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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
Causes of myocardial ischemia during anesthesia
Coronary artery occlusion Tachycardia High PCWP/CVP (>12-15) Hypotension Severe Hypertension Increased workload of heart or high CO (sepsis)
26
Signs of myocardial ischemia
ST segment abnormality Dysrhythmia Conduction abnormality PA waveform abnormality Decreased myocardial performance (low CI or BP) Wall motion abnormality
27
Nitrates intervention for myocardial ischemia
Greatly decrease LV wall tension and coronary resistance Slight increase in HR and contractility No change in aortic pressure
28
Beta blockers as interventions for myocardial ischemia
Greatly decrease contractility and heart rate Decrease LV wall tension and aortic pressure No change in coronary resistance
29
Calcium blocking drugs as interventions for myocardial ischemia
Greatly decrease coronary resistance Decrease LV wall tension and aortic pressure
30
Subgroups of pt requiring higher perfusion pressures (higher MAP)
Acute MI/ongoing ischemia Renal/cerebral insufficiency L main/Lmain equivalent Aortic stenosis Chronic hypertension
31
4 potential sources of conduit for bypass grafts for CABG
Mammary harvest Vein graft harvest Radial vein harvest Gastric-epiploic harvest
32
Mammary harvest for conduit for CABG
LIMA most common Prone to spasm (papaverine)
33
Vein graft harvest for conduit for CABG
Saphenous most common (5-10 years) Hearing 3000 units prior to removal
34
Blood pressure maintenance during aortic cannulation
Maintain SBP <100mmHg
35
Sources of rhythm disturbances associated with surgical manipulation immediately prior to CPB
Atrial cannulation RFG catheter (retrograde cardioplegia) Pericardiotomy Lap under heart to explore distal Ischemia Dissection out heart for pericarditis
36
Heparin dose and target ACT for on pump CABG
300 units/kg ACT >400 seconds after pericardiotomy and prior to aortic cannulation
37
Hemodynamic consequences of “mixing” or “RAPing”
Decreases viscosity and circulating NE levels Decreased SVR
38
What is “mixing” “RAPing”
Draining venous blood to prime CPB circuit
39
4 goals of priorities of CPB
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
Order and cross clamping strategies for anastomoses
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
Protamine dose after separation from CPB
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
Potential advantages of off pump CABG over on pump CABG
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
Subgroups of pt that may benefit from OPCAB
>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
Role of intracoronary shunts during distal anastamosis
Reduces bleeding Reduced but maintains blood flow
45
Methods used to displace the heart for distal anastamoses
Octopus stabilization lifts and immobilizes site Suction cup or starfish lifts apex with suction Saline/CO2 irrigation to maintain clear surgical field
46
Effect of cardiac displacement on CI, LV/RV filling, myocardial oxygen supply and demand, heart rate
Decreased RV filling but increased pressures (compression) Decreased RV output = under filled LV = low SV/CO Hypotension Valve dysfunction MI Dysrhythmia
47
Target vessel positioning most associated with decrease in SV and increased CVP
Vertical position Distorts MV and TV = significant regurgitation
48
Strategies to manage heart rhythm disturbances during OPCAB
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
Heparinization and target ACTS for OPCAB
1.5-2mg/kg Goal ACT >250 during anastamoses Usually dose 10,000-15,000 units (1/2 full CPB dose) ACT q30minutes
50
Best monitors for evaluating cardiac performance and ischemia during cardiac displacement
Arterial line and operative field
51
PAC and TEE use for monitoring cardiac performance and ischemia during cardiac displacement
CI superior to TEE with displacement TEE useful for RWMA
52
Management of heart rate, vascular tone, and LV filling immediately prior to cardiac displacement
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
Uses and limitations of NTG during OPCAB
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
Protamine reversal of heparin with OPCAB
1mg protamine for every 1.3mg heparin Usually 100mg protamine
55
Grafting order for OPCAB
Collateralized LAD with LIMA Proximal before distal Diagonal RCA PDA Circ, 2nd and 3rd OM Posterior lateral Ramus
56
Ventilation and acid base balance during OPCAB
Hand ventilation and low tidal volumes during distal Treat metabolic acidosis with NaHCO3 to keep pH >7.3 Compliance and FRC reduced
57
Proximal anastamoses during OPCAB BP
Partial cross clamp applied SBP 100
58
To eligible for extubation in OR pt must
Awake Normothermia Non-acidotic Adequately ventilating

CV Anesthesia (4 decks)

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