Exam III: Cardiac Anesthesia (not done yet) Flashcards
The primary testing components for cardiac testing are:
EKG, Chest X-Ray, echo, stress test (exercise, nuclear, stress echo), and heart catheterization.
While other testing often accompanies these modalities, the actual ordering and interpreting of testing falls outside of the scope of this presentation. For each of the tests, _____ ______ should be included to as much detail as possible.
pre-anesthetic notation
____: Rate, rhythm, presence of ischemic changes, chamber enlargement, conduction blocks.
EKG
____ ____: Cardiac, mediastinal, aortic silhouette, pulmonary effusion, pulmonary congestion, evidence of implantation/ previous surgical marks.
Chest X-Ray
ECHO: Anatomic ____ and calculated values (pertinent positives), ____ performance with particular attention to presence of ____ and ____ of the 4 valves, systolic function (graded EF and presence of any RWMA), presence of effusions, air, thrombus, vegetation, or anatomical abnormalities (PFO/ ASD etc)
measurements
valvular
stenosis and regurgitation
Stress test: type of test and performance summary including:
ejection fraction, EKG or uptake abnormalities, failure criteria, regional perfusion distribution report,
Heart Catheterization: Cardiac output measurement, Specific vessel findings and severity, interventions performed (previous and current). An ___ ____ is usually provided along with ____ measurements.
EF estimate
gradient
At minimum, the following items should be setup for a cardiac case. [This is understood that noninvasive monitoring and monitoring from the standards of anesthesia monitoring for general anesthesia checklist are already in place.]
For a refresher on what basic monitoring is required, the American Society of Anesthesiologists document can be found here:
http://www.asahq.org/quality-and-practice-management/standards-and-guidelines
the items set up will be discussed in following cards
____ access equipment with transducer.
Arterial
Central venous access equipment with ____ [facility specific as to type].
transducer
Warming devices. Fluid warmer at ____. Some facilities utilize forced air warmers. This is even more important for _____ procedures where the inability to warm is noticed.
minimum
off-pump
Temperature monitoring device. ____ and ____ temperature are most common.
Esophageal and bladder
PAC if facility utilizes. [Not generally _____ due to sterility; multiple types/ facility specific]
opened
Neuro monitoring. [Some facilities utilize ___/____ _____ +/- cerebral oximetry].
BIS/ level of consciousness
Cardiac output monitor if facility uses. [Sometimes from ___ ___, sometimes from ____].
arterial line
PAC
Lab testing device. [very facility specific, some hospitals have in OR labs, iStat device, or TEG, the ability to monitor ACT, the ability to follow (3 things) are critical. ]
ABGs, and electrolyte and blood counts
Induction drugs:
Versed, Fentanyl, Etomidate, Anectine, NDMR, Lidocaine.
Heparin. (generally 30ml of 1000u/ml concentration is accepted.
** It is strongly advised to never open, draw up, remove from cart, or prepare _____ as an inadvertent administration is catastrophic and almost certainly fatal. _____ is never an emergent medication that needs to be prepared in advance. **
Protamine
Protamine
Pressors:
This is very facility specific. Some facilities will require various agents to be placed into a ___ for ____. Which drugs are to be loaded is also very facility specific.
pump for infusion
Pressors: In general, a beta agonist, alpha agonist, and arterial/ venous dilator are safe infusions; for example, ____, ____, _____
epinephrine, neosynephrine, and nitroglycerin.
Pressors: Regardless of which agents are placed in an infusion pump, it both prudent and expected to have syringes of ___ ____ immediately available throughout the case.
diluted pressors
Pressors: One benefit is that in the event of a pump failure, medications can be ____ while the pump issue is resolved.
bolused
Pressors: Additionally, in the event of an IV/CVL failure where medications are being transfused, boluses may given by different route while access is re-acquired. At minimum, these pressors should include: (3). Some facilities add (3) to this list.
Neosynephrine, calcium chloride, and nitroglycerin
epinephrine, ephedrine and levophed
Antibiotics. [facility specific as to ____ and ____ requirements]
agent and dosing
_____; functioning. Sites and surgical case requirements vary with the use of esophageal, PA cath, transcutaneous, and epicardial pacing use.
Pacemaker
Defibrillator with ___ ____, some facilities use external pads
pacing capability
____ device
Doppler
____/____ probe. [Facility specific as to availability and usage]
Echocardiogram/ TEE
Banked Blood Availability if patient is a ____ ____.
a willing recipient
There are numerous drugs that come time mind in the cardiac anesthesia setting. Most are not uncommon to other areas of ___ ___ and ___ ____, yet are routinely used and must be mastered for the cardiac patient.
critical care and vascular anesthesia
___-___ ___ are one key piece of the cardiac management realm.
Vaso-active drugs
Knowledge of ___, mechanism of action, ___ ___, utility, and dosing are mandatory.
class
side effects
Selection of the right drug to achieve a specific outcome is intuitively the goal, yet in practice, many clinicians fail to choose the best drug to address a particular problem; sometimes due to lack of familiarity with the _____ and sometimes due to lack of familiarity with the ______of medications.
pathology
vasoactive family
For practicality, the following chart is used to apply the mechanism of action to a problem as evidenced by monitored parameters. The choice of agent to use then comes commonly from: (3)
availability, comfort level of the clinician, and side effects.
In sum, the three components of blood pressure are:
heart rate, stroke volume (SV), and systemic vascular resistance (SVR).
SV has influence by _____ and _____.
contractility and preload
The greater the pre-load, the greater the SV according to ____ ____.
Starling’s Law
Contractility can be broken down into ____ and ____ contractility.
regional and global
Regional pumping is influenced by ___ ____ such as poor blood flow from the LAD to the anterior wall of the heart causing poor pumping of the anterior wall.
ischemic factors
Global contractility might be evidenced by excess ___ ___, excess ____, ____, or acidosis causing the entire myocardium to be sluggish.
beta blocker
agent
hypoxia
The obvious question is how do we know which parameter is at fault in order to initiate precisely the ___ ___?
correct therapy
The ___ is probably the single best answer as we are able to determine all the components of the SV end of the equation where no other device is able to do so.
TEE
Once the causative factor is established, appropriate methods should be employed to ____ the causative factor.
manipulate
This same practice should apply to all our troubleshooting processes in anesthesia and yet, we often employee the ____ or ___ ___ ____.
shotgun or random pattern technique
There are various methods to deciding which vasopressor to use once a particular issue has been identified. Hospital and clinical preference, availability, and cost are a few influencing factors. M & M table 22-3 list common vasopressors, their action, and their recommended dosing range. (3rd reading list reference).
This textbook is available on Access Anesthesiology on the Samford Library website
*One reason the SV may be high in these cases of low SVR is that such little ____ may cause the heart to eject slightly more than normal.
resistance (afterload)
An additional family of medications that is intrinsic to cardiac surgery is the ______medications.
anti-coagulation
Existing medications that may be used pre-operatively must be known and in some cases allowed time to ___ ___, while others must be ___ or ____.
metabolize away
continued or reversed
Additionally, intentional anti-coagulation is necessary for cardiac bypass and subsequently must be _____ post-surgery.
reversed
Additionally, intentional anti-coagulation is necessary for cardiac bypass and subsequently must be _____ post-surgery.
reversed
Various agents have entered and exited the market for the purpose of reducing ____ ____ and assisting in _____.
microvascular bleeding
hemostasis
Finally, blood products are frequently used to both replace ___ ___ and subsequent _____ associated with surgery.
blood lost
coagulopathies
It is considered standard to have a minimum of ___ ____ of PRBCs available and reserved for the cardiac patient.
2 units
While is imperative to have suction connected to both the venous reservoir of the bypass machine and the cell saver, ____ ____ _____ strategies may be employed which extend beyond the scope of this presentation.
additional blood conservation
____ ____ & _____may be employed requiring specific equipment and coordination with blood bank teams.
autologous donation and hemodilution
Of note, the ___ ___ ___ classically collects, filters, and returns the red cells lost to the suction. Though hemoconcentration and increased hematocrits may be achieved, in the presence of significant blood loss, ____ & ____ may be required to supplement coagulation.
cell saver machine
plasma and platelets
Finally, it is noteworthy that for each 2.5-3 liters of blood loss, ___ __ of ___ ___ are returned.
1 liter of red cells
This implication becomes significant when large volumes of return are being administered as it indicates significant ___ ___ and potential for _____.
blood loss
coagulopathy
____ is the most common anti-coagulant used in cardiac surgery.
Heparin
Its primary goal is to prevent ___ ___ in the pump that is used for the surgery.
clot formation
The mechanism of action is to potentiate the action of the endogenous _________.
antithrombin III (ATIII)
This action increases the inhibition of the clotting action of thrombin by _____ fold.
1000
Classic dosing is _____ to achieve an activated clotting time (ACT) of >400 within ___ minutes.
300units/ kg
3-5
In the event that the ACT does not respond, a ____ ____ may be considered, and additional dosing provided.
heparin resistance
Subsequently, a deficiency of ATIII may be considered requiring the administration of ATIII and further ____ or administration of ___ ___ ___ followed by heparin.
heparin
fresh frozen plasma (FFP)
Lastly, it should be mentioned that there can be heparin reactions, though rare, such as ____ ____ _____.
heparin induced thrombocytopenia (HIT)
This potentially fatal and incapacitating process may require anticoagulation by an agent ___ ___ ____ for surgery.
other than heparin
In such a case, careful attention to remove heparin from the supply area should take place. This would include IV ___ ___ and arterial line ___ ___.
heparin flushes
transducer bags
____ is given only once cardiopulmonary bypass is completely disengaged.
Protamine
Administration of protamine while ____ in ____ will almost necessarily result in catastrophic pump clotting and failure
bypass in progress
___ ____ will decrease the likelihood of mild reactions though some suggest that a true anaphylactic reaction can occur no matter the dosing amount.
Slow administration
Dosing classically follows the ____ of Protamine per 100units of Heparin given.
1mg
This results in an electrostatic ____ &_____ of the heparin.
binding and inactivation
An ____ should be evaluated and compared to the pre-heparinization level.
ACT
Administration may be given by peripheral IV to reduce the severity of heparin response such as ______.
hypotension
It has been suggested that an anaphylactic reaction that is going to occur to a medication will occur ____ of the dose or the route.
regardless
Using this principle, some choose to deliver protamine via the ____ to insure its delivery since blood aspiration is possible.
CVL
Some surgeons choose to directly inject the protamine into the ____.
heart
Some facilities use a solu-set to deliver the meds while others inject as a ___ ___. This is very facility specific.
slow bolus
Specifically regarding antifibrinolytic agents, there are ___ commonly used in cardiac surgery.
two
________ and ______ are used often to reduce post-operative microbleeding and venous oozing.
Aminocaproic acid (Amicar) and Transexamic Acid (TXA)
Though they do not affect the ACT, some clinicians do not advise the use of the agents until ____ the ____ ____ has been achieved to avoid heparin interference for bypass.
after the therapeutic ACT
Dosing and timing are specific though literature is increasingly prevalent for the use of ____ in all types of bleeding emergencies.
TXA
Systemic Vascular Resistance =
(MAP - CVP)/ Cardiac Output x 80
Cardiac Output =
Heart Rate x Stroke Volume
Ejection Fraction =
EDV - ESV/ EDV x100
Coronary Perfusion Pressure =
Diastolic pressure – Left Ventricular End Diastolic Pressure
normal CVP:
5-10
normal PA:
15-30/5-10
normal SVR:
700-1600 dynes
normal CI:
2-4 liters/min/m2
Oxygen Supply and Demand- primarily collected from the ___ optional resource
2nd
Undoubtedly, one of the greatest principles to understand for cardiac anesthesia is that of ____ ____ ____.
myocardial oxygen balance
Because this principle is critical in ____ ____but extends to cardiac patients with ______ surgery, the following physiology portion is being included within the management section.
cardiac surgery
non-cardiac
Myocardial oxygen demand is a function of three principle parts;
wall stress, heart rate, and contractility
Myocardial oxygen supply is a function of four principle parts;
coronary blood flow, oxygen content of the perfusing blood, oxyhemaglobin disassociation curve, and oxygen extraction.
In the absence of anemia and with adequate oxygen content, the primary focus for increasing myocardial oxygen supply is ___ ___ ____
coronary blood flow.
The most vulnerable section of the heart muscle is the _____ of the LV
subendocardium
Notably, isolated subendocardial ischemic events do not result in the classic ___ _____ that most clinicians monitor for.
ST elevation
The clinician must anticipate more subtle forms of ST/T wave changes as well as the ___ ___ ___ that presents under anesthesia.
entire clinical picture
These are in fact ___ ____ and can result in tissue death thus calling into the question the teaching of some that only ST elevation changes are critical or legitimate screening tools for infarction.
ischemic events
Coronary perfusion pressure (CPP) is __ ___ minus the LV end-diastolic pressure.
diastolic pressure
In other words, the pressure in the coronaries minus the pressure that remains inside the ___ during ____.
LV
rest
Keep the heart _____ to reduce wall tension and avoid increased contractility. Judicious use of preload, use of ____, ____, and other venous capacitance tools is advocated.
“unloaded”
nitroglycerin, morphine
