Ex1 L3 Flashcards
HTN - definition
140/90 or higher
Minimum 2 occasions
At least 1-2 weeks apart
PreHTN definition
120-139/80-89
HTN is major cause of
IHD CHF CVA Arterial aneurysm ESRD
95% of all HTN
Primary HTN
Primary HTN
Essential HTN
No identifiable cause
Primary HTN Pathophysiology
- Autonomic NS - dysregulation of baro/chemoreceptor pathways (RAAS)
- Dysregulation of classical RAAS - elevated renin, angioII, increased aldosterone
- Endogenous vasodilator/vasoconstrictor balance-oxidative stress—> NPs released
Highest risk population - HTN
African American males
Secondary HTN causes
Renovascular dx Hyperaldosteronism Aortic coarctation Pheochromocytoma Cushing’s syndrome Renal parynchymal disease Pregnancy induced HTN
Tx primary HTN
Lifestyle modifications, Rx tx
Associated with primary HTN
Insulin resistance Dyslipidemia, HL IHD, angina, LVH CHF, CVA PVD, renal insuff. ETOH, tobacco, obesity, OSA
HTN emergency
BP > 180/120 + evidence of target organ damage
HTN emergency Tx
1st hour: Lower BP 20%
2-6h: more gradually
**d/t rebound cerebral perfusion
HTN urgency
BP severely elevated (no evidence of target organ damage)
H/A, epistaxis, anxiety
Evidence of target organ damage in HTN emergency
Pulm edema Encephalopathy LV failure Aortic dissection Renal insufficiency PVD, CVA, CVdx, CHF, LVH, Angina
HTN Emergency - proceed, delay, cancel surgery?
Postpone
HTN emergency Tx Rx
DOC: Sodium nitroprusside: 0.5-10 mcg/kg/min
Labatelol - used for any type of HTN emergency
Alternates: nicardipine, fenoldopam, esmolol
Operative changes that can exaggerate BP swings
Positioning
PPV
Blood loss
What DBP would change elective surgical plans?
DBP 110-115 — postpone surgery
Pharmacological management - HTN
ACEI or ARBS
HTN medication management in preop period
ACEI - hold 24-48 h before surgery (“pril”)
ARBs - hold 24 hours before surgery (“sartan”)
Pt accidentally took ACEI day of surgery. Risks?
Blunted RAAS; blunted ANS (induction)
*** vasopressin system is left
Pt accidentally took ARB day of surgery. Risks?
Refractory to ephedrine/phenylephrine
May require volume + pressors
Risk of induction - HTN patients
- Hypotension - d/t peripheral vasodilation, dec. IV fluid volume
- HTN - d/t direct laryngoscopy
Risk of HTN during induction
MI
How to reduce risk in HTN pts during induction
Preemptive management of HTN in essential HTN pts
- opioids, IAs, BB, vasodilator
- limit amount of DL attempts
Optimal choice anesthetic for HTN pt
Regional - especially nerve block
pHTN is defined as
Mean Pulmonary Artery pressure > or = 25 mmHg at rest
+ PAOP 15mmHg or less, elevated PVR of > 3 wood units
Classification of pHTN
Mild: mPAP 25-40
Moderate: 41-55
Severe: > 55
PulmHTN Tx
Ca Channel Blocker Viagra (Phosphodiesterase inhibitor) O2/Anticoagulation/diuretics Prostacyclins (Flolan Remodulin, Ventavis) Endothelial receptor agonist (Tracleer)
Severe pHTN - what should be available?
Nitric***
ECMO
Do NOT perform at community hospital
Biggest risk of pHTN
Drop in SVR —> if systemic BP < pulm artery pressure = pt arrests
Moderate - severe pHTN risks
RHF
Periop period - pHTN medications
Caution with: volatiles, diuretics
Avoid: hypoxia, hypercarbia, acidosis
**continue vasodilators
VA used in pHTN pts
Sevoflurane
Intraoperative Rx - pHTN
Sildenafil if not on already
NO
Avoid sedatives
-opioids/propofol okay - careful prop (bp drop)
AVOID ketamine/etomidate + regional (spinal/epidural)
NEED A-line
Ejection Fraction
(EDV - ESV)/EDV
Or
Stroke volume/EDV
Stroke volume
EDV - ESV
PFO - issues associated with it
Stroke
Common, most people don’t know they have it
Most common cause of RV failure
LV failure
Why do all forms of HF have high ventricular EDP?
Neurohormonal
HF is most often a result of
Impaired myocardial contractility
Cardiac valve abnormalities
Systemic HTN, pHTN (cor pulmonale)
Diseases of pericardium
Systolic HF
Decreased ventricular wall motion
-M > F
Causes of Systolic HF
CAD Dilated cardiomyopathy Chronic pressure overload (AS, HTN) Chronic volume overload (regurgitation valves, high output cardiac failure) Decreased EF
Diastolic HF
Symptomatic HF w/ normal LV fxn
Systolic HF most often associated with
CAD
Diastolic HF most often associated with
HTN
Obesity
DM
Diastolic HF causes
IHD
Long standing essential HTN
Progressive AS
Main difference between acute/chronic HF
Acute: req emergency tx, hypotension
Chronic: BP maintained
High output vs. Low output HF
High output: hypothyroidism, pregnancy
Low output: CAD, cardiomyopathy, valve dx
Fxn Classes of HF
I: ordinary physical activity = no s/s
II: S/S with ordinary exertion
III: s/s with less than ordinary exertion
IV: s/s at rest
Short term fix for the decrease in CO (HF)
Decreased renal blood flow —> activates RAAS (aldosterone)
ACC/AHA stages of HF
A: high risk, no s/s —> tx HTN/DM/HL, decrease risks
B: Structural dx, no s/s —> ACEI/ARBs
C: Structural dx + s/s —> ACEI + BB, revascularization, aldosterone antagonist
D: Refractory req special Intvns —> inotrope, VAD, transplant, Hospice
Treatment - systolic HF
First line: ACEI
ARBS, aldosterone antagonists, BB, diuretic, dig
Treatment: DHF
Decrease risk factors
Increase LV filling time: BB, CAchannel blockers, dig
Control volume: diuretics, nitrates
Decrease ventricular remodeling: ACEI, statins
HF - preop management
Continue BB
DOS - d/c diuretics, digoxin
Day prior - d/c ARBs
Caution d/c-ing ACEI
HF - intraop management
Aline, TEE
Regional anesthesia possible
Post op management of HF
Watch for Acute HF, manage pain, restart preop meds ASAP
Most common genetic CVS disease
Hypertrophic cardiomyopathy
HCM - decrease obstruction
BB, VA, CCBs, hypovolemia, Bradycardia, HTN, alpha adrenergic stimulation
HCM - management
Vent: use small TV, avoid PEEP
Treat hypotension with alpha agonist
