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NUNA 692 Principles III > Exam III: Vascular Anesthesia > Flashcards

Exam III: Vascular Anesthesia Flashcards

1
Q

Atherosclerosis is the primary process leading to…

A

CAD, stroke, extremity ischemia, and aneurysms

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2
Q

presumed progression of atherosclerosis

A

fatty streaks to fibrous plaques to complicated lesions

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3
Q

atherosclerosis - common formation in:

A

coronary arteries, carotid bifurcation, infrarenal abdominal aorta, iliac arteries, superficial femoral artery

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4
Q

Although atherosclerosis is a slow, gradual process, the reason for the ultimate injury is:
_____ ____ reducing blood flow
_____ of plaque-associated platelet thrombi or debris
Complete _____ of ______ by advanced plaques.

A

Plaque enlargement
Embolism
occlusion of arteries

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5
Q

risk factors for atherosclerosis

A

hyperlipidemia
smoking (8x)
diabetes
HTN (60%)
family history
male
advanced age
insulin resistance
physical inactivity
elevated c-reactive protein
elevated lipoprotein

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6
Q

arteriosclerosis (pathologic)
_____abdominal aorta
_____abdominal aorta
_____ _____ aorta

A

infrarenal abdominal aorta
thoracoabdominal aorta
descending thoracic aorta

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7
Q

____ ____ ____ - degeneration of the aortic media (ascending aorta)

A

cystic medial necrosis

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8
Q

aortic aneurysm mortality rates
- elective repair
- ruptured
- untreated

A
  • elective repair: 1-11%
  • ruptured: 75%
  • untreated: 5-year 81%, 10-year 100%
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9
Q

Due to the relatively low mortality rate with elective AAA repair, surgery is recommended for any one with greater than ____ cm in diameter aneurysm.

A

5.0 cm

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10
Q

Aneurysms greater than __ to __ cm in diameter require surgery.

A

4 to 5

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11
Q

AAA grow approximately ___ ____.

A

4 mm/year

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12
Q

Law of Laplace

A

As the radius of the vessel increases, the wall tension increases. The bigger the aneurysm, the higher risk of rupture.

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13
Q

Law of Laplace
formula

A

T = P x r

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14
Q

25-41% of aneurysms larger than 5 cm rupture spontaneously within __ ____.

A

5 years

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15
Q

DeBakey type I – originates in the ____ ____ aorta and usually involves the ascending aorta, arch and can go to abdominal aorta

A

proximal ascending

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16
Q

DeBakey type II - confined to the ____ ____

A

ascending aorta

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17
Q

DeBakey type III - (a) - confined to the _____ ____ aorta

A

descending thoracic

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18
Q

DeBakey type III - (b) - may extend into the _____ aorta and ____ arteries

A

abdominal
iliac

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19
Q

Stanford classification:
Type A: the ascending aorta is involved, ____ or _____ the _____ or the descending aorta.

A

with or without the arch

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20
Q

Stanford classification:
Type B: the descending thoracic aorta is involved, with or without ____ or _____ extension.

A

proximal or distal

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21
Q

Aneurysms occur most commonly:
Ascending thoracic aorta close to the ____ _____
Descending thoracic aorta just distal to the ____ ______ _____.

A

aortic valve
left subclavian artery

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22
Q

Myocardial infarction, respiratory failure, renal failure, and stroke are the major causes of _____ and _____

A

morbidity and mortality.

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23
Q

Co-existing diseases should be evaluated, optimized, and recorded _______. (See Box 28.4 Nagelhout)

A

preanesthesia

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24
Q

CAD – _____ ______ are responsible for 40-70% of all fatalities occurring after AAA repair.
50% of patients for AAA reconstruction have CAD

A

Myocardial infarctions

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25
Q

The greater number of _______ that exist, the greater the risk of morbidity and mortality during the perioperative period.

A

comorbidities

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26
Q

____ ____ ____ is common during the perioperative period; this is associated with a high risk for cardiovascular-specific mortality comparable to that seen with chronic kidney disease.

A

Acute kidney injury (AKI)

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27
Q

Aortic Cross- Clamping

Hemodynamic effects depend on the ____ of the clamp, the patient’s pre-op ____ ____, and the patient’s intravascular _____.

A

site
cardiac reserve
volume

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28
Q

Aortic Cross- Clamping

With X-clamping, hypertension occurs _____ the X-clamp and hypotension occurs _____.

A

above
below

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29
Q

Aortic Cross- Clamping

systems involved

A

Hemodynamic
Myocardial
Pulmonary
Renal
Spinal cord
Hormonal / Metabolic

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30
Q

Aortic Cross- Clamping

Hemodynamic/cardiac Effects of X-clamp
afterload?
MAP and SVR?
HR?
CO?
LVEDP?

A

Afterload increases – myocardial wall tension increases.
Mean arterial pressure and SVR increase.
Heart rate unchanged
Cardiac output may decrease or remain unchanged.
LVEDP may increase or show no change.

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31
Q

Aortic Cross- Clamping

Patients with poor cardiac reserve may have decreased ____ ____ and _____ _____. They will have an increase in LVEDP.

A

ventricular function and myocardial ischemia

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32
Q

LVEDP, CVP and PCWP may ______ due to vasoconstriction of venous vasculature distal to the x-clamp – increasing preload

A

increase

33
Q

The effects of the X-clamp are altered depending on the _____ of the occlusion.

A

location

34
Q

The longer the duration of the X-clamping, the greater the increase in ____ and decrease of ____

A

SVR
CO

35
Q

Pulmonary damage related to:
______ pulmonary vascular resistance (more at unclamping)
Increased capillary membrane _______
Development of ______ _____

A

Increased
permeability
pulmonary edema

36
Q

potential causes of pulm damage:

A

hypervolemia
prostaglandins, oxygen free radicals, activation of RAAS, complement cascade

37
Q

prostaglandins cause ________

A

bronchoconstriction

38
Q

Renal Effects of X-clamp

Renal blood flow is _____ 40% and renal vascular resistance ______ 75% when the X-clamp was placed infrarenally.

A

decreased
increased

39
Q

Renal Effects of X-clamp

______ & ______ cross-clamping can decrease renal blood flow by as much as 80%.

A

Suprarenal and juxtarenal

40
Q

Renal Effects of X-clamp

Renal failure post aortic surgery is usually acute tubular necrosis r/t ____-____ injury.

A

ischemic-reperfusion

41
Q

_____ occurs in as many as 18% of patients undergoing aortic aneurysm repair.

A

AKI

42
Q

____ _____ damage is associated with aortic X-clamping.

A

Spinal cord

43
Q

Specifically, the ____ of _____ is occluded with no collateral flow to the anterior portion which is motor.

A

artery of Adamkiewicz

44
Q

The more proximal the X-clamp, the greater the risk for ______.

A

paraplegia

45
Q

Somatosensory Evoked Potential – SSEP – does not provide information about the _____ spinal cord.

A

anterior

46
Q

Anterior Spinal Syndrome

the higher the cross clamping the greater the chance of ____ ____ ____

A

spinal cord ischemia

Elective infrarenal 0.2%, Ruptures of the descending aorta 40%

47
Q

Anterior Spinal Syndrome

Main blood supply to anterior cord is from the artery of Adamkiewicz; origin ____ ____-____

A

unknown (T5-L2)

48
Q

Anterior Spinal Syndrome

spinal cord perfusion =

A

MAP - CSF pressure

49
Q

Anterior Spinal Syndrome

drainage of CSF has allowed the ____ ____ of ischemia, limited x-clamp time of 30 mins

A

best avoidance

50
Q

Anterior Spinal Syndrome

artery of adamkiewicz nearly always comes from ____ side

A

left

51
Q

anterior spinal preventative measures

A

Shunt from the left atrium to the common femoral artery
Maintenance of hypertension during X-clamp (post-op*)
Methylprednisolone
Moderate hypothermia (30-32 degrees C)
Avoiding hyperglycemia
Mannitol – lowers CSF pressure by decreasing production
Drainage of CSF

52
Q

anterior spine syndrome

Nipride decreases pressure proximal to the clamp, BUT also _____ to the _____. This may contribute to the increased risk of spinal cord ischemia.

A

distal to the clamp

53
Q

anterior spinal syndrome

classic s&s: loss of what and preservation of what

A

Loss of motor function and pinprick sensation
Preservation of vibration and proprioception (posterior)

54
Q

*Maintain ____tension (systolic > ______) through the second postoperative day decreased the incidence of paraplegia during thoracic aortic reconstruction

anterior spinal syndrome

A

normo
120 mm Hg

55
Q

Metabolic/Hormonal Effects of X-clamping

Tissues distal to the clamp are hypoxic causing metabolites such as _____ to accumulate.

A

lactate (metabolic acidosis)

56
Q

Metabolic/Hormonal Effects of X-clamping

Decreased _____ consumption due to the portion of tissues not being perfused.

A

oxygen

57
Q

Metabolic/Hormonal Effects of X-clamping

Decreased total body oxygen extraction; Increased ____ ____ ____ saturation

A

mixed venous oxygen

58
Q

Metabolic/Hormonal Effects of X-clamping

Increased levels of ______ circulating during X-clamp time (decreased renal blood flow)

A

catecholamines

59
Q

Metabolic/Hormonal Effects of X-clamping

Respiratory _____ (decreased ____ production)

A

alkalosis
CO2

60
Q

Intraoperative Interventions during AoX-clamping

reduce afterload:

A
  • nipride
  • inhalation agents
  • milrinone
  • shunt: aorta to femoral bypass
61
Q

Intraoperative Interventions during AoX-clamping

reduce preload:

A
  • NTG
  • atrial to femoral bypass
62
Q

Intraoperative Interventions during AoX-clamping

renal protection:

A
  • fluid
  • renal cold perfusion
  • pharmacologic
63
Q

Intraoperative Interventions during AoX-clamping

_____thermia, decrease ______ ventilation, ______

A

hypo
minute ventilation
NaBicarb

64
Q

Release of Aortic X-clamp

Metabolites such as lactate are circulated which cause _____, increased _____, hypotension.

A

vasodilation
ETCO2

65
Q

Release of Aortic X-clamp

afterload and SVR _____

A

decrease

66
Q

Release of Aortic X-clamp

MAP

A

decreases

67
Q

Release of Aortic X-clamp

preload

A

decreases

68
Q

Release of Aortic X-clamp

CO _____ or no change or _____

A

increases
decreases

69
Q

Release of Aortic X-clamp

wedge

A

decreases

70
Q

Release of Aortic X-clamp

EtCO2 _____ and pH ______

A

increases
decreases
(metabolic acidosis)

71
Q

Release of Aortic X-clamp

temperature

A

decreases

72
Q

Unclamping Hypotension

Blood shifting to _____ – in reperfused tissue

A

periphery

73
Q

Unclamping Hypotension

Hypoxia-related _____ in vessels below the level of the X-clamp

A

vasodilation

74
Q

Unclamping Hypotension

Release of _____ & ______ ______metabolites in the reperfused tissues
Increased lactate, prostaglandins, activated complement, metabolic acidosis
Increased myocardial depressant factors

A

vasoactive and myocardial depressant

75
Q

To minimize the effects of the X-clamp release

Intravascular _____ must be maintained or restored.

A

volume

76
Q

To minimize the effects of the X-clamp release

Replace ____ loss

A

blood

77
Q

To minimize the effects of the X-clamp release

To prevent hypotension and decreased cardiac output with release of X-clamp, the PCWP should be raised ___ to ___ ____ above pre-clamp values just prior to release.

A

3 to 4 mm Hg

78
Q

To minimize the effects of the X-clamp release

The lower the sight of clamping, the ____ ____ the changes.

A

less drastic

79
Q

To minimize the effects of the X-clamp release

The clamp can be released _____

A

gradually.

NUNA 692 Principles III (20 decks)

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