Final Exam Review

Question 1

High risk (>5% morbidity) surgeries for patients with preexisting CV disease: ___ surgery; major ___ surgery; ___ vascular surgery

Answer 1

Aortic surgery; major vascular surgery; peripheral vascular surgery

These surgeries have higher rates of morbidity just based on the procedure alone (not even considering additional patient factors)

Question 2

___ risk surgeries: intraperitoneal; transplant; carotid; peripheral artery angioplasty; endovascular aneurysm repair (open AAA repair would be HIGH risk); head/neck surgery; major neurologic/orthopedic surgery—i.e.: multi-level fusion surgery, hip repair; intrathoracic—i.e.: lung surgery; major urologic—i.e.: prostatectomy, nephrectomy

Answer 2

Intermediate risk (1-5% morbidity)

Question 3

___ risk surgeries: breast; dental; endoscopic; superficial; endocrine; cataract; gynecological; reconstructive; minor orthopedic; minor urologic

Answer 3

Low risk (< 1% morbidity)

Question 4

METs = ___, how we measure a patient’s ___ capacity

Answer 4

Metabolic equivalents, how we measure a patient’s functional capacity

Question 5

Gold standard of evaluating a patient’s functional capacity (main question we ask patients when doing our pre-op assessment?)

Answer 5

“Are you able to climb two flights of stairs without stopping, regardless of limiting symptoms?”

Question 6

Inability of patients to climb two flights of stairs without stopping, regardless of limiting symptoms, leads to a ___% increase in risk for cardiopulmonary complications postoperatively

Answer 6

82% increase in risk

Question 7

1 MET = ___ functional capacity

Answer 7

Poor

Examples = self-care, eating, dressing, using the toilet, walking indoors/around the house, walking 1-2 blocks on level ground at 2-3 mph

Question 8

4 METs = ___ functional capacity

Answer 8

Good

Examples = light housework; climbing a flight of stairs without stopping, or walking up a hill longer than 1 to 2 blocks; walking on level ground at 4 mph; running a short distance; golf; dancing; throwing a baseball

Question 9

Greater than 10 METs = ___ functional capacity

Answer 9

Excellent

Example = strenuous sports

Question 10

8 clinical risk factors for CV surgery: poor ___ (right/left) ventricular function; ___ heart failure; ___ angina or MI within the past ___ months; age > ___; severe ___ity; reoperation (i.e.: redo CABG); ___ surgery; severe uncontrolled ___ illness (i.e.: COPD or diabetes + noncompliance)

Answer 10

Poor LV function; congestive heart failure; unstable angina or MI within the past 6 months; age > 65; severe obesity; reoperation (i.e.: redo CABG); emergency surgery; severe uncontrolled systemic illness (i.e.: COPD or diabetes + noncompliance)

Question 11

___ = highest risk factor for perioperative MI

Answer 11

Unstable angina—chest pain that doesn’t go away with nitroglycerin or by stopping activity; unpredictable

Question 12

Patient with history of MI—MI in the past > ___ months increase periop risk of infarction 6%

Answer 12

> 6 months

Question 13

Patient with history of MI—MI in the past ___-___ months increase periop risk of infarction 15%

Answer 13

3-6 months

Question 14

Patient with history of MI—MI in the past ___ months increase periop risk of infarction 30%

Answer 14

3 months

Question 15

Patient with history of MI—highest at risk period for perioperative infarction is within ___ days after an acute MI

Answer 15

30 days

Question 16

Patient with history of MI—AHA guidelines recommend waiting at least ___-___ weeks after an MI before undergoing elective surgery

Answer 16

4-6 weeks

Question 17

Elective non-cardiac surgery should NOT be scheduled within ___ weeks after bare metal stent placement

Answer 17

6 weeks

Question 18

Elective non-cardiac surgery should NOT be scheduled within ___ months after drug eluting stent placement

Answer 18

12 months

Question 19

Which valvular disorder poses the greatest patient risk for non-cardiac surgery?

Answer 19

Severe aortic stenosis

Question 20

Aortic stenosis is the greatest risk for non-cardiac surgery, especially when the cross sectional area of the valve is less than ___ cm ^ 2

Answer 20

< 1 cm ^ 2–indicates severe aortic stenosis

Question 21

Electromagnetic interference risk is low as long as cautery is > ___ cm away from the pacemaker device (~ distance from pacemaker to ___)

Answer 21

> 15 cm away from the pacemaker device (~distance from pacemaker to belly button)

Typically do not need to disable the AICD in these cases because the chance of interference is so low

Question 22

This class of medications enhances endothelial function; improves atherosclerotic plaque stability; and reduces vascular inflammation

Answer 22

Statins

Question 23

Statin therapy should be continued perioperatively—T/F?

Answer 23

True

Question 24

This medication class restores oxygen supply/demand mismatch; reduces perioperative ischemia; redistributes coronary blood flow to subendocardium; stabilizes plaques; increases V Fib threshold

Answer 24

Beta blockers

Question 25

If patient is on beta blocker, it should be given within ___ hours of surgery

Answer 25

24 hours

Question 26

ACE inhibitors have a ___ (shorter/longer) half-life than beta blockers

Answer 26

Longer half-life

Question 27

Hold ACE inhibitors ___-___ days prior to surgery d/t extreme refractory ___tension that occurs when combined with volatile anesthetics

Answer 27

1-2 days prior to surgery d/t extreme refractory hypotension that occurs when combined with volatile anesthetics

Question 28

Arterial catheter waveform—dicrotic notch = closure of the ___ valve

Answer 28

Aortic valve

Question 29

Overdamped arterial line waveform = falsely ___estimates systolic BP and ___estimates diastolic BP

Answer 29

Falsely underestimates systolic BP and overestimates diastolic BP

Question 30

Underdamped arterial line waveform = falsely ___estimates systolic BP and ___estimates diastolic BP

Answer 30

Falsely overestimates systolic BP and underestimates diastolic BP

Question 31

___ test is performed to assess level of damping/accuracy of BP reading based on the amount of ___

Answer 31

Square wave test is performed to assess level of damping based on the amount of ringing (number of oscillations after the square wave)

Question 32

Square wave test—optimally damped = ___-___ oscillations

Answer 32

1-2 oscillations

Question 33

Square wave test—overdamped = ___ oscillations

Answer 33

< 1 oscillations

Question 34

Square wave test—underdamped = ___ oscillations

Answer 34

> 2 oscillations

Question 35

___damped waveform = bubbles in tubing; clots in tubing; vasospasm; long, narrow tubing (excessive tubing); compliant tubing—make sure pressure tubing is used if extension is required, NOT IV tubing; friction in fluid pathway

Answer 35

Overdamped waveform

Question 36

___damped waveform = catheter whip or artifact; stiff, non-compliant tubing; hypothermia; tachycardia or dysrhythmia

Answer 36

Underdamped waveform

Question 37

Distance to junction of vena cava and RA from different central line insertion sites—subclavian ___ cm; RIJ ___ cm; LIJ ___ cm; femoral ___ cm

Answer 37

Subclavian 10 cm; RIJ 15 cm; LIJ 20 cm; femoral 40 cm

Question 38

CVP measures the ___ pressure; acts as a good predictor of patient ___ and ___ status

Answer 38

RA; acts as a good predictor of patient preload and volume status

Question 39

Normal CVP range ___-___

Answer 39

1-10

Question 40

CVP waveform—A wave = ___ of the right atrium

Answer 40

Contraction of the right atrium

Question 41

CVP waveform—C wave = closure of ___ valve

Answer 41

Tricuspid valve

Question 42

CVP waveform—V wave = ___ of right atrium; coincides with part of ___

Answer 42

Passive filling of right atrium; coincides with part of RV systole

Question 43

___ (low/high) CVP readings—RV failure, pulmonary HTN, volume overload, pericarditis, cardiac tamponade, tricuspid stenosis or tricuspid regurgitation

Answer 43

High CVP readings

Question 44

___ (low/high) CVP readings—hypovolemia, ARDS

Answer 44

Low CVP readings

Question 45

PA catheter systolic range = ___-___ mm Hg

Answer 45

20-30 mm Hg

Question 46

PA catheter diastolic range = ___-___ mm Hg

Answer 46

8-12 mm Hg

Question 47

___ (low/high) PA catheter readings—LV failure; volume overload; pulmonary HTN; catheter “whip” (catheter may be coiled or advanced too far); ASD or VSD; L-R shunt; mitral stenosis or mitral regurgitation

Answer 47

High PA catheter readings

Question 48

___ (low/high) PA catheter readings—hypovolemia, RV failure, tricuspid regurgitation or stenosis

Answer 48

Low PA catheter readings

Question 49

Wedge/occlusion pressure is used to estimate ___

Answer 49

LVEDP

Question 50

Normal wedge = ___-___ mm Hg

Answer 50

8-12 mm Hg (same as PA diastolic reading)

Question 51

Wedge pressure is not a commonly monitored value d/t increased risk of vessel rupture when wedging is performed incorrectly/catheter is not in the ideal position—T/F?

Answer 51

True

Question 52

___ (low/high) wedge pressures—LV failure; mitral stenosis or regurgitation; cardiac tamponade; constrictive pericarditis; ischemia; volume overload

Answer 52

High wedge pressures

Question 53

___ (low/high) wedge pressures—hypovolemia, RV failure, tricuspid regurgitation/stenosis, PE

Answer 53

Low wedge pressures

Question 54

Normal CO = ___-___ L/min

Answer 54

5-6 L/min

Question 55

How can we measure CO?

Answer 55

Thermodilution method

Question 56

Thermodilution method—area under the curve is ___ proportional to CO

Answer 56

Inversely

The greater the area under the curve, the lower the CO

The lesser the area under the curve, the greater the CO

Question 57

Thermodilution method—overestimates of CO (less area under the curve) = ___ (low/high) injectate volume; injectate that’s too ___ (warm/cold); ___ on thermistor of PA catheter

Answer 57

Low injectate volume; injectate that’s too warm; thrombus on thermistor of PA catheter

Question 58

Thermodilution method—underestimates of CO (more area under the curve) = ___ (low/high) injectate volume; injectate that’s too ___ (warm/cold)

Answer 58

High injectate volume; injectate that’s too cold

Question 59

Chronic cardiac medications should be administered perioperatively with rare exceptions—T/F?

Answer 59

True

Question 60

Keep patient on ___

Answer 60

Beta blocker

Question 61

Hold ___ and ___ for at least 24 hours before surgery

Answer 61

ACE inhibitors (i.e.: lisinopril) and ARBs (i.e.: losartan) for at least 24 hours before surgery d/t refractory hypotension that can occur with these medications + volatile agents

Question 62

Fentanyl induction dose—___-___mcg/kg

Answer 62

3-10 mcg/kg

Question 63

Sufentanil is ___-___ times more potent than fentanyl

Answer 63

7-10 times more potent

Question 64

Remifentanil induction dose ___-___mcg/kg; onset time ___ min and recovery time of ___-___ min

Answer 64

0.5-1 mcg/kg; onset time 1 min and recovery time of 9-20 min

Question 65

Metabolism of remifentanil = ___ hydrolysis by nonspecific tissue and blood ___

Answer 65

Extrahepatic hydrolysis by nonspecific tissue and blood esterases (why it has such a short half-life)

Question 66

Remifentanil may cause a rebound ___ when turned off; if you turn off remi without giving additional pain medication, patient will wake up in a/an ___ (increased/decreased) amount of pain

Answer 66

Rebound hyperalgesia when turned off; patient will wake up in an increased amount of pain

Question 67

If you want patient to wake up without narcotic fog after turning off remifentanil, give ___ and ___

Answer 67

Ketamine and mag sulfate

Question 68

Propofol induction dose—___-___mg/kg

Answer 68

1-2 mg/kg

Will give much smaller doses of prop to CV patients*

Question 69

If patient’s BP is very high to start, you can give a large dose of prop for induction—T/F?

Answer 69

False—doesn’t mean you should give a large dose of prop for induction…likely they will bottom out faster

Question 70

Prop ___ (increases/decreases) SVR, MAP, CI, and SV

Answer 70

Decreases

Always have phenylephrine ready!

Question 71

If HD stable, you will use ___ for induction

Answer 71

Prop

Question 72

If HD unstable, you will use ___ for induction

Answer 72

Etomidate

Question 73

Prop ___ (increases/decreases) PONV

Answer 73

Decreases

Question 74

Etomidate induction dose ___ mg/kg

Answer 74

0.2 mg/kg

Question 75

Etomidate produces a small ___ (increase/decrease) in MAP and SVR; ___ (increase/decrease) in HR and CO

Answer 75

Small decrease in MAP and SVR; increase in HR and CO

Question 76

Etomidate may initiate ___; ___ (increase/decrease) incidence of epileptiform activity in patients with known ___ disorders

Answer 76

Etomidate may initiate myoclonus; increase incidence of epileptiform activity in patients with known seizure disorders

Question 77

Do NOT use etomidate in patients with ___ disorders

Answer 77

Seizure

Question 78

Etomidate can induce ___ suppression—refractory ___tension, will need ___ to treat

Answer 78

Induce adrenal suppression—refractory hypotension, will need vasopressin to treat

Question 79

Etomidate ___ (increases/decreases) PONV

Answer 79

Increases PONV

Question 80

Ketamine induction dose ___mg/kg

Answer 80

2 mg/kg—this dose will make patient crazy for days

Question 81

Ketamine dose given during case in combo with other drugs—___-___mg/kg

Answer 81

0.1-0.5 mg/kg

Question 82

___ anesthesia is a common side effect of ketamine

Answer 82

Dissociative anesthesia—unique cataleptic trance

Question 83

Ketamine causes unconsciousness in ___-___ seconds

Answer 83

20-60 seconds

Question 84

Ketamine ___ (increases/decreases) HR, MAP, and plasma epinephrine levels (dependent on intact ___ reserve and robust ___)

Answer 84

Ketamine increases HR, MAP, and plasma epinephrine levels (dependent on intact sympathetic reserve and robust myocardium

Question 85

Ketamine is advantageous for induction in ___volemia, major ___, or cardiac ___

Answer 85

Hypovolemia, major hemorrhage, or cardiac tamponade

Question 86

Ketamine ___ (increases/decreases) ICP and coronary demand from ___

Answer 86

Increases ICP and coronary demand from sympathetic stimulation—why it is beneficial to give a smaller dose of ketamine with other agents

Question 87

Ketamine works on the ___ receptor

Answer 87

NMDA receptor

Question 88

Predominant effect of all inhalational agents is dose-dependent vaso___, reducing ___ and ___

Answer 88

Dose-dependent vasodilation, reducing BP and SVR

Question 89

All inhalational agents cause dose-dependent ___cardia; will see this the most with ___, so never use this agent in cardiac cases

Answer 89

All inhalational agents cause dose-dependent tachycardia; will see this the most with desflurane, so never use this agent in cardiac cases

Question 90

Usually will use ___ (what inhalation agent?) in heart cases

Answer 90

Isoflurane—cardiac steal and also doesn’t cause a lot of reflex tachycardia; patients wake up more clear-headed with iso than they do with sevo/des

Question 91

PVD risk factors—___ing, ___tension, diabetes mellitus, family ___/___, ___ (males vs. females), elevated tri___, hyper___

Answer 91

Smoking, hypertension, diabetes mellitus, family history/genetics, males > females, elevated triglycerides, hyperlipidemia

Question 92

PVD and blood pressure—patients with PVD may rely on ___ (increased/decreased) MAP to perfuse their vital organs

Answer 92

Increased MAP

Question 93

PVD and blood pressure—even short periods of hypotension can lead to ___ in these patients; ___ BP monitoring is recommended for these cases

Answer 93

Even short periods of hypotension can lead to ischemia in these patients; invasive BP monitoring is recommended for these cases

Question 94

PVD and blood pressure—rule of thumb—stay within ___% of the patient’s baseline BP

Answer 94

20%

Question 95

Greatest risk factor for abdominal aortic aneurysm = ___

Answer 95

Smoking

Question 96

Other major risk factors for AAA—___ age, gender—___ > ___

Answer 96

Old age, gender—males > females

Question 97

Other risk factors for AAA—family ___, ___ disease, ___ cholesterol, ___, ___tension

Answer 97

Family history, coronary artery disease, high cholesterol, COPD, hypertension

Question 98

AAA is ___-___ times more common in men than women

Answer 98

2-6 times

Question 99

AAA is 2-3 times more common in white males vs. black males—T/F?

Answer 99

True

Question 100

What is the imaging test of choice for AAA?

Answer 100

CTA

Question 101

AAA surgical criteria—risk of rupture is low for AAA less than ___ cm in diameter

Answer 101

Less than 4 cm

Question 102

Surgical intervention is recommended for: AAA ___ cm or greater; AAA 4-5 cm with greater than ___ cm enlargement in the last 6 months; ___ AAA; patients who are ___ with AAA

Answer 102

AAA 5.5 cm or greater; AAA 4-5 cm with greater than 0.5 cm enlargement in the last 6 months; ruptured AAA; patients who are symptomatic with AAA

Question 103

AAA vessel dimensions correlate with the law of ___

Answer 103

LaPlace

Question 104

Law of LaPlace—T = P x r

Answer 104

T = wall tension
P = transmural pressure
R = vessel radius

Question 105

Law of LaPlace—wall tension is directly proportional to vessel ___ and ___; wall tension is inversely proportional to wall ___

Answer 105

Wall tension is directly proportional to vessel radius and pressure; wall tension is inversely proportional to wall thickness

Question 106

Contraindications to elective AAA repair—intractable ___; recent ___; severe ___ dysfunction—recent ___, uncontrolled ___; chronic ___ insufficiency

Answer 106

Intractable angina; recent MI; severe pulmonary dysfunction—recent bronchitis, uncontrolled COPD; chronic renal insufficiency

Question 107

Most frequent/preferred AAA site = ___

Answer 107

Infrarenal

Question 108

Infrarenal AAA has decreased risk of renal ___ and renal ___ post-op

Answer 108

Renal ischemia and renal failure post-op

Question 109

AAA repair—EKG monitoring—lead ___ to evaluate for arrhythmias; lead ___ for detection of ischemic ST changes

Answer 109

Lead II to evaluate for arrhythmias; lead V5 for detection of ischemic ST changes

Question 110

PA catheters are routinely used intraoperatively during AAA repair—T/F?

Answer 110

False—NOT routinely used

Question 111

Aortic cross clamping—hemodynamic changes—___ (increased/decreased) BP above clamp; ___ (increased/decreased) BP below clamp; ___ (increase/decrease) in afterload; ___ (increase/decrease) in MAP; ___ (increase/decrease) in SVR

Answer 111

Increased BP above clamp; decreased BP below clamp; increase in afterload; increase in MAP; increase in SVR

Question 112

Aortic cross clamping—metabolic alterations—___ic and ___ic environment distal to the clamp

Answer 112

Hypoxic and ischemic environment distal to the clamp

Question 113

Aortic cross clamping—traction on mesentery (tugging on the mesentery done for exposure to the aorta) may cause ___ (increase/decrease) in BP, SVR; ___cardia; ___ (increased/decreased) CO; and facial ___…aka ___ syndrome

Answer 113

May cause decrease in BP, SVR; tachycardia; increased CO; and facial flushing…aka mesenteric traction syndrome

Question 114

Aortic cross clamp and AKI—___renal and ___renal cross clamp are associated with higher risk of kidney injury—reduce renal blood flow by as much as 80%

Answer 114

Suprarenal and juxtarenal cross clamp

Question 115

___ is the preferred AAA because risk for kidney injury is decreased

Answer 115

Infrarenal—reduces renal blood flow by 40% (instead of 80%)

Question 116

Suprarenal cross clamp times longer than ___ minutes increases the risk of postop renal failure

Answer 116

30 minutes

Question 117

Aortic cross clamp and AKI management—most important—tight hemodynamic ___ and minimization of ___ times

Answer 117

Tight hemodynamic stabilization and minimization of aortic cross clamp times

Question 118

Blood flow to the spinal cord—posterior—two posterior and two Posterolateral arteries = ___% of spinal cord blood flow; supply the ___ (sensory/motor) portion of the spinal cord

Answer 118

20% of spinal cord blood flow; supply the sensory (dorsal) portion of the spinal cord

Question 119

Blood flow to the spinal cord—anterior—one anterior spinal artery—___% of spinal cord blood flow—supplies the ___ (sensory/motor) portion of spinal cord

Answer 119

80% of spinal cord blood flow—supplies the motor portion of the spinal cord

Question 120

Blood flow to the spinal cord—any damage to the ___ spinal artery is detrimental because it provides 80% of the blood flow to the spinal cord; will see ___ (sensory/motor) damage if blood flow to this artery is compromised

Answer 120

Any damage to the anterior spinal artery is detrimental because it provides 80% of the blood flow to the spinal cord; will see motor damage if blood flow to this artery is compromised

Question 121

Blood flow to the spinal cord—transverse blood flow to the spinal cord is provided via the ___ artery, AKA artery of ___

Answer 121

Greater radicular artery, AKA artery of adamkiewicz

Question 122

This artery often gets injured during AAA repair; injury can cause post-op paraplegia

Answer 122

Greater radicular artery/artery of adamkiewicz

Question 123

Risk is highest for ___ (sensory/motor) spinal dysfunction during AAA repair…why?

Answer 123

Motor spinal dysfunction because the anterior/motor cord receives 80% of spinal cord blood flow and it only goes through one artery—development of collateral flow is more difficult

Question 124

Methods to decrease risk of spinal cord ischemia during AAA repair: CSF ___ (via ___ drain); mild ___thermia; maintenance of ___tension (SBP > ___) through the second postop day

Answer 124

CSF drainage (via lumbar drain); mild hypothermia; maintenance of normotension (SBP > 120) through the second postop day

Question 125

Aortic cross clamp release—SVR ___ (increases/decreases), blood goes into previously dilated ___, leads to ___ (increased/decreased) venous return

Answer 125

SVR decreases, blood goes into previously dilated veins, leads to decreased venous return

Question 126

Aortic cross clamp release causes transient vaso___—tissue ___, release of ___, leads to ___ (increased/decreased) preload and afterload

Answer 126

Transient vasodilation—tissue hypoxia, release of adenine, leads to decreased preload and afterload

Question 127

Aortic cross clamp release—___ (increase/decrease) anesthetic depth (if you can); turn off vaso___; will need ___ and ___ at this point

Answer 127

Decrease anesthetic depth; turn off vasodilators; will need fluids and pressors at this point

Question 128

Anesthetic management for open AAA repair—___ anesthesia is the most common approach; concern for dose-dependent myocardial ___ with anesthetic agents

Answer 128

General anesthesia is the most common approach; concern for dose-dependent myocardial depression with anesthetic agents

Question 129

Fluid management is key for open AAA repair—third space losses of around ___ ml/kg/hr

Answer 129

10 ml/kg/hr

Question 130

Open AAA repair—keep urine output at least ___ ml/kg/hr

Answer 130

1 ml/kg/hr

Question 131

Ruptured aortic aneurysms—mortality rate ___-___%

Answer 131

80-90%

Question 132

Triad of symptoms for ruptured AAA—severe ___/___ pain; altered level of ___ from ___tension; ___ abdominal mass

Answer 132

Several abdominal/back pain; altered level of consciousness from hypotension; pulsatile abdominal mass

Question 133

Thoracic aortic aneurysm—___ (increased/decreased) incidence of rupture compared to abdominal aortic aneurysm

Answer 133

Increased incidence of rupture compared to abdominal aortic aneurysm

Question 134

___ is the most common cause of thoracic aortic aneurysm

Answer 134

Atherosclerosis

Question 135

S/S of thoracic aortic aneurysm—___, ___, ___

Answer 135

Pain, stridor, cough

Question 136

Thoracic aortic aneurysm—aneurysm can impinge on ___ nerve—patient may have hoarseness; caution ___

Answer 136

Left recurrent laryngeal nerve—patient may have hoarseness; caution intubating!

Question 137

Surgical repair of thoracic aneurysms—preferred site for arterial line is ___

Answer 137

Right radial (because left side of body will be lacking adequate perfusion d/t the aneurysm, will get poor readings)

Question 138

Thoracic aneurysms have ___ (lower/higher) risk of spinal cord injury/ischemia during repair

Answer 138

Higher risk

For this reason, will likely place lumbar drain and monitor SSEPs/MEPs

Question 139

Spinal cord perfusion pressure = ___

Answer 139

MAP - CSF pressure

Question 140

Aortic cross clamp and spinal cord perfusion pressure—CSF pressure ___ (increases/decreases) distal to the clamp; arterial pressure ___ (increases/decreases) distal to the clamp; this causes spinal cord perfusion pressure to ___ (increase/decrease), which is why we use lumbar drain to drain CSF

Answer 140

CSF pressure increases distal to the clamp; arterial pressure decreases distal to the clamp; this causes spinal cord perfusion pressure to decrease, which we don’t want…which is why we use lumbar drain to drain CSF

Question 141

Goal CSF pressure = ___ mm Hg

Answer 141

Less than 10 mm Hg

Question 142

Spontaneous tear of the vessel wall results in passage of blood along a false lumen—what condition is this describing?

Answer 142

Aortic dissection

Question 143

What is the most common factor that contributes to progression of aortic dissection?

Answer 143

HTN

Question 144

___ aortic dissection has the highest incidence of rupture

Answer 144

DeBakey Type I/Stanford Type A

Question 145

Classifications of acute aortic dissections—___ and ___ classifications

Answer 145

DeBakey and Stanford classifications

Question 146

What type of aortic dissection is this?—originates in the ascending aorta and extends at least to the aortic arch and often to the descending aorta (and beyond); highest risk of rupture

Answer 146

DeBakey Type I

Question 147

What type of aortic dissection is this?—originates in the ascending aorta; confined to this segment

Answer 147

DeBakey Type II

Question 148

What type of aortic dissection is this?—originates in the descending aorta, usually just distal to the left subclavian artery, and extends distally

Answer 148

DeBakey Type III

Question 149

What type of aortic dissection is this?—dissections that involve the ascending aorta (with or without extension into the descending aorta); highest risk of rupture

Answer 149

Stanford Type I

Question 150

What type of aortic dissection is this?—dissections that do not involve the ascending aorta

Answer 150

Stanford Type II

Question 151

Types of endoleak—attachment site leaks

Answer 151

Type I

Treatment = proximal or distal graft extension; secondary endograft; open repair

Question 152

Types of endoleak—branch vessel leaks (i.e.: lumbar artery, renal artery, internal iliac artery, inferior mesenteric artery)

Answer 152

Type II

Treatment = monitor for enlargement; laparoscopic clip application; embolization

Question 153

Types of endoleak—graft defect (i.e.: fabric tear, modular disconnection)

Answer 153

Type III

Treatment = secondary endograft, open repair

Question 154

Types of endoleak—graft wall fabric hole or suture holes

Answer 154

Type IV

Treatment = observation, open repair

Question 155

___ = systemic pressure in aneurysm sac despite no evidence of endoleak

Answer 155

Endotension

Treatment = secondary endograft; open repair

Question 156

___ = the second most common vascular operation performed (2nd to coronary revascularization—i.e.: stents in cath lab, CABG)

Answer 156

Carotid endarterectomy (CEA)

Question 157

___ (ischemic/hemorrhagic) strokes are responsible for 80% of first time strokes

Answer 157

Ischemic strokes

Question 158

CEA is performed on patients with greater than ___% carotid artery stenosis

Answer 158

70%—no benefit to performing surgery on patients with < 70% stenosis; most patients develop adequate collateral

Question 159

S/S of carotid artery stenosis = ___/___; carotid ___; ___ocular blindness

Answer 159

TIA/stroke; carotid bruit (or palpable carotid thrill); monocular blindness

Question 160

Diagnosis of carotid artery stenosis = ___, carotid ___

Answer 160

CTA, carotid ultrasound

Question 161

Cerebral perfusion pressure = ___ - ___

Answer 161

MAP - ICP

ICP is typically not elevated in carotid stenosis, so MAP plays the major role in determining cerebral perfusion pressure

Question 162

When MAP is maintained between ___-___ mm Hg, cerebral autoregulation occurs (perfusion to the brain remains constant)

Answer 162

60-160 mm Hg

Question 163

Chronic HTN shifts a patient’s cerebral autoregulation curve to the ___ (right/left)

Answer 163

Right—thus, a higher MAP is needed to maintain adequate cerebral perfusion

Question 164

Anesthetic management for CEA—cerebral monitoring—nurse anesthetist will implement ___ monitoring

Answer 164

Cerebral oximetry monitoring

Question 165

Anesthetic management for CEA—interventions for cerebral protection—avoid ___glycemia (usually goal < ___); hemodilution (blood ___); maintenance of ___carbia; tight control of ___

Answer 165

Avoid hyperglycemia (usually goal < 140); hemodilution (blood thinning); maintenance of normocarbia; tight control of BP

Question 166

Cerebral oximetry during CEA—set ___ cerebral oximetry values prior to induction of anesthesia

Answer 166

Baseline—set so it automatically calculates changes in cerebral oximetry throughout the case

Question 167

Cerebral oximetry during CEA—a decrease in cerebral oximetry values greater than ___% coincides with regional and global ischemia during CEA

Answer 167

20%

Question 168

Anesthetic management for CEA—BP control—during carotid cross clamping, need MAP at ___% or ___ than the patient’s preoperative MAP; often goal is SBP ___ mm Hg or greater

Answer 168

At 20% or greater than the patient’s preoperative MAP; often goal is SBP 160 mm Hg or greater

Question 169

Anesthetic management for CEA—BP control—watch for carotid sinus baroreceptor manipulation during carotid cross clamping—may see ___tension and ___cardia—if sustained, tell surgeon

Answer 169

May see hypotension and bradycardia

Question 170

Carotid cross clamp is usually only on for ___-___ mins

Answer 170

30-45 mins

Question 171

Goal BP following CEA and cross clamp removal—SBP ___ mm Hg or less

Answer 171

140 mm Hg or less

Question 172

Regional anesthesia for CEA—deep/superficial ___ plexus block

Answer 172

Deep/superficial cervical plexus block

Question 173

Advantages of regional anesthesia for CEA—awake patient for better ___ exam

Answer 173

Neuro

Question 174

Anesthetic selections for CEA—no difference proven in better outcomes between regional vs. general; for this reason, general is usually used—T/F?

Answer 174

True

Question 175

Do not use ___ (what inhalation agent?) during CEA

Answer 175

Nitrous oxide—risk for pneumocephalus

Question 176

Postop complications of CEA—most common = ___—systolic BP greater than ___ mm Hg is associated with increased incidence of TIA, stroke, or MI

Answer 176

HTN—systolic BP greater than 180 mm Hg is associated with increased incidence of TIA, stroke, or MI

Question 177

Postop complications of CEA—___ syndrome—caused by increased blood flow to the brain d/t loss of cerebral autoregulation; results in severe headache, visual disturbances, LOC, seizures

Answer 177

Cerebral hyperperfusion syndrome

Question 178

Case selection—carotid stenting vs. CEA—stenting is worse for patients with ___ age; patients who can’t tolerate ___ agents; patients with ___ dysfunction; or patients with ___ related problems (i.e.: aortic occlusive disease that would make it difficult to do the procedure under fluoroscopy)

Answer 178

Advanced age; patients who can’t tolerate antiplatelet agents; patients with renal dysfunction; or patients with access related problems (i.e.: aortic occlusive disease that would make it difficult to do the procedure under fluoroscopy)

Question 179

Case selection—carotid stenting vs. CEA—stenting is better in patients with ___ disease; CHD with an abnormal cardiac ___, ___ angina, or MI less than ___ month ago; ___ heart disease; CHF with EF < ___%; contralateral ___ nerve dysfunction; severe obesity; previous neck ___/___; trach___; ___ immobility; recurrent stenosis; high lesions (above C___); contralateral carotid ___

Answer 179

COPD; CHD with an abnormal cardiac stress test, unstable angina, or MI less than 1 month ago; valvular heart disease; CHF with EF < 30%; contralateral RLN dysfunction; severe obesity; previous neck radiation/surgery; tracheostomy; neck immobility; recurrent stenosis; high lesions (above C2); contralateral carotid occlusion

Question 180

Complications of carotid stenting—most common = ___

Answer 180

Stroke caused by thromboembolism

Question 181

Normal aortic valve area = ___-___ cm^2

Answer 181

2-4 cm^2

Question 182

Aortic valve area with severe aortic stenosis = ___

Answer 182

< 1 cm ^2

Question 183

Patho of aortic stenosis—chronic LV ___ (pressure/volume) overload; ___ (eccentric/concentric) LV hypertrophy to decrease wall stress

Answer 183

Chronic LV pressure overload; concentric LV hypertrophy to decrease wall stress

Question 184

Patho of aortic stenosis—concentric left ventricular hypertrophy causes decreased ___ (systolic/diastolic) compliance; ___ (increased/decreased) coronary blood flow

Answer 184

Decreased diastolic compliance; decreased coronary blood flow

LV can’t relax because it is so stiff; supply and demand is mismatched

Question 185

Patho of aortic stenosis—decreased diastolic compliance leads to ___ (increased/decreased) LVEDP/LVEDV

Answer 185

Increased LVEDP/LVEDV (because the blood can’t get out of the LV into the aorta)

Question 186

Patho of aortic stenosis—myocardial ___ results from LV hypertrophy, ___ (increased/decreased) wall stress, ___ (increased/decreased) diastolic coronary perfusion, ___ (increased/decreased) coronary flow reserve

Answer 186

Myocardial ischemia results from LV hypertrophy, increased wall stress, decreased diastolic coronary perfusion, decreased coronary flow reserve

Question 187

Hemodynamic goals—AS—maintain sinus ___; optimal HR ___-___; maintain ___ and avoid myocardial ___; treat ___tension promptly

Answer 187

Maintain sinus rhythm; optimal HR 60-80; maintain contractility and avoid myocardial depressants; treat hypotension promptly

Question 188

___ and ___ anesthesia are contraindicated in patients with severe AS

Answer 188

Spinal and epidural anesthesia are contraindicated in patients with severe AS

Question 189

Aortic regurgitation—most common etiology = aortic root dilatation from ___; can also result from deformed/thickened cusps—___ valve is most common

Answer 189

Aortic root dilatation from HTN; can also result from deformed/thickened cusps—bicuspid valve is most common

Question 190

Patients with aortic regurgitation may be ___ for many years

Answer 190

Asymptomatic

Question 191

Chronic AR—LV ___ and ___ overload occurs; LV maintains ___ (diastolic/systolic) function by dilation and increased compliance; LV decompensates at later stages with ___ (increased/decreased) LVEDP and LVEDV, leading to CHF, arrhythmias, sudden death

Answer 191

LV volume and pressure overload occurs; LV maintains systolic function by dilation and increased compliance; LV decompensates at later stages with increased LVEDP and LVEDV, leading to CHF, arrhythmias, sudden death

Question 192

Aortic stenosis = ___ (volume/pressure) problem; ___ (eccentric/concentric) hypertrophy

Answer 192

Pressure problem; concentric hypertrophy

Question 193

Aortic regurgitation = ___ (volume/pressure) problem; ___ (eccentric/concentric) hypertrophy

Answer 193

Volume problem; eccentric hypertrophy

Question 194

Acute AR = LV ___ (pressure/volume) overload occurs; ___ (increased/decreased) LVEDP/LVEDV results in acute ___; emergency surgery often needed

Answer 194

LV volume overload occurs; increased LVEDP/LVEDV results in acute pulmonary edema; emergency surgery often needed

Question 195

Hemodynamic goals—AR—optimal HR = ___; avoid ___cardia because it increases regurgitation; avoid ___ (increased/decreased) afterload

Answer 195

Optimal HR = 90; avoid bradycardia because it increases regurgitation; avoid increased afterload

SNP (sodium Nitroprusside) is preferred to keep afterload low

Question 196

Acute AR—often need ___ + ___

Answer 196

Inotropes + vasodilator (epi + SNP/milrinone)

Question 197

___ is contraindicated in AR because it increases diastolic filling of the LV

Answer 197

IABP

Increases diastolic filling of the LV, which increases regurgitant volume…so you are pushing more blood back into the LV which is what you don’t want

Question 198

Mitral stenosis = ___ (volume/pressure) problem

Answer 198

Pressure problem—blood can’t get out of the LA into the LV

Question 199

Patho of MS—pressure gradient between LA and LV prevents ___ filling; pulmonary ___ results from increased ___ pressure

Answer 199

Prevents LV filling; pulmonary hypertension results from increased LA pressure

Question 200

Patho of MS—increased LAP leads to left atrial ___, atrial ___

Answer 200

Left atrial enlargement, atrial arrhythmias (AFib)

Question 201

Patho of MS—pulmonary hypertension leads to ___ dysfunction, ___ enlargement, ___ regurgitation

Answer 201

Pulmonary hypertension leads to RV dysfunction, RV enlargement, tricuspid regurgitation (patient may need tricuspid valve repair)

Question 202

Hemodynamic goals—MS—maintain ___ rhythm; avoid ___cardia, which ___ (increases/decreases) diastolic filling of LV and worsens MS; avoid factors which worsen pulmonary ___—___carbia, ___osis, ___thermia, ___ nervous system activation, ___ia

Answer 202

Maintain sinus rhythm; avoid tachycardia, which decreases diastolic filling of LV and worsens MS; avoid factors which worsen pulmonary HTN—hypercarbia, acidosis, hypothermia, sympathetic nervous system activation, hypoxia

Question 203

Hypercarbia causes vaso___ in the pulmonary vasculature, ___ (increases/decreases) pulmonary blood flow

Answer 203

Vasoconstriction in the pulmonary vasculature, decreases pulmonary blood flow

Question 204

Hypercarbia causes vaso___ in the neurovasculature (i.e.: carotid arteries); this would ___ (increase/decrease) your cerebral blood flow

Answer 204

Vasodilation in the neurovasculature; this would increase cerebral blood flow

Question 205

Anesthetic management MS—control of ___ is essential

Answer 205

Heart rate—can use beta blockers, digoxin, calcium channel blockers, amiodarone

Question 206

Intraoperative management—MS—___ is the single most useful drug with severe MS, even if patient has CHF/pulmonary edema

Answer 206

Esmolol

Fast on, fast off

10-20 mg bolus; 50-100 mcg/kg/min

Question 207

Intraoperative management—MS—avoid ___ (what inhalation agent?) because of effects on pulmonary HTN

Answer 207

Nitrous oxide—increases pulmonary vasoconstriction and would thus worsen pulmonary HTN

Question 208

Intraoperative management—MS—___ should be avoided because it can cause reflex tachycardia

Answer 208

Pancuronium

Question 209

After MV replacement, hemodynamics usually improve because obstruction to LV filling is resolved; if patient had pulmonary HTN/RV dysfunction perioperatively, may need ___ or ___

Answer 209

Milrinone or nitric oxide

Question 210

Patho of MR—___ (pressure/volume) overload of LV, leading to LV and LA ___

Answer 210

Volume overload of LV, leading to LV and LA enlargement

Question 211

Patho of MR—LA can massively ___; ___ arrhythmias with LA enlargement; dilated LV decompensates at later stages with ___ (increased/decreased) LVEDV

Answer 211

LA can massively dilate; atrial arrhythmias with LA enlargement; dilated LV decompensates at later stages with INCREASED LVEDV (because regurgitation is occurring during systole, so less blood will be pumped out of LV during systole and more volume will be leftover in the LV at the end of systole)

Question 212

Hemodynamic goals—MR—vaso___ to ___ (increase/decrease) afterload/regurgitant fraction and ___ (increase/decrease) forward flow; goal is to maintain ___ (low/high) normal HR to increase time of ventricular ___ (systole/diastole); maintain ___

Answer 212

Vasodilators to decrease afterload/regurgitant fraction and increase forward flow; goal is to maintain high normal HR to increase time of ventricular systole; maintain contractility

Question 213

Hemodynamic goals for regurgitant valves (AR/MR)—want to keep the heart ___, ___ and ___ so that blood doesn’t flow backwards

Answer 213

Fast, forward, and full

Question 214

MV repair—___ unmasked after surgery

Answer 214

LV dysfunction unmasked after surgery

LV function may be normal preop; after MV repair, it will be worse…because before surgery, LV had two outlets—could go out the LV outflow tract or back into the LA…after surgery, all blood has to go out of LV

Question 215

___ regurgitation is not very common

Answer 215

Tricuspid

Question 216

TR patho—RV + RA become ___ and ___; RA is very compliant, so RAP only rises with ___ stage disease; pulmonary HTN d/t MV disease ___ (increases/decreases) RV afterload and worsens TR; leads to ___ heart failure

Answer 216

RV + RA become overloaded and dilated; RA is very compliant, so RAP only rises with end stage disease; pulmonary HTN d/t MV disease increases RV afterload and worsens TR; leads to right heart failure—hepatomegaly, ascites

Question 217

Hemodynamic goals—TR—if secondary to MV disease, treat ___ heart lesion; avoid pulmonary ___ and ___ (low/high) PVR; maintain normal to high ___ for RV stroke volume; ___tension treated with inotropes + volume because vasoconstrictors may worsen ___

Answer 217

If secondary to MV disease, treat left heart lesion; avoid pulmonary HTN and high PVR; maintain normal to high preload for RV stroke volume; hypotension treated with inotropes + volume because vasoconstrictors may worsen pulmonary HTN

Question 218

EKG morphology—___ is the end of the QRS and beginning of ST segment

Answer 218

J point

Question 219

We utilize the ___ along with the ___ to identify myocardial ischemia

Answer 219

J point along with the ST segment

Question 220

Threshold values for ST segment depression—males and females of all ages in leads V2-V3 = -___ mm

Answer 220

-0.5 mm (-0.05 mV)

Question 221

Threshold values for ST segment depression—males and females of all ages in ALL other leads = -___ mm

Answer 221

-1.0 mm (-0.1 mV)

Question 222

What lead is typically used to monitor for ST segment changes?

Answer 222

Lead V5

Question 223

What lead is used to assess narrow QRS complex rhythms?

Answer 223

Lead II

Question 224

What EKG rhythm is this?—no P waves; PR interval not discernible; “controlled” if ventricular rate is < 100 BPM; only concern is when rate is > 100 bpm/there is a decrease in EF

Answer 224

Atrial fibrillation

Question 225

What EKG rhythm is this?—saw toothed flutter waves; cannot measure PR interval; QRS is usually normal, but ST segment and T waves are not identifiable, so you can’t monitor ST segment for signs of iscehmia; a “regular” irregularity

Answer 225

A-flutter

Question 226

What EKG rhythm is this?—prolonged PR interval > 0.2 sec and constant with each EKG cycle; usually clinically insignificant

Answer 226

First degree AV block

Question 227

What EKG rhythm is this?—atrial rhythm is regular, but ventricular rhythm is irregular; longer, longer, longer, drop, then you’ve got a ___

Answer 227

Wenckebach (Second degree AV block—Mobitz I)…mobitz I because you wink (wenckebach) with one eye

Question 228

What EKG rhythm is this?—P waves are normal, but some are not followed by a QRS; PR intervals are constant, the dropped QRS occurs without warning; “if some P’s don’t get through, then you’ve got a ___”

Answer 228

Second degree AV block—Mobitz II

EKG looks normal, and then you will have a P wave that is not followed by a QRS

Question 229

What EKG rhythm is this?—rate < 45 bpm; no relationship between P wave and QRS complex; “when Q’s and P’s don’t agree, then you’ve got a ___”; ___ needs to be placed!

Answer 229

Third degree AV block; pacemaker needs to be placed

Question 230

What EKG rhythm is this?—rate 150-250 bpm; P wave buried in QRS; QRS complex usually wide and with physic variation twisting around a central axis; seen with hypokalemia, hypocalcemia, hypomagnesemia

Answer 230

Torsades de Pointes

Question 231

Torsades may be worsened by ___ administration

Answer 231

Lidocaine administration

Question 232

Treat torsades with ___

Answer 232

Magnesium sulfate

Question 233

Treatment for V-Fib = ___

Answer 233

CPR, epi, defibrillation

Question 234

What EKG rhythm is this?—absent PR interval; wide, bizarre QRS complex; can be pulseless or with a pulse

Answer 234

V-Tach

Question 235

Treatment for V-Tach with a pulse = ___

Answer 235

Synchronized cardioversion

Question 236

Treatment for pulseless V-Tach = ___

Answer 236

CPR

Question 237

What is the most common hospital source of pacemaker electromagnetic interference (EMI)?

Answer 237

Electrocautery

Question 238

As long as cautery is used below the ___, you shouldn’t have issues with EMI

Answer 238

Waist

Question 239

___ pads can interfere with pacemakers

Answer 239

Defibrillation pads

Question 240

___ is generally contraindicated in patients with pacemakers

Answer 240

MRI

Question 241

What surgical procedure may have a negative effect on pacemaker systems?

Answer 241

ESWL—electrocorporeal shock wave lithotripsy

Question 242

How does ESWL affect pacemakers? The shock waves from the lithotripsy can cause ___ phenomenon

Answer 242

R on T phenomenon

Specifically—the shock wave can produce ventricular extrasystoles, so it is synchronized to the R wave (causing R on T phenomenon)…this will send the patient into crazy EKG rhythms and puts them at risk for V-Tach

Question 243

NBG code for pacemakers—the first letter refers to the chamber(s) being ___

Answer 243

Paced

V = ventricle
A = atrium
D = dual
O = none
S = single (A or V)

Question 244

NBG code for pacemakers—the second letter refers to the chamber(s) being ___

Answer 244

Sensed

V = ventricle
A = atrium
D = dual
O = none
S = single (A or V)

Question 245

NBG code for pacemakers—the third letter refers to the pacemaker’s response to a ___

Answer 245

Sensed event

T = triggered
I = inhibited
D = dual (triggered + inhibited)
O = no response

In a single chamber mode, “triggered” means that when an intrinsic event is sensed, a pace is triggered immediately thereafter. In a dual chamber mode, “triggered” means that a sensed atrial event will initiate (trigger) an A-V pace.

Question 246

Things affecting pacemakers—external defibrillation—paddles should be placed ___ and ___ if possible; if bilateral anterior placement is necessary, try to maintain __ inches from the device

Answer 246

Anterior and posterior if possible; if bilateral anterior placement is necessary, try to maintain 6 inches from the device

Question 247

Things affecting pacemakers—electrosurgery—use ___ (mono/bipolar) cautery whenever possible; use ___ (minimal/maximal) bovie settings; keep emergency external pacing/defibrillating device within reach; monitor mode of the device; ___ device post-op; keep a ___ handy

Answer 247

Use bipolar cautery whenever possible; use minimal bovie settings; keep emergency external pacing/defibrillating device within reach; monitor mode of the device; interrogate device post-op; keep a magnet handy

Question 248

Things affecting pacemakers—magnets—placing magnet over permanent pacemaker will set the pacemaker into ___ mode, ___ rate—pacemaker will automatically pace the patient at the ___ rate

Answer 248

Backup mode, asynchronous rate—pacemaker will automatically pace the patient at the backup rate

Question 249

Things affecting pacemakers—magnets—placing magnet over AICD will suspend ___ detection so the AICD will not shock the patient

Answer 249

EMI

Question 250

Pacemakers in the ambulatory setting—have a ___ available in your room; make sure patient had a pre-op ___ and a recent pacemaker interrogation done within the last ___-___ months; know what the pacemaker ___ is set at and what the ___ rate is

Answer 250

Have a magnet available in your room; make sure patient had a pre-op EKG and a recent pacemaker interrogation done within the last 1-2 months; know what the pacemaker rate is set at and what the backup rate is

Question 251

There is usually an EP person available to come interrogate a pacemaker at an ambulatory surgery center—T/F?

Answer 251

False—there is no EP person at an ambulatory surgery center

Question 252

Procedures done at ambulatory surgery center usually have no cautery, so risk of EMI with pacemakers is very low—T/F?

Answer 252

True

Question 253

Cardiac clearance is required for patients with a pacemaker/AICD planning to undergo surgery at an ambulatory surgery center—T/F?

Answer 253

True

Question 254

Off-pump CABG can be performed minimally invasively through a thoracotomy approach, but typically a full sternotomy approach is still used—T/F?

Answer 254

True

Question 255

Mid-lateral thoracotomy approach for off-pump CABG allows better healing for the patient because it’s a smaller wound; the procedure itself will take longer and there will be less visualization for the surgeon—T/F?

Answer 255

True

Question 256

For off-pump CABG, a perfusionist and CPB machine are not necessary—T/F?

Answer 256

False—must still have a perfusionist available with a CPB machine ready in the room in the event that you have to go on-pump

Question 257

Off-pump CABG is a ___ (shorter/longer) procedure than a traditional CPB CABG

Answer 257

Longer procedure—usually ~1.5 hours longer

Question 258

Patient considerations for off-pump CABG—patient must have relatively good ___ function to be a candidate

Answer 258

LV function—the heart needs to have good enough squeeze as it is being manipulated by the surgeon—manipulation can cause swings in BP, restricts flow to the heart

Question 259

___ management of the off-pump CABG patient is key

Answer 259

Fluid management

Question 260

You will give ___ (more/less) crystalloid/colloid during an off-pump CABG vs. on pump; ___ has to be diligent in the management of fluids for off-pump CABG

Answer 260

More; CRNA has to be diligent in the management of fluids for off-pump

Perfusionist manages fluids on pump

Question 261

___thermia is necessary during off-pump CABG; goal temperature of ___ C

Answer 261

Normothermia; goal temperature of 36 C

Question 262

If patient does not maintain normothermia during off-pump CABG, you can still extubate them in the OR at the end of the case—T/F?

Answer 262

False—cannot extubate if patient is not normothermic

This is a key difference for off-pump and on-pump CABGs…on pump CABGs will always remain intubated and will be extubated in the ICU; off-pump CABGs can be extubated at the end of the case in the OR and taken to the ICU extubated if and only if they are normothermic

Question 263

Anticoagulation for off-pump CABG—aminocaproic acid ___ (is/is not) administered

Answer 263

Is not administered for off-pump CABG

Aminocaproic acid (amicar) is an antifibrinolytic; normally give amicar when patient is on pump—start after central line is put in; give bolus and then infusion that runs for 4-5 hours; MOA = inhibition of plasminogen binding to fibrin, thus inhibits conversion of fibrin to plasmin

Question 264

Anticoagulation for off-pump CABG—patient is still ___, but typically at a lesser dose vs. on pump CABG

Answer 264

Heparinized

Question 265

Anticoagulation for off-pump CABG—partial heparinization ___-___ units/kg; goal ACT > ___

Answer 265

100-200 units/kg; goal ACT > 300

Some surgeons will still elect to fully heparinize for off-pump CABG at 300-400 units/kg

Question 266

___ reversal will still be given for off-pump CABG, regardless of whether you do partial or full heparinization

Answer 266

Protamine reversal

Question 267

Protamine should be pushed fast—T/F?

Answer 267

False—need to push your protamine SLOW!!! Over 5 minutes!

Question 268

Procedural considerations for off-pump CABG—will see ___tension when the heart is initially lifted with footplate stabilizers/retractors

Answer 268

Hypotension

Question 269

___ (more/less) manipulation is needed to bypass the LAD/diagonal arteries

Answer 269

Less manipulation

Usually do these grafts first; surgeon doesn’t need to turn/lift the heart as much to visualize these vessels, so you won’t see a lot of swings in BP

Question 270

___ (more/less) manipulation is needed to bypass the PDA/circumflex arteries; keep MAP ___ (low/elevated) during this time

Answer 270

More; keep MAP elevated during this time—volume load with albumin

Usually do these grafts after LAD/diagonal; heart will be turned/manipulated a lot

Question 271

Can see extreme hemodynamic compromise and myocardial ischemia during ___/___ grafting; may need to start ___ and/or ___

Answer 271

PDA/circumflex grafting; may need to start inotropes and/or vasopressors

Question 272

At the point of proximal graft aortic anastomosis, MAP is lowered to ___ mm Hg because there is a higher concern for ___ when you’re working directly on the aorta

Answer 272

Lowered to 60 mm Hg because there is a higher concern for bleeding when you’re working directly on the aorta

May have to pause drips at this time!

Question 273

Advantages to off-pump CABG—___ (more/less) surgical bleeding; ___ (more/less) heparin/concern for residual anticoagulation; if ___thermia maintained throughout, can potentially ___ patient while still in the OR; avoidance of aortic ___

Answer 273

Less surgical bleeding; less heparin/concern for residual anticoagulation (because you may do partial heparinization); if normothermia maintained throughout, can potentially extubate patient while still in the OR; avoidance of aortic cross-clamp

Question 274

Advantages of off-pump CABG—avoidance of aortic cross clamp = ___ (more/less) risk of ischemia, debris embolization

Answer 274

Less risk of ischemia, debris (anything accumulating on the clamp) embolization

Question 275

Mechanical circulatory assist devices—intraaortic balloon pump (IABP)—uses synchronized counterpulsation to enhance myocardial ___; ___ (increases/decreases) afterload during systole; ___ (increases/decreases) coronary blood flow to the heart during diastole

Answer 275

Uses synchronized counterpulsation to enhance myocardial perfusion; decreases afterload during systole; increases coronary blood flow to the heart during diastole

Question 276

IABP therapy can be used to stabilize preop CABG patients following an acute ___; placed on patients who have difficulty separating from ___; used as a supplement during ___ (off/on pump) CABG

Answer 276

Can be used to stabilize preop CABG patients following an acute MI; placed on patients who have difficulty separating from CPB; used as a supplement during off pump CABG

Question 277

Contraindications to placement of IABP—___sis; ___ (ascending/descending) aortic disease; severe ___; severe aortic ___

Answer 277

Sepsis; descending aortic disease; severe PVD; severe aortic regurgitation

Question 278

Placement of IABP—typically placed through the ___ artery; tip of the balloon sits at the junction of the aortic ___ and the ___ aorta; should be 2 cm distal to the origin of the ___ (right/left) subclavian artery

Answer 278

Typically placed through the femoral artery; tip of the balloon sits at the junction of the aortic arch and the descending aorta; should be 2 cm distal to the origin of the left subclavian artery

Question 279

Inflation of IABP—timed with the ___ on the arterial waveform; the balloon inflates once the AV ___ (opens/closes) and ___ (systole/diastole) begins; inflated balloon acts as a seal to ___ (increase/decrease) pressure and send the blood towards the ___ arteries

Answer 279

Timed with the dicrotic notch on the arterial waveform; the balloon inflates once the AV closes and diastole begins; inflated balloon acts as a seal to increase pressure and send the blood towards the coronary arteries

Question 280

Deflation of IABP—the ballon deflates immediately before the onset of ___ (systole/diastole), at the beginning of the ___ wave on EKG

Answer 280

Deflates immediately before the onset of systole, at the beginning of the R wave on EKG

Question 281

Deflation of IABP—deflation causes a vacuum effect—___ (increases/decreases) aortic pressure, ___ (increases/decreases) afterload; facilitates ventricular ___ (ejection/relaxation); ___ (increases/decreases) myocardial oxygen demand

Answer 281

Decreases aortic pressure, decreases afterload; facilitates ventricular ejection; decreases myocardial oxygen demand

Question 282

Timing of IABP—usually a ___:___ or ___:___ ratio

Answer 282

1:1 or 1:2 ratio

Question 283

Timing of IABP—1:1 ratio—the balloon inflates with ___

Answer 283

Every systole/diastole

Question 284

Timing of IABP—1:2 ratio—the balloon inflates with ___

Answer 284

Every other systole/diastole

Question 285

Timing of IABP—to wean patient off of IABP, trial a ___:___ ratio

Answer 285

1:4 ratio

If the patient starts on 1:1 ratio, try 1:2 for a little while, then 1:4

Question 286

You can immediately remove the IABP if the patient is on a 1:1 ratio—T/F?

Answer 286

False—have to wean the balloon pump before removing it!

Question 287

Complications of IABP—___—patient will be on anti___ for long term IABP management; ___ injuries; ___ at insertion site; ___cytopenia

Answer 287

Thrombus—patient will be on anticoagulation for long term IABP management; vascular injuries (vessel ischemia); infection at insertion site; thrombocytopenia

Question 288

Most common complication of IABP is ___

Answer 288

Vascular injuries

Question 289

ECMO = ___

Answer 289

Extracorporeal membrane oxygenation

Question 290

ECMO provides both ___ and ___ arterial perfusion support

Answer 290

Pulmonary and systemic arterial perfusion support

Question 291

ECMO is a closed circuit device that allows the ___/___ to recover from injury or trauma while maintaining ___ and ___

Answer 291

Allows the heart/lungs to recover from injury or trauma while maintaining oxygenation and perfusion

Question 292

Indications for use of ECMO—___ shock; failure to wean from ___; ___ (left/right) heart failure; heart failure that cannot be treated with ___ device; resuscitation of patients requiring ___; patients with severe ___ failure/___

Answer 292

Cardiogenic shock; failure to wean from CPB; right heart failure; heart failure that cannot be treated with ventricular assist device; resuscitation of patients requiring CPR; patients with severe respiratory failure/ARDS

Question 293

Two types of ECMO—___ and ___

Answer 293

Venovenous and venoarterial

Question 294

___ ECMO is the preferred method for respiratory failure in patients whose cardiac function is intact

Answer 294

Venovenous ECMO

Question 295

Venovenous ECMO—___ and ___ veins are the common cannulation sites; blood is drained from the ___ and ___ through cannula in vein; blood is oxygenated by ___ and returned to the ___

Answer 295

Femoral and IJ veins are the common cannulation sites; blood is drained from the SVC and IVC through cannula in femoral or IJ vein; blood is oxygenated by ECMO circuit and returned to the RA

Question 296

Venovenous ECMO—can either utilize separate drainage/return cannulae or can use a single double lumen cannula—T/F?

Answer 296

True

Question 297

Venoarterial ECMO is chosen for patients who require ___ ventricular support in addition to ___ support; it is used for patients who have poor ___ function

Answer 297

Patients who require left ventricular support in addition to pulmonary support; it is used for patients who have poor cardiac function

Question 298

Venoarterial ECMO bypasses ___ circulation altogether; this causes a ___ (lower/higher) arterial oxygenation

Answer 298

Bypasses pulmonary circulation altogether; this causes a higher arterial oxygenation

Question 299

Venoarterial ECMO—cannulas are usually placed ___ (centrally/peripherally); blood is drained from ___ and returned via cannula in the ___; process is similar to CPB; blood drains to a roller pump that circulates blood at ___-___L/min through a membrane oxygenator—___ is removed, ___ is added; blood is re___ before it is returned

Answer 299

Cannulas are usually placed centrally; blood is drained from RA and returned via cannula in the ascending aorta; process is similar to CPB; blood drains to a roller pump that circulates blood at 3-6 L/min through a membrane oxygenator—CO2 is removed, O2 is added; blood is rewarmed before it is returned

Question 300

Venoarterial ECMO—central vs. peripheral cannulation

Answer 300

Central cannulation—typically used on patients who can’t wean from CPB, crashing patients; cannula drains blood from RA and is returned via cannula in the ascending aorta

Peripheral cannulation—blood is drained from RIJ or femoral vein and returned via femoral artery

Question 301

Complications of ECMO—___ (anticoagulation is required); ___; ___; limb ___; multiorgan ___

Answer 301

Bleeding; stroke; infection; limb ischemia; multiorgan dysfunction

Question 302

Ventricular assist devices (VADs)—indications—___ shock from acute MI; ___ cardiomyopathies; post-___

Answer 302

Cardiogenic shock from acute MI; viral cardiomyopathies; post-CPB

Question 303

Contraindications for VADs—active ___; irreversible ___ or ___ dysfunction; severe ___ HTN; ___ cancer; major ___ disorders

Answer 303

Active infection; irreversible renal or hepatic dysfunction; severe pulmonary HTN; metastatic cancer; major coagulation disorders (i.e.: von Willebrand’s disease)

Question 304

LVAD—mechanical circulatory assist device attached to the heart through a cannula; collects ___ (deoxygenated/oxygenated) blood that is returned to the ___ from an inflow cannula (that is usually placed at the apex of the ___); ejects blood out through an outflow cannula that is attached to the ___

Answer 304

Collects oxygenated blood that is returned to the LA from an inflow cannula (that is usually placed at the apex of the LV); ejects blood out through an outflow cannula that is attached to the aorta

Question 305

RVAD—similar construction to LVAD but it receives ___ (oxygenated/deoxygenated) blood from the ___ and pumps blood into the ___ (pulmonary/systemic) circulation through an outflow cannula in the ___

Answer 305

It receives deoxygenated blood from the RA and pumps blood into the pulmonary circulation through an outflow cannula in the pulmonary artery

Question 306

VAD categories—type of flow—___ or ___; ___ of time for use; location of device—___-, ___-, or ___-corporeal; source of driving power—___ or ___

Answer 306

Type of flow—continuous or pulsatile; length of time for use; location of device—intra-, extra-, or para-corporeal; source of driving power—pneumatic or electric

Question 307

___ is a small, percutaneously inserted VAD

Answer 307

Impella

Question 308

Impella is placed through ___ artery access via retrograde approach to access the ___ valve

Answer 308

Femoral artery access to access the aortic valve

Question 309

Impella pumps blood from the ___ into the ___

Answer 309

Left ventricle into the ascending aorta

Question 310

Impella pump rate ___L/min

Answer 310

2.5 L/min

Question 311

Impella pumps ___

Answer 311

On its own

IABP is timed and requires the patient’s arterial pressure to pump; impella pumps regardless of what the patient’s body is doing—2.5L/min

Question 312

Anesthetic management of patients with LVADs—patients may have ___ congestion from ___ (left/right) heart failure; patients may be on preop anti___, so there is concern for major ___ during procedures

Answer 312

Patients may have hepatic congestion from right heart failure; patients may be on preop anticoagulation, so there is concern for major bleeding during procedures

Question 313

Anesthetic management of patients with LVADs—how these patients do is extremely dependent on ___; important to prevent ___cardia and maintain ___ tone during induction and maintenance of anesthesia; use ___ for induction, higher ___ dose; keep patient ___ throughout the case so you can maintain a ___ (lighter/deeper) anesthetic level without the patient moving

Answer 313

How these patients do is extremely dependent on heart rate; important to prevent bradycardia and maintain sympathetic tone during induction and maintenance of anesthesia; use etomidate for induction, higher narcotic dose (little to no propofol); keep patient paralyzed throughout the case so you can maintain a lighter anesthetic level without the patient moving

Question 314

LVAD patients CANNOT tolerate ___cardia and ___tension

Answer 314

Bradycardia and hypotension

Question 315

Anesthetic management of patients with LVADs—strict ___ technique must be maintained with invasive line placement due to ___ risk

Answer 315

Strict sterile technique must be maintained with invasive line placement due to infection risk

SEPSIS IS THE LEADING CAUSE OF MORTALITY IN LVAD PATIENTS

Question 316

What is the leading cause of mortality in LVAD patients?

Answer 316

Sepsis

Question 317

Anesthetic management of patients with LVADs—30% of LVAD recipients develop ___ ventricular dysfunction; use ___ to monitor and avoid overfilling of the ___

Answer 317

Right ventricular dysfunction; use TEE to monitor and avoid overfilling of the RV

Question 318

Anesthetic management of patients with LVADs—treatment of RV dysfunction—___ to decrease RV afterload; ___ to dilate the pulmonary vasculature

Answer 318

Inotropes to decrease RV afterload (i.e.: epi, milrinone); inhaled nitric oxide to dilate pulmonary vasculature

Question 319

Anesthetic management of patients with LVADs—LVAD flow is highly dependent on ___—use ___ and ___ products

Answer 319

Volume!!! Use blood and blood products

Don’t want these patients to become hypovolemic

Use blood to resuscitate—don’t slam in bags of crystalloid; if you don’t have blood right then and there, use albumin first

Question 320

Anesthesia for non-cardiac thoracic procedures—pulmonary function criteria—suggests high risk if…FVC < ___%; FEV1 < ___L; FEV1/FVC < ___%; diffusing capacity < ___% predicted; PaCO2 > ___ mm Hg

Answer 320

FVC < 50%; FEV1 < 2 L; FEV1/FVC < 50%; diffusing capacity < 50% predicted; PaCO2 > 45 mm Hg

Question 321

Drug therapy for non-cardiac thoracic procedures—sympathomimetics = beta ___ (agonists/antagonists) that ___ (increase/decrease) formation of cyclic-AMP, resulting in broncho___

Answer 321

Beta agonists that increase formation of cyclic-AMP, resulting in bronchodilation

Examples = metaproterenol, albuterol, terbutaline

Question 322

Drug therapy for non-cardiac thoracic procedures—parasympatholytics = ___ (increase/decrease) levels of cyclic-GMP, which modulate broncho___

Answer 322

Decrease levels of cyclic-GMP, which modulates bronchoconstriction (so preventing bronchoconstriction by decreasing cyclic-GMP)

Examples = atropine, ipratropium bromide

Question 323

Drug therapy for non-cardiac thoracic procedures—phosphodiesterase inhibitors—___ (inhibits/enhances) enzymatic breakdown of cyclic-AMP, which ___ (increases/decreases) cellular levels

Answer 323

Inhibits enzymatic breakdown of cyclic-AMP, which increases cellular levels

Example = aminophylline; therapeutic blood levels 5-20 micrograms/ml; loading dose 5-7mg/kg infused over 20 min; continuous infusion 0.5-0.7 mg/kg/hr

Question 324

Drug therapy for non-cardiac thoracic procedures—steroids—reduce mucosal ___ and suppress ___

Answer 324

Reduce mucosal edema and suppress inflammation

Example = beclomethasone

Question 325

Drug therapy for non-cardiac thoracic procedures—cromolyn sodium = mast cell stabilizer preventing degranulation and release of ___

Answer 325

Histamine

Question 326

Drug therapy for non-cardiac thoracic procedures—digitalis—useful with ___ (left/right) sided heart failure or supraventricular dysrhythmias with rapid ___ response

Answer 326

Useful with left sided heart failure or supraventricular dysrhythmias with rapid ventricular response

Question 327

Positioning for non-cardiac thoracic procedures—___ position is used anytime there is a desire to prevent flooding to the tracheobronchial tree during procedures

Answer 327

Prone

Question 328

Positioning for non-cardiac thoracic procedures—___ is standard thoracotomy position

Answer 328

Lateral decubitus

Question 329

Physiologic considerations of lateral decubitus—in upright position, apices of lungs are better ___, bases of lungs are better ___

Answer 329

Apices of lungs are better ventilated, bases of lungs are better perfused

Question 330

Physiologic considerations of lateral decubitus—in lateral position, dependent (downward) lung gets more ___, upper lung gets more ___

Answer 330

Dependent (downward) lung gets more blood flow (perfusion), upper lung gets more air (ventilation…because air rises)

Question 331

Physiologic considerations of lateral decubitus—if you clamp a lung (whether it’s the up or down lung), that becomes the “___” lung

Answer 331

That becomes the “down” lung or the lung that is not being ventilated

Question 332

Lateral decubitus—in the awake patient who is breathing spontaneously…blood flow to the ___ (independent/dependent) lung > blood flow to the ___ (independent/dependent) lung; ventilation is greater in the ___ (independent/dependent) lung

Answer 332

Blood flow to the dependent lung > blood flow to the independent lung; ventilation is greater in the dependent lung

Question 333

Lateral decubitus—in the anesthetized patient who is spontaneously breathing, chest closed—___ (independent/dependent) lung is better perfused; FRC is ___ (increased/decreased) in both lungs; ___ (independent/dependent) lung becomes less compliant, ___ (independent/dependent) lung becomes more compliant; ___ (increase/decrease) in shunt and dead space ventilation

Answer 333

Dependent lung is better perfused; FRC is decreased in both lungs; dependent lung becomes less compliant, independent (upper) lung becomes more compliant; increase in shunt and dead space ventilation

Question 334

Lateral decubitus—in the anesthetized, paralyzed, mechanically ventilated patient, chest closed—___ (independent/dependent) lung is better perfused; ventilation to ___ (independent/dependent) lung is even greater

Answer 334

Dependent lung is better perfused; ventilation to independent lung is even greater

Question 335

Lateral decubitus—in the anesthetized patient who is spontaneously breathing, chest open—___ shift; ___ respiration

Answer 335

Mediastinal shift; paradoxical respiration (instead of chest/abdominal wall moving out when taking a breath, it moves inward…this is what is causing the mediastinal shift)

Question 336

Lateral decubitus—in the anesthetized patient, ventilation controlled, chest open—open chest ___ (increases/decreases) compliance of both lungs; airway pressure ___ (increased/decreased) in both lungs; cardiac index ___ (increases/decreases); MAP is ___ (changed/unchanged); CO2 elimination is greater from ___ (independent/dependent) lung; ___ (increased/decreased) amount of zone 1 and dead space ventilation

Answer 336

Open chest increases compliance of both lungs; airway pressure decreased in both lungs; cardiac index increases; MAP is unchanged; CO2 elimination is greater from independent lung; decreased amount of zone 1 and dead space ventilation

Question 337

Disadvantages of lateral decubitus position—opposite hemithorax ___ (is/is not) accessible; V/Q ___; contamination of ___ (independent/dependent) lung; ___ (increased/decreased) FRC, airway closure and atelectasis in ___ (independent/dependent) lung; ___ from positioning

Answer 337

Opposite hemithorax is not accessible; V/Q mismatch; contamination of dependent lung; decreased FRC, airway closure and atelectasis in dependent lung; injury from positioning

Question 338

In order to separate the lungs during intrathoracic operations, we use ___ lumen endotracheal tube; allows us to selectively ___/___ a lung during procedure

Answer 338

Double lumen endotracheal tube; allows us to selectively ventilate/collapse a lung during procedure

Question 339

General anesthesia and one lung anesthesia—do not use ___ (what inhalation agent?); avoid ___emia; ___ infusion may be a choice; maintain good muscle ___

Answer 339

Do not use nitrous oxide; avoid hypoxemia; ketamine infusion may be a choice; maintain good muscle relaxation

Question 340

Hypoxia that occurs during one lung ventilation may require—get an ___; may need to ___ the collapsed lung; give ___ to independent (up, deflated) lung; give ___ to dependent (down, inflated) lung

Answer 340

Get an ABG; may need to reinflate the collapsed lung; give CPAP to independent (up, deflated) lung; give PEEP to dependent (down, inflated) lung

Question 341

Hypoxia that occurs during one lung ventilation—give CPAP to ___ (independent/dependent) lung; give PEEP to ___ (independent/dependent) lung

Answer 341

Give CPAP to independent (up, deflated) lung; give PEEP to dependent (down, inflated) lung

Question 342

At the conclusion of lung resection, the deflated lung should be re-inflated carefully; positive pressure is held at ___-___ cm H2O to allow the surgeon to view suture lines and check for air leaks

Answer 342

35-40 cm H2O

Question 343

What to do if sat drops from 100% to 93% during one lung anesthesia (patient becomes hypoxic)…switch to ___% FiO2; switch from ___ ventilation to ___ ventilation and check compliance; confirm DLT ___; send an ___; suction out the lung that is ___ (inflated/deflated); give ___ (CPAP/PEEP) to the deflated/up lung; if sat still does not come up, give ___ (CPAP/PEEP) to the inflated/down lung

Answer 343

Switch to 100% FiO2; switch from continuous ventilation to manual ventilation and check compliance; confirm DLT placement; send an ABG; suction out the lung that is deflated (up/independent lung); give CPAP to the deflated/up lung; if sat still does not come up, give PEEP to the inflated/down lung

If desaturation persists even after all of these interventions, you can unclamp the double lumen ETT, reinflate the deflated lung, and do two lung ventilation until the sats come back up

Question 344

Why do we give CPAP to the deflated/up lung if hypoxia occurs during one lung anesthesia?

Answer 344

The deflated/up lung is NOT being ventilated, but it is being perfused (to an extent less than the inflated/dependent lung)…so blood is flowing to the lung but is not being oxygenated…desaturation can occur d/t the ongoing V/Q mismatch occurring in the deflated/up lung while it is not being ventilated

Give CPAP to lessen the V/Q mismatch—give some oxygen to the blood that is flowing there so you get a little ventilation with your perfusion

Question 345

Why do we give PEEP to the inflated/down lung if hypoxia occurs during one lung anesthesia?

Answer 345

You should only do this if your sat still doesn’t come up after giving CPAP to the deflated/up lung

You can give PEEP to the inflated/down lung because this lung is being ventilated, so PEEP will allow some of those small alveoli to open up more so more oxygen can be delivered to the blood that is flowing there

HOWEVER…PEEP increases your intrathoracic pressure. So in theory, it would cause blood (perfusion) to shift from the inflated/down lung to the deflated/up lung (the lung that is NOT being ventilated). This would increase your V/Q mismatch even more. This is why PEEP is not first line when hypoxia occurs.

Question 346

Contraindications to DLT—___ along the tube’s pathway; difficulty obtaining direct ___ during intubation; critically ill patients who don’t tolerate ___; ___ stomach/risk for ___

Answer 346

Lesion along the tube’s pathway; difficulty obtaining direct visualization during intubation; critically ill patients who don’t tolerate apnea; full stomach/risk for aspiration

Question 347

Regional/GA for non-cardiac thoracic procedures—may use combination of general anesthesia with ___ epidural (level determined by surgery); utilizes ___ (more/less) narcotics, ___ (lower/higher) gas concentrations; enables ___ (slower/faster) emergence/recovery with benefits of good analgesia

Answer 347

May use combination of general anesthesia with thoracic epidural (level determined by surgery); utilizes less narcotics, lower gas concentrations; enables faster emergence/recovery with benefits of good analgesia

Question 348

Rigid bronchoscopy is performed for—removal of ___ bodies; massive ___; dilate trachobronchial ___; ___ placement; biopsy and staging of ___ processes; establishment of an ___ airway

Answer 348

Removal of foreign bodies; massive hemoptysis; dilate tracheobronchial strictures; stent placement; biopsy and staging of malignant processes; establishment of an emergent airway

Question 349

What do we worry about with rigid bronchoscopy?

Answer 349

Sharing the airway with the surgeon—requires extremely high vigilance and excellent ongoing communication

Also worry about arrhythmias, hypertension, hypoxemia

Question 350

Patient position for rigid bronchoscopy—___ or ___

Answer 350

Sitting or supine

Question 351

Give ___ early for rigid bronchoscopy

Answer 351

Glycopyrrolate—antisialogogue to dry up patient’s mouth

Question 352

Rigid bronchoscopy—usually give patient ___ + ___ anesthetic; use ___ (short/long) acting drugs; postop hypoxemia will usually correct with supplemental ___; keep the sedation ___ (light/deep) to avoid ___ventilation

Answer 352

Usually give patient sedation + topical anesthetic; use short-acting drugs (remifentanil drip); postop hypoxemia will usually correct with supplemental O2; keep the sedation light to avoid hypoventilation

Question 353

Fiberoptic bronchoscopy allows evaluation of the tracheobronchial tree ___ than rigid bronch

Answer 353

Deeper

Question 354

Fiberoptic bronchoscopy is used for ___ disease diagnosis; staging ___; lavage/aspiration of thick secretions in acute ___; transbronchial ___ and ___

Answer 354

Pulmonary disease diagnosis; staging carcinomas; lavage/aspiration of thick secretions in acute atelectasis; transbronchial biopsy and brushings

Question 355

Absolute contraindications for fiberoptic bronchoscopy = unstable ___ system; current life threatening cardiac ___; and severe ___emia

Answer 355

Unstable CV system; current life threatening cardiac arrhythmias; and severe hypoxemia

Question 356

Problems during fiberoptic bronchoscopy—___ing; ___tension; ___cardia; may require lung separation if ___ develops

Answer 356

Coughing; hypertension; tachycardia (usually indicates inadequate anesthesia/topical anesthetic); may require lung separation if bleeding develops

Question 357

EBL during fiberoptic bronchoscopy is usually ___

Answer 357

Negligible

Question 358

Need to know from surgeon for fiberoptic bronchoscopy—if proceeding through ETT, will need ETT size ___-___; if proceeding next to ETT, will need ETT size ___-___

Answer 358

If proceeding through ETT, will need ETT size 7.5-8.0

If proceeding next to ETT, will need ETT size 5.0-6.0

Question 359

Indications for pneumonectomy—___ lung cancer; drug resistant ___, ___bacterium, ___ infections, necrosis; ___ (done as a last resort)

Answer 359

Non-small cell lung cancer; drug resistant TB, mycobacterium, fungal infections, necrosis; trauma (done as a last resort)

Question 360

Preop pneumonectomy—___ation, anti___, broncho___, place ___ epidural; monitors—A-line, CVP, PA on ___ (same/opposite) side; ___ lumen ETT

Answer 360

Hydration, antibiotics, bronchodilators, place thoracic epidural; monitors—A-line, CVP, PA on opposite side; double lumen ETT

Question 361

Fluid management during pneumonectomy—want to run patient ___; EBL is usually ___

Answer 361

Want to run patient dry; EBL is usually < 500 cc

Question 362

Post-op pneumonectomy—anticipate unrecognized ___ loss; postop pulmonary ___, ___asis; dys___; DVT and pulmonary embolism occur in ___% of patients; persistent ___ leak; excessive ___ shift, can be life threatening

Answer 362

Anticipate unrecognized blood loss; postop pulmonary edema, atelectasis; dysrhythmias; DVT and pulmonary embolism occur in 20% of patients; persistent air leak; excessive mediastinal shift, can be life threatening

Question 363

Post-op pneumonectomy—ipsilateral (same side as the pneumonectomy) mediastinal shift—___tension; ___mias; cardiac ___; pulmonary ___

Answer 363

Hypotension; arrhythmias; cardiac herniation; pulmonary edema

Question 364

Post-op pneumonectomy—contralateral (opposite side of the pneumonectomy) mediastinal shift—decreased ___ function; ___ (increased/decreased) venous return

Answer 364

Decreased lung function; decreased venous return

Question 365

Chest tubes are kept ___ to prevent mediastinal shifts

Answer 365

Clamped—only brief unclamp for drainage of fluids