Intraoperative Management CV Surgery

Question 1

8 steps for preparation of administering anesthesia during open heart surgery?

Answer 1

1. enter correct weight in to pumps
2. check all the pumps and tubing to make sure they are labeled and are indeed what they say they are
3. check airway tools
4. draw up narcs
5. dilute 100 mcg nitro in 10 mL (TV) to make 10mcg/mL
6. draw up heparin 300U/kg
7. review plan w CRNA and MD
8. review plans for catastrophic events

Question 2

Dose of heparin to have available in an emergency?

Answer 2

3 mg/kg or 300 U/kg

Question 3

Before meeting the patient before surgery, why should you check w the charge CRNA?

Answer 3

make sure patient doesn’t need to be picked up because they need to be monitored or have IABP

Question 4

What MUST you check about the procedure before starting the art line?

Answer 4

if it is a radial artery harvest

Question 5

What time do you have to be in the OR by?

Answer 5

0715

Question 6

Who is most likely to cardiac arrest (I think this is on induction)? And what should you do to prepare?

Answer 6

proximal left main disease or left main equivalent, severe mitral stenosis, severe AS (AVA

Question 7

What is the goal for opioid use during heart surgery?

Answer 7

modest use/ 2.5-3 mcg/kg over the course of the surgery

Question 8

When does Dr. White give versed for open heart surgery?

Answer 8

holding room, when arrive in OR, when go on pump, when warming, and right before SICU: she gives a total of 6-8 mg throughout surgery

Question 9

What does hypothermia mean for muscle relaxants?

Answer 9

they won’t metabolize muscle relaxants as well while they’re hypothermic

Question 10

4 advantages of opioids?

Answer 10

no myocardial depression, diminish stress response, bradycardia, decreases SVR (fent wont)

Question 11

5 disadvantages of opioids?

Answer 11

no myocardial depression, chest wall rigidity, apnea, decreases SVR, long duration at higher doses

Question 12

Does fentanyl or sufentanil release histamine?

Answer 12

no

Question 13

What is the fentanyl dose for balanced technique?

Answer 13

10-25 mcg/kg

Question 14

What is the fentanyl dose when used as a sole agent?

Answer 14

50-100 mcg/kg

Question 15

Is sufenta more or less potent than fentanyl?

Answer 15

more

Question 16

How can you more easily control the dosing of sufenta?

Answer 16

dilute it

Question 17

What is the balanced dose of sufenta?

Answer 17

1-5 mcg/kg

Question 18

What is the sole agent dose of sufenta?

Answer 18

10-30 mcg/kg

Question 19

6 characteristics of thiopental?

Answer 19

ok if EF is good, good if increased ICP, brain protective, depresses myocardium, and decreases venous return, reflex tachycardia

Question 20

6 characteristics of propofol?

Answer 20

decreases N/V, short duration, less reflex tachycardia, post-op fast track, depresses myocardium, apnea longer

Question 21

5 characteristics of etomidate?

Answer 21

rapid on and off, HD stability, stable renal/hepatic perfusion, myoclonus, adrenal suppression

Question 22

6 characteristics of ketamine?

Answer 22

increases SVR, increases filling pressures, increases contractility, increases heart rate, depresses myocardium, supports BP via catecholamines

Question 23

4 characteristics of benzos?

Answer 23

prevents recall, potent amnestic, decreases BP, reflex tachycardia

Question 24

Big disadvantage of inhalational anesthetics as far as the heart is concerned?

Answer 24

dose related depression in contractility

Question 25

3 characteristics of isoflurane?

Answer 25

less myocardial depression, coronary vaodilator, ?coronary steal?

Question 26

2 things to keep in mind about sevoflurane?

Answer 26

less airway reactivity, theoretical renal considerations

Question 27

2 things to keep in mind about desflurane?

Answer 27

fast-track agent, airway problems

Question 28

3 things to keep in mind about halothane?

Answer 28

only useful for tetralogy of fallot, maintains SVR and relaxes RV infundibulum, improves pulmonary blood flow

Question 29

What is coronary steal?

Answer 29

complete blockage of one coronary artery and partial blockage of another. in normal situations the blocked artery gets collateral flow. however, coronary steal is a theory that with isoflurane, the vasodilation decreases the MAP and flow going in to collateral flow is backfilling for the blocked artery which is not good and the patient becomes ischemic

Question 30

What do you want to do to prevent coronary steal?

Answer 30

keep MAP up

Question 31

6 characteristics of pancuronium?

Answer 31

vagolytic, sympathomimetic, rapid onset, long duration, no histamine, inexpensive

Question 32

4 characteristics of vecuronium?

Answer 32

stable HD, intermediate duration, no histamine, inexpensive

Question 33

5 characteristics of rocuronium?

Answer 33

faster onset, slightly vagolytic, intermediate duration (shorter than vec), no histamine, more expensive

Question 34

Drug of choice in patient with renal failure?

Answer 34

cisatracurium

Question 35

4 characteristics of cisatracurium?

Answer 35

Hoffman elimination, intermediate duration, no histamine, more expensive

Question 36

6 characteristics of succinylcholine?

Answer 36

rapid onset, short duration, hyperkalemia, myalgia, increased gastric pressure, histamine release followed by decreased BP

Question 37

3 situations commonly encountered on induction for open heart surgery?

Answer 37

hypotension, HTN/tachycardia, cardiac arrest

Question 38

Treatment for HTN/tachycardia on induction in open heart patients?

Answer 38

b-blockers or nitro, esmolol if tachy

Question 39

Antibiotics that you give for open heart surgery?

Answer 39

if >100 kg 1.5 g Vanc 2 hours prior to incision and RUN SLOWLY on the pump, zinacef 1.5 g 1 hour prior to incision

Question 40

What is amicar/aminocaproic acid? How does it work?

Answer 40

antifibrinolytic that is a lysine analog that binds to the lysine-binding sites on plasmin and plasminogen, thus inhibiting fibrin lysis. has some effect in preventing platelet disaggregation

Question 41

What is the dose of amicar?

Answer 41

5 g load over 30 min, then 1 g/h for duration of case

Question 42

Why is aprotenin currently off the market?

Answer 42

2 fold increase in renal failure, 55% increase in MI rates, 181% increased risk of stroke

Question 43

Describe positioning for open heart surgery?

Answer 43

supine (duh) with arms tucked, gel pads to elbows, towels around hands, sleds (to prevent tired residents from leaning on arms), bair hugger must go under patient and must make sure when you tuck the arms that you don't cut off the airflow to the bair hugger

Question 44

What's the butt check for the a line?

Answer 44

lean butt on a line arm to make sure it doesn't dampen since it is likely that surgeon will lean on it during surgery

Question 45

Which side should the ETT be on and why?

Answer 45

left so RIJ for CL placement

Question 46

During induction and after you secure the ETT on the left side, what are the next 4 things you should do?

Answer 46

NG in and out, TEE in to stay, be certain you can reach foley bag, ether screen positioning (put towards head of bed, high, towards end of rail on table and tip back quite a bit, and make sure that if someone leans on it it won't move)

Question 47

When comparing a PAC and CVC, what is one additional risk of a PAC?

Answer 47

rupture of pulmonary artery

Question 48

What are the RA, RV, PA, and PAOP landmarks for a PAC?

Answer 48

RA= 25 cm, RV=35 cm, PA= 45 cm, PAOP= 50 cm

Question 49

If you're in to 60 cm w the PAC, what is happening?

Answer 49

you're in too far and there is probably a kink somewhere, deflate the balloon and withdraw the catheter and readvance

Question 50

When do you know you're in the RV outflow tract?

Answer 50

trace starts to change on upstroke of ventilation. the PA is right after RV outflow tract

Question 51

Normal mixed venous O2 sat according to this lecture?

Answer 51

67-77%

Question 52

What does mixed venous O2 sat reflect?

Answer 52

reserves left at the end of circulation; it is the oxygen content of mixed venous blood

Question 53

At what value of SvO2 do you expect loss of consciousness? And what value do you expect cellular death?

Answer 53

LOC

Question 54

You would expect an SvO2 of less than ____ if lactic acidosis had been left untreated?

Answer 54

50%

Question 55

As far as SVO2, what is more important when monitoring- the actual number or a trend?

Answer 55

trend

Question 56

Why does SVO2 rise with nitroprusside toxicity?

Answer 56

there is no O2 consumption going on because of poisoning by cyanide ions

Question 57

What is the equation to calculate SVO2?

Answer 57

SaO2 - [VO2/(CO x 1.36 x Hgb)]

Question 58

What is VO2?

Answer 58

oxygen consumption

Question 59

What is SaO2?

Answer 59

arterial oxygen saturation

Question 60

What are some causes of increased SVO2?

Answer 60

high CO (sepsis), artifact (wedged), anesthesia, paralysis, hypothermia, cyanide poisoning

Question 61

What are some causes of decreased SVO2?

Answer 61

increased O2 consumption, shivering, fever, stress

Question 62

What labs should you get before incision?

Answer 62

baseline glucose, ABG, ACT

Question 63

Is hypothermia due to drift okay? Why?

Answer 63

yes; it decreases MVO2