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CV Anesthesia, plus renal (Skuta) > CV Special Populations > Flashcards

CV Special Populations Flashcards

1
Q

At rest, myocardium consumes ~ _____% of the oxygen delivered to it.

A

70%

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2
Q

Tachycardia effects both _______ and _________.

A

Supply and Demand

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3
Q

When the heart requires more oxygen, coronary blood flow and/or CaO2 must ________.

A

increase

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4
Q

What is the most useful measure of coronary perfusion?

A

MAP!!!!

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5
Q

____%of blood flow to the left ventricle happens during _______ when LVEDP is low -> diastolic time ______ as HR _______, thus giving less time for adequate perfusion

A

-80%
-diastole
-decreases
-increases

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6
Q

Decreased Oxygen Delivery:

A

-Decreased Coronary flow
-Decreased CaO2
-Decreased O2 extraction (left shift of HGB curve)

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7
Q

Increased O2 Demand

A

-Tachycardia
-HTN
-SNS stimulation
-Increased Wall Tension
-Increased LVEDV
-Increased Afterload and Contractilty

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8
Q

The heart acts as an “________” organ under stress

A

endocrine

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9
Q

ANP is released in response to _______ _________.

A

Volume Overload

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10
Q

B-type natriuretic peptide is released from the ventricles in response to ______ _______.

A

wall stress

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11
Q

______ is a marker for diagnosis of heart failure

A

BNP

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12
Q

Hallmark of LV Heart Failure:

A

Decreased EF with an increased EDV
-Ventricle doesn’t empty well

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13
Q

LV HF: shape change

A

-becomes more spherical shaped

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14
Q

LV HF: Volume overload causes _____ ______.

A

Eccentric Hypertrophy

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15
Q

Calculation for EF:

A

SV/EDV

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16
Q

EF levels (normal, mild, moderate, severe)

A

Normal: >55%
Mild: 45-54%
Moderate: 30-44%
Severe: <30%

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17
Q

Causes of Systolic HF:

A

CAD / myocardial Ischemia
Volume Overload ( d/t Valve insufficiency)
Dilated cardiomyopathy

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18
Q

Compensatory mechanism in Systolic HF:

A

SV reduces –> SNS activates –> raise the resting HR to try and maintain CO

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19
Q

Systolic HF: Anesthesia Considerations

A

Preload: already high, (avoid overload, diuretics if too high)

Afterload: DECREASE to reduce myocardial workload
-coronary pressure must be maintained
-SNP (nipride) works well if volume adequate

Contractility: may be reduced –> INOTROPES

HR: usually HIGH d/t SNS
-if EF low then HIGHER HR needed to perserve CO (do not decrease HR)

FULL FAST FOWARD

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20
Q

Left Heart Failure: Diastolic Dysfunction

A

-Ventricle doesn’t FILL properly
HALLMARK: symptomatic HF with preserved EF

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21
Q

Left HF Diastolic Dysfunction: Chronic pressure overload leads causes the myocardium to _______.
Pressure overload leads to ________ _______.

A

-thicken
- concentric hypertrophy

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22
Q

Left HF Diastolic Dysfunction: ______ ischemia from chronic _____ _____.

A

Demand
pressure overload

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23
Q

Most common type of heart failure in women and the elderly

A

Left HF Diastolic Dysfunction
Preserved EF = >40%

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24
Q

Left Heart Failure: Diastolic dysfunction
CAUSES:

A

Demand ischemia from chronic pressure overload

Myocardial ischemia
Stenotic heart valves
Hypertrophic cardiomyopathy
Chronic hypertension
Cor pulmonale
Obesity

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25
Q

Diastolic HF: Anesthetic Considerations

A

PRELOAD: volume required to stretch non-compliant ventricle

AFTERLOAD: usually already elevated, if not keep elevated to perfuse THICK myocardium
-PHENYLEPHRINE –> GIVE WITH INDUCTION

CONTRACTILITY: usually normal, caution with agents that depress function

HR: slow/normal to maximize diastolic time for coronary perfusion and decrease MVO2

** The LV with concentric hypertrophy is prone to ischemia, Maintenace of a high MAP and slow normal HR is crucial. Hypotension should be treated promptly with phenylephrine!

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26
Q

Diastolic HF: Anesthetic Considerations (2)

A

Similar to stenotic lesions: Slow, Full, Constricted

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27
Q

Right Ventricular Failure: The right heart is _______, more _______, and _______ than the left heart

A

thinner, more compliant and weaker

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28
Q

Most common cause of right heart failure is:

A

Left heart failure

Also caused by pulmonary HTN and right sided MI

29
Q

_______ ______ HF causes systemic congestion, hepatomegaly, and peripheral edema

A

Right Sided

30
Q

Anything that increases _____ can impair RV function

A

PVR

31
Q

Factors that can increase PVR (RV HF)

A

Hypoxemia, hypercarbia, Acidosis
N2O and Desflurane can increase PVR

32
Q

Treatment of Right Ventricular HF:

A

main goal is to improve contractility while reducing right heart afterload
Inotropes and decreased PVR

Management of right sided HF can be more difficult than left sided HF because fewer options exist for unloading and supporting the right ventricle

33
Q

Remodeling can be reversed by _______ and ________.

A

Ace Inhibitors and aldosterone inhibitors

34
Q

Cerebral Autoregulation Curve:

A

Describes the range of blood pressures where cerebral perfusion remains constant

35
Q

Chronic hypertension shifts the curve to the _____.

A

RIGHT

This helps the brain tolerate a higher range of blood pressures
However, it can not tolerate lower blood pressures

36
Q

Malignant HTN —–> __________/__________

A

Hemorrhagic stroke/cerebral edema

37
Q

Hypotension —–> ______________

A

cerebral hypoperfusion

38
Q

Acute Pericarditis: Pathology

A

Usually from result of inflammation
Does NOT impair diastolic filling unless inflammation leads to constrictive pericarditis or tamponade

39
Q

Most common cause of Acute Pericarditis (others as well)

A

VIRAL INFECTION

Dressler’s Syndrome (inflammation from necrotic myocardium s/p MI)
TB
Autoimmune diseases – RA, SLE, Scleroderma
Cardiac injury – trauma, surgery
Cancer (radiation)

40
Q

Acute Pericarditis pain symptoms

A

Acute chest pain with pleural component
Increased pain with inspiration and postural changes
Pain relieved by leaning forward

41
Q

Constrictive Pericarditis:

A

Fibrous tissue encapsulates the heart and limits its ability to expand during DIASTOLE

42
Q

Constrictive Pericarditis: patient will have abnormal ________ ________.

A

diastolic filling

Ventricles adapt by increasing myocardial mass

43
Q

Constrictive Pericarditis:
Increased _______
Decreased ________

A

Increased: filling pressures
Decreased: SV and CO

44
Q

Constrictive Pericarditis: CAUSES

A

Cancer (radiation), cardiac surgery, rheumatoid arthritis, TB, uremia

45
Q

Constrictive Pericarditis: Signs and Symptoms

A

Gradually increasing fatigue and dyspnea
Kussmauls sign – JVD during inspiration
Pulsus Paradoxes - decreased SBP by 10 mmHg during inspiration
Increased venous pressure – distended neck veins, hepatomegaly, ascites, peripheral edema
Atrial dysrhythmias
T wave inversion or notched P waves on ECG
Pericardial shock

46
Q

Kussmauls sign

A

JVD during inspiration

47
Q

Constrictive Pericarditis: Treatment

A

Pericardiotomy (risky) high mortality
Hemorrhage and dysrhythmias common

Large bore Ivs
Invasive hemodynamic monitoring
Have a CPB machine ready and available in the room

48
Q

Constrictive Pericarditis: Management (what to avoid, what to maintain)

A

Cardiac output is dependent on HR*
Avoid Bradycardia
Maintain Afterload

49
Q

Meds to help preserve HR and Contractility (Constrictive Pericarditis)

A

Ketamine and Pancuronium are good
Opioids, benzos, etomidate are okay

50
Q

Cardiac Tamponade: What is it?

A

Accumulation of fluid inside the pericardium —>pericardial pressure high enough to compress myocardium —-> interferes with the hearts ability to fill and act like a pump

51
Q

Cardiac Tamponade (LV pressure, volume, CO, HR) Effects

A

Increased pericardial pressure compresses the heart
Increased LV pressure
Decreased ventricular volume = decreased SV, decreased CO, increased HR

52
Q

Cardiac Tamponade: Causes

A

Trauma – blunt force trauma (major cause), sharp trauma, dissecting aortic aneurysm
Complications with cardiac surgery
Malignancy within the mediastinum
Expansion of pericardial effusions after pericarditis

53
Q

Cardiac Tamponade: Becks Triad

A

Hypotension, JVD, Muffled heart tones

54
Q

The most sensitive method to detect pericardial effusion and exclusion of tamponade

A

Echocardiogram

55
Q

Definitive treatment of Cardiac Tamponade

A

pericardiocentesis

56
Q

Cardiac Tamponade intubation considerations

A

Compression of heart, lungs, trachea, and esophagus d/t mass effect
Video laryngoscope, fiber optic, delicate intubation

57
Q

Cardiac Tamponade- Anesthetic Management

A

If GA – primary goal is to preserve myocardial function

Stroke volume is severely decreased but increased SNS tone (increased contractility and afterload) provide compensation
Any drug that depresses the myocardium or reduces afterload can precipitate and CV collapse

58
Q

____ preferred for pericardiocentesis

A

LA

59
Q

Anesthesia Drugs to Avoid with Cardiac Tamponade

A

Halogenated agents
Propofol
Thiopental
High dose opioids
Neuraxial anesthesia

60
Q

Drugs that are safer for Cardiac Tamponade

A

Ketamine
Nitrous oxide
Benzodiazepines
Opioids

61
Q

Best anesthesia drug for cardiac tamponade?

A

Ketamine

62
Q

Cardiac Tamponade- (HR, Rhythm, Preload, Afterload, Contractility)

A

Heart Rate = Maintain
Rhythm = NSR
Preload = Maintain or Increase
Contractility = Maintain or Increase
Afterload = Maintain

63
Q

Most common cause of sudden cardiac death in young adults

A

Obstructive Hypertrophic Cardiomyopathy

LVOT obstruction caused by:
Congenital hypertrophy of intraventricular septum
Systolic anterior motion (SAM) of anterior leaflet of mitral valve

64
Q

SAM is….

A

Systolic Anterior Motion of the Mitral valve

65
Q

Conditions that distend the LVOT ——>

A

GOOD!

66
Q

Conditions that narrow the LVOT ——>

A

BAD!

67
Q

Surgical Procedures with Increased Risk for Infective Endocarditis

A

Dental procedures involving gingival manipulation and/or damage to mucosal lining
Respiratory procedures that perforate the mucosal lining
Biopsy of infected lesion on skin or muscle

68
Q

HALLMARK for Left Heart Failure: Diastolic Dysfunction

A

Symptomatic HF with preserved EF

69
Q

Causes of Systolic HF:

A

CAD / myocardial Ischemia
Volume Overload ( d/t Valve insufficiency)
Dilated cardiomyopathy

CV Anesthesia, plus renal (Skuta) (11 decks)

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