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NUNA 692 Principles III > Exam IV: Cong Hearts > Flashcards

Exam IV: Cong Hearts Flashcards

1
Q

ASD (L to R)

Many types including _____ _____ _____ (____)

A

Patent Foramen Ovale (PFO)

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2
Q

ASD (L to R)

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

A

not treated
30

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3
Q

ASD (L to R)

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

A

bubble precautions

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4
Q

VSD (L to R)

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

A

perimembranous

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5
Q

VSD (L to R)

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

A

low
less

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6
Q

VSD (L to R)

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

A

high
more

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7
Q

VSD (L to R)

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

A

size
shunting

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8
Q

VSD (L to R)

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

A

systemic hypotension

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9
Q

VSD (L to R)

approx. ___% close by 1 year old

A

75%

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10
Q

PDA (L to R)

Remnant of fetal circulation - connects pulmonary artery to _____ _____

A

descending aorta

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11
Q

PDA (L to R)

usually closes soon ______ _____

A

after birth

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12
Q

PDA (L to R)

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

A

RV to PA

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13
Q

PDA (L to R)

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

A

lungs

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14
Q

PDA (L to R)

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

A

surgically closed (ligation via left thoracotomy)

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15
Q

PDA (L to R)

intubated neonates: _____ _____?

A

bedside procedure?

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16
Q

PDA (L to R)

pre and post ductal ____ ____?

A

pulse oximetry

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17
Q

PDA (L to R)

only ____ ductal limb: R hand

A

pre

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18
Q

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 _____

A

ductus arteriosus.
R
BEFORE
ductus

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19
Q

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.

A

ductus arteriosus
L foot or R foot
AFTER

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20
Q

TOF (R to L)

most common ______ defect

A

cyanotic

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21
Q

TOF (R to L)

4 features

A

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

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22
Q

TOF (R to L)

can be ____ to _____

A

mild to severe

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23
Q

TOF (R to L)

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

A

hypercyanotic

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24
Q

TOF (R to L)

chronic hypoxemia causes _____ of fingers and toes

A

clubbing

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25
Q

TOF (R to L)

AIs: optimize ____ filling

A

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

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26
Q

“Tet Spells”

Cyanosis (R to L shunt) dependent on _____ and ____.

A

RVOTO and SVR

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27
Q

“Tet Spells”

triggers: (exact mech unknown )

A
  • crying
  • feeding
  • acidosis
  • hypercarbia
  • catecholamines
  • surg stimulation
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28
Q

“Tet Spells”

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

A

infundibular

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29
Q

“Tet Spells”

children learn to ______ to increase SVR

A

squat

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30
Q

“Tet Spells”

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

A

LV

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31
Q

“Tet Spells”

treatment of choice

A

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

32
Q

“Tet Spells”

____ _____ (____) to relax infundibular spasm

A

Beta blocker (propranolol)

33
Q

TGA (Complex, Mixed)

_____ rises from the R ventricle; ____ arises from the L ventricle.

A

Aorta
PA

34
Q

TGA (Complex, Mixed)

Cyanotic shunt with 2 circulations running _____ rather than in ____

A

parallel
series

35
Q

TGA (Complex, Mixed)

Without a PDA or VSD, systemic circulation would have ____ _____

A

NO oxygenation

36
Q

TGA (Complex, Mixed)

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

A

VSD

37
Q

TGA (Complex, Mixed)

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

A

Arterial “switch”

38
Q

TGA (Complex, Mixed)

______ ______ must also be transected/reconnected.

A

Coronary arteries

39
Q

TGA (Complex, Mixed)

Once repaired, AIs theoretically ____ _____ than general population.

A

no different

40
Q

HLHS (complex, mixed)

5 features

A

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

41
Q

HLHS (complex, mixed)

_____ used to keep PDA open until surgical repair

A

PGE1

42
Q

HLHS (complex, mixed)

Surgical goal: ____ _____ becomes systemic pump with passive pulmonary flow from ____ and _____

A

R ventricle
SVC and IVC

43
Q

HLHS (complex, mixed)

3 stages

A

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

44
Q

HLHS (complex, mixed)

When R ventricle begins to fail, ______ is only option.

A

transplantation

45
Q

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.

A

hydration, inotropes
SaO2

46
Q

Aortic Stenosis (Obstructive)

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

A

O2 supply/demand
LVH

47
Q

Aortic Stenosis (Obstructive)

Treatment varies with _____ and _____ at diagnosis.

A

severity and age

48
Q

Aortic Stenosis (Obstructive)

Emergent ______ done for severe AS in neonates.

A

valvuloplasty

49
Q

Aortic Stenosis (Obstructive)

AIs: maintain normal _____ to maintain supply/demand balance. AVOID _______!

A

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

50
Q

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

A

Neonatal
> 1 year old

51
Q

Coarctation of the Aorta (Obstructive)

often have ____ after repair

A

HTN

52
Q

CPB:

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

A

hemodilution and dilutional coagulopathies

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

53
Q

CPB:

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

A

colloids
metabolic acidosis

54
Q

CPB:

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

A

bi-caval

55
Q

CPB:

_____ heparinization

A

heavy

56
Q

CPB:

systemic _____ as low as ____

A

cooling
22 C

57
Q

CPB:

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

A

asystole

58
Q

CPB:

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

A

clamp

59
Q

CPB:

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

A

protamine

60
Q

CPB:

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

A

remain open

61
Q

CPB:

Shorter bypass times and increasing age = ____ _____

A

better outcomes

62
Q

Pre-op Eval for Non-Cardiac Surgery

A
  • 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).
63
Q

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:

A
  • Prosthetic valves
  • History of endocarditis
  • Unrepaired cyanotic CHD (includes palliatives)
  • Prosthetic devices/materials placed within last 6 months
  • Transplant patients with valve pathology
64
Q

Sub-acute Bacterial Endocarditis (SBE) Prophylaxis

Tx of choice: _____ and if allergic use ______ or ______

A

PCN
cephalosporin or clindamycin

65
Q

Perioperative Considerations

Hypo_____: Must consider specific defect and identify cause.

A

Hypotension

66
Q

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%.

A

Polycythemia

67
Q

Perioperative Considerations

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

A

hypotension, hypovolemia, vasodilation

68
Q

Perioperative Considerations

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

A

overload, regurg
lesions

69
Q

Perioperative Considerations

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

A

Myocardial Ischemia

70
Q

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.

A

unrepaired CHD
known triggers

71
Q

Perioperative Considerations

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

A

Bubble

72
Q

Perioperative Considerations

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

A

CHD pathology

73
Q

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.

A

1-2 weeks
high
1-3 days

74
Q

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.

A

cardiologist
chronotropes

75
Q

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).

A

Irreversible pulmonary
Poor
sudden ventricular dysrhythmias

76
Q

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 _____ _____!

A

parasympathetic
ASEPTIC TECHNIQUE

NUNA 692 Principles III (20 decks)

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