Exam IV: Cong Hearts Flashcards by Linsley Lloyd

ASD (L to R)

Many types including _____ _____ _____ (____)

Patent Foramen Ovale (PFO)

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ASD (L to R)

PFOs: Usually ____ _____; usually close soon after birth. However, ____% of all adults have an asymptomatic PFO.

not treated
30

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ASD (L to R)

Usually need no specific anesthetic considerations EXCEPT ______ ______. (Why???)

bubble precautions

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VSD (L to R)

Most common CHD in children. Several types: _______ most common

perimembranous

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VSD (L to R)

restrictive (____ flow, _____ problematic), LV pressure > RV

low
less

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VSD (L to R)

Nonrestrictive (____ flow, ____ problematic), LV nearly equals RV

high
more

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VSD (L to R)

Severity and management dependent on defect ____, degree of ______, PVR (pulm) and SVR.

size
shunting

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VSD (L to R)

decreased PVR leads to increased left to right flow, increased pulm blood flow (pulm steal), and finally _____ _____

systemic hypotension

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VSD (L to R)

approx. ___% close by 1 year old

75%

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PDA (L to R)

Remnant of fetal circulation - connects pulmonary artery to _____ _____

descending aorta

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PDA (L to R)

usually closes soon ______ _____

after birth

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PDA (L to R)

Fetal: ____ to _____ to descending aorta (d/t high PVR)

RV to PA

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PDA (L to R)

after birth: RV to PA to _____ (d/t low PVR)

lungs

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PDA (L to R)

large PDAs that remain open lead to increased pulm blood flow; must be _____ ______

surgically closed (ligation via left thoracotomy)

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PDA (L to R)

intubated neonates: _____ _____?

bedside procedure?

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PDA (L to R)

pre and post ductal ____ ____?

pulse oximetry

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PDA (L to R)

only ____ ductal limb: R hand

pre

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Pre-ductal: Area near aortic opening closest to the _____ ______
Probe to ___ hand.
Blood flows to upper extremities, coronary and carotid arteries.
Pre-ductal saturation measures arterial O2 after leaving the heart but ______ it reaches the _____

ductus arteriosus.
R
BEFORE
ductus

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Post-ductal: Area near aortic opening which is distal from the _____ _____.
Probe to ____ _____ or ____ _____. (L hand pre- or post- ?)
Blood is sent to lower extremities, femoral arteries and renal arteries.
The post-ductal saturation measures arterial O2 after leaving the heart and _____ it has passed through the ductus arteriosus.
Pre-ductal SaO2 at least 3% above post-ductal = R to L ductal shunting.

ductus arteriosus
L foot or R foot
AFTER

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TOF (R to L)

most common ______ defect

cyanotic

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TOF (R to L)

4 features

RV outflow tract obstruction (RVOTO) (1)
RV hypertrophy (2)
Overriding aorta (3)
VSD (4)

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TOF (R to L)

can be ____ to _____

mild to severe

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TOF (R to L)

spasmodic narrowing (RVOTO) just below pulm valve (infundibulum) causing ______ episodes (“tet spells”)

hypercyanotic

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TOF (R to L)

chronic hypoxemia causes _____ of fingers and toes

clubbing

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TOF (R to L) AIs: optimize ____ filling

RV filling (decrease PVR, increase preload, NL SVR, avoid tachycardia)

“Tet Spells” Cyanosis (R to L shunt) dependent on _____ and ____.

RVOTO and SVR

“Tet Spells” triggers: (exact mech unknown )

- crying - feeding - acidosis - hypercarbia - catecholamines - surg stimulation

“Tet Spells” crying causes _____ narrowing (increased RVOTO) leading to increased r to l shunt through VSD and then cyanosis

infundibular

“Tet Spells” children learn to ______ to increase SVR

squat

“Tet Spells” emergent intervention: increase SVR leads to increase _____ pressure, decrease R to L shunt (decreased cyanosis)

“Tet Spells” treatment of choice

phenylephrine (1 mcg/kg) bolus, repeat until BP up and SaO2 improved. may need infusion.

“Tet Spells” ____ _____ (____) to relax infundibular spasm

Beta blocker (propranolol)

TGA (Complex, Mixed) _____ rises from the R ventricle; ____ arises from the L ventricle.

Aorta PA

TGA (Complex, Mixed) Cyanotic shunt with 2 circulations running _____ rather than in ____

parallel series

TGA (Complex, Mixed) Without a PDA or VSD, systemic circulation would have ____ _____

NO oxygenation

TGA (Complex, Mixed) 25% TGAs have a ____. If not, PDA is kept open with prostaglandins (PGE1) and/or surgical balloon septostomy done at birth.

VSD

TGA (Complex, Mixed) Definitive repair: ____ _____ procedure (2 arterial trunks transected and re-anastamosed to correct position)

Arterial “switch”

TGA (Complex, Mixed) ______ ______ must also be transected/reconnected.

Coronary arteries

TGA (Complex, Mixed) Once repaired, AIs theoretically ____ _____ than general population.

no different

HLHS (complex, mixed) 5 features

Hypoplastic L ventricle Mitral stenosis/atresia Aortic stenosis/atresia Hypoplastic aortic arch Ductal-dependent circulation

HLHS (complex, mixed) _____ used to keep PDA open until surgical repair

PGE1

HLHS (complex, mixed) Surgical goal: ____ _____ becomes systemic pump with passive pulmonary flow from ____ and _____

R ventricle SVC and IVC

HLHS (complex, mixed) 3 stages

Norwood I Norwood II (hemi-Fontan) Norwood III (Fontan)

HLHS (complex, mixed) When R ventricle begins to fail, ______ is only option.

transplantation

HLHS (complex, mixed) AIs: Maintain CO with ______, ______. (Ketamine good choice d/t CV stability.) Keep ____ near baseline (75-85%) with NL to low TVs and low PEEP to maintain venous return.

hydration, inotropes SaO2

Aortic Stenosis (Obstructive) Several variants, but primary pathophysiology: Imbalance of ____ _____/_____ (decreased coronary blood flow with increased L ventricular workload), ____/failure.

O2 supply/demand LVH

Aortic Stenosis (Obstructive) Treatment varies with _____ and _____ at diagnosis.

severity and age

Aortic Stenosis (Obstructive) Emergent ______ done for severe AS in neonates.

valvuloplasty

Aortic Stenosis (Obstructive) AIs: maintain normal _____ to maintain supply/demand balance. AVOID _______!

HR TACHYCARDIA (think about factors r/t perioperative infants and children)

Coarctation of the Aorta (Obstructive) 2 general classifications: _____: pre-ductal, require PGE1 to maintain PDA, few collaterals, poor LV function (may be in failure), large gradient in pre-stenosis SBP (R arm) and post-stenosis SBP (L leg) ______: good collaterals, better LV fxn

Neonatal > 1 year old

Coarctation of the Aorta (Obstructive) often have ____ after repair

HTN

CPB: No peds circuits available. Children prone to ______ & ______ _____ while on bypass.

hemodilution and dilutional coagulopathies Ex: Example: 3 kg, EBV: 270 mL, 350 mL priming volume = >100% dilution

CPB: Children respond well to _____. No lactate and dextrose (to minimize _____ _____).

colloids metabolic acidosis

CPB: Most centers use _____ cannulation (aorta + SVC + IVC)

bi-caval

CPB: _____ heparinization

heavy

CPB: systemic _____ as low as ____

cooling 22 C

CPB: when flow is established, aortic cross clamp, then cardioplegia, and finally ______

asystole

CPB: after repair, de-airing, _____ removed, myocardial reperfusion with slow rewarming and then correct labs

clamp

CPB: Separation: T-burg w aortic vent, TEE, treat hemodynamics and dysrhythmias, reverse heparin (______)

protamine

CPB: Post-op: Mild hypothermia, poly-pharmacy, monitor bleeding, sternum may ____ _____.

remain open

CPB: Shorter bypass times and increasing age = ____ _____

better outcomes

Pre-op Eval for Non-Cardiac Surgery

- Identify CHD and comorbidities - Prior repair/anesthesia/hospitalization history - Last CV visit/ECHO/EKG/CXR/MRI - get interpretations on chart - Discuss CV symptoms (tachypnea, dyspnea, tachycardia), feeding (FTT), exercise tolerance. - Document usual RA SaO2 and DOS SaO2. (Definitive repairs: N = >95%. Palliatives: N = 75-85%) - With aortic arch abnormalities, check upper and lower BPs. - Look for edema, clubbing, cap refill. - Auscultate for murmurs. - Labs depend on CHD (CBC, FBP, coags).

Sub-acute Bacterial Endocarditis (SBE) Prophylaxis 2007 (current) AHA Guidelines: Most post-surgical CV patients do NOT need SBE prophylaxis. Consult cardiologist and consider SBE prophylaxis for the following:

- Prosthetic valves - History of endocarditis - Unrepaired cyanotic CHD (includes palliatives) - Prosthetic devices/materials placed within last 6 months - Transplant patients with valve pathology

Sub-acute Bacterial Endocarditis (SBE) Prophylaxis Tx of choice: _____ and if allergic use ______ or ______

PCN cephalosporin or clindamycin

Perioperative Considerations Hypo_____: Must consider specific defect and identify cause.

Hypotension

Perioperative Considerations _______: Due to chronic hypoxemia. ↑ viscosity/sludging leads to decreased organ perfusion & ↑ risk of thrombotic events. Hydrate well, de-bubble all lines (consider filters), normovolemic hemodilution (?) for Hct > 65%.

Polycythemia

Perioperative Considerations Tet spells: Common during induction (stress). Uncommon with non-cardiac procedures during GA. Avoid ______, _______, _______ (maintain SVR).

hypotension, hypovolemia, vasodilation

Perioperative Considerations Heart Failure: In infants, usually d/t ventricular _____, _____, or obstructive ______.

overload, regurg lesions

Perioperative Considerations _____ _____: Chronic hypoxemia, shunting, ↓ coronary perfusion, ↑ blood viscosity

Myocardial Ischemia

Perioperative Considerations Pulmonary Hypertension: Common with _____ _____. May be fixed or reactive. “Crisis” leads to arrest (severe R to L shunting). Avoid _____ ____: Acidosis, hypercarbia, hypothermia, hypoxemia, light anesthesia, pain. With known PAH history, in-depth risk/benefit analysis is essential.

unrepaired CHD known triggers

Perioperative Considerations Paradoxical Air Embolus: Mainly with R to L shunts and increased R side pressure. ______ precautions!!!

Bubble

Perioperative Considerations Dysrhythmias: Any agent or technique can cause. Must know ____ _____ to avoid biggest risks. (Ex: Tachycardia is lethal in aortic stenosis.)

CHD pathology

Perioperative Considerations Anticoagulation (AC): Dilemma - Risk of surgical bleeding vs. risk of thrombotic event. Lack of specific guidelines. Generally: For atrial arrhythmias, ACs should be stopped ___-____ _____ pre-op. For prosthetic valves, thrombus risk is ____ if ACs stopped. Can be admitted for pre-op heparin infusion or ASA therapy substituted. ACs should be restarted ___-___ ____ post-op.

1-2 weeks high 1-3 days

Perioperative Considerations Pacemakers: Always consult with ______. Have magnet in the room to enable asynchronous pacing (if pacer malfunctions d/t interference). Back-up pacing and ______ must be available. Should be evaluated and reprogrammed post-op.

cardiologist chronotropes

Perioperative Considerations Eisenmenger Syndrome: _____ _____ vascular disease leads to shunt reversal with severe hypoxemia. Uncommon now d/t better surgical repairs early in life. ____ life expectancy; most die from _____ ____ ______. “…overall poor prognosis and extremely high risk of untoward events…” (Miller-Hance, p. 546).

Irreversible pulmonary Poor sudden ventricular dysrhythmias

Perioperative Considerations Post-transplant: Delayed compensatory responses, respond poorly to indirect meds. ↑ HR d/t loss of _____ tone. Immunosuppressants can cause drug interactions, renal, hepatic, hemodynamic problems. STRICT _____ _____!

parasympathetic ASEPTIC TECHNIQUE