Exam 3: CABG, pump, vascular, pacemakers Flashcards
what motions move the TEE probe anterior and posterior
anteflex/retroflex
what motions move the TEE probe R and L
flex to right, flex to Left
what is used to rotate the ultrasound beam
omniplane
what information do we get form basic TEE
L and R vent function
heat wall motion
heart chamber volume
vessel integrity
valve function and integrity
heart tumors
pericardial effusion
what are absolute contraindications to TEE
perforated viscous
esophageal stricture/tumor
esophageal perforation/laceration
esophageal diverticulum
active upper GI bleed
what are some relative contraindications to TEE
radiation fo neck/mediastinum
GI surgery/bleed
barretts esophagus
dysphagia/hiatal hernia
neck immobility/cervical disc disease
symptomatic hiatal hernia
esophageal varicies
coagulopathy
what distance do you initially insert TEE probe to
30-35 centimeters
what are the four positions for TEE
upper esophageal
mid esophageal
transgastric
deep transgastric
the LV should be ______x larger than the RV
1.5
what is the first view we go for in TEE
mid esophageal four chamber view
what distance for mid esophageal four chamber view
30-35 cm
what do we assess in mid esophageal four chamber view
chamber size
ventricular function
anterolateral/inferoseptal WMA
mitral valve disease
tricuspid valve disease
atrial septal defect
pericardial effusion
what is the second view we do in TEE
mid esophageal two chamber (LA/LV)
how do we get midesophageal two chamber view
rotate 80-100 degrees
what structures are visible in midesophageal two chamber view
LA
LV
mitral valve (posterior on left, anterior Right)
what do we assess in midesophageal two chamger
LA mass/thrombus
LV size and function
anterior/inferior WMA
MV disease
MV annulus measurement
what is the third view in TEE
midesophageal long axis
how do we get midesophageal long axis view
rotate to 130 degrees
what structures are in midesophageal long axis view
LA
LV
LVOT
Aortic valve
mitral valve
RV
what can we assess with midesophageal long axis
LV function
anterospeptal/infeolateral WMA
MV disease
AV and aortic root disease
interventricular septum pathology
cardiac air
what is the fourth view for TEE
midesophageal bicaval
how do we get midesophageal bicaval
omni to 90?
what is visible in ME bicaval
LA
RA
SVC
IVC
intratrial septum
what view is good for finding PFOs/ASDs
ME bicaval
what can be assessed in ME bicaval
ASD
PFO
lines/wires
venous cannula
what is the fifth view for TEE
ME aortic valve short axis
how do we get ME aortic valve short axis view
pull probe back, rotate to 10 degrees
what structures are in ME aortic valve short axis view
LA
IAS
RA
RV
PA
Aortic valve (L, R and non coronary cusps)
what do we assess in ME aortic valve short axis view
aortic valve disease
ASD
LA size
coronaries
what is the sixth view on TEE
ME RV inflow outflow view
what structures are in ME RV in flow out flow view
LA
RA
TV
AV
PA
PV
RV
what do we assess in ME RV in flow out flow view
pulmonic valve disease
pulmonary artery
RVOT
tricuspid valve disease
PAC position
what is the seventh view of TEE
ME ascending aorta Short access view
how do we find ME ascending aorta Short access view
pull back from ME aortic valve view
what structures are in ME ascending aorta Short access view
PA
PV
ascending aorta
SVC
RPA
what do we assess for in ME ascending aorta Short access view
pulmonary artery pathology
pulmonary emboli
ascending aorta pathology
PDA
PAC position
atherosclerotic disease
what is the eight view of TEE
ME ascending aorta long axis view
how do we get ME ascending aorta long axis view
turn 90 degrees from ascending aorta short axis
what structures are in ME ascending aorta long axis view
RPA
Ascending aorta
what do we assess in ME ascending aorta long axis view
aortic pathology
pericardial effusion
pulmonary embolus
what is the ninth view of the TEE
descending aorta short axis
how do we get descending aorta short axis
rotate to left
what structures are in descending aorta short axis
descending aorta
what do we assess in descending aorta short axis
aortic pathology
flow reversal (aortic regurge)
balloon pump/percutaneous bypass wire position
left pleural effusoin
atherosclerotic disease
what is the the tenth view of the TEE
descending aorta long axis
how do we get descending aorta long axis
90 -105 degrees degrees omni beam to go verticle
what structures are in descending aorta long axis
descending aorta
what do we assess in descending aorta long axis
aortic pathology (dissection)
flow reversal from AR
IABP position
what is the eleventh view of TEE
trans gastric short-axis view
how do we get to transgastric short axis view
70 cm into stomach
anteflex
what structures are in transgastric short axis view
LV
ventricular septal wall
papillary muscles
ventricle walls
what do we assess for in transgastric short axis view
LV size function
interventricualr septal motion
VSD
pericardial effusion
volume status
what views do we get in ME location
four chamber
two chamber
long axis
short axis
bicaval
aortic valve short axis
RV IF/OF
ascending aorta short axis
ascending aorta long axis
descending aorta short axis
descending aorta long axis
what is the only non ME view in basic TEE
TG short axis
what is red flow on color doppler
towards transducer
what is blue flow on color doppler
away from the transducer
what view is this
ME 4 chamber
what is 1
RA
what is 2
RV
what is 3
LA
what is 4
LV
what view is this
ME two chamber
what is 1
LA
what is 2
LV
what view is this
ME long axis
what is 1
LA
what is 2
LV
what is 3
aorta
what is 4
LVOT
what is 5
RV
what view is this
ME bicaval
what is 1
LA
what is 2
RA
what is 3
IVC
what is 4
SVC
what view is this
ME right ventricular inflow outflow
what is 1
LA
what is 2
RA
what is 3
TV
what is 4
RV
what is 5
pulm valve
what is 6
pulm art
what is 7
Aortic valve
what view is this
ME aortic valve short axis
what is 1
LA
what is 2
RA
what is 3
RV
what is 4
pulm art
what is 5
left coronary cusp
what is 6
right coronary cusp
what is 7
noncoronary cusp
what view is this
ME ascending aorta short axis
what is 1
SVC
what is 2
ascending aorta
what is 3
pulm valve
what is 4
Pulm art
what is 5
right pulm art
what view is this
ME ascending aorta long axis
what is 1
right pulm art
what is 2
ascending aorta
what view is this
descending aorta short axis
what is 1
descending aorta
what view is this
descending aorta long axis
what is 1
descending aorta
what view is this
transgastric short axis
what is 1
LV
what does the first letter of a pacemaker code refer to
chambers paced
what does the second letter of a pacemaker code refer to
chambers sensed
what does the third letter of a pacemaker code refer to
response to sensing
what is AAI pacemaker
atrium paced
atrium sensed
inhibit (demand mode)
what is VVD pacemaker
ventricle paced
ventricle sensed
dual (dependent)
what kind of heart rhythms use inhibit mode on pacemaders
fast
AFIB with RVR
what kind of heart rhythms use Dual mode on pacemaker
blocks
what is DDD pacemaker
dual paced
dual sensed
dual (dependent)
what does a magnet do to a pacemaker
VOO for single chamber
DOO for dual chamber
pacing on
sensing off
response off
what part of the ECPP is a holding tank/filter/defoamer for blood
venous reservoir
what part of the ECPP provides mechanical oxygenation/ventilation
oxygenator
what part of the ECPP cools/warms blood
heat exchanger
what part of the ECPP supplies medical air/FiO2 to oxygenator
Blender
what part of the ECPP pumps blood
Arterial pump
what part of the ECPP scavenges blood from surgical field/vents heart (prevents excess blood loss/poor surgical field of view)
cardiotomy suction/vent lines
what part of the ECPP allows for myocardial arrest
Cardioplegia System
what part of the ECPP supplies anesthetic gas to oxygenator
Vaporizer
what part of the ECPP Bridges the HLM to the patient
Cannulae
what is normal dose for Heparin
300-400 units/kg
what is the half life of Heparin
2.5 hours
what does heparin bind to
antithrombin 3
what clotting factors does heparin inactivate
2a
9a
10a
11a
12a
what is ACT goal for CPB
480 seconds
what is ACT goal for TAVRs
250-300 seconds
what is antidote dose for heparin
1-1.3 mg/100 heparin
what deficiency leads to heparin resistance
antithrombin 3 deficiency
what is treatment for AT3 deficiency
FFP
if patient has heparin resistance, what two medications can we use for anticoagulation
bivalrudin
argatroban
what is the MOA of bivalrudin
direct thrombin inhibitor
what is the dose for bivalrudin for CPB
1mg/kg bolus
2.5 mg/kg/hr infusion
what labs do we monitor for bivalrudin
ACT
aPTT
your patient has heparin resistance and renal failure, what anticoagulant do you use
argatroban
your patient has heparin resistance and liver failure, what anticoagulant do you use
bivalrudin
what is the moa of argatroban
direct thrombin inhibitor
what labs do we monitor with argatroban
ACT
aPTT
what anticoagulant do we use for patients with HIT
argatroban
what is the half life of argatroban
45-55 min
what is the half life of bivalrudin
25 min
what is the MOA of amicar/aminocaproic acid
Aminocaproic acid is a lysine analog that binds competitively to plasminogen, blocking plasminogen from binding to fibrin and the subsequent conversion to plasmin
This activity subsequently results in the inhibition of fibrin degradation (fibrinolysis)
what is the MOA of TXA (tranexamic acid)
-lysine analog that inhibits plasminogen activation
-synthetic plasminogen-activator, inhibition of fibrinolysis and clot degradation
formula for calculating CPB HCT
(preop hct x pt blood volume) / (patient blood volume+ prime volume + anesthesia volume)
SVR calculation
MAP-CVP/CO x 80
for every 7* drop in temp, VO2 is reduced by ____________
50%
what is mild hypothermia for CPB
34-36
what is moderate hypothermia for CPB
28-33
what is severe hypothermia for CPB
22-27
what is deep hypothermia for CPB
21
what is glucose goal post CPB
<180
where does antegrade cardioplegia go
coronary arteries
drains out of coronary sinus/RA
where does retrograde cardioplegia go
coronary sinus
drains out of coronary arteries
monitored via coronary sinus pressure
what two labs often increase on rewarming
K
glucose
how many chambers
2
how many chambers
1
how many chambers
1
what kind of pacemaker
dual chamber AICD
what kind of pacemaker
single chamber AICD
what kind of pacemaker
biventricular pacemaker
what kind of device
leadless pacemaker
what is this device
loop recorder
what happens with collateral myocardial circulation and CAD
increase in size and number
T/F collateral myocardial circulation exists in normal hearts
true
T/F collateral myocardial circulation is beneficial at rest
true
what can happen with collateral myocardial circulation during increased myocardial demand
coronary steal
Coronary steal graphic
what is an anastomosis
a connection made between 2 vessels
what does the # of grafts refer to
the number of DISTAL anastomosis made
what do we do PREOP for CABG
*Beta-blocker administration within 24 hrs. of procedure
*All should receive statin
*Continuation of calcium channel blockers
*ACE inhibitor continuation is controversial - I prefer holding
*ASA continue or hold 6-24 hrs. pre-op
*Antiplatelet is typically held 5-7 days
*Heparin usually discontinued in pre-op 1 hour prior
*Typically metformin held 24-48 hrs. pre-op
T/F give BB prior to CABG
true
T/F give statin before CABG
T, to all patients
T/F continue CCB before CABG
true
T/F continue ACE-I before CABG
false
T/F continue ASA before CABG
either continue or hold for 6-24 hours
T/F continue anti-platelet therapy before CABG
F, hold for 5-7 days
T/F continue heparin before CABG
F, D/C 1 hour prior
T/F continue metformin before CABG
F, hold for 24-48 hours
what do CRNAs do PREOP for CABG
large bore IV placement
A-line placement
CVL or CORDIS placement
anxiolytics
what intraop monitors do we use for CABG
A line
CVP
PA
CO/CI
TEE
SvO2
TEG
what drugs do we have prepped for induction of CABG
INDUCTION
-lidocaine
-fentanyl/sufentanil
-etomidate
-roc/vec/cis
UPPERS
neo stick
levophed on pump
epinephrine on pump
DOWNERS
nitroglycerin
what occurs post induction for CABG
line placement and TEE
what lab monitors clot formation and breakdown graphically
TEG- thromboelastography
what does R value of TEG tell us
time for initial clot/fibrin formation
what does K value of TEG tell us
speed of clot formation at the end of R until amplitude reaches 20 mm
what does the Alpha Angle of TEG tell us
Speed of clot formation like K. Both are speed of clot strengthening
what does MA of TEG tell us
Strength of clot based on platelet function, fibrin, and interaction between platelets and polymerizing fibrin. (Maximum Amplitude) of clot. Maximum strength of clot
TEG picture
what is the most controllable and important determinant of myocardial oxygen consumption
HR
what is formula for coronary perfusion pressure
Diastolic BP-PCWP
what is goal of intraop BP maintanence for CABG
maintain adequete coronary perfusion pressure
what is hemodynamic goal for preload for CABG
decrease
(decreased LVEDP will increase myocardial O2 supply and decrease demand. Nitroglycerin selectively dilates coronary vessels)
what drug selectively dilates coronary vessels
nitroglycerin
what is goal for HR for CABG
slow/normal
(too fast=ischemia, consider BB)
(too slow= not enough CO for coronary perfusion)
what medication can we give during CABG if HR is too fast
B-BLocker
what can too fast of a HR during CABG lead to
ischemia
what can too slow of a HR during CABG lead to
decreased coronary perfusion
what is goal for rhythm for CABG
maintain Sinus
(maintains 20% atrial kick for CO)
what is goal for compliance during CABG
increase
(concentric LCH common with HTN history decreases compliance)
what cardiac change can HTN lead to
concentric LVH
what is goal for contractility in CABG if normal LVF
depress
(decreased contractility= decreased MVO2)
what is goal for contractility in CABG if decreased LVF
support
what does a decrease in contractility lead to
decreased myocardial use of O2 (MVO2)
what is goal of SVR for CABG
maintain
(hypertension is better than hypotension)
what do we treat hypotension with in CABG
phenylephrine
what is goal of PVR for CABG
maintain
(usually not a problem)
what are sights for graft harvesting with CABG
saphenous vein
radial artery
LIMA/RIMA
which graft has longer patency
LIMA/RIMA
GRAFT type graphics
what is an important anesthesia action during sternotomy
‘OFF LUNGS”
hold ventilations, switch to manual
what is an anesthetic consideration during LIMA harvest
keep low TV to prevent obstructing surgeons view
what occurs in CABG after sternotomy/LIMA harvest
aortic cannulation
what is target ACT for CABG/PUMP
480 sec
what is minimum ACT for pump
400
what is bolus dose of CABG for initial heparization
300-400 units/kg
what is off pump dose of heparin for CABG
1/2 pump dose (150-200units/kg)
when do we give heparin bolus for CABG
prior to the LIMA/RIMA takedown
what is BP goal for aortic cannulation
BP <90 sys
when can we allow BP to rise
after cannula is placed
what do we monitor during CABG
*Monitor electrolytes
*Monitor glucose
*Monitor MAP
*Monitor cerebral oximeter
*Ensure anesthetic is being delivered (perfusionist)
*Meds upon warming
what do we do when preparing to come off pump
resume ventilation
prepare to receive circuit volume
how can we prepare to receive circuit volume when coming off pump
*Make room by decreasing SVR
*Maintain MAP of 60-70
*Monitor right heart via swan and surgeon’s eyes
*TEE to assess LV function
*Add inotrope support if necessary
*Ask perfusion to spin down the rest for later administration
what is BP goal for aortic decannulation
systolic BP <90
what is dose of protamine for reversal of heparin
1 mg per 100u heparin
when do we give protamine
after decannulation has occurred
what kind of line do we give protamine in
peripheral IV
what do we give to ‘pretreat” for histamine reaction
antihistamine
H2 agonist such as famotidine
what is a consideration for protamine administration
give slow
what are S/S protamine reaction
increase PiP
decreased BP
when do we get ACT after protamine admin
5 min
what may happen that could require more protamine
cell savor blood is given (still hepranized)
what is HCT goal post op
22-25%
what is EF requirement for OPCABG
> 30%
what hemodynamic change do we prepare for in OPCABG
extreme swings in BP
what medications do we prepare to combat OPCABG BP swings
albumin 500 ml 5%
nitro
levo
what is it called when they lift the heart up out of the chest during OPCABG
verticalization of heart
exposure for the __________ is considered with the most dramatic deterioration in stroke volume
circumflex
what are features of noncompliant LV (LVH)
compromised diastolic filling
dependence on atrial kick
how is LVEDP in concentric hypertrophy
maintained
what is C
TV
what is D
RA
what is E
LV
what is F
MV
what is G
LA
what is A
RV
what is B
TV
what is C
RA
what is D
LV
what is E
MV
what is F
LA
what view is this
Subcostal 4 chamber view
what view is this
subcostal IVC view
what is A
diaphragm
what is B
hepatic vein
what is C
RA
what is D
IVC
what is E
Liver
what view is this
apical 4 chamber view
what is A
apex of heart
what is B
LV
What is C
AV
what is D
MV
what is E
LA
What is F
RV
what is G
TV
what is H
RA
what view is this
PLAX
what is A
RV
what is B
aortic outflow
what is C
AV
what id D
LV outflow
what is E
LV
what is F
MV
what is G
LA
what view is this
PSAX
what is A
RV
What is B
LV
what is C
papillary muscles
5 Ps of limb ischemia
Pulselessness -early sign
Pallor-early sign
pain
Parathesia-late sign
paralysis-late sign
what ABI ratio is abnormal
<0.9
what ABI ratio is associated with limb threatening ischemia
<0.4
Type 1 crawford aneurysm
all or most of the descending thoracic aorta
and the upper abdominal aorta
crawford type II aneurysm
involve all or most of the descending thoracic aorta and all or most of the abdominal aorta
type III crawford
involve the lower portion of the descending thoracic aorta and most of the abdominal aorta
type IV crawford
involve all or most of the abdominal aorta, including the visceral segment.
type 1 debakey
begin in the ascending aorta and extend throughout the entire aorta.
type II debakey
confined to the ascending aorta
type III debakey
begin just distal to the left subclavian artery and extend either to the diaphragm(type IIIA) or to the aortoiliac bifurcation (type IIIb).
stanford type A
involve the ascending aorta
standford type B
do not involve the ascending aorta
crawford type I
crawford type 2
crawford type 3
crawford type 4
