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Advanced Principles C > Ischemic Heart Disease II > Flashcards

Ischemic Heart Disease II Flashcards

1
Q

Preoperative Assessment for CABG

A
  • When was the patient’s last MI
  • EF
  • Angiography results
  • Labs
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2
Q

When should the arterial line be placed during a CABG?

A

Preoperatively/Preinduction

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3
Q

What are the components that can be adjusted with an abnormal cerebral oximeter?

A
  • Hgb
  • FiO2
  • MAP
  • ETCO2
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4
Q

What artery will usually be taken first as a graft in a CABG?

A

Mammary artery

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5
Q

Considerations for a repeated sternotomy?

A
  • Have blood in the room ready
  • Have the bypass machine primed and ready
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6
Q

Ventilation considerations when the pericardium is tacked

A

Decrease Tidal Volume

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7
Q

Recommended SBP during cannulation

A

Should not exceed 90-100 mmHg

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8
Q

Heparin dose during CABG

A

300 units/kg

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9
Q

Prefer ACT if CABG is on pump

A

ACT >400

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10
Q

Prefer ACT if CABG is off pump

A

ACT > 300-350

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11
Q

What could prevent the ACT from climbing with repeated doses of heparin?

Intervention?

A
  • AT III deficiency
  • FFP can help increase the ACT in cases of heparin resistance d/t AT III deficiency.
  • FFP contains AT III which heparin needs to function effectively.
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12
Q

How often does the patient undergo cardioplegia infusion?

A

20-30 minutes

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13
Q

Temperature goal during bypass

A

32 degrees Celsius

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14
Q

CMRO2 decreases by how many percent each Celsius?

A

7% decrease / degree Celsius

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15
Q

What joules should the internal paddles be charged to for defibrillation?

A

20-30 Joules

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16
Q

SBP for decannulation

A

90-100 mmHg

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17
Q

Protamine dose to reverse heparin

A

1 mg/ 100 units heparin

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18
Q

What drug may be used for inotropic support after coming off pump?

A

Levophed

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19
Q

What are the types of cardio bypass pumps?

A
  • Roller
  • Centrifugal (adults)
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20
Q

What should the pump be primed with if a patient has renal failure and a Hgb of 7?

A

Primed with albumin and PRBC

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21
Q

What are pumps typically primed with?

A

Crystalloid

Can also be primed with albumin, PRBC, lytes, mannitol, and heparin

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22
Q

What is the average prime volume?

A

1500-2500 mL

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23
Q

Range of Hct on pump

A

17-25%

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24
Q

What three routes can cardioplegia be administered?

A
  • Antegrade: Aortic Root
  • Retrograde: Coronary Sinus
  • Bypass graft
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25
Q

Pulmonary complications of cardiopulmonary bypass

A
  • Acute Lung Injury (“Pump Lung”)
  • Diffused congestion
  • Alveolar and interstitial edema
  • Hemorrhagic Atelectasis
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26
Q

CNS complications of cardiopulmonary bypass

A
  • Stroke from emboli
  • Hypotension causing confusion (“Pump Head”)
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27
Q

GI complications of cardiopulmonary bypass

A
  • Hypo-perfusion can embolize the mesentery artery, causing a mesenteric infarction.
  • HITT
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28
Q

What factors can cause renal complications of cardiopulmonary bypass?

A
  • Duration on pump
  • Excessive blood loss
  • DM
  • Use of pressors
  • Advanced age
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29
Q

Preferred urinary output during a CABG

A

1 ml/kg/hr

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30
Q

MOA of TXA (Cyclokapron)

A

Anti-fibrinolytic that inhibits the activation of plasminogen

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31
Q

Off pump coronary artery by pass is most successful with a normal ______.

A

EF (50-70%)

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32
Q

Which vessels are grafted first during OFF pump bypass?

A
  • Aorta first (proximal fist)
  • Then distal (will need vasopressor support)
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33
Q

Which vessels are grafted first during ON pump bypass?

A
  • Distal first
  • Then proximal
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34
Q

For off pump CAB, ACT is done by anesthesia every _____ minutes and redose heparin prn.

A

20 minutes

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35
Q

When will cardiac transplantation be indicated?

A

End-stage cardiomyopathy

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36
Q

Anesthetic issues w/ cardiac transplantation

A
  • Denervated heart (vagus nerve has been cut)
  • S/E of immunosuppressive therapy
  • can develop CAD
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37
Q

Considerations for Denervated Hearts?

A
  • No sympathetic innervation (No HR change to DL, Pain, HOTN)
  • No parasympathetic innervation (Runs ST, cardiac dysrhythmias)
  • No sensory ability
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38
Q

Immunosuppressives considerations for cardiac transplantation.

A

Must be continued during preoperative period

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39
Q

Effects of immunosuppressives on NDMR.

A

Enhance neuromuscular blockade

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40
Q

Concerns of immunosuppressives and gingival hypertrophy

A

Can cause bleeding into the airway

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41
Q

Concerns of immunosuppressives with seizures thresholds

A
  • Can decrease seizures threshold
  • No Hyperventilation

Hypocapnia raises the neuronal excitability by alkalinizing the extracellular environment, which can provoke or worsen seizures.

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42
Q

Anesthesia considerations for cardiac transplantation.

A
  • Maintain preload (SVV/vigileo/echo)
  • Avoid vasodilation (GA vs SAB/epidural)
  • Continue pacemaker
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43
Q

Two most common views of an echocardiogram

A
  • Transverse 4-chamber view
  • Transgastric short axis view
44
Q

Contraindications for TEE

A
  • Esophageal stricture
  • Esophageal masses
  • Recent bleeding from esophageal varices
  • Zenckers diverticulum
  • S/p radiation to neck
  • Recent gastric bypass surgery/ gastric band
45
Q

Where in the heart will most of the clot be in a patient with atrial fibrillation?

A

Left atrial appendage

46
Q

Types of replacement heart valves

A
  • Bioprosthetic
  • Mechanical
  • Polymer
47
Q

What are bioprosthetic valves made out of?

A

Porcine or bovine

48
Q

How long do bioprosthetic valves last?

A
  • 10-15 years
  • Ideal for older patients (80-85 years)
49
Q

What is the thrombogenic potential of bioprosthetic valves?

A
  • Low thrombogenic potential
  • No need to be on anticoagulants
50
Q

What are mechanical valves made out of?

A

Metal or carbon alloy

51
Q

How long do mechanical valves last?

A
  • 20-30 years
  • Ideal for younger patients (30-50 years)
52
Q

What is the thrombogenic potential of mechanical valves?

A
  • High thrombogenic potential
  • Will need to be on routine anticoagulants
53
Q

Risk factors for Mitral Stenosis.
What is the most common risk factor?

A
  • Rheumatic Fever (most common)
  • Female
  • RA
  • SLE
  • Stenosis s/p repair
54
Q

Patho of Mitral Stenosis

A
  • Diffuse thickening of mitral leaflets
  • Calcification of annulus and leaflets
  • Occurs very slowly (20-30 years)
55
Q

What problems are developed from Mitral Stenosis?

A
  • CHF
  • Pulmonary HTN
  • Right heart failure
56
Q

Sx of Mitral Stenosis

A
  • Obstruction of LV diastolic filling
  • ↑ LA volume and pressure
  • ↑ Pulmonary venous pressure
  • DOE
  • Orthopnea
  • Paroxysmal Nocturnal Dyspnea (PND)
57
Q

What distinct feature can be seen on a CXR for someone with mitral valve stenosis?

A

Left atrial enlargement on CXR

58
Q

What distinct feature can be seen on an EKG for someone with mitral valve stenosis?

A
  • Broad notched P-waves (LAE on EKG)
  • A-fib common
59
Q

Desired HR for Mitral Stenosis

A

Sinus rhythm

60
Q

Treatment for Mitral Stenosis

A
  • Diuretics to ↓ LAP
  • HR control if A-fib develops
  • BB, CCB, Dig/combo
  • Anticoagulants (7-15% risk/yr for stroke)
  • Balloon valvotomy/ commissurotomy/ replacement
61
Q

Treatment for patient w/ Mitral Stenosis in A-fib RVR.

A
  • Cardioversion
  • Amiodarone
  • BB/CCB/Digoxin
62
Q

What factors can increase central volume in mitral valve stenosis?

A
  • Excessive fluid administration
  • Tredelenburg position
  • Uterine contractions

Avoid these things in mitral valve stenosis.

63
Q

SVR consideration for mitral valve stenosis

A
  • Avoid ↓ SVR
  • Body will respond to ↓SVR w/ tachycardia, which will worsen CO
  • Need adequate afterload, consider phenylephrine/ vasopressin
64
Q

Mitral Stenosis Pre-Op Considerations

A
  • Caution with sedatives, more susceptible to ventilatory depression
  • No anticholinergics (Rubinol)
  • Continue HR control drugs
65
Q

Mitral Stenosis Induction/Maintenance Considerations

A
  • Avoid tachycardia (No Ketamine, Pavulon, Histamine releasers)
  • Have short-acting BB on hand
  • Avoid light anesthesia
  • Reverse gently
  • Care with excessive fluids
66
Q

Why would you want to avoid hypoventilation-induced respiratory acidosis in mitral valve stenosis?

A
  • Tachycardia
  • ↑ PVR
67
Q

Causes of Mitral Regurgitation

A
  • Endocarditis
  • MV Prolapse
  • LVH
  • Papillary muscle dysfunction
  • SLE
  • Rheumatoid arthritis
  • Ankylosing spondylitis
  • Carcinoid syndrome
68
Q

Normal size a of mitral valve

69
Q

Mitral valve stenosis size

70
Q

Patho of Mitral Regurgitation

A
  • Decrease forward LV stroke volume
  • Regurgitatant fraction > 0.6 (severe)
  • LVH
71
Q

Regurgitant fraction is dependent on these factors:

A
  • Size of MV orifice
  • HR
  • Pressure gradient (LV compliance and impedance to LV ejection)
72
Q

Dx of Mitral Valve Regurgitation

A
  • Holosystolic apical murmur, radiates to axilla
  • Cardiomegaly
  • LA enlargement and LV hypertrophy on EKG
73
Q

Treatment of Mitral Valve Regurgitation

A
  • Avoid bradycardia
  • Avoid acute afterload increases
  • Digoxin
  • Vasodilators…ACE inhibitors
  • Biventricular pacing

FAST FORWARD FULL

74
Q

Indicators for early mitral valve replacement for MR.

A
  • EF < 30%
  • Regurgitant SV > 65 mL
75
Q

Why is MV repair preferred over replacement for Mitral Valve Regurgitation?

A

Maintain normal LV ejection anatomy

76
Q

Anesthesia goals for MR

A
  • Prevent and treat ↓CO
  • Improve forward LV SV with afterload reduction
  • Maintain normal to slightly high HR
  • Foward, Fast, Full
77
Q

Mitral Regurgitation Induction/Maintenance Considerations

A
  • Avoid excessive narcotic-induced bradycardia
  • Use etomidate (min myocardial depression/ min SNS activity)
  • VA to ↓ SVR
  • Maintain adequate volume
  • Neuraxial technique to decrease afterload
78
Q

Patho of aortic stenosis

A
  • Disease of age
  • Caused by degeneration and calcification of leaflets
  • Associated with hypertension and hypercholesterolemia
  • Obstruction to ejection from LV into aorta
  • LV Pressure increases/ workload increases
  • Myocardial O2 delivery decreases
79
Q

When will aortic stenosis occur if a patient has congenital bicuspid aortic valves?

A

Earlier in life (30-50 years)

80
Q

Normal size of aortic valve

A

2.5-3.5 cm2

81
Q

Size of severe aortic valve stenosis

82
Q

Sx of aortic stenosis

A
  • Angina
  • Syncope
  • DOE
  • Systolic murmur that radiates to neck (mimics carotid bruit)
  • LVH on EKG
83
Q

Aortic Stenosis mortality rate within 3 years

84
Q

Treatment of Aortic Stenosis

A
  • May delay replacement until symptomatic
  • Balloon valvotomy useful in young adults
85
Q

Anesthesia goals for aortic stenosis

A
  • Similar to Mitral Stenosis
  • Maintain normal HR
  • Maintain normal volume and afterload
  • Cardiac arrest victims very difficult to resuscitate with severe AS
86
Q

Aortic Stenosis Induction/Maintenance Considerations

A
  • Do not decease SVR
  • Avoid tachycardia (no ketamine)
  • Treat HOTN with alpha agonist (phenylephrine)
  • Treat Bradycardia (glyco, atropine, ephedrine)
  • Treat Tachy dysrhythmias
87
Q

What device can help distinguish hypovolemia from heart failure in aortic stenosis?

A

Pulmonary artery catheters

88
Q

Causes of Aortic Regurgitation

A
  • Endocarditis
  • Rheumatic fever
  • Bicuspid aortic valve
  • Aortic dissection
  • Marfan’s syndrome
  • Anorexigenic drugs (drugs that reduce food intake)
89
Q

Pathophysiology of AR

A
  • Decrease in CO
  • Pressure and volume overload of LV
  • LV typically compensates for increased volume
90
Q

The amount of Regurgitant in AR is dependent on these two factors

91
Q

Dx of AR

A
  • Diastolic murmur radiates to the right sternal border
  • Widened pulse pressure
  • LV dysfunction…fatigue, dyspnea, coronary ischemia
  • LVH on EKG
  • Abnormal echo
92
Q

Asymptomatic mortality of AR

93
Q

Symptomatic mortality of AR

94
Q

Anesthetic goals for AR

A
  • Maintain Forward, LV SV
  • HR around 80
  • Prevent abrupt increase in SVR
  • Maintain contractility
  • FAST, FORWARD, FULL
95
Q

Aortic Regurgitation Induction/Maintenance Considerations

A
  • Prevent extreme bradycardia
  • Volatile anesthetics awesome at ↓ SVR
  • Maintain fluid volume to support preload.
  • FAST, FORWARD, FULL
96
Q

Should anticoagulants be continued for minor surgery if the patient has a mechanical valve?

97
Q

Coumadin/ Direct thrombin inhibitors should be discontinued how many days before preop?

A
  • 3-5 days
  • Lovenox instituted for major surgery
98
Q

What will be given post-op to patients w/ mechanical valves until oral anticoagulation is adequate?

99
Q

Preop abx should be given to patients with mechanical valves to prevent _________-

A

Bacterial endocarditis

100
Q

What is A?

A

Normal heart sound

101
Q

What is B?

A

Aortic Stenosis

Systolic murmur that radiates to neck, excess vibrations d/t narrowed valve that increases blood velocity, small diameter, loudest heart sound, more turbulence

102
Q

What is C?

A

Mitral Regurgitation

Blood will move in the wrong direction during systole, resulting in a holosystolic apical murmur radiating to axilla

103
Q

What is D?

A

Aortic Regurgitation

When there is high pressure in the aorta and low pressure and volume in the ventricle, blood will flow back to the LV during diastole. Causing a diastolic murmur radiating to the right sternal border.

104
Q

What is E?

A

Mitral Stenosis

Diastolic murmur, due to blood flow through the narrowed valve, filling issue. The diastolic murmur is louder towards the end d/t atrial contraction

105
Q

What is F?

A

Patent Ductus Arteriosus

Diastolic and systolic murmur present, there is blood flow going from the aorta (100 mmHg) to the pulmonary artery (16 mmHg)

Advanced Principles C (11 decks)

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