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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
Diastolic HF: Anesthetic Considerations
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!
26
Diastolic HF: Anesthetic Considerations (2)
Similar to stenotic lesions: Slow, Full, Constricted
27
Right Ventricular Failure: The right heart is _______, more _______, and _______ than the left heart
thinner, more compliant and weaker
28
Most common cause of right heart failure is:
Left heart failure Also caused by pulmonary HTN and right sided MI
29
_______ ______ HF causes systemic congestion, hepatomegaly, and peripheral edema
Right Sided
30
Anything that increases _____ can impair RV function
PVR
31
Factors that can increase PVR (RV HF)
Hypoxemia, hypercarbia, Acidosis N2O and Desflurane can increase PVR
32
Treatment of Right Ventricular HF:
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
Remodeling can be reversed by _______ and ________.
Ace Inhibitors and aldosterone inhibitors
34
Cerebral Autoregulation Curve:
Describes the range of blood pressures where cerebral perfusion remains constant
35
Chronic hypertension shifts the curve to the _____.
RIGHT This helps the brain tolerate a higher range of blood pressures However, it can not tolerate lower blood pressures
36
Malignant HTN -----> __________/__________
Hemorrhagic stroke/cerebral edema
37
Hypotension -----> ______________
cerebral hypoperfusion
38
Acute Pericarditis: Pathology
Usually from result of inflammation Does NOT impair diastolic filling unless inflammation leads to constrictive pericarditis or tamponade
39
Most common cause of Acute Pericarditis (others as well)
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
Acute Pericarditis pain symptoms
Acute chest pain with pleural component Increased pain with inspiration and postural changes Pain relieved by leaning forward
41
Constrictive Pericarditis:
Fibrous tissue encapsulates the heart and limits its ability to expand during DIASTOLE
42
Constrictive Pericarditis: patient will have abnormal ________ ________.
diastolic filling Ventricles adapt by increasing myocardial mass
43
Constrictive Pericarditis: Increased _______ Decreased ________
Increased: filling pressures Decreased: SV and CO
44
Constrictive Pericarditis: CAUSES
Cancer (radiation), cardiac surgery, rheumatoid arthritis, TB, uremia
45
Constrictive Pericarditis: Signs and Symptoms
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
Kussmauls sign
JVD during inspiration
47
Constrictive Pericarditis: Treatment
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
Constrictive Pericarditis: Management (what to avoid, what to maintain)
Cardiac output is dependent on HR* Avoid Bradycardia Maintain Afterload
49
Meds to help preserve HR and Contractility (Constrictive Pericarditis)
Ketamine and Pancuronium are good Opioids, benzos, etomidate are okay
50
Cardiac Tamponade: What is it?
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
Cardiac Tamponade (LV pressure, volume, CO, HR) Effects
Increased pericardial pressure compresses the heart Increased LV pressure Decreased ventricular volume = decreased SV, decreased CO, increased HR
52
Cardiac Tamponade: Causes
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
Cardiac Tamponade: Becks Triad
Hypotension, JVD, Muffled heart tones
54
The most sensitive method to detect pericardial effusion and exclusion of tamponade
Echocardiogram
55
Definitive treatment of Cardiac Tamponade
pericardiocentesis
56
Cardiac Tamponade intubation considerations
Compression of heart, lungs, trachea, and esophagus d/t mass effect Video laryngoscope, fiber optic, delicate intubation
57
Cardiac Tamponade- Anesthetic Management
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
____ preferred for pericardiocentesis
LA
59
Anesthesia Drugs to Avoid with Cardiac Tamponade
Halogenated agents Propofol Thiopental High dose opioids Neuraxial anesthesia
60
Drugs that are safer for Cardiac Tamponade
Ketamine Nitrous oxide Benzodiazepines Opioids
61
Best anesthesia drug for cardiac tamponade?
Ketamine
62
Cardiac Tamponade- (HR, Rhythm, Preload, Afterload, Contractility)
Heart Rate = Maintain Rhythm = NSR Preload = Maintain or Increase Contractility = Maintain or Increase Afterload = Maintain
63
Most common cause of sudden cardiac death in young adults
Obstructive Hypertrophic Cardiomyopathy LVOT obstruction caused by: Congenital hypertrophy of intraventricular septum Systolic anterior motion (SAM) of anterior leaflet of mitral valve
64
SAM is....
Systolic Anterior Motion of the Mitral valve
65
Conditions that distend the LVOT ------>
GOOD!
66
Conditions that narrow the LVOT ------>
BAD!
67
Surgical Procedures with Increased Risk for Infective Endocarditis
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
HALLMARK for Left Heart Failure: Diastolic Dysfunction
Symptomatic HF with preserved EF
69
Causes of Systolic HF:
CAD / myocardial Ischemia Volume Overload ( d/t Valve insufficiency) Dilated cardiomyopathy 

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

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