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Anesthesia & Coexisting Disease > Ex1 L3 > Flashcards

Ex1 L3 Flashcards

1
Q

HTN - definition

A

140/90 or higher
Minimum 2 occasions
At least 1-2 weeks apart

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2
Q

PreHTN definition

A

120-139/80-89

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3
Q

HTN is major cause of

A 
IHD
CHF
CVA
Arterial aneurysm 
ESRD
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4
Q

95% of all HTN

A

Primary HTN

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5
Q

Primary HTN

A

Essential HTN

No identifiable cause

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6
Q

Primary HTN Pathophysiology

A
  1. Autonomic NS - dysregulation of baro/chemoreceptor pathways (RAAS)
  2. Dysregulation of classical RAAS - elevated renin, angioII, increased aldosterone
  3. Endogenous vasodilator/vasoconstrictor balance-oxidative stress—> NPs released
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7
Q

Highest risk population - HTN

A

African American males

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8
Q

Secondary HTN causes

A 
Renovascular dx
Hyperaldosteronism
Aortic coarctation 
Pheochromocytoma
Cushing’s syndrome
Renal parynchymal disease
Pregnancy induced HTN
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9
Q

Tx primary HTN

A

Lifestyle modifications, Rx tx

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10
Q

Associated with primary HTN

A 
Insulin resistance
Dyslipidemia, HL
IHD, angina, LVH
CHF, CVA
PVD, renal insuff. 
ETOH, tobacco, obesity, OSA
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11
Q

HTN emergency

A

BP > 180/120 + evidence of target organ damage

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12
Q

HTN emergency Tx

A

1st hour: Lower BP 20%
2-6h: more gradually
**d/t rebound cerebral perfusion

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13
Q

HTN urgency

A

BP severely elevated (no evidence of target organ damage)

H/A, epistaxis, anxiety

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14
Q

Evidence of target organ damage in HTN emergency

A 
Pulm edema
Encephalopathy
LV failure
Aortic dissection 
Renal insufficiency
PVD, CVA, CVdx, CHF, LVH, Angina
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15
Q

HTN Emergency - proceed, delay, cancel surgery?

A

Postpone

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16
Q

HTN emergency Tx Rx

A

DOC: Sodium nitroprusside: 0.5-10 mcg/kg/min

Labatelol - used for any type of HTN emergency

Alternates: nicardipine, fenoldopam, esmolol

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17
Q

Operative changes that can exaggerate BP swings

A

Positioning
PPV
Blood loss

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18
Q

What DBP would change elective surgical plans?

A

DBP 110-115 — postpone surgery

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19
Q

Pharmacological management - HTN

A

ACEI or ARBS

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20
Q

HTN medication management in preop period

A

ACEI - hold 24-48 h before surgery (“pril”)

ARBs - hold 24 hours before surgery (“sartan”)

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21
Q

Pt accidentally took ACEI day of surgery. Risks?

A

Blunted RAAS; blunted ANS (induction)

*** vasopressin system is left

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22
Q

Pt accidentally took ARB day of surgery. Risks?

A

Refractory to ephedrine/phenylephrine

May require volume + pressors

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23
Q

Risk of induction - HTN patients

A
  1. Hypotension - d/t peripheral vasodilation, dec. IV fluid volume
  2. HTN - d/t direct laryngoscopy
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24
Q

Risk of HTN during induction

A

MI

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25
Q

How to reduce risk in HTN pts during induction

A

Preemptive management of HTN in essential HTN pts

  • opioids, IAs, BB, vasodilator
  • limit amount of DL attempts
26
Q

Optimal choice anesthetic for HTN pt

A

Regional - especially nerve block

27
Q

pHTN is defined as

A

Mean Pulmonary Artery pressure > or = 25 mmHg at rest

+ PAOP 15mmHg or less, elevated PVR of > 3 wood units

28
Q

Classification of pHTN

A

Mild: mPAP 25-40
Moderate: 41-55
Severe: > 55

29
Q

PulmHTN Tx

A 
Ca Channel Blocker
Viagra (Phosphodiesterase inhibitor)
O2/Anticoagulation/diuretics
Prostacyclins (Flolan Remodulin, Ventavis)
Endothelial receptor agonist (Tracleer)
30
Q

Severe pHTN - what should be available?

A

Nitric***
ECMO
Do NOT perform at community hospital

31
Q

Biggest risk of pHTN

A

Drop in SVR —> if systemic BP < pulm artery pressure = pt arrests

32
Q

Moderate - severe pHTN risks

A

RHF

33
Q

Periop period - pHTN medications

A

Caution with: volatiles, diuretics
Avoid: hypoxia, hypercarbia, acidosis
**continue vasodilators

34
Q

VA used in pHTN pts

A

Sevoflurane

35
Q

Intraoperative Rx - pHTN

A

Sildenafil if not on already
NO
Avoid sedatives
-opioids/propofol okay - careful prop (bp drop)
AVOID ketamine/etomidate + regional (spinal/epidural)
NEED A-line

36
Q

Ejection Fraction

A

(EDV - ESV)/EDV
Or
Stroke volume/EDV

37
Q

Stroke volume

A

EDV - ESV

38
Q

PFO - issues associated with it

A

Stroke

Common, most people don’t know they have it

39
Q

Most common cause of RV failure

A

LV failure

40
Q

Why do all forms of HF have high ventricular EDP?

A

Neurohormonal

41
Q

HF is most often a result of

A

Impaired myocardial contractility
Cardiac valve abnormalities
Systemic HTN, pHTN (cor pulmonale)
Diseases of pericardium

42
Q

Systolic HF

A

Decreased ventricular wall motion

-M > F

43
Q

Causes of Systolic HF

A 
CAD
Dilated cardiomyopathy
Chronic pressure overload (AS, HTN)
Chronic volume overload (regurgitation valves, high output cardiac failure)
Decreased EF
44
Q

Diastolic HF

A

Symptomatic HF w/ normal LV fxn

45
Q

Systolic HF most often associated with

A

CAD

46
Q

Diastolic HF most often associated with

A

HTN
Obesity
DM

47
Q

Diastolic HF causes

A

IHD
Long standing essential HTN
Progressive AS

48
Q

Main difference between acute/chronic HF

A

Acute: req emergency tx, hypotension
Chronic: BP maintained

49
Q

High output vs. Low output HF

A

High output: hypothyroidism, pregnancy

Low output: CAD, cardiomyopathy, valve dx

50
Q

Fxn Classes of HF

A

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

51
Q

Short term fix for the decrease in CO (HF)

A

Decreased renal blood flow —> activates RAAS (aldosterone)

52
Q

ACC/AHA stages of HF

A

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

53
Q

Treatment - systolic HF

A

First line: ACEI

ARBS, aldosterone antagonists, BB, diuretic, dig

54
Q

Treatment: DHF

A

Decrease risk factors
Increase LV filling time: BB, CAchannel blockers, dig
Control volume: diuretics, nitrates
Decrease ventricular remodeling: ACEI, statins

55
Q

HF - preop management

A

Continue BB
DOS - d/c diuretics, digoxin
Day prior - d/c ARBs
Caution d/c-ing ACEI

56
Q

HF - intraop management

A

Aline, TEE

Regional anesthesia possible

57
Q

Post op management of HF

A

Watch for Acute HF, manage pain, restart preop meds ASAP

58
Q

Most common genetic CVS disease

A

Hypertrophic cardiomyopathy

59
Q

HCM - decrease obstruction

A

BB, VA, CCBs, hypovolemia, Bradycardia, HTN, alpha adrenergic stimulation

60
Q

HCM - management

A

Vent: use small TV, avoid PEEP

Treat hypotension with alpha agonist

Anesthesia & Coexisting Disease (23 decks)

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