Exam II: CHF, Cardiomuopathies, Pericardial Disease, Sepsis Flashcards
CHF: Inability of the heart to ___ and ___ blood sufficient to meet ___ ___.
fill and pump, tissue demands
CHF Symptoms
exertional ___
d___
c___
ankle swelling
dyspnea more in the supine position
h___
fatigue
dyspnea
congestion
hypoperfusion
CHF Causes
Cardiac valve abnormalities
Impaired ___ ___due to ischemic heart disease or cardiomyopathy
Systemic ___
Pulmonary hypertension (___ ___)
Pericardial disease
myocardial contractility, hypertension, cor pulmonale
Cor pulmonale is defined as an alteration in the ___ and ___ of the ___ ventricle caused by a primary disorder of the respiratory system.
structure, function, right
Pulmonary hypertension is the common link between ___ and ___.
lung dysfunction, the heart in cor pulmonale
Right-sided ventricular disease caused by a primary abnormality of the ___side of the heart or ___ is not considered cor pulmonale, but cor pulmonale can develop secondary to a wide variety of cardiopulmonary disease processes.
left, congenital heart disease
In chronic cor pulmonale,___ hypertrophy ___ generally predominates.
RV, (RVH)
What condition has these causes: emphysema, pulmonary thromboembolism, interstitial lung disease, adult respiratory distress syndrome, and rheumatoid disorders are associated with what disorder
Cor Pulmonale
Chronic obstructive pulmonary disorder is the most common cause of ___.
cor pulmonale
decreased ___ wall motion
[Systolic heart failure ]
ventricular
decreased ___(0.45) leads to the increased diastolic volume in the ___ ventricle
[Systolic heart failure ]
ejection fraction, left
___ contractility
[Systolic heart failure ]
decreased
inability to___
[Systolic heart failure ]
empty
Causes:
CAD – ischemia – local dysfunction
Chronic___ or ___
overload
P___
Toxins (ETOH, cocaine)
[Systolic heart failure ]
pressure or volume,
Pericardial disease,
Toxins (ETOH, cocaine)
Systolic heart failure is also called:
[Systolic heart failure ]
heart failure with reduced ejection fraction
Chronic pressure overload – ___ and ___
[Systolic heart failure]
aortic stenosis and chronic HTN
(notes slide 5)
Chronic volume overload – ___ and ___
[Systolic heart failure]
regurgitant valvular disease and high-output cardiac failure
(notes slide 5)
All other causes (other than ___/___ cause global dysfunction)
[Systolic heart failure]
CAD/ischemia
Hallmark of chronic LV systolic dysfunction is:
___ ___ ___
[Systolic heart failure]
Decreased ejection fraction
Higher LV volume required to produce
___ ___
[Systolic heart failure]
stroke volume
Loss of ___ ___ results
in stroke volume reduction
[Systolic heart failure]
inotropic force
Decreased compliance of the ___and inability to ___ at normal pressures.
[Diastolic heart failure]
LV, fill
Increased ___in a chamber of normal size.
[Diastolic heart failure]
pressures
Impaired ___ of the LV
inability to fill.
[Diastolic heart failure]
relaxation
Causes: CAD, HTN, aortic stenosis (___hypertrophy), ____ cardiomyopathy, pericardial disease, fibrosis, diabetes, aging
[Diastolic heart failure]
concentric, hypertrophic
Seen more in ___
[Diastolic heart failure]
females
Also called:___
[Diastolic heart failure]
heart failure with preserved ejection fraction
Increased LV pressure with __ ___
[Diastolic heart failure]
diastolic filling
Decreased ___filling due to decreased compliance.
[Diastolic heart failure]
LV
Decreased stroke volume due to decreased___volume
[Diastolic heart failure]
LVED
Age:
[Systolic HF versus Diastolic HF]
Sys: 50-70
Dia: Frequently elderly
Gender:
[Systolic HF versus Diastolic HF]
Sys: Male
Dia: Female
EF:
[Systolic HF versus Diastolic HF]
Sys: Depressed EF </= 40%
Dia: Preserved >/= 40%
Left ventricle:
[Systolic HF versus Diastolic HF]
Sys: Dilated LV
Dia: Concentric hypertrophy-nl size
Cause:
[Systolic HF versus Diastolic HF]
Sys: MI
Dia: HTN, diabètes obesity, chronic lung
LV Filling
[Systolic HF versus Diastolic HF]
Sys: Decreased wall motion, preserved filling
Dia: Non-compliant LV, resistant to filling
Systolic or ___
[Forms of heart failure]
diastolic
Acute or ___
[Forms of heart failure]
chronic
___ – sudden reduction in CO, systemic hypotension, no peripheral edema.
[Forms of heart failure]
Acute
Chronic – pre-existing long-term___, ___ congestion, BP maintained
[Forms of heart failure]
cardiac disease, venous, maintained
___ or right-sided
[Forms of heart failure]
Left-sided
___-___ (normal CI, but unable to respond to stress; caused by CAD, cardiomyopathy, HTN, valvular disease, pericardial disease)
[Forms of heart failure]
Low-output
High-output (a___, pregnancy, AV fistulas, severe ___, beri-beri)
[Forms of heart failure]
anemia, hyperthyroidism
Cardiac output – resting CO may be normal, but with exertion it can’t ___ or CO may be ___.
[Hemodynamic effects of CHF]
increase, decreased
Frank-Starling –___ ___ is decreased so a lower ___ ___ is produced at any given LVEDP.
[Hemodynamic effects of CHF]
Myocardial contractility, stroke volume
Inotropic state – ___is decreased due to depletion of ___ in the heart.
[Hemodynamic effects of CHF]
contractility, catecholamines
Afterload – increased ___ – (def: tension the ___muscle must develop to open the aortic or pulmonic valve)
[Hemodynamic effects of CHF]
vasoconstriction, ventricular
Heart rate – increased to raise ___because ___ ___ is fixed or decreased; tachycardia (increased sympathetic tone).
[Hemodynamic effects of CHF]
CO,stroke volume
Sympathetic nervous system – activated causing ___ and ___constriction.
[Hemodynamic effects of CHF]
arteriolar and venous
Myocardial hypertrophy – compensation for ___ ___ overload
[Hemodynamic effects of CHF]
chronic pressure
Cardiac dilation – compensation for ___ ___to increase ___by Frank-Starling law; increases myocardial oxygen demands.
[Hemodynamic effects of CHF]
volume overloads, CO
Concentric – ___
[Hemodynamic effects of CHF]
hypertrophied, thickened muscle
Pressure overload
Eccentric – ____
[Hemodynamic effects of CHF]
dilated ventricle
Volume overload
___ cardiac output
[Pathophysiologic key elements]
Decreased
____ stroke volume
[Pathophysiologic key elements]
Decreased
___ventricular end-diastolic pressures
[Pathophysiologic key elements]
Increased
Ventricular ___ or ___
[Pathophysiologic key elements]
dilation or hypertrophy
___ BP
[Pathophysiologic key elements]
Decreased
___tissue perfusion
[Pathophysiologic key elements]
Decreased
Peripheral vaso___
[Pathophysiologic key elements]
Vasoconstriction
___ blood volume (retention of ___, ___
[Pathophysiologic key elements]
Increased, Na+, water)
Metabolic___
[Pathophysiologic key elements]
acidosis
Treatment medically: (4)
[Pathophysiologic key elements]
diuretics, angiotension-converting enzyme inhibitors, vasodilators, digitalis.
Diuretics provide ___
[Pathophysiologic key elements]
relief of circulatory congestion
ACE inhibitors – (3)
[Pathophysiologic key elements]
enalapril, captopril , ramipril
ACE inhibitors – enalapril, captopril , ramipril – improve ___ ___ and may prolong life
[Pathophysiologic key elements]
LV function
Compensatory mechanisms to maintain CO (3)
Cardiac, autonomic nervous system, humoral
Cardiac:
Frank-Starling – ___ preload to ___stroke volume (SV becomes relatively___ over time)
[Compensatory mechanisms to maintain CO]
increase, increase, fixed
Cardiac:
Ventricular ___ or ___
[Compensatory mechanisms to maintain CO]
dilation or hypertrophy
Cardiac:
___cardia
[Compensatory mechanisms to maintain CO]
Tachy
Autonomic Nervous System
Increased ____ tone – venous, arterial vasoconstriction
[Compensatory mechanisms to maintain CO]
sympathetic
Autonomic Nervous System
Decreased ___tone
[Compensatory mechanisms to maintain CO]
parasympathetic
Humoral
Renin-Angiotensin-Aldosterone system activated
___ renal perfusion – maladaptive
[Compensatory mechanisms to maintain CO]
Decreased
Humoral
___ ADH
[Compensatory mechanisms to maintain CO]
Increased
Humoral
Increased catecholamines – ___, ___, ___
[Compensatory mechanisms to maintain CO]
myocyte necrosis, remodeling, death
Humoral
___atrial natriuretic peptide, B- type natriuretic peptide – cause diuresis, vasodilation, anti-inflammation (___over time)
[Compensatory mechanisms to maintain CO]
Increased, blunted
Increased atrial natriuretic peptide, B- type natriuretic peptide – released in response to stretching of the ___ and ___ – helps blunt ___ for a while
[Compensatory mechanisms to maintain CO]
atria and ventricle, remodeling
Heart failure results in the release of biologically active signaling molecules, the so-called “___ ___” that is initially compensatory in maintaining cardiac output and blood pressure but that, over time, results in progressive
___ ___ dysfunction
[Compensatory mechanisms to maintain CO]
neurohumoral response, left ventricular
This paradigm of progressive heart failure has led to studies showing that treatment with drugs that block the activity of these biologic mediators (___ ___) ___ mortality
[Compensatory mechanisms to maintain CO]
beta blockers, reduces
This concept is further supported by extensive
data showing that mortality is ___ in heart failure patients treated with ____
[Compensatory mechanisms to maintain CO]
reduced, angiotensin-converting enzyme inhibitors
Pulmonary congestion:
Pulmonary edema
[LV HF VS RV HF]
LVHF
Jugular venous distention, edema, hepatomegaly, ascites, weight gain, ankle swelling, abdominal distention
[LV HF VS RV HF]
RVHF
Tachypnea, moist rales, resting tachycardia, S3 gallop, hypotension, diaphoresis
[LV HF VS RV HF]
LVHF
Hypoxia, fatigue, cough, rales
[LV HF VS RV HF]
LVHF
Systemic congestion
Peripheral venous HTN, peripheral edema
[LV HF VS RV HF]
RVHF
Class I: Ordinary physical activity ___ ___ cause symptoms
[NY Heart Association Classification – Based on Functional Status of Patient]
does not
Class II: Symptoms occur with ___ exertion
[NY Heart Association Classification – Based on Functional Status of Patient]
ordinary
Class III: Symptoms occur with___exertion
[NY Heart Association Classification – Based on Functional Status of Patient]
less than ordinary
Class IV: Symptoms occur___
[NY Heart Association Classification – Based on Functional Status of Patient]
at rest
Severity of___symptoms has an excellent correlation with ___ and ___.
[NY Heart Association Classification – Based on Functional Status of Patient]
HF, quality of life and survival.
Stage A: ___
[AHA classification]
High risk with no symptoms
Stage A: Risk factor reduction, ___ and ___education
[AHA classification]
patient and family
Stage A: Treat HTN, DM, dyslipidemia; ___ or ___in some patients
[AHA classification]
ACE inhibitors or ARBs
Stage B: ___heart disease, no symptoms
[AHA classification]
Structural
Stage B: Ace inhibitors or ARBs in all patients, ___ ___in selected patients
[AHA classification]
Beta blockers
Stage C: Structural disease, ___ or ___ symptoms
[AHA classification]
previous or current
Stage C: ___ and ____ in all patients
[AHA classification]
ACE inhibitors and Beta blockers
Stage C: Dietary sodium restriction, ___ and ____
[AHA classification]
diuretics and digoxin
Stage C: Cardiac resynchronization if ___ ___ ___present
[AHA classification]
bundle branch block
Stage C: ____, mitral valve surgery
[AHA classification]
Revascularization
Stage C: Consider ___ team
[AHA classification]
multidisciplinary
Stage C: Aldosterone antagonist,___
[AHA classification]
nesiritide
Stage D: ____symptoms requiring special intervention
[AHA classification]
Refractory
Stage D: Iso___
[AHA classification]
topes
Stage D: ___, transplantation
[AHA classification]
VAD
Stage D: H___
[AHA classification]
Hospice
Reversing pathophysiology of ___ ___ and stop the cycle of ___ ___ mechanisms
[CHF Treatment goals]
heart failure, poor compensatory
Short term goals:
Relieve ___
Improve___ ___
Improve quality ___ ___
[CHF Treatment goals]
congestion
tissue perfusion
of life
Long term goals:
Slowing or reversing the progression of ___ ___
[CHF Treatment goals]
ventricular remodeling
Two drug classes that have shown to decrease ventricular remodeling are ___ and ___
[CHF Treatment goals]
beta-blockers and ACE inhibitors.
ACE inhibitors: ___, ___, ___, ___.
[Treatment Systolic HF]
enalapril, captopril, lisinopril, quinapril
Beta-blockers: ___, ___, ___
[Treatment Systolic HF]
Metoprolol (Lopressor), bisopropolol (Zebeta), carvedilol (Coreg)
Aldosterone antagonist: ___, ___
[Treatment Systolic HF]
spironolactone, eplerenone
Angiotensin II receptor blockers – (all of the above can slow progression of___, reduce M &M)
[Treatment Systolic HF]
vent remodeling
Class III antiarrhythmics: ___
[Treatment Systolic HF]
amiodarone
Diuretics: ___ and ___
[Treatment Systolic HF]
thiazide and loop
Digitalis: ___
[Treatment Systolic HF]
digoxin
Vasodilators: ___, ___
[Treatment Systolic HF]
hydralazine, isorbide dinitrate
Statins – ___ and ____
[Treatment Systolic HF]
lipid lowering and anti-inflammatory effects
Di___
Vasodilators (___, ___)
Inotropic support
[Treatment of ACUTE HF]
Diuretics, NTG, SNP
Catecholamines (___, ___)
[Treatment of ACUTE HF]
dobutamine, dopamine
Phosphodiesterase-3 inhibitor (____)
[Treatment of ACUTE HF]
milrinone
Exogenous B-Type natriuretic peptide*
once response to endogenous BNP, is blunted over time, exogenous BNP causes diuresis, ___, vasodilation, ____ effect and ___ and the sympathetic nervous system.
[Treatment of ACUTE HF]
natriuresis, anti-inflammatory, inhibition of RAAS
“the presence of CHF has been described as the ___ ___ ___ risk factor for predicting perioperative cardiac morbidity and mortality”
single most important
Goal:
[CHF Anesthetic management]
optimize cardiac output
If surgery is elective, ___ to maximize patient’s condition – precipitating factors.
[CHF Anesthetic management]
postpone
Ketamine supports ___ ___
[CHF Anesthetic management]
cardiac output
Volatile agent used cautiously due to ___ effects (greater)
[CHF Anesthetic management]
depressant
Opioids as only drug is justified – depress ___ ___
[CHF Anesthetic management]
sympathetic stimulation
*Cahoon doesn’t agree with this
Consider positive pressure ventilation and ___
[CHF Anesthetic management]
PEEP
Avoid sympathetic stimulation which might cause ___
[CHF Anesthetic management]
arrhythmias
Avoid _____ if on digoxin
[CHF Anesthetic management]
hyperventilation
Careful fluid titration (____) – advanced monitoring
[CHF Anesthetic management]
euvolemic
Continue medications to day of surgery, except:
____
[CHF Anesthetic management]
Diuretics
2014 ACC/AHA Guidelines on Perioperative Cardiovascular Eval and Management of Patients undergoing Noncardiac Surgery – “continuation is reasonable”
____
____
[CHF Anesthetic management]
ACE inhibitors
Angiotensin receptor blockers
Check lytes (prone to ___ due to excess ADH), EKG, ___
[CHF Anesthetic management]
hyponatremia, Echo
Regional anesthesia
____SVR by blocking peripheral sympathetic stimulation
____ cardiac output
continuous epidurals with their___onset is the best.
[CHF Anesthetic management]
decreases, increases, slow
Acute heart failure during surgery – take to ICU for __ and __
[CHF Anesthetic management]
invasive monitoring and treatment
Post-op pain – can cause ___ which can worsen heart failure
[CHF Anesthetic management]
sympathetic stimulation
Cardiomyopathies: Progressive, life-threatening ___ ___ ___
congestive heart failure
Cardiomyopathies:
Classified as ___ and ___
primary, secondary
Cardiomyopathies:
Classified as ___, ___, and ___ cardiomyopathy with restrictive physiology
dilated, hypertrophic, and secondary
Cardiomyopathies:
Primary – confined to heart muscle mostly – ___, ___, ___.
genetic, acquired, mixed
Cardiomyopathies:
Secondary – heart involved in relationship to___ disorder
multiorgan
Most ___ type
[Dilated Cardiomyopathy]
common
Characteristics:
left or bilateral ventricular ___ (___)
[Dilated Cardiomyopathy]
dilation, (eccentric)
Characteristics:
impaired myocardial contractility –___dysfunction
[Dilated Cardiomyopathy]
systolic
Characteristics:
___cardiac output
[Dilated Cardiomyopathy]
decreased
Characteristics:
___ ventricular filling pressures
[Dilated Cardiomyopathy]
increased
Characteristics:
Ventricular ___ and ___ are common (ICD placement)
[Dilated Cardiomyopathy]
dysrhythmias, sudden death
Characteristics:
Principle indication for cardiac ____
[Dilated Cardiomyopathy]
transplantation
Etiology is unknown, may be___, or associated with ___.
[Dilated Cardiomyopathy]
genetic, infection
Many secondary cardiomyopathies are ___.
[Dilated Cardiomyopathy]
dilated
___ __ men at increased risk
[Dilated Cardiomyopathy]
African American
Initial presentation – ___ ___ – chest pain on exertion mimics ___.
[Dilated Cardiomyopathy]
heart failure, angina
Ventricular dilation may cause ____and ___ ___.
[Dilated Cardiomyopathy]
mitral, tricuspid regurg
Thrombosis formation in floppy ventricle – needs ____.
[Dilated Cardiomyopathy]
anticoagulation
Placement of ___ for arrhythmias.
[Dilated Cardiomyopathy]
ICD
___ transplant
[Dilated Cardiomyopathy]
Cardiac
Goals – avoid ___ ___, maintain ___, prevention of increased ventricular ___.
[Management of Anesthesia: DC]
cardiac depression, normovolemia, afterload
Expect slow ___times.
[Management of Anesthesia: DC]
circulation
Treat hypotension with ____ (beta); the ___stimulation with ____ could cause adverse increased afterload due to increase SVR.
[Management of Anesthesia: DC]
ephedrine, alpha, phenylephrine
Regional – acceptable due to decreases in ___ and ___; slow onset of ___ is best.
May be anticoagulated – limits ___anesthesia
[Management of Anesthesia: DC]
preload and afterload, sympathetic blockade, regional
Most commonly seen with ___
Also ____, sarcoidosis, carcinoid
[Secondary Cardiomyopathy with restrictive physiology]
amyloidosis, hemochromatosis
Characteristics
Systemic diseases that cause ___ ___ that result in increased stiffness of the myocardium.
[Secondary Cardiomyopathy with restrictive physiology]
myocardial infiltrates
Severe ___dysfunction.
[Secondary Cardiomyopathy with restrictive physiology]
diastolic
NO cardiomegaly or ___dysfunction
[Secondary Cardiomyopathy with restrictive physiology]
systolic
Atrial fibrillation is common; can have conduction system involvement (can lead to___ ___ or ___ ___)
[Secondary Cardiomyopathy with restrictive physiology]
heart block, vent dysrhythmias
Cardiac___ is NOT a treatment option – myocardial infiltrates would recur.
[Secondary Cardiomyopathy with restrictive physiology]
transplant
Prognosis is ___.
[Secondary Cardiomyopathy with restrictive physiology]
very poor
Management of anesthesia:
Maintain sinus rhythm, avoid abrupt ___ (stroke volume is ___).
[Secondary Cardiomyopathy with restrictive physiology]
bradycardia, fixed
Management of anesthesia:
Loss of ___ ___ is detrimental to ventricular filling.
[Secondary Cardiomyopathy with restrictive physiology]
atrial kick
Management of anesthesia:
Maintain venous return and___.
[Secondary Cardiomyopathy with restrictive physiology]
normovolemia
Management of anesthesia:
If anticoagulated, ____ is avoided.
[Secondary Cardiomyopathy with restrictive physiology]
regional
Characteristics:
Left ventricular outflow obstruction; due to ___interventricular septum that can lead to obstruction of outflow if the ventricle is empty or ___.
[Hypertrophic Cardiomyopathy]
hypertrophied, hypercontractile
Characteristics:
Mitral regurgitation – systolic ___movement
___ without any perceived reason (no HTN or AS).
[Hypertrophic Cardiomyopathy]
anterior, LVH
Characteristics:
Dynamic LV ___.
[Hypertrophic Cardiomyopathy]
outflow tract obstruction
Characteristics:
Diastolic _____
[Hypertrophic Cardiomyopathy]
dysfunction
Characteristics:
Myocardial ____
[Hypertrophic Cardiomyopathy]
ischemia
Characteristics:
___rhythmias
[Hypertrophic Cardiomyopathy]
Dysrhythmias
Made worse by ___therapy,
diuresis, and ___(treat CHF)
[Hypertrophic Cardiomyopathy]
inotropic, nitrates
Affects 1 in ___ adults – genetic ___ ___trait – most common cardiac
[Hypertrophic Cardiomyopathy]
500, autosomal dominant
___ ___ is first presentation in patients less than 30 years
[Hypertrophic Cardiomyopathy]
Sudden death
___ of patients with HCM (during exercise) have an abnormal response – systolic BP fails to increase ___ mm Hg or a fall in systolic BP – poorer prognosis. Either due to dynamic___obstruction or systemic ___ during exercise
[Hypertrophic Cardiomyopathy]
25%, > 20, LVOT, vasodilation
Pathphysiology:
Diastolic dysfunction
Loss of diastolic compliance and inability of the ventricle to ___.
[Hypertrophic Cardiomyopathy]
relax
Pathophysiology:
Diastolic dysfunction
Elevated___ despite hyperdynamic ventricular function.
[Hypertrophic Cardiomyopathy]
LVEDP
Pathphysiology:
Diastolic Dysfunction
___ heart sound
[Hypertrophic Cardiomyopathy]
Fourth
Obstructed LV outflow in ___of patients
[Hypertrophic Cardiomyopathy]
75%
Pathophysiology:
Obstructed LV outflow
Loud mid to late ___murmur.
[Hypertrophic Cardiomyopathy]
systolic
Pathophysiology:
Obstructed LV outflow
Obstruction worsened by enhanced contractility (low ___ ___, decreased___ ___ - stimulates the SNS).
[Hypertrophic Cardiomyopathy]
ventricular volume, LV afterload
Pathophysiology:
Mitral regurgitation in ___patients
[Hypertrophic Cardiomyopathy]
most
Pathophysiology:
Mitral Regurgitation
Movement of mitral valve leaflets restricted by ___ ___.
[Hypertrophic Cardiomyopathy]
hypertrophied septum
Pathophysiology:
EKG - LV hypertrophy, ___, supraventricular and ventricular arrhythmias, ___ ___.
[Hypertrophic Cardiomyopathy]
deep Q waves, myocardial ischemia
Factors influencing LVOT
Events that increase outflow obstruction (3):
[Hypertrophic Cardiomyopathy]
Increased myocardial contractility
Decreased preload
Decreased after load
Factors influencing LVOT
Increased myocardial contractility:
___-Adrenergic stimulation (catecholamines)
___
[Hypertrophic Cardiomyopathy]
Beta
Digitalis
Factors influencing LVOT
Decreased preload:
Hypo___
Vaso___
___cardia
Positive pressure ventilation
[Hypertrophic Cardiomyopathy]
volemia
dilators
Tachy
Factors influencing LVOT
Decreased afterload:
___tension
___dilators
[Hypertrophic Cardiomyopathy]
Hypo
Vaso
Factors influencing LVOT
Events that decrease Outflow obstruction (3):
[Hypertrophic Cardiomyopathy]
Decreased myocardial contractility
Increased preload
Increased after load
Factors influencing LVOT
Decreased myocardial contractility:
Beta-Adrenergic ___
___ anesthetics
Calcium ___
[Hypertrophic Cardiomyopathy]
blockade
Volatile
Entry Blockers
Factors influencing LVOT
Increased Preload:
___volemia
___cardia
[Hypertrophic Cardiomyopathy]
Hyper
Brady
Factors influencing LVOT
Increased afterload:
___tension
Alpha___
[Hypertrophic Cardiomyopathy]
Hyper
-adrenergic Stimulation
HC – ___ Contractility
[Anesthetic management: Hypertrophic Cardiomyopathy]
Halt
Decrease myocardial contractility (avoid ___)
[Anesthetic management: Hypertrophic Cardiomyopathy]-Drug
ketamine
Increase ___ (avoid PEEP) and ___
[Anesthetic management: Hypertrophic Cardiomyopathy]
preload, afterload
Avoid ___ (? anticholinergics)
[Anesthetic management: Hypertrophic Cardiomyopathy]
tachycardia
Treat with esmolol, ____
Anxiolytics
[Anesthetic management: Hypertrophic Cardiomyopathy]
metoprolol
[Avoid Tachycardia]
Minimize ____stimulation
[Anesthetic management: Hypertrophic Cardiomyopathy]
sympathetic
If hypotensive, use ____
[Anesthetic management: Hypertrophic Cardiomyopathy]
phenylephrine
If hypertensive, don’t use ___ or ___
[Anesthetic management: Hypertrophic Cardiomyopathy]
Nipride or NTG
Maintain __ ___ (NSR)
[Anesthetic management: Hypertrophic Cardiomyopathy]
atrial kick
If present, turn off ___ and have defib available
[Anesthetic management: Hypertrophic Cardiomyopathy]
AICD
Minimize ___ obstruction
[Anesthetic management: Hypertrophic Cardiomyopathy]
outflow
Monitoring: CVP and PA pressure monitoring will not reflect ___ ___ in these patients.
[Anesthetic management: Hypertrophic Cardiomyopathy]
LV filling
Treat hypovolemia cautiously – poor ___ compliance
[Anesthetic management: Hypertrophic Cardiomyopathy]
LV
Acute pericarditis
Most common cause – ___infection
[Pericardial Disease Acute pericarditis]
viral
Also seen r/t post MI ___, postcardiotomy, metastatic disease, ___, TB, rheumatoid arthritis
[Pericardial Disease Acute pericarditis]
syndrome, irradiation
Pathophysiology
___ ___reaction – small effusion
[Pericardial Disease Acute pericarditis]
Serofibrinous inflammatory
Pathophysiology
Usually ___-___ – rarely can lead to chronic constrictive
[Pericardial Disease Acute pericarditis]
self-limiting
Sudden onset chest pain – differentiated from ischemia-type pain by worsening with ___ and relief with postural changes, sitting or ___ ___.
[Pericardial Disease Acute pericarditis]
inspiration, leaning forward
Characteristics: fever, ___ ___ rub, ___ elevation in cardiac enzymes, diffuse ST changes in most ___ leads and two or three limb leads
[Pericardial Disease Acute pericarditis]
pericardial friction, no, precordial
Anesthetic management – unchanged – may be treating ___ illness (NSAIDs)
[Pericardial Disease Acute pericarditis]
underlying
MI Syndrome – occurs ___days following a transmural MI – interaction between the healing necrotic myocardium and the ____.
[Pericardial Disease Acute pericarditis]
1-3, pericardium
Dressler syndrome – delayed form of acute pericarditis following acute MI – can occur ___ to ___ after initial MI – thought to be an ___ initiated by the entry of bits of necrotic myocardium into the circulation (acting as antigens).
[Pericardial Disease Acute pericarditis]
weeks to months, autoimmune process
Pericardial thickening and ___
[Pericardial Disease Chronic Constrictive pericarditis]
fibrosis
__ – most common in past
[Pericardial Disease Chronic Constrictive pericarditis]
TB
Pathophysiology
Abnormal diastolic___ of both ventricles
[Pericardial Disease Chronic Constrictive pericarditis]
filling
Patho:
Filling pressures increase – ___ and ___congestion
[Pericardial Disease Chronic Constrictive pericarditis]
pulmonary and peripheral
Patho:
___ and CO may decrease
[Pericardial Disease Chronic Constrictive pericarditis]
SV
Patho:
Equilibration of ___, PCWP, ___
[Pericardial Disease Chronic Constrictive pericarditis]
PAD, RAP
___systolic function is good initially, but may atrophy over time
[Pericardial Disease Chronic Constrictive pericarditis]
LV
Diffuse low-voltage QRS, T-wave ___, ___ P-waves
[Pericardial Disease Chronic Constrictive pericarditis]
inversion, notched
Treatment – ___ – risk of dysrhythmias, bleeding (high m & m of 6-19%)
[Pericardial Disease Chronic Constrictive pericarditis]
pericardiotomy
Anesthetic Management
Plan for hemorrhage, need to go on ___.
[Pericardial Disease Chronic Constrictive pericarditis]
CPB
Anesthetic Management
Large gauge IVs, ___ line
[Pericardial Disease Chronic Constrictive pericarditis]
arterial
Anesthetic Management
Preserve myocardial contractility
SV is ___ – preserve HR – ___ needs to be avoided.
[Pericardial Disease Chronic Constrictive pericarditis]
fixed, bradycardia
Anesthetic Management
Use agents like ___, ketamine.
[Pericardial Disease Chronic Constrictive pericarditis]
pancuronium
Anesthetic Management
___ preload
[Pericardial Disease Chronic Constrictive pericarditis]
Preserve
Anesthetic Management
Be careful with positive pressure ventilation – decreased ___ ___
[Pericardial Disease Chronic Constrictive pericarditis]
venous return
Anesthetic Management
___ afterload
[Pericardial Disease Chronic Constrictive pericarditis]
Preserve
Anesthetic Management
Postop low CO may persist due to ___ of myocardium – may require ___support
[Pericardial Disease Chronic Constrictive pericarditis]
atrophy, inotropic
Medical history
Constrictive Pericarditis:
Previous pericarditis, cardiac ___, trauma, radiotherapy, ___ ___disease
Restrictive Cardiomyopathy:
___ ___ history
[Constrictive Pericarditis v. Restrictive Cardiomyopathy]
surgery, connective tissue
No such
Mitral or tricuspid regurgitation
Constrictive Pericarditis: Usually ___
Restrictive Cardiomyopathy:
Often ___
[Constrictive Pericarditis v. Restrictive Cardiomyopathy]
absent
present
Ventricular septal movement with respiration
Constrictive Pericarditis:
Movement towards left ventricle ___
Restrictive Cardiomyopathy:
___movement toward left ventricle
[Constrictive Pericarditis v. Restrictive Cardiomyopathy]
on inspiration
Little
Respiratory variation in mitral and tricuspid flow velocity
Constrictive Pericarditis:
___% in most cases
Restrictive Cardiomyopathy:
___% in most cases
[Constrictive Pericarditis v. Restrictive Cardiomyopathy]
> 25
<15
Equilibrium of diastolic pressures in all cardiac chambers
Constrictive Pericarditis:
Within ___ in nearly all cases
Restrictive Cardiomyopathy:
___ in only a small proportion of cases
[Constrictive Pericarditis v. Restrictive Cardiomyopathy]
5mm Hg
Present
Respiratory variation of ventricular peak systolic pressures
Constrictive Pericarditis:
Right and Left ventricular peak systolic pressures are ___
Restrictive Cardiomyopathy:
Right and Left ventricular peak systolic pressures are ___
[Constrictive Pericarditis v. Restrictive Cardiomyopathy]
out of phase (discordant)
in phase
MRI/CT
Constrictive Pericarditis:
___pericardial thickening in most cases
Restrictive Cardiomyopathy:
___ pericardial thickening
[Constrictive Pericarditis v. Restrictive Cardiomyopathy]
Show
Rarely show
Endomyocardial Biopsy
Constrictive Pericarditis: ___ or ___findings
Restrictive Cardiomyopathy:
___ in some cases
[Constrictive Pericarditis v. Restrictive Cardiomyopathy]
Normal or nonspecific
Amyloid present
Angina pectoris-lying down ___-due to change in outflow obstruction when ventricle has greater___
[Hypertrophic Cardiomyopathy Symptoms]
relieves, preload
F___
[Hypertrophic Cardiomyopathy Symptoms]
Fatigue
S___
[Hypertrophic Cardiomyopathy Symptoms]
Syncope
Tachydysrhythmias-dysrhythmias are cause of ___ ___ in young adults
[Hypertrophic Cardiomyopathy Symptoms]
sudden death
Heart ___
[Hypertrophic Cardiomyopathy Symptoms]
failure
Treatment goals
Improve diastolic ___
[Hypertrophic Cardiomyopathy Symptoms]
filling
Treatment goals
Reduce ___ ___obstruction
[Hypertrophic Cardiomyopathy Symptoms]
LV outflow
Treatment goals
Decrease myocardial ___
[Hypertrophic Cardiomyopathy Symptoms]
ischemia
___-the reduction of arterial blood pressure more than 10 mm Hg from exhalation to inhalation
Pulsus paradoxus
Kussmaul sign –
distention of jugular veins during inspiration
Ventricular discordance – opposing responses of the right and left ___ to filling during the ___ cycle
ventricles, respiratory
Continual increases in the ___ pressure resulting in impaired diastolic filling
[Cardiac Tamponade]
intrapericardial
Slow accumulation allows the ___ to stretch
[Cardiac Tamponade]
pericardium
Rapid accumulation can cause ___ ___
[Cardiac Tamponade]
cardiovascular collapse
Causes:
Trauma
Cardiac ___
Malignancy within ___
Expansion of ___ after pericarditis
[Cardiac Tamponade]
surgery
mediastinum
effusion
Normal intrapericardial pressure – ___
[Cardiac Tamponade]
subatmospheric
Any accumulation changes ____
Poor diastolic ___
___ in SV and CO
Peripheral ___
Poor tissue perfusion
Catecholamine ___
[Cardiac Tamponade]
pressure
filling
Decrease
congestion
release
Catecholamine release:
___cardia
Vaso___
Increased venous pressure to maintain ___
[Cardiac Tamponade]
Tachy
constriction
CO
Beck’s triad:
[Cardiac Tamponade]
hypotension, jugular venous distention, distant muffled heart sounds
Equilibration of LA, RA, and RVEDP at ___
[Cardiac Tamponade]
20 mm Hg
___ and ___ in the presence of a hemodynamically significant cardiac tamponade can result in life-threatening hypotension.
[Cardiac Tamponade-Anesthetic management]
GA and pos press ventilation
___is your drug of choice – increases contractility, SVR, and HR.
[Cardiac Tamponade-Anesthetic management]
Ketamine
In a hemodynamically unstable patient to undergo general anesthesia, some recommend prepping and draping prior to___to allow for quicker relief of tamponade.
[[Cardiac Tamponade-Anesthetic management]
induction
Often seen after release of severe tamponade, a swing from ___ to marked ___. Be prepared!
[Cardiac Tamponade-Anesthetic management]
hypotension, hypertension
Conditions in which there are pathogenic microorganisms in the ___.
[Sepsis]
bloodstream
___ from localized effect to severe generalized inflammation with ___ ___
[Sepsis]
Continuum, multi-organ failure
___plus systemic inflammatory response syndrome (SIRS)
Estimated mortality: ___%
[Sepsis]
Infection
10-25
Infection:
___ detected in blood or tissue
Estimated mortality: ___%
[Sepsis]
Pathogens
0-10
Severe sepsis:
Sepsis plus ___ ___: Lactic acidosis, Oliguria, Confusion, Hepatic dysfunction
Estimated mortality: ___%
[Sepsis]
organ dysfunction
25-50
Severe sepsis plus hypotension (systolic BP ___mmHg despite adequate fluid resuscitation)
Estimated mortality:
[Sepsis]
<90
50-80
Sepsis:
F___
___glycemia
Altered mental status
(___)
Fever
Hyper
encephalopathy
SIRS
WBC ___ or ___ or more than ___% bands
Heart rate > ___beats/min
Temp >38 or <36o C
Resp rate >20 breathes/min or PaCO2 <___ mm Hg
> 12,000 or <4000
10%
90
32
Septic Shock
Perfusion ___
Lactic acidosis
Oliguria
Hemodynamic instability
High output cardiac ___(hypotension, bounding pulse, wide pulse pressure)
abnormalities
failure
Anesthesia management
___ until treatment of sepsis with antibiotics
Postpone
Anesthesia Management
May not be able to delay as cause of sepsis is the reason for urgent surgery – “___ ___surgery” - abscess, bowel perforation, infected device
source control
Preop goals – optimize patient’s condition
MAP ___mm Hg
CVP* of____ mm Hg
___ urine output
Normal pH without lactic acidosis
MvO2 ___
Antibiotics – within ___ hour of sepsis recognition
[Sepsis-Anesthetic management]
MAP > 65
CVP 8 – 12
Adequate UOP
MvO2 > 65%
one
Intraop goals
Invasive monitoring – ___ ___
IV access – volume and blood products
Inotropic/___
[Sepsis-Anesthetic management]
poor reserve
vasopressors
