angiography

84
Q

When should a patient have a pre-op cath?

A

1) Stable angina with left main CAD
2) Stable angina with 3 vessel disease
3) Stable angina 2-vessel disease with significant LAD lesion and EF <50% or demonstrable ischemia on noninvasive stress testing
4) High-risk unstabile angina or non-STEMI
5) Acute STEMI

85
Q

Need to wait _____days after balloon angioplasty before a patient can be taken off anticoagulants for another surgery

A

At least 14 days

86
Q

Need to wait _____days after bare-metal stent placement before a patient can be taken off anticoagulants for another surgery

A

At least 30-45 days

87
Q

Need to wait _____days after drug-eluting stent placement before a patient can be taken off anticoagulants for another surgery

A

At least 365 days

88
Q

MRI can be very sensitive to detecting infarctions when using this dye

A

Gadolinium

89
Q

Cardiac conditions placing a patient at high risk for SBE

A

Prosthetic heart valves
History of infective endocarditis
Unrepaired cyanotic congenital heart disease
Repaired congenital heart disease with residual effects
Cardiac transplant recipients with cardiac valvular disease

90
Q

For patients with high SBE risk, patients undergoing these surgeries should receive SBE prophylaxis

A

Dental and respiratory surgeries

91
Q

SBE prophylaxis is not recommended with these surgeries

A

GI/GU

92
Q

Standard SBE prophylaxis dosing

A

Single dose 30-60 min before surgery
Ampicillin 2g IV
or Cefazolin 1g IV
or Ceftriaxone 1g IV

If PCN allergy, give Clindamycin 600mg

Anesthesia II (11 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions