Exam III: Cardiac Anesthesia (not done yet)

Question 1

The primary testing components for cardiac testing are:

Answer 1

EKG, Chest X-Ray, echo, stress test (exercise, nuclear, stress echo), and heart catheterization.

Question 2

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.

Answer 2

pre-anesthetic notation

Question 3

____: Rate, rhythm, presence of ischemic changes, chamber enlargement, conduction blocks.

Answer 3

EKG

Question 4

____ ____: Cardiac, mediastinal, aortic silhouette, pulmonary effusion, pulmonary congestion, evidence of implantation/ previous surgical marks.

Answer 4

Chest X-Ray

Question 5

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)

Answer 5

measurements
valvular
stenosis and regurgitation

Question 6

Stress test: type of test and performance summary including:

Answer 6

ejection fraction, EKG or uptake abnormalities, failure criteria, regional perfusion distribution report,

Question 7

Heart Catheterization: Cardiac output measurement, Specific vessel findings and severity, interventions performed (previous and current). An ___ ____ is usually provided along with ____ measurements.

Answer 7

EF estimate
gradient

Question 8

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

Answer 8

the items set up will be discussed in following cards

Question 9

____ access equipment with transducer.

Answer 9

Arterial

Question 10

Central venous access equipment with ____ [facility specific as to type].

Answer 10

transducer

Question 11

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.

Answer 11

minimum
off-pump

Question 12

Temperature monitoring device. ____ and ____ temperature are most common.

Answer 12

Esophageal and bladder

Question 13

PAC if facility utilizes. [Not generally _____ due to sterility; multiple types/ facility specific]

Answer 13

opened

Question 14

Neuro monitoring. [Some facilities utilize ___/____ _____ +/- cerebral oximetry].

Answer 14

BIS/ level of consciousness

Question 15

Cardiac output monitor if facility uses. [Sometimes from ___ ___, sometimes from ____].

Answer 15

arterial line
PAC

Question 16

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. ]

Answer 16

ABGs, and electrolyte and blood counts

Question 17

Induction drugs:

Answer 17

Versed, Fentanyl, Etomidate, Anectine, NDMR, Lidocaine.

Question 18

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. **

Answer 18

Protamine
Protamine

Question 19

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.

Answer 19

pump for infusion

Question 20

Pressors: In general, a beta agonist, alpha agonist, and arterial/ venous dilator are safe infusions; for example, ____, ____, _____

Answer 20

epinephrine, neosynephrine, and nitroglycerin.

Question 21

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.

Answer 21

diluted pressors

Question 22

Pressors: One benefit is that in the event of a pump failure, medications can be ____ while the pump issue is resolved.

Answer 22

bolused

Question 23

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.

Answer 23

Neosynephrine, calcium chloride, and nitroglycerin
epinephrine, ephedrine and levophed

Question 24

Antibiotics. [facility specific as to ____ and ____ requirements]

Answer 24

agent and dosing

Question 25

_____; functioning. Sites and surgical case requirements vary with the use of esophageal, PA cath, transcutaneous, and epicardial pacing use.

Answer 25

Pacemaker

Question 26

Defibrillator with ___ ____, some facilities use external pads

Answer 26

pacing capability

Question 27

____ device

Answer 27

Doppler

Question 28

____/____ probe. [Facility specific as to availability and usage]

Answer 28

Echocardiogram/ TEE

Question 29

Banked Blood Availability if patient is a ____ ____.

Answer 29

a willing recipient

Question 30

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.

Answer 30

critical care and vascular anesthesia

Question 31

___-___ ___ are one key piece of the cardiac management realm.

Answer 31

Vaso-active drugs

Question 32

Knowledge of ___, mechanism of action, ___ ___, utility, and dosing are mandatory.

Answer 32

class side effects

Question 33

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.

Answer 33

pathology vasoactive family

Question 34

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)

Answer 34

availability, comfort level of the clinician, and side effects.

Question 35

In sum, the three components of blood pressure are:

Answer 35

heart rate, stroke volume (SV), and systemic vascular resistance (SVR).

Question 36

SV has influence by _____ and _____.

Answer 36

contractility and preload

Question 37

The greater the pre-load, the greater the SV according to ____ ____.

Answer 37

Starling’s Law

Question 38

Contractility can be broken down into ____ and ____ contractility.

Answer 38

regional and global

Question 39

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.

Answer 39

ischemic factors

Question 40

Global contractility might be evidenced by excess ___ ___, excess ____, ____, or acidosis causing the entire myocardium to be sluggish.

Answer 40

beta blocker agent hypoxia

Question 41

The obvious question is how do we know which parameter is at fault in order to initiate precisely the ___ ___?

Answer 41

correct therapy

Question 42

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.

Answer 42

TEE

Question 43

Once the causative factor is established, appropriate methods should be employed to ____ the causative factor.

Answer 43

manipulate

Question 44

This same practice should apply to all our troubleshooting processes in anesthesia and yet, we often employee the ____ or ___ ___ ____.

Answer 44

shotgun or random pattern technique

Question 45

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

Question 46

*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.

Answer 46

resistance (afterload)

Question 47

An additional family of medications that is intrinsic to cardiac surgery is the ______medications.

Answer 47

anti-coagulation

Question 48

Existing medications that may be used pre-operatively must be known and in some cases allowed time to ___ ___, while others must be ___ or ____.

Answer 48

metabolize away continued or reversed

Question 49

Additionally, intentional anti-coagulation is necessary for cardiac bypass and subsequently must be _____ post-surgery.

Answer 49

reversed

Question 50

Additionally, intentional anti-coagulation is necessary for cardiac bypass and subsequently must be _____ post-surgery.

Answer 50

reversed

Question 51

Various agents have entered and exited the market for the purpose of reducing ____ ____ and assisting in _____.

Answer 51

microvascular bleeding hemostasis

Question 52

Finally, blood products are frequently used to both replace ___ ___ and subsequent _____ associated with surgery.

Answer 52

blood lost coagulopathies

Question 53

It is considered standard to have a minimum of ___ ____ of PRBCs available and reserved for the cardiac patient.

Answer 53

2 units

Question 54

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.

Answer 54

additional blood conservation

Question 55

____ ____ & _____may be employed requiring specific equipment and coordination with blood bank teams.

Answer 55

autologous donation and hemodilution

Question 56

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.

Answer 56

cell saver machine plasma and platelets

Question 57

Finally, it is noteworthy that for each 2.5-3 liters of blood loss, ___ __ of ___ ___ are returned.

Answer 57

1 liter of red cells

Question 58

This implication becomes significant when large volumes of return are being administered as it indicates significant ___ ___ and potential for _____.

Answer 58

blood loss coagulopathy

Question 59

____ is the most common anti-coagulant used in cardiac surgery.

Answer 59

Heparin

Question 60

Its primary goal is to prevent ___ ___ in the pump that is used for the surgery.

Answer 60

clot formation

Question 61

The mechanism of action is to potentiate the action of the endogenous _________.

Answer 61

antithrombin III (ATIII)

Question 62

This action increases the inhibition of the clotting action of thrombin by _____ fold.

Answer 62

1000

Question 63

Classic dosing is _____ to achieve an activated clotting time (ACT) of >400 within ___ minutes.

Answer 63

300units/ kg 3-5

Question 64

In the event that the ACT does not respond, a ____ ____ may be considered, and additional dosing provided.

Answer 64

heparin resistance

Question 65

Subsequently, a deficiency of ATIII may be considered requiring the administration of ATIII and further ____ or administration of ___ ___ ___ followed by heparin.

Answer 65

heparin fresh frozen plasma (FFP)

Question 66

Lastly, it should be mentioned that there can be heparin reactions, though rare, such as ____ ____ _____.

Answer 66

heparin induced thrombocytopenia (HIT)

Question 67

This potentially fatal and incapacitating process may require anticoagulation by an agent ___ ___ ____ for surgery.

Answer 67

other than heparin

Question 68

In such a case, careful attention to remove heparin from the supply area should take place. This would include IV ___ ___ and arterial line ___ ___.

Answer 68

heparin flushes transducer bags

Question 69

____ is given only once cardiopulmonary bypass is completely disengaged.

Answer 69

Protamine

Question 70

Administration of protamine while ____ in ____ will almost necessarily result in catastrophic pump clotting and failure

Answer 70

bypass in progress

Question 71

___ ____ will decrease the likelihood of mild reactions though some suggest that a true anaphylactic reaction can occur no matter the dosing amount.

Answer 71

Slow administration

Question 72

Dosing classically follows the ____ of Protamine per 100units of Heparin given.

Answer 72

1mg

Question 73

This results in an electrostatic ____ &_____ of the heparin.

Answer 73

binding and inactivation

Question 74

An ____ should be evaluated and compared to the pre-heparinization level.

Answer 74

ACT

Question 75

Administration may be given by peripheral IV to reduce the severity of heparin response such as ______.

Answer 75

hypotension

Question 76

It has been suggested that an anaphylactic reaction that is going to occur to a medication will occur ____ of the dose or the route.

Answer 76

regardless

Question 77

Using this principle, some choose to deliver protamine via the ____ to insure its delivery since blood aspiration is possible.

Answer 77

CVL

Question 78

Some surgeons choose to directly inject the protamine into the ____.

Answer 78

heart

Question 79

Some facilities use a solu-set to deliver the meds while others inject as a ___ ___. This is very facility specific.

Answer 79

slow bolus

Question 80

Specifically regarding antifibrinolytic agents, there are ___ commonly used in cardiac surgery.

Answer 80

two

Question 81

________ and ______ are used often to reduce post-operative microbleeding and venous oozing.

Answer 81

Aminocaproic acid (Amicar) and Transexamic Acid (TXA)

Question 82

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.

Answer 82

after the therapeutic ACT

Question 83

Dosing and timing are specific though literature is increasingly prevalent for the use of ____ in all types of bleeding emergencies.

Answer 83

TXA

Question 84

Systemic Vascular Resistance =

Answer 84

(MAP - CVP)/ Cardiac Output x 80

Question 85

Cardiac Output =

Answer 85

Heart Rate x Stroke Volume

Question 86

Ejection Fraction =

Answer 86

EDV - ESV/ EDV x100

Question 87

Coronary Perfusion Pressure =

Answer 87

Diastolic pressure – Left Ventricular End Diastolic Pressure

Question 88

normal CVP:

Answer 88

5-10

Question 89

normal PA:

Answer 89

15-30/5-10

Question 90

normal SVR:

Answer 90

700-1600 dynes

Question 91

normal CI:

Answer 91

2-4 liters/min/m2

Question 92

Oxygen Supply and Demand- primarily collected from the ___ optional resource

Answer 92

2nd

Question 93

Undoubtedly, one of the greatest principles to understand for cardiac anesthesia is that of ____ ____ ____.

Answer 93

myocardial oxygen balance

Question 94

Because this principle is critical in ____ ____but extends to cardiac patients with ______ surgery, the following physiology portion is being included within the management section.

Answer 94

cardiac surgery non-cardiac

Question 95

Myocardial oxygen demand is a function of three principle parts;

Answer 95

wall stress, heart rate, and contractility

Question 96

Myocardial oxygen supply is a function of four principle parts;

Answer 96

coronary blood flow, oxygen content of the perfusing blood, oxyhemaglobin disassociation curve, and oxygen extraction.

Question 97

In the absence of anemia and with adequate oxygen content, the primary focus for increasing myocardial oxygen supply is ___ ___ ____

Answer 97

coronary blood flow.

Question 98

The most vulnerable section of the heart muscle is the _____ of the LV

Answer 98

subendocardium

Question 99

Notably, isolated subendocardial ischemic events do not result in the classic ___ _____ that most clinicians monitor for.

Answer 99

ST elevation

Question 100

The clinician must anticipate more subtle forms of ST/T wave changes as well as the ___ ___ ___ that presents under anesthesia.

Answer 100

entire clinical picture

Question 101

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.

Answer 101

ischemic events

Question 102

Coronary perfusion pressure (CPP) is __ ___ minus the LV end-diastolic pressure.

Answer 102

diastolic pressure

Question 103

In other words, the pressure in the coronaries minus the pressure that remains inside the ___ during ____.

Answer 103

LV rest

Question 104

Keep the heart _____ to reduce wall tension and avoid increased contractility. Judicious use of preload, use of ____, ____, and other venous capacitance tools is advocated.

Answer 104

“unloaded” nitroglycerin, morphine