E2 Flashcards
(392 cards)
1
Q
Which leads show RCA infarct and MI type
A
Leads II, III, aVF
Inferior
2
Q
Blood administration complications r/t Ca++
Signs and treatment.
A
DECREASED Ca++ (factor IV)
Hypocalcemia b/c citrate
Signs = Chovstick, Trouseau, LOW BP
Give = Ca chloride (faster); Ca gluconate (longer)
3
Q
Purpose of glycoproteins on the plt
A
Adheres to injured endothelium, collagen and fibrinogen
4
Q
Causes of right axis deviation?
A
Vertical heart shift Marfan's syndrome Connective tissue disorders RVH Anterolateral MI (V3-V6)
5
Q
Indications for plt transfusion.
A
Thrombocytopenia (low plt)
6
Q
Lasix class and action
A
Diuretic
Decrease PRELOAD
7
Q
The CVP waveform that has a diastolic component is
A
a wave
h wave
y descent
8
Q
What is the most common hereditary blood disorder, and disease process?
A
vWF disorder is a deficiency of F VIII:vWF preventing platelet adhesion
9
Q
Describe CVP y descent
A
Early diastole
Early vent filling
Diastolic collapse
10
Q
Charges and chemical makeup of heparin and protamine.
A
Heparin = NEGATIVE, CHO- Protamine = POSITIVE CHON+
11
Q
What are the precordial chest leads?
A
V1 - V6
12
Q
Cushing’s triad is indicative of what?
A
A late sign of anoxic brain injury d/t sustained increased ICP and progression to herniation and brain death
13
Q
Pertinent lab work and alterations for DIC
A
Plt = very low (<100,0000)
PT/PTT/TT = very high
Soluble fibrin degradation products = high
14
Q
5 procoagulant mediators.
A
Coagulation factors Collagen vWF Fibronectin Thrombomodulin
15
Q
What conditions are people at risk for when given RBCs that are not leukoreduced?
A
CMV
TRALI
16
Q
Describe 1st heart sound
Valves
Cardiac cycle
Sound/volume
A
S1
Valves = closure of mitral and tricuspid valves
Cycle = Onset of systole, begin iso contraction
End of LV filling
Sound= volume proportional to contraction force
Louder w/ vigorous contraction
Softer w/ poor contraction
17
Q
EKG diagnostic criteria for myocardial ischemia?
A
Inverted, symmetrical T wave
- *MUST be in 2 contiguous (side-by-side) leads to be diagnostic
- from baseline
18
Q
Which leads show circumflex infarct and MI type
A
Leads I, aVL, V5, V6
Lateral
19
Q
NTG class and action.
A
N+ donor
Vasodilator (veno)
Decrease PRELOAD
20
Q
Describe 4th heart sound
Due to
Cardiac cycle
Sound/volume
A
S4
Due to= atrial systole
Cycle= end diastole
Sound= before S1
21
Q
What is the purpose of CVP monitoring
A
Monitor fluid status
22
Q
What is the positional effect on NIBP?
A
20 cm above = 15 mmHg LOWER
20 cm below = 15 mmHg HIGHER
23
Q
When is the fibrin clot formed in hemostasis?
A
Secondary hemostasis
24
Q
What blood component may be necessary when treating HELLP and when
A
Platelets
Give for active bleeding
25
Characteristic arterial waveforms for aortic regurgitation.
```
Bisferiens pulse (double peak)
Wide PP
```
26
What are 6 factors affecting cardiac supply
```
Coronary artery anatomy
Diastolic pressure
Diastolic time
O2 extraction
Hb
SaO2
```
27
If the patient has CAD and requires emergent noncardiac surgery do you proceed?
Yes, proceed with surgery
| No, proceed to next question.
28
What would be included in risk reduction for emergent noncardiac surgery?
Beta-adrenergic blockers, statins, pain management
29
What is cryoprecipitate, shelf-life, and factors.
Protein fraction off the top of FFP when thawed
Frozen for up to 1 year
Factors = I, vWF, VIII, XIII
30
Characteristic arterial waveforms for hypertrophic cardiomyopathy.
Spike-and-dome pattern (midsystolic obstruction)
31
Digitalis class and action
Cardioglycoside
| increase CONTRACTILITY
32
Medications used to reverse coumadin?
1) Vitamin K
2) PCC (prothrombin [II] complex concentrate)
3) Recombinant F VIIa
4) FFP
33
After one unit of platelets (thrombocytes) how much will it increase?
5,000-10,000
34
Describe the hearts workload with the PV loop widens?
Workload increases
35
What is the purpose of the valsalva maneuver?
• To test integrity of surgery and sutures
| “opens alveoli”
36
Uses and complications of PA catheters.
Use: open heart, some neuro cases
Complications: arrhythmias, PA rupture (hemoptysis)
37
What factors can decrease arterial oxygen content?
Hypoxemia
| Anema
38
Is aortic stenosis preload or afterload dependent
Afterload dependent
| **if afterload is lost then CO is lost
39
What are unstable coronary syndromes that are contraindicated when proceeding with nonemergent noncardiac procedures? (3)
1. Unstable or severe angina at rest, increase symptoms, duration >30 mins and symptoms not responsive to TX
2. Acute MI w/in past 7 days--> postpone elective surgery
3. Recent MI w/in 7-30 days w/ myocardium risk (+stress test and symptoms)
40
```
How much does a unit of
RBC
FFP
Cryo
Plt
Increase their respective labs?
```
```
RBC
--INC Hgb 1 g/dL
--INC Hct 3%
Cryo
--50 mg/dL
Plt
--INC plt by 5K-10K
```
41
Biggest problem with SCD?
Oxygenation
Symptoms start
PaO2 40 = 75% SpO2
42
What are the landmarks for valve auscultation
Aortic Valve Area = 2nd R intercostal space (ICS), right sternal border
Pulmonic valve = 2nd L ICS, L sternal border
Erb's Point = 3rd left ICS, left sternal border ( where S2 is heard much better)
Tricuspid = 4th left ICS, left sternal border
Mitral valve = 5th ICS, left mid-clavicular line
43
What substance mediates the vascular phase?
Endothelin - primary hormone
44
Two thrombogenic factors contained in the media?
Collagen
| Fibronectin
45
What are severe valvular diseases that are contraindicated when proceeding with nonemergent noncardiac procedures?
Severe aortic or mitral stenosis
46
Severe hypotension in a patient with aortic stenosis can result in?
Myocardial injury and death
47
What mediators are released during aggregation? What is their purpose?
alpha/dense granules
Contractile granuels
Thrombin
Others
Purpose = to promote procoagulant activity
48
Purpose of the intima layer?
Separates flowing blood from the vessel
49
MI location and artery when leads II, III and aVF involved
Inferior
| RCA (posterior descending)
50
Which pathways of the clotting cascade does FFP effect and why?
Intrinsic
Extrinsic
Common
Because FFP has all clotting factors
51
Describe 3rd heart sound
due to
Cardiac cycle
Sound/volume
S3
Due to= flaccid, inelastic heart (HF)
Cycle= middle 1/3 diastole (after S2)
Sound= gallop rhythm (rumbling)
52
EKG diagnostic criteria for right atrial hypertrophy.
Initial diphasic P wave component larger in V1
| Initial diphasic P wave > 2.5 mm in ANY lead
53
What is HELLP syndrome?
HELLP=In pregnant women
- Red cell HEMOLYSIS and HTN (H)
- ELEVATED LIVER enzyme level (EL)
- LOW PLATELET count (LP)
54
When is cryo used in vWF disorder
If pt is not responsive to DDAVP
55
Which blood component has antithrombin III
```
FFP
antithrombin III (tissue factor)
```
56
What is sequestration crisis in SCD and manifestations?
Splenic RBC removal GREATER than RBC production
Manifestations:
Severe anemia
Hemodynamic instability
57
Complications of CVC placement
PTX, nerve injury, cardiac tamopnade, chylothorax (lymph injury on LEFT side neck)
58
What view do the limb leads vs precordial leads show of the heart?
limb leads = frontal view
| precordial leads = horizontal/transverse view
59
Comorbid causes of right ventricular hypertrophy?
Pulmonary HTN
--> from LA problems?
Pulmonic valve stenosis
Ends stage mitral regurg?
60
What are active cardiac conditions that may affect or postpone noncardiac surgeries? (4)
1. Unstable coronary syndrome
2. Decompensated HF
3. Significant arrhythmias
4. Severe valvular disease
61
Characteristic arterial waveforms for systolic LV failure.
Pulsus alternans (alternating PP amplitude)
62
What happens over time to 2,3-DPG in blood?
It decreases
Shifts oxyhgb curve LEFT
Impairs O2 delivery
63
Acute chest syndrome in SCD is due to
Lung infiltration
64
Vitamin K use, onset, drawbacks?
```
Use = coumadin reversal
Onset = 6-8 hrs
drawback = Not as rapid as other reversals
```
65
What is the role of collagen in hemostasis?
Potent and important stimulus for platelet attachment in injured vessel wall
66
Factor V leiden is due to
Mutation of factor V that is not responsive to activated protein C inactivation of F V
67
Mag sulfate dose
Loading
Maintenance
Therapeutic range
Loading = 4g over 5 mins
Maintenance = 1-2 g/hr
Therapeutic range = 4-6 mEq/L
68
Surgical considerations for pt with vWF disorder (avoid)
```
Avoid:
trauma
Arterial puncture
laryngeal trauma during intubation
IM injection
```
69
EKG evidence of "old" MI
Q wave in contiguous leads
70
What can occur with valsalva?
Stimulates baroreceptors
| Drop in HR, BP, contractility and vasodilation due to increased intrathoracic pressure
71
Confirmation of CVC placement includes?
Aspirated blood is dark = venous
| Xray = TIP at T4 - T5 interspace
72
What preop home medication is important to hold in pts with AS and why?
ACE-i (-prils)
| To prevent hypotension in OR
73
What structure on the plt is derived of phospholipids
TXA
74
```
Regarding coronary supply and demand, which increases coronary blood flow
Aortic transvalular gradient of 4 mmHg
Elevated HR
Increased pulse pressure
Coronary vasoconstrition
```
Aortic transvalvular gradient of 4 mmHg
75
Risks of neuraxial block in pts with vWF
Increased risk for
hematoma
Compression of neurological structures
76
4 blood component therapy
RBC
FFP
Cryo
PLT
77
Diastolic HF
| etiology, hallmark, preload, afterload, contractility, HR, LV geometry
Etiology=Filling problem, MI, valve STENOSIS, HTN, HYPERTROPHIC cardiomyopathy, cor pulmonale, obesity
Hallmark= normal EF w/HIGH LVEDP, low compliance,
Preload=Volume needed to stretch noncompliant LV
LVEDP doesn't correlate to LVEDV
Afterload=Keep elevated to perfuse thick myocardium, maintain CPP
Contractility=Normal
HR=Slow/normal to increase diastolic filling time and CPP
LV geometry= Concentric hypertrophy (THICK)
78
Indications(4) and possible findings(3) in a preop echo for SCD pts.
Indication = limited physical ability, hypoxemia, respiratory distress, symptoms of cor pulmonale
Common findings = LVH, RV dilation, atrial enlargement
79
Incidence of asthma and pulmonary HTN in SCD pts and mortality
Asthma = 50%
Pulm HTN = 10%
Mortality greatly increased when asthma and pulm HTN present
80
Cryo is used to treat...
Hypofibrinogenemia
| Low fibrinogen
81
How is the baroreceptor stimulus integrated?
Inc/Dec action potentials in AFFERENT vagus nerve X (AORTIC ARCH) or herring's nerve IX to CV centers of medulla in brainstem
82
What is the bainbridge reflex stimulus?
Stretch receptors in the right atrial wall and cavoatrial junction
83
Anesthetic considerations when giving Mag?
1) Mag inhibits ACh release at NMJ
2) Use MRs cautiously
3) Decrease use of sedative and opiates (b/c hypoventilation and hemodynamic instability)
3) Exaggerated hypotensive response to regional
84
Two main external projections types on plts
Glycoproteins
| Phospholipids
85
What vessel action mediators do endothelial cells release?
Vasoconstrictors (TXA2, ADP)
| Vasodilators (NO, prostacyclin)
86
What is aplastic crisis, causes and what can it lead to?
```
Occurs when RBC production is suppressed
Causes:
Mild bone marrow suppression
Viral infection (parovirus B19)
Leads to = rapid onset of anemia
```
87
Universal donor and recipient
```
Donor = O-
Recipient = AB+
```
88
2 drugs that affect preload
Lasix
| NTG
89
What is the effect of the bainbridge reflex? autonomic response
PSNS stimulation
| DEC HR and BP
90
What is the definitive treatment for HELLP?
Deliver the baby
91
What is acute chest syndrome (ACS) in the SCD pt? The incidences, Treatment and preventative measures?
```
Lung infiltration (resembles PNA) w/ pain, no EKG changes, and pulmonary signs
Incidence = r/t infection, higher in children
Treatment = supportive (pain meds, hydration)
Preventative = Transfusions, post-op IS
```
92
What is the purpose of actin/myosin and thrombosthenin in the plt?
```
Actin/Myosin = contraction to form plt plug
Thrombosthenin = plt contraction
```
93
What are the 6 components to the Lee revised cardiac risk index and purpose?
Purpose = Greater # of predictors, higher ricsk of cardiac complications
1) High-risk surgery
2) Ischemic heart dx
3) H/o CHF
4) H/O CVA/TIA
5) DM needing insulin
6) Crt >2.0 mg/dL
94
What are positional effects on arterial line BP
There is no effect on A-Line BP reading
95
What action would be important prior to extubation if herniation/cushings triad is suspected?
- Trial respirations
| - Irregular respirations are masked by mechanical ventilation
96
Why is there a time frame for blood transfusion after removal from cooler?
Prevents bacterial growth
97
What are phosphate, dextrose and adenine components for in blood storage?
```
Phosphate = buffer
Dextrose = fuel source
Adenine = substrate for ATP synthesis
```
98
Clinical features of vWF disorder?
EAsy bruising
Recurrent epistaxis
Menorrhagia
99
Systolic HF
| etiology, hallmark, preload, afterload, contractility, HR, LV geometry
Etiology = Pump problem, MI, valve INSUFFICIENCY, DILATED cardiomyopathy
Hallmark = Low EF w/ high LVEDV d/t volume overload
Preload= Already high
Afterload= DEC to reduce myocardial workload, maintain CPP
Contractility = augment
HR = Usually high d/t INC SNS tone and to preserve CO
LV Geometry = eccentric hypertrophy (dilated)
100
Characteristic arterial waveforms for cardiac tamponade.
Pulsus paradoxus (huge decrease in SBP during INSpiration)
101
Which leads show LAD infarct & MI type
Leads V1, V2, V3, V4
| Septal, anerior
102
EKG diagnostic criteria for left ventricular hypertrophy?
(S in V1) + (R in V5) = > 35 mm
103
Diagnosis criteria for HTN and causes?
Diagnosis = BP must be obtained on 2 separate occasions atleast 1-2 wks apart
Causes = INCREASE CO/SVR
-Most likely due to HIGH SVR b/c INC vascular smooth muscle tone
104
Management and treatment for DIC
```
Management = correct underlying cause
Treatment = blood component replacement with coag factors and plts
```
105
What happens to 2,3-DPG with blood storage?
Prolong storage DECREASES 2,3-DPG
LEFT shift oxyhgb dissociation curve
Impairs O2 delivery
106
When pt requires surgery and it is not emergent, what is the next consideration?
Does the patient have active cardiac conditions
107
What are 7 structures insideof plt that are used for hemostais?
1) Actin/Myosin
2) ADP
3) Ca++
4) Fibrin-stabilizing factor
5) Serotonin
6) Growth factor
7) Thrombosthenin
108
What is the integration process for the oculocardiac reflex?
The afferent path (sensory) --> trigeminal nerve (V1-opthalmic branch)
The efferent branch (motor) --> vagus (X)
109
Platelets are able to participate in the activation of other platelets in the surroundings due to which structure in the plt cytoplasm
Serotonin
110
EKG evidence of right axis deviation.
QRS in aVF = positive
| QRS in I = negative
111
To prevent hypotension and tachycardia in a pt with AS, what medications may be given
BP: alpha-adrenergic agonist (neosynephrin)
HR: beta blocker
112
Septal MI leads, artery, side of heart
```
Leads = V1, V2
Artery = LAD
Side = Left
```
113
What are 2 endothelial mediators that vasoconstrict?
Thromboxane A2
Adenosine diphosphate (ADP)
Serotonin (5HT)
114
2 drugs that affect afterload
Neosynephrine
| Nipride
115
Adrenergic receptor drug treatment for HTN
alpha-1 antagonist
beta-1 antagonists
Mixed alpha-1/beta-1/2 antagonists
alpha-2 agonists
116
Noninvasive testing for CAD pts with cardiac risk factors?
```
Stress test (pts w/ 1-2 predictors)
Exercise or pharmacological
Pharmacological stress test for pts that can't exercise, have PM, severe bradycardia, on high dose beta-blockers
```
117
What is the normal progression of inflection/deflection of precordial leads V1, V3, V6?
```
V1 = negative
V3 = half/half
V6 = positive
```
118
Pharmacological treatment of HTN, drug classes
Adrenergic receptors drugs
CCBs
Drugs targeting kidneys (ACE-i, ARBs, diuretics)
Drugs targeting myocardium or vasculature
119
Protamine structre?
Positive polypeptide (amino acid)
120
What is the vascular phase of hemostasis?
VASCULAR SPASM - from damage
Generally localized to injured area
Very short--progresses to next phase quickly
121
What are the 3 vessel layers (in to out)?
Intima
media
Adventitia
122
What is prostacyclin function?
Vasodilates
Inhibits aggregation
promotes smooth muscle relaxation
123
What is the integration process for the celiac reflex?
Efferent signal via vagus nerve
124
The V1 electrode should be positioned where?
4th ICS, right of the sternum
125
What CHF qualifications are contraindicated when proceeding with nonemergent noncardiac procedures?
New onset CHF
NYHA class IV
--Based on exercise tolerance and associated clinical symptoms
126
How is the chemoreceptor stimulus integrated?
Afferent impulses sent via carotid sinus herring's nerve IX AND vagus nerve X
-to chemosensitive area of medulla
127
What are the best intraop strategies for mitral regurg?
Maintain contractility
| Decrease SVR
128
What storage components are used in blood storage?
Citrate
Phosphate
Dextrose
Adenine
129
Pressure vs volume overload valvular diseases
Pressure overload = STENOSIS (mitral and aortic)
| Volume overload = REGURGITATION or insufficiency (mitral and aortic)
130
What vessels supply the coronary blood flow?
The left and right coronary arteries supply the myocardium with oxygenated blood
131
What is the most likely lead to monitor on all patients?
II
132
Pathophysiology of factor V leiden and cause?
Patho = F V (proacceleran) is resistant and not inactivated by activated protein C like normal
This leads to continued fibrin clotting
Cuause = genetic mutation of F V
133
How is the oculocardiac reflex stimulated?
Traction on the extraocular muscles
| Leads to: dec BP and a reflex dec HR ,and arrhythmias
134
Purpose of the adventitia layer
Control of blood flow by influencing vasodilation/constriction
135
What does a h/o sequestration crisis indicate for SCD pts.
Indication for early splenectomy
136
Monitoring and reversal of heparin? How does reversal work?
Monitor PTT and ACT
Reversal = Protamine rapid
Protamine is a positive polypeptide (amino acid) that binds to negative heparin
Forms stable complex and neutralizes heparin
137
Ketorolac administration lab considerations for SCD pts?
Know Crt and Plt
138
Most common drug for vWF disorder and what do you give if it doesn't work?
1st line = DDAVP
then cryoprecipitate
Then Factor VIII
139
Where is atrial hypertrophy going to be evident (wave and lead)?
```
Wave = p
lead = V1
```
140
Nipride class and action
N+ donor
| Vasodilator to decrease AFTERLOAD
141
What are 2 endothelial mediators of vasodilation
NO
| Prostacyclin
142
Describe PT, PTT, and BT in vWF disorder?
PT and aPTT normal
| BT prolonged
143
Aortic stenosis severity is dependent on...
Increased transvalvular gradient and decreased valve size
144
Describe CVP waveform for A-Fib
Loss of a wave d/t poor atrial contraction
| Prominent c wave
145
Treatment of vWF disorder
Correct vWF deficiency
Use desmopressin
Transfuse cryo
Give specific factor VIII
146
6 anesthesia periop considerations for SCD?
1) Preop hgb,
2) Preop echo (LV hypertrophy, RV dilation, atrial enlargement)
3) Preop transfusion to get to hgb 10
4) Intraop transfusion--keep hgb 10
5) Maintain normothermia
6) Maintain hydration
147
Antifibrinolytics MOA and agents?
MOA = inhibits conversion of plasminogen to plasmin
promotes clotting
Agents = TXA, aminocaproix acid, aprotinin
148
What are the considerations when giving narcotics to SCD pts?
Induced hypoventilation
Causing hypercardia and hypoxemia (worsening)
Can exacerbate ACS
149
Prophylaxis treatments for F V leiden and why
Anticoaglant to prevent thromboses
| Give Warfarin, UFH, LMWH
150
Milrinone class and action.
PDE-i
| increases CONTRACTILITY
151
What is the function of GpIb
To attach the plt to vWF
152
Side effects of DDAVP administration
```
Headache
rubor
hypotension
tachycardia
HYPONATREMIA
WATER INTOXICATION
```
153
Describe CVP h wave, cardiac cycle and EKG correlation
Mid to late diastole
Diastolic plateau
Only present during bradycardia
Before P wave
154
What is the function of tissue pathway factor inhibitor?
Inhibits tissue factor III
155
Drugs that target kidneys to treat HTN.
ACE-i
ARBs
Loop, K sparing and thiazide diuretics
Aldosterone antagonist
156
How is plt obtained and supplied and what is the increase in plt after one unit transfusion?
Platelet only, obtained from whole blood or platepheresis donation
One bag= random value
One bag pheresis = 250 - 300 mL
One unit = INCREASE plt 5k-10k
157
What phase hemostasis are platelets activated?
Primary hemostasis
158
What are 5 clinical features/manifestation of SCD?
```
Vaso-occlusive crisis (VOC)
Acute Chest syndrome (ACD)
Sequestration crisis
Aplastic crisis
Asthma and pulmonary HTN
```
159
What is the integration of the stimulus for the bainbridge reflex?
Changes in RIGHT-sided filling pressure send VAGAL nerve X afferent signals to CV centers of medulla
160
When does HF occur, what is cardiac remodeling and how can that be reversed?
```
HF = when ventricles are unable to fill or pump
Remodeling = heart changes shape, size and function to preserve CO, eventually fails
Reversal = ACE-i, aldosterone inhibitors (spironolactone)
```
161
What is the second phase of plt response?
ACTIVATION
162
Increased myocardial O2 demand causes (3) and interventions (3)
```
Causes = INC HR/BP/PAOP
Intervention = beta blockers, INC anesthetic, vasodilators (NTG)
```
163
MI location and artery when leads V1, V2 involved
Septal
| LAD
164
Describe CVP a wave
End diastole
Atrial contraction
P wave
165
Describe 2nd heart sound
Valves
Cardiac cycle
Sound/volume
S2
Valves= Closure of aortic and pulmonary valves
Cycle= Onset of diastole, begin iso relaxation
End of LV ejection
Sound= volume proportional to LV pressure
Louder w/ HTN, softer w/ hypotension
166
What are high risk vascular cases and estimated risk of cardiac death or nonfatal MI?
>5%
Aortic and other major vascular surgeries
Peripheral vascular surgery
167
What makes up the 1% other solutes in plasma? (5)
Ions, nutrients, waste products, gases, regulatory substances
168
MI location and artery when leads I, aVL, V5, V6 involved
Lateral
| Circumflex
169
Describe the workload changes of the PV loop when height increases
Workload increases
170
Once preop risk stratification is complete for CAD pt what are 3 therapeutic options before elective noncardiac surgery?
1) Revascularization by surgery (+3 factors)
2) Revascularization by PCI w/ stent (1-2 factors)
3) Optimal medical management
171
Indications for RBC transfusion.
Bleeding
| To increase O2 carrying capacity
172
What factors decrease myocardial O2 delivery and coronary flow and can lead to ischemia? (8)
1. Tachycardia
2. Decreased PaO2
3. Decreased O2 extraction
4. DEC aortic pressure
5. INC EDP
6. Coronary vessel diameter
7. DEC Hgb
8. DEC P50 (left shift)
173
Pt w/ CAD is having a high risk surgery, how do you proceed and what does the next step involve?
Assess patient functionality
Functional Capacity = MET (metabolic equivalent units)
O2 consumption at rest = 3.5 ml/kg/min = 1 MET
Good =/> 4 METs
Proceed to surgery
174
MOA of fibrinolytics and drug examples?
MOA = Converts plasminogen to plasmin which cleaves fibrin (Ia) and causes clot dissolution
Drugs = tissue plasminogen activator (tPA)
streptokinase (SK)
urokinase (UK)
175
What are the 3 phases of platelet formation?
Adherence
Activation
Aggregation
176
What factors affect decreased coronary flow?
1. Tachycardia
2. Decreased aortic pressure
3. decreased vessel diamter (spasm/hypocapnia)
4. Increased EDP
177
Drugs that target myocardium or vasculature for HTN
dihydropyridines, non-dyhydropyridines
Areriodilators
Venodilators
178
What factors can increase O2 demand?
```
Tachycardia
HTN (INC afterload)
SNS stimulation ("light")
INC wall tension
INC EDV
INC afterload
INC contractility
```
179
What is the equation for cardiac output and the normal value
```
CO = SV X HR
CO = (EDV - ESV) x HR
```
5 - 6 L/min
180
Where is an arterial line zeroed
Phlebostatic axis
181
How is the Bezold - Jarisch Reflex stimulated?
By irritants stimulation in the LV via chemo/mechanoreceptors
182
Describe the phases (begin to end) of oscillation when taking a cuff pressure.
Osillation:
•begins at systolic pressure
•peaks at mean arterial pressure
•disappears once again at diastolic pressure.
183
Neosynephrine action
Vasoconstrictor
Increase SVR
Increase AFTERLOAD
alpha-adrenergic agonist
184
Normal EF and equation
SV / EDV
(EDV-ESV) / EDV
60-70%
185
What is the effect seen with the bainbridge reflex?
Inhibition of PSNS
| Activates SNS actions
186
EKG diagnostic criteria for myocardial injury/infarction?
ST segment elevation
* off of isoelectric line
- -S wave does not return to isoelectric line
187
How does increased thoracic pressure from valsalva affect CO and VR?
Decreased CO
| Decreased VR
188
What is the purpose of ADP and Ca++ in the plt?
```
ADP = Plt activation and aggregation
Ca++ = Role in coagulation cascade (F IV)
```
189
Causes of right atrial hypertrophy.
Tricuspid regurgitation
| Pulmonary hypertension
190
How long do you have after blood is removed from the cooler to transfuse it?
30 minutes
| Needs to be used within 30 minutes
191
What makes up PRBCs?
RBCs from whole blood
Plasma removed
Contains leukocytes unless leukoreduced
192
Describe CVP waveform for cardiac tamponade.
Dominant x descent
| Attenuated y descent
193
What is the amount of coronary blood flow per minutes and what percentage of CO is it?
Coronary blood flow is 225-250 mL/min or roughly 4-7% of the CO
194
What occurs if the plt plug is not enough for the injury?
Progression to secondary hemostasis and clotting cascade
195
Considerations for pre, intra and postop RBC transfusion in the SCD pt.
Preop = Low Hgb, INCREASE to 10 g/dL
what surgery?
Intraop = significant blood loss, maintain hgb >10 g/dL
196
Describe CVP v wave
Late systole
Systolic filling of the RA
After T wave
197
Indications for FFP transfusion? (8)
1) Correct inherited and acquired factor deficiencies when PT/aPTT >1.5 times the control, bleeding, or prior to surgery
2) Liver dysfunction w/ bleeding
3) DIC w/ bleeding
4) Microvascular bleeding associated w/ MT and EBL >1 lood volume
5) Reversal of Vit K antagonists
6) Heparin resistance 2/2 antithrombin deficiency if AT not available
7) Thrombotic pathologies (HELLP, TTP)
8) Hereditary angioedema if C1-esterase inhib not available
198
Briefly, what are the purposes of each hemostasis phase?
```
Vascular = vascular spasm
Primary = Form plt plug
Secondary = Coagulation cascade and fibrin formation
Fibrinolysis = Clot lysis
```
199
How much volume does atrial kick provide and when does this happen
5 - 10%
| At the end of phase 1 filling
200
Process of NO's action?
NO diffuses from endothelial cells into muscle cell (adventitia)
- Activates soluble guanylate cyclase
- 2nd messenger cGMP produced
- cGMP causes muscle relaxation
201
What occurs during activation phase of plt response? (5)
1) TF causes conformational change of plt
2) active plt swells, is oval and irregular shape
3) GpIIb/IIIa surface
4) GpIIb/IIIa adhere other activated plts together
5) Plt seal site of injury
202
What is the effect of the B-J refelx
Efferent impulses sent to heart via CN X
PSNS stimulation: DEC HR, BP
Coronary dilation
203
What proteins are contained in plasma, from greatest to least? (4)
Albumin
Globulin
Fibrinogen
Prothrombin
204
What leads to TRALI and how can it be prevented?
ABO mismatch
| Leukoreduced RBCs
205
What is the normal life span of an RBC and change in SCD?
```
Normal = 120 days
SCD = 12-17 days
```
206
Preop considerations for vWF disorders or any bleeding disorder?
```
type and screen prior to surgery
A-line??
Hematologist assessment
Infuse DDAVP 60 min prior to surgery
Normalize bleeding time by confirming F VIII level improvement prior surgery
```
207
How do arterial waveforms compare between aortic arch (proximal site) and femoral artery (distal site)?
•Wider pulse pressure (fem vs aorta)
-HI SBP and LOW DBP
•A delayed upstroke (femoral)
•A delayed, slurred dicrotic notch (femoral)
•Prominent dicrotic notch for aortic wave
•More prominent diastolic wave (femoral)
208
Hyponatremia can result from what blood disorder treatment & can eventually lead to...
vWF disorder
DDAVP administration
Seizures
209
Where is ventricular hypertrophy going to be evident (wave and lead)? Positive or negative?
```
Wave = QRS
Lead = V1
```
210
Another name for platelet?
Thrombocytes
211
EKG diagnostic criteria for right ventricular hypertrophy?
V1 QRS is POSITIVE
| all other precordial leads QRS become progressively smaller
212
Pathophysiology of heparin-induced thrombocytopenia (HIT), clinical presentation, and condition results?
Patho = Autoimmune-mediated drug reaction in ~5% of pts receiving heparin
Mediated by IgG antibody
Immune complex = IgG + platelet fact 4 (PF4) and heparin
Presentation = Thrombocytopenia 2/in 5-14 days of heparin
PLT <100,000
Results in = plt activation, potential for venous and arterial thromboses
213
1st line treatment for vWF
DDAVP
214
Diagnostic criteria for a Q wave or old MI?
```
Q wave must be
-1 mm wide
-2 mm deep (neg)
OR
-1/3 of QRS tall
AND
-2 side-by-side leads
```
215
Why are steroids given to moms with HELLP syndrome?
To help mature baby's lungs by increasing surfactant production
May increase platelet count for mom
216
Pt with CAD passes functional capacity assessment, what is the next step and what should be considered(5)?
```
Assess clinical predictors
1) Ischemic heart dx
2) compensated or prior HF
3) Cerebrovascular dx (CVA, TIA)
4) DM
5) Renal insufficiency
No clinical predictors? proceed with surgery
```
217
What can poor R wave progression indicate? Where is it seen?
- Old MI if Q wave not present
- Seen in PRECORDIAL leads
- A lot of dead tissue that electricity has to go around
218
Purpose of CPDA in blood storage?
Preservative to prolong blood component storage
Citrate = Ca++ chelation & prevents clotting (Factor IV)
Phosphate = buffer
Dextrose = fuel source
Adenine = substrate for ATP synthesis
219
Heparin-induced thrombocytopenia manifests in what lab specifically?
Low platelets
220
What is a Q wave?
When QRS is deflected negative FIRST
-1mm wide
-2 mm deep
OR 1/3 height/depth of QRS
221
When do alterations to hgb occur in SCD? How does it become unstable?
Alteration = when hgb S is exposed to low O2 concentration
Unstable = Hgb polymerizes w/ other Hgb S molecules
-forms a crystalline gel which deforms the hgb into characteristic sickle shape
222
Heparin MOA?
Thrombin (F II) inhibitor
So fibrinogen (I) can't conert to fibrin (Ia)
Activates antithrombin III
223
EKG evidence of left axis deviation.
QRS in aVF = negative
| QRS in I = positive
224
What are eicosanoids?
```
Lipids that form:
-Prostaglandins/cyclins
-Leukotrienes
-Thromboxanes
(From the AracA pathway)
```
225
What is NOs function?
vasodilation
| promotes smooth muscle relaxation
226
Diastolic HF treatments for
preload
afterload
contractility
```
Preload = TEE to assess
Afterload = neo (alpha-1 antag)
```
227
How to prevent 5 triggers for sickling?
Preoxygenate
Optimize hydration with blood (hgb 10) then fluids
Warm room and maintain normothermia
228
What components are in plasma?
Water
proteins
Solutes
229
What occurs in plt adherence? (3)
1) vFW mobilizes from endothelial cell and emerges
2) GpIB surface on plt
3) GpIb attaches to vWF and attracts other plts
230
6 Causes and treatment for secondary HTN.
```
Causes=coarctation of aorta
renovascular dx
hyperadrenocorticism
hyperaldosteronism
pheochromocytoma
pregnancy
Treatment = treat the cause
```
231
Inferior MI leads, artery, side of heart
```
Leads = II, III, aVF
Artery = RCA (posterior descending)
Side = Right
```
232
What makes up formed elements and normal ranges?
Platelets = 140K-340K
Leukocytes (WBCs) = 5k-10k
Erythrocytes (RBCs) = 4.2--6.2 million
233
Risks and treatment of HIT?
Risks = thrombosis (30-75%)
Treatment = DC heparin** (catheters, flushes and LMWH)
Alternative non-heparin anticoag
-Direct thrombin inhibitors
--Bivalirudin, lepirudin, argatroban
-Fondaparinux (synthetic Factor Xa inhibitor) for VTE
234
Causes of DIC
```
Underlying disorders
Trauma
amniotic fluid embolus
malignancy
sepsis
incompatible blood transfusion
```
235
What are 8 cardiac reflexes?
```
Baroreceptor
Valsalva
Cushing
Chemoreceptor
Bainbridge reflex
Oculocardiac
Celiac
Bezolh-Jarish
```
236
What effect occurs with the celiac reflex? autonomic response?
PSNS stimulation
| DEC HR and BP
237
Causes of left atrial hypertrophy?
Mitral regurgitation
| Long-term HTN
238
Aortic stenosis grades, velocity, mean pressure gradient and valve area
m/sec mmHg cm2
Mild: <3 m/sec, <25 mmHg, >1.5 cm2
Mod: 3-4 25-40 1.0-1.5
Severe: 4-4.5 40-50 0.7-1.0
Critical >4.5 >50 <0.7
239
Oxygen delivery to the cell is a product of...
CO
| Arteerial O2 content
240
What are significant arrhythmias that are contraindicated when proceeding with nonemergent noncardiac procedures?
```
Mobitz II
3rd degree HB
SVT or AFib RVR (new onset)
Symptomatic ventric arrhythmia or brady
New V-Tach
```
241
What makes up whole blood and percentage by volume?
Plasma = 55%
| Formed elements = 45%
242
What is the function of GpIIb/IIIa?
Links activated plt together
243
4 phases of hemostasis and coagulation.
1. Vascular phase
2. Primary Hemostasis
3. Secondary Hemostasis
4. Fibrinolysis
244
What is myocardial ischemia indicative of?
DECREASED O2 supply to myocardium from coronary arteries
245
What are some platelet properties, normal level and life-span?
+Round and disk-like
+freely circulating
+Normal levels 150K-300K
+1-2 week lifespan
246
What process activates initial platelets and clotting factors? What is initially formed?
Damage to the endothelium
| Platelet plug
247
What do endothelins do? (3)
+Stimulate smooth muscle contraction
+Stimulate cell division of endothelial cells, smooth muscle cells and fibroblasts
+Aids in repairing damaged site
248
What is the valsalva maneuver?
Forced expiration against a closed glottis
249
What is the shape of the p wave for atrial hypertrophy
diphasic
250
When do most periop MIs occur?
Most perioperative MI occurs 24-48 hours post op – accounts for 20% mortality
251
A lateral wall MI would suggest a blockage in what coronary artery and be evident in which leads?
Circumflex
| I, aVL, V5, V6
252
Possible treatment to decrease or abolish inverted T wave?
INCREASE supply
DECREASE demand
(rest, vasodilate etc)
253
How many liters of blood loss before fibrinogen drops and why?
1.5 L
| Fibrinogen is first factor that is used up in hemostasis
254
What is the effect of the chemoreceptor reflex? Autonomic response
1. Medulla responds by stimulating respiratory centers to INC/DEC respiratory drive
2. Inhibition of PSNS to INC HR and contractility
255
What pathways of the clotting cascade does cryoprecipitate effect and why?
Intrinsic (factor VIII:vWF, VIII:C)
| Common (I, XIII)
256
What is the mechanism of acute chest syndrome, how is it diagnosed, and the mortality rate?
```
Mechanism:
Thrombosis, embolism, infection
Diagnosis:
New lung infiltrates on CXR (generally 1 lung segment) WITH--chest pain, cough, dyspnea, wheezing, hypoxemia
Mortality = 20%
```
257
MI vs pericarditis 12-lead and symptoms.
Pericarditis has ST elevation in ALL leads
| and pain is sharp NOT pressure
258
What type of leads are the 1st three leads in a 12-lead EKG?
Bipolar limb leads
259
What is primary hemostasis?
Initiated in vascular phase isn't sufficient
Injured vessel attract platelets
Forms platelet plug
260
Why is FFP used for hemostasis?
Contains ALL clotting factors EXCEPT platelets
261
Causes of left axis deviation
Inferior MI
LVH
Obesity
Pregnancy
262
Oxygen consumption of a 70 kg pt is 1225 ml/min. How many METs is this? Explain.
5 METS
O2 consumption is 3.5 ml/kg/min in 1 MET.
70 kg x 3.5 = 245 (1 MET)
1225/245 = 5 METS
263
What are the limb leads? Are they bipolar or unipolar?
```
Bipolar = I, II, II
Unipolar = aVR, aVF, aVL
```
264
What substances do the endothelial cells secrete or synthesize?
Procoagulants
Anticoagulants
Fibrinolytics
265
What are the effects of the baroreceptor reflex?
1. Inc/Dec action potentials in efferent vagus nerve X to change HR and CO
2. Inc/Dec in APs in SNS to
a. HEART (contractility/SV/CO)
b. venous vessels (venodilation and constriction, VR, CO),
c. arterial vessels (SVR)
3. Change in BP
266
Which of the 8 cardiac reflexes is cardio protective?
Bezold-Jarisch reflex
267
What are some causes of tachycardia in the OR?
```
Hypovolemia (blood loss)
hyperthermia
Alertrness
Pain
Stenosis
```
268
Bradycardia during a strabismus repair is caused by activation of which cardiac reflex and which afferen and efferent nerves?
Oculocardiac
V1 (opthalmic branch)
X
269
In mitral stenosis, the murmur is characterizes as
mid-diastolic
270
What are the normal inflections of augmented limb leads
```
aVR = negative
aVF = postive (greatest)
aVL = positive (less)
```
271
Mom with HELLP has received a lot of mag. She is now hypotensive, bradycardic and weak. What is wrong and medication should be given?
Mag toxicity
| Give Calcium = Antidote for Mag toxicity.
272
What is the max dose of mag sulfate?
6 mEq/L
273
Patient receives massive blood transfusion, what are some lab changes of Ca++ and K+?
hypocalcemia
| hyperkalemia
274
What components are in the formed elements?
Platelets
Leukocytes
Erythrocytes
275
How does mag sulfate affect mom's with HELLP? (4)
1) Decreases CNS irritability and increases SZ threshold
2) Decreases activity at NMJ and increases weakness
3) Relaxes uterus and smooth muscles and increases uterine BF
4) Treats HTN
276
What is tissue factors action?
Activated extrensic factor (III) from injured endothelium
277
When a patient has no active cardiac conditions what are the next surgical considerations when proceeding with noncardiac nonemergent surgery.
Is the procedure low risk or high risk?
High risk = proceed to 4
Low risk = proceed with surgery
278
Considerations for tourniquet cases in SCD pts?
To decrease peripheral bleeding
Increases risks for peripheral crisis
Monitor time <60 min ideal
279
How is the B-J reflex integrated?
Afferent impulses sent via CN X to CV centers of medullar
280
What role dose fibrin-stabilizing factor, serotonin and growth factor play in the plt?
Fibrin-stab factor = cross links w/ fibrin
Serotonin = Nearby plt activation
Growth factor = Repair damaged walls
281
Conditions when TXA is contraindicated
H/o thrombotic stroke
| DIC
282
MI location and artery when leads V3, V4 involved
Anterior
| LAD
283
What hemostatic medications are contraindicated in DIC?
Antifibrinolytics
TXA
Amicar
284
What is the function of antithrombin III?
Degrades factors XII, XI, X, IX, II
| Anticoagulant
285
Signs of mag toxicity and treatment?
1) loss of DTRs
2) Skeletal weakness
3) Hypoventilation
4) Cardiac arrest (low BP, bradycardia)
Treat = give Ca++
286
What are the augmented limb leads and which is most likely used?
aVR, aVF, aVL
| used = aVF
287
2 drugs that affect inotropy
Milrinone
| Digitalis
288
Characteristic arterial waveforms for aortic stenosis.
```
Pulsus parvus (narrow PP)
Pulsus tardus (delayed upstroke)
```
289
Anterior MI leads, artery, side of heart
```
Leads = V3, V4
Artery = LAD
Side = Left
```
290
What would be included in cardiac surveillance for emergent noncardiac surgery?
serial ECGs, cardiac enzymes, monitoring
291
FFP may be given with which abnormal lab?
Very high PTT
292
Activated clotting time measures the anticoag properties of what medication?
Heparin
293
5 types of leukocytes, greatest to least?
```
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
```
294
What is normal stroke volume (SV), it’s components and equation.
SV = EDV - ESV
End diastolic volume
End systolic volume
50 - 110 ml/beat
295
What is the physiologic response that leads to Cushing's?
1. Stimulation of cardiac centers of medulla to INC perfusion
2. INC SNS response
3. Initially INC HR, BP and contractility
296
Purpose of allen's test.
To test collateral flow in palmar arch
| To predict complications associated with radial artery cannulation
297
5 preoperative assessment questions for CAD patients undergoing noncardiac surgery.
1. Consider surgery urgency
2. Consider active cardiac conditions
3. Consider risk of surgical procedure
4. Assess patient's functionality
5. Consider patients with poor or indeterminate functional capacity and their comorbidities.
298
Preservative used for blood storage?
Citrate phosphate dextrose adenine (CPDA-1)
299
What is vWF?
Clotting factor released from injured endothelial cells for platelets to adherence to the injured site.
300
What are endothelial procoagulants?
von Wilibrand factor
| Tissue factor
301
3 natural fibrinolytics and their function.
```
Plasminogen = converts to plasmin
tPA = activates plasmin
Urokinase = Activates plasmin
```
302
In mitral stenosis, increased pulmonary artery occlusive pressure increases the risk of?
A-fib
| Pulmonary edema
303
What do EKG reciprocal ST changes indicate? What is seen and where?
Better confirmation of acute MI
| ST depression in reciprocal leads
304
What stimulates the celiac reflex?
Traction on the mesentery or the gallbladder causing changes in thoracic and abdominal cavity pressures
305
What ANS response occurs with valsalva?
SNS inhibition
| PSNS stimulation
306
How long does addition of adenine extend blood storage?
21 to 35 days
307
Inspection of CV includes
Assess RIJ distention - determine if JVD is present
308
What is hgb in the SCD pt prone to?
Hemolysis
| Polymerization of hgb S
309
What nerve mediates the valsalva maneuver?
Vagus and herring's nerve from the aortic arch and carotid sinus respectively
310
What is the third phase of plt response?
AGGREGATION
311
Leads and artery for anterolateral MI
```
Leads = V3, V4, V5, V6
Artery = LAD and CIRC
```
312
Where are platelets located?
They run along the vessel walls, not the middle of the vessels
1. because they are small and pushed aside by large cells
2. So they are strategically ready if injury is detected
313
Where is NO produced?
- In endothelial cells
| - Shear force on endothelial cells stimulates NOS to convert L-arginine into NO
314
What are considered intermediate risk cases and estimated risk of cardiac death or nonfatal MI?
```
1-5%
Intraperitoneal and intrathoracic surgery
CEAs
Head and neck surgery
Orthopedic surgery
Prostate surgery
```
315
Where are plts formed?
Bone Marrow
| By megakaryocytes
316
What is the stimulation for the baroreceptor reflex?
1. Change in arterial flow (inc/dec)
| 2. Ind/dec stretch of baroreceptors in carotid sinus of aortic arch
317
When do the chemoreceptors respond?
PaO2 < 50 mmHg
| Acidosis = low pH, hi H+
318
Most common echo finding in pt with SCD
Dilated RV
319
Average functional capacity defined as
Ability to walk 1-2 glights of stairs or 4 blocks on level surface (MET 5)
320
Decreased O2 supply causes (3) and interventions (6)
```
Causes = DEC HR/BP, INC PAOP
Interventions
1/2. HR = Anticholinergic, pacing
3/4 BP = vasoconstrictor, DEC anesthetic
5/6. PAOP = NTG, inotrope
```
321
What are 2 glycoproteins on the plt?
GPIb
| GPIIb/IIIa
322
Presentation of F V leiden (4) and anesthesia implications?
Presentation = Generally found during pregnancy, DVTS, repeated abortions and recurrent fetal loss
Anesthesia implications = high risk for DVT and/or PE
Give anticoagulants
323
What are the components to Cushing's triad?
1. Hypertension with wide pulse pressure (HI SBP, Lo dbp[for coronary perf])
2. Reflex bradycardia (prolong diastolic time for coronary perfusion)
3. Irregular respirations <>
cheynne-stoke/bradypnea
324
Sickling of the hgb occurs as a result of
```
LOW PaO2 (hypoxia)
Hypoventilation
Hypothermia
Stress/Pain
Hypovolemia
```
325
What stimulates the peripheral chemoreceptor reflex?
Chemosensitive cells in carotid bodies and aortic arch sense changes to pH and blood O2 content/tension
326
What is the purpose of the vascular phase?
To maybe slow down or stop bleeding via vasoconstriction
To keep injury local
Most useful in small injury
327
What is ejection fraction, the equation and normal value
Percentage of the end-diastolic volume ejected during systole
EF = EDV-ESV/EDV
EF = SV/EDV
60-70%
328
What lead and wave do you look at for normal axis? QRS direction?
```
Lead = I and aVF
Wave = QRS POSITIVE
OR
QRS in aVF =positive
QRS in I = positive
```
329
What is considered a high risk case?
Anything above low risk (intermediate and vascular cases)
330
What is the feedback mechanism that regulates BP?
SNS response d/t barorecetpor repose
Stimulates RAAS
Release vasopressin (fluid retention)
ALL stimulate vascular smooth muscle and increase SVR w/ Ca++
331
Describe CVP x descent
Mid systole
Atrial relaxation
Systolic collapse
ST segment
332
During a stellate ganglion block, the pt becomes tachy and begins to cough. The MOST appropriate intervention is to ____ and why?
Get a CXR, to r/o PTX
Lung is inferior to stellate ganglion at C7
Tachycardia and coughing indicate suspicion for PTX
333
Systolic HF treatments for
preload
afterload
contractility
```
Preload = diuretics if too high
Afterload = SNP
Contractility = dobutamine
```
334
How is the cardiac index adjusted, what is the equation, and what is the normal value?
Adjusted for patient size, their BSA
CI = CO/BSA,
2.8 -4.2 L/min/m2
335
What is the spleens role in plt process?
1. aids in clearance of plts
| 2. Stores 1/3 of circulating plts for later use
336
Primary hemostasis ends with
Platelet plug
337
What are the unipolar leads?
aVR, aVF, aVL
338
5 triggers for sickling of hgb
```
Hypoxia
Hypovolemia
Hypothermia
Stress
Pain
```
339
What is FFP, how much is in a bag, expiration and dosing?
```
Fresh Frozen Plasma
Separated from RBC and plt
One bag = 200-250 ml
Expiration = 12 mos
Dose = 10--15 mL/kg
```
340
What makes up plasma and percentage by volume?
Proteins = 7%
Water = 92%
Other solutes = 1 %
341
How much does the fibrinogen level increase with cryo?
50 mg/dL
342
What is the normal plt value and lifespan?
Value=150k -300k
| lifespan = 1-2 weeks
343
Consideration for pts with CAD and 1-2 clinical predictors and =/>3 predictors? What is the risk level?
1-2 = intermediate risk
Proceed to OR w/ HR control
Consider noninvasive testing if management will change
=/>3 = higher risk
Consider testing if management will change
344
Explain EKG evidence of poor R wave progression
- Instead of V1-V6 going from more negative S wave to more positive R wave
- R wave does NOT progressively get positive like it should
- V6 R wave is not mostly positive
345
Pathophysiology of DIC
Systemic activation of coag system simultaneously
Leads to thrombus formation
exhaustion of plt and coag factors
346
What is myocardial injury indicative of?
Infarction
Dead tissue
NO O2 supply
347
What is the autoregulation range for coronary blood flow?
The coronary vasculature autoregulates between a MAP of 60-140 mmHG
348
What is the intima composition?
Endothelial cells
349
Treatment of HELLP?
Control HTN
Deliver baby
Stabilize mom by preventing seizures
350
What is a pretreatment option to prevent the bainbridge reflex?
Retrobulbar block of CN V1 (opthalmic branch)
351
How many alpha and beta chains are in hgb?
```
alpha = 2
beta = 2
```
352
Describe CVP c wave, cardiac cycle and EKG wave correlation.
early systole
Isovolumetric contraction
tricuspid (bulging) motion to RA
R wave
353
What surgeries are considered a low risk case?
Superficial or endoscopic
Cataract or breast
Ambulatory
354
How are plts cleared?
Macrophages in
1. reticuloendothelial system
2. Spleen
355
Citrate binds to?
Ca++ aka Factor IV
356
When is a mesh, plt plug formed in hemostasis?
Primary phase
357
MI vs Prinzmetal's angina on 12-lead & treatment?
ST elevation for both
CATH clean for Prinzmetals
Treat Prinzmetals w/ CCBs
358
How is HTN control in HELLP syndrome?
Mag Sulfate
359
Difference and incidence for primary and secondary HTN
```
Primary = NO identifiable cause, 95% cases
Secondary = has identifiable cause; 5% cases
```
360
Coagulation factors are made of what and in what state?
Proteins
| Inacitve
361
Coumadin MOA?
MOA = Vitamin K antagonist, interferes w/ hepatic synthesis of Vit-K dependent factors (F II, VII, IX, X)
362
Lateral MI leads, artery, side of heart
```
Leads = I, aVL, V5, V6
Artery = Circ (left circumflex)
Heart = Left
```
363
How does the endothelial layer help with vasodilation or constriction?
Releases NO or prostacyclins that act on the adventitia which is primarily smooth muscle
364
6 Indications for plt?
1) Thrombocytopenia <10000 w/o bleeding
2) Prophylaxis for LPs, CVC <50,000
3) Bleeding <50,000
4) DIC w/ bleeding<75,000
5) MTPs <75,000
6) Eye/CNS surgery <100,000
365
What is prostacyclin?
Lipid molecule produced in endothelial cells (via AracA pathway)
- POWERFUL VASODILATOR
- INTERFERES W/ PLT FORMATION AND AGGREGATION
366
How is F VIII concentrate acquired, benefit over cryo, and contains what? When should it be given?
Acquired from pool of plasma, large number of donors
Has viral attenuation, decrease infection risk
Contains F VIII and vWF
Give preop and intraop
367
SCD hgb abnormality
Beta chain
6th position
Valine (nonpolar) instead of glutamate (polar)
Affects quaternary structure stablity
368
How do you perform the valsalva maneuver?
Off vent -- go to manual mode
↑APL (adjustable pressure limiting
• ↑ to 30 mmHg
Press bag to ↑ intrathoracic pressure
369
What are the components of ejection fraction
End diastolic volume EDV
| End systolic volume ESV
370
Indications for cryoprecipitate? (4)
LOW fibrinogen (factor I)
1) Microvascular bleeding w/ LOW fibrinogenemia
2) DIC w/ fibrinogen<80-100 mg/dL
3) Hemorrhage or MT w/ fibrinogen <100-150 mg/dL
4) Prophylaxis in hemophelia A, vWD, or congenital dysfibrinogenemias
371
Purpose of endothelin in vasoactive phase.
Stimulates smooth muscle contraction
Stimulates cell division of endothelial cells, smooth muscle cells, fibroblasts
Aids repair of damaged sites
372
Causes of right HF and treatment
```
Causes = INC PVR that impairs RV fxn b/c right heart is thinner and more compliant
Treatment= inotropes, DEC PVR, NO donors
```
373
What are some treatments for cardiac reflex?
Anticholinergic (glycopyrolate, atropine)
| Decrease insuflation
374
5 Postulated mechanisms of primary HTN
1) Chronic vasoconstriction activating RAAS and fluid retention
2) SNS over-activity leads to chronic vasoconstriction and INC SVR
3) Vasodilatory deficiency (low NO, PGs)
4) Collagen/protein deposition in arterial intima = stiff
5) High Na+ diet intake
375
What is vaso-occlusive crisis (VOC), how does it manifest, what is the periop incidence and how is it treated?
```
Most frequent manifestation
D/T tissue ischemia or infarction
Causes mild to severe pain
Incidence = 10%
Treat
Mild pain = PO analgesics, hydration
Severe pain = hospitalization, IV narcotics, IV hydration, O2
```
376
After blood is removed from cold storage, max time to be given and why?
Less than 30 minutes
| Longer time promotes bacterial growth
377
What factors can decrease O2 fraction?
LEFT shift in Oxyhgb dissociation curve
| Decreased capillary density
378
What is the drawback to cryoprecipitate preparation?
Not submitted to viral attenuation
| Poses increased risk of infection
379
When proceeding with noncardiac emergency surgery, what should be the cardiac focus?
Focus on perioperative surveillance and risk reduction
380
How can the bainbridge reflex be blunted?
Release of stimulus
| Give anticholinergic like glycopyrolate (vagalytic)
381
Where do clotting factors hang out?
Endothelial cells of the intima layer of vessels
382
What is the role of fibronectin in hemostasis?
Facilitates anchoring of fibrin during formation of hemostatic plug
383
Prostacyclins cause vessels to do what?
Vasodilate
384
What is the first phase of plt activation?
ADHERENCE
385
What is platelet aggregation?
- The release of mediators following plt metamorphosis
| - To prompt plts to form primary PLT PLUG
386
What are 4 cardiac demand variables
Heart rate
Preload
Afterload
Contractility
387
List the types of vWF disorder from most most treatable to least. Also indicates severity.
```
Type 1
Type 2A
Type 2M
Type 2B
Type 2N
Type 3
```
388
EKG diagnostic criteria for left atrial hypertrophy
```
Terminal portion of diphasic P wave
-- LARGER, >1 small box
OR
Diphasic P wave
-- >120 ms (3 small boxes)
```
389
What are bipolar leads and their normal inflections?
Leads with both positive & negative
Leads I, II, III
Normally positive
390
Purpose of the media layer in the vessel
Extremely active thrombogenic middle layer
391
Effects of mag sulfate on CNS and NMJ.
CNS decrease irritability-- increase Sz threshold
| NMJ decrease activity-- may cause weakness
392
Hemoptysis after PA cath insertion is indicative of?
PA rupture
