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CV Anesthesia > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Major branches of Left Coronary Artery

A

LAD (diagonal, septal perforator, intermediate)

Circumflex (OM, PDA in some)

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2
Q

Major branches of RCA

A

SA nodal

AV nodal acute marginal

PDA in most people

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3
Q

Most effective monitors used to detect myocardial ischemia

A

ECG
PAC
TEE
Visual

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4
Q

Factors which both decrease myocardial oxygen supply and increase demand

A

Heart rate

PCWP

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5
Q

2 factors affecting coronary perfusion pressure

A

DBP and PCWP

CPP= DBP - PCWP

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6
Q

Role of heart rate management in optimizing myocardial oxygen supply and demand

A

Total time in diastole decreases as heart rate increases

Total time in diastole is key in perfusion

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7
Q

Most important causes of myocardial ischemia

A

Heart rate

CPP

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8
Q

Hemodynamic variable most commonly associated with myocardial ischemia

A

Heart rate

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9
Q

Factors which may adversely affect ventricular wall tension

A

SBP

Afterload

LV filling volumes

Myocardial ischemia

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10
Q

Effect of IABP on myocardial oxygen supply

A

Augments DBP via coronary and systemic perfusion

Decreases demand, increases supply of oxygen

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11
Q

Effect of IABP on myocardial oxygen gemand

A

Decrease workload

Decrease oxygen consumption

Increases CO

Decreases hemodynamic abnormalities associated with mechanical defects

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12
Q

Most commonly associated complication associated with CABG

A

Afib or rhythm disturbances 22%

MI 5-50%

Bleeding 5%

Death 3-4%

ARF, sternal wound infection 2-5%

Pumphead, pumplung

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13
Q

Predictors of M&M with CABG

A 
Age
Prior MI
Location of MI
Coagulopathies
CHF
Dysrhythmia
HTN
DM
CVA
PVD
Valvular disease 
Smoking
Lung disease
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14
Q

Time period most associated with M&M after an MI

A

<1 month 35%

<6 months 15%

> 6 months 5%

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15
Q

2 tests measuring ventricular function in pt presenting for CABG

A

Echo

LHC

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16
Q

Commonly used home meds in patients with CAD presenting for CABG

A

Beta blockers

Calcium channel blockers/ACE inhibitors

Diuretics/thiazides

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17
Q

Indications for placement of PAC

A

LV dysfunction

Angina w/i 48 hours

Symptomatic valve disease

Severe HTN with angina hx

Large operation- vascular vol changes

Vascular surgery w/ major artery clamp

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18
Q

Uses of PAC data during CABG

A

Measure CO & optimize perfusion

Detect, treat, and trend myocardial ischemia and valve dysfunction

Measure and optimize ventricular preload in sg with lg volume shifts or aortic cross clamp

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19
Q

Uses of intraop TEE during CABG

A

Ventricular function (EF, motion)

Wall motion abnormalities

Valve dysfunction

Stenosis or regurgitation

Chamber side may be indicative of dysrhythmia, dysfunction

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20
Q

2 important aspects of pt management during CABG

A

Avoid hypoxia and hypotension

Support hemodynamics

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21
Q

Effect of fentanyl on volatile agent requirements

A

Higher dose = more reduction in MAC

25 mcg/kg 40%

100mcg/kg 75%

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22
Q

Fentanyl and sternotomy

A

Increase HR, MAP, CI and MVO2

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23
Q

Halothane and nitrous during sternotomy

A

Control HR but decrease MAP, CI, MVO2

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24
Q

Dose of epi associated with extrasystoles when using isoflurane

A

10mcg/kg epi= 100% ventricular exprasystoles

7 mcg/kg = 50%

5mcg/kg = less than 20%

25
Q

Causes of myocardial ischemia during anesthesia

A

Coronary artery occlusion

Tachycardia

High PCWP/CVP (>12-15)

Hypotension

Severe Hypertension

Increased workload of heart or high CO (sepsis)

26
Q

Signs of myocardial ischemia

A

ST segment abnormality

Dysrhythmia

Conduction abnormality

PA waveform abnormality

Decreased myocardial performance (low CI or BP)

Wall motion abnormality

27
Q

Nitrates intervention for myocardial ischemia

A

Greatly decrease LV wall tension and coronary resistance

Slight increase in HR and contractility

No change in aortic pressure

28
Q

Beta blockers as interventions for myocardial ischemia

A

Greatly decrease contractility and heart rate

Decrease LV wall tension and aortic pressure

No change in coronary resistance

29
Q

Calcium blocking drugs as interventions for myocardial ischemia

A

Greatly decrease coronary resistance

Decrease LV wall tension and aortic pressure

30
Q

Subgroups of pt requiring higher perfusion pressures (higher MAP)

A

Acute MI/ongoing ischemia

Renal/cerebral insufficiency

L main/Lmain equivalent

Aortic stenosis

Chronic hypertension

31
Q

4 potential sources of conduit for bypass grafts for CABG

A

Mammary harvest

Vein graft harvest

Radial vein harvest

Gastric-epiploic harvest

32
Q

Mammary harvest for conduit for CABG

A

LIMA most common

Prone to spasm (papaverine)

33
Q

Vein graft harvest for conduit for CABG

A

Saphenous most common (5-10 years)

Hearing 3000 units prior to removal

34
Q

Blood pressure maintenance during aortic cannulation

A

Maintain SBP <100mmHg

35
Q

Sources of rhythm disturbances associated with surgical manipulation immediately prior to CPB

A

Atrial cannulation

RFG catheter (retrograde cardioplegia)

Pericardiotomy

Lap under heart to explore distal

Ischemia

Dissection out heart for pericarditis

36
Q

Heparin dose and target ACT for on pump CABG

A

300 units/kg

ACT >400 seconds after pericardiotomy and prior to aortic cannulation

37
Q

Hemodynamic consequences of “mixing” or “RAPing”

A

Decreases viscosity and circulating NE levels

Decreased SVR

38
Q

What is “mixing” “RAPing”

A

Draining venous blood to prime CPB circuit

39
Q

4 goals of priorities of CPB

A

Oxygenation of blood and removal of CO2 (ventilation)

Circulation of the blood

Systemic cooling and rewarming

Diversion of blood from heart to provide bloodless field

40
Q

Order and cross clamping strategies for anastomoses

A

Distal done with cross clamp on

Mammary done last

Partial clamp on for proximal

Hear defibrillated 10 min after clamp off if in VF/VT

At risk for ischemia until proximal completed

41
Q

Protamine dose after separation from CPB

A

10mg test dose after venous circuit of machine empties into reservoir

25 mg every minute

Remove aortic cannulation when 1/2 total dose given

Total dose 250mg

Then return volume from reservoir

42
Q

Potential advantages of off pump CABG over on pump CABG

A

Less neuro impairment

Transient periods of ischemia instead of global ischemia

Fewer inotrope

Improved hemostasis

Less transfusions and fluid needs

Less postop renal insufficiency

43
Q

Subgroups of pt that may benefit from OPCAB

A

> 70 yrs old

Low EF

Reoperative surgery

Calcified or plaque in aorta

Pt refusing blood products

Significant comorbidities (PAD, CVA, COPD, coagulopathies, renal dysfunction)

44
Q

Role of intracoronary shunts during distal anastamosis

A

Reduces bleeding

Reduced but maintains blood flow

45
Q

Methods used to displace the heart for distal anastamoses

A

Octopus stabilization lifts and immobilizes site

Suction cup or starfish lifts apex with suction

Saline/CO2 irrigation to maintain clear surgical field

46
Q

Effect of cardiac displacement on CI, LV/RV filling, myocardial oxygen supply and demand, heart rate

A

Decreased RV filling but increased pressures (compression)

Decreased RV output = under filled LV = low SV/CO

Hypotension

Valve dysfunction

MI

Dysrhythmia

47
Q

Target vessel positioning most associated with decrease in SV and increased CVP

A

Vertical position

Distorts MV and TV = significant regurgitation

48
Q

Strategies to manage heart rhythm disturbances during OPCAB

A

Due to ischemia or mechanical issues

Lidocaine infusion esp for RCA

Mag 2 gm

Maintain K+ >4.0

NTG for distal anastamoses spasm

Pacer always available

49
Q

Heparinization and target ACTS for OPCAB

A

1.5-2mg/kg

Goal ACT >250 during anastamoses

Usually dose 10,000-15,000 units (1/2 full CPB dose)

ACT q30minutes

50
Q

Best monitors for evaluating cardiac performance and ischemia during cardiac displacement

A

Arterial line and operative field

51
Q

PAC and TEE use for monitoring cardiac performance and ischemia during cardiac displacement

A

CI superior to TEE with displacement

TEE useful for RWMA

52
Q

Management of heart rate, vascular tone, and LV filling immediately prior to cardiac displacement

A

Maintain reasonable HR

Levo infusion 2-6mcg/min background

Use gtt instead of bolus

Epi blouses 10-20mcg if CI < 1.5

Volume load immediately prior to verticalization and stabilization

53
Q

Uses and limitations of NTG during OPCAB

A

Decreases PCWP so optimizes coronary perfusion

Decreases wall tension and MVO2

Decrease MR and PAP

(Decreased preload can be detrimental bc higher filling pressures are needed to ensure optimal ventricular filling)

54
Q

Protamine reversal of heparin with OPCAB

A

1mg protamine for every 1.3mg heparin

Usually 100mg protamine

55
Q

Grafting order for OPCAB

A

Collateralized

LAD with LIMA

Proximal before distal

Diagonal

RCA

PDA

Circ, 2nd and 3rd OM

Posterior lateral

Ramus

56
Q

Ventilation and acid base balance during OPCAB

A

Hand ventilation and low tidal volumes during distal

Treat metabolic acidosis with NaHCO3 to keep pH >7.3

Compliance and FRC reduced

57
Q

Proximal anastamoses during OPCAB BP

A

Partial cross clamp applied

SBP 100

58
Q

To eligible for extubation in OR pt must

A

Awake

Normothermia

Non-acidotic

Adequately ventilating

CV Anesthesia (4 decks)

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