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Lecture 3 Flashcards

1
Q

_____ is the Peripheral circulatory failure resulting in underperfusion of tissues. Characteristics include: ______ oxygen delivery to tissues.
_________ in anaerobic metabolism

A

Shock

Decrease oxygen delivery to tissues.
Increase in anaerobic metabolism

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2
Q

The three types of shock include:

A

Septic, Hypovolemic, and Cardiogenic

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3
Q

What happens to CI, PCWP, and SVR in septic shock?

A

Septic: Increased CI, Decreased PCWP, Decreased SVR

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4
Q

What happens to CI, PCWP, and SVR in hypovolemic shock?

A

Hypovolemic: Dec CI, Dec PCWP, Inc SVR

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5
Q

What happens to CI, PCWP, and SVR in cardiogenic shock?

A

Cardiogenic: Dec CI, Inc PCWP, Inc SVR

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6
Q

______ is the end result of many conditions. (ischemic heart disease, hypertension) and results in decreased ___________

A

CHF

intracellular cAMP

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7
Q

Decreased intracellular cAMP in CHF results in:

A

Downregulation of Beta receptors

Impaired coupling between beta receptors and adenyl cyclase

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8
Q

CHF responds to:

A

Responds to preload reduction, afterload reduction, and improved contraction

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9
Q

Low Cardiac Output Syndrome (LCOS) is seen in patients coming off of CPB and is a combination of:

A 
Inadequate oxygen delivery to tissues
Hemodilution
Mild hypocalcemia
Hypomagnesemia
Kaliuresis
Tissue thermal gradients
Variable levels of systemic vascular resistance
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10
Q

Risk factors for Low Cardiac Output Syndrome (LCOS) include:

A

Risk factors: DM, Increasing age, female, pre-op decreased LVEF, increased duration of CPB

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11
Q

Treatment of Low Cardiac Output syndrome includes:

A

positive inotropes to increase the contractility of normal and stunned myocardium
hypotension, unlike CHF, responds poorly to vasodilators alone

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12
Q

Goal of Low Cardiac Output syndrome:

A

increase levels of O2 delivery

increase O2 consumption

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13
Q

cAMP Dependent Positive Inotropes include:

cAMP Independent Positive Inotropes include:

A

cAMP Dependent:
Beta Agonists
Dopaminergic Agonists
Phosphodiesterase Inhibitors

cAMP Independent:
Cardiac Glycosides
Calcium

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14
Q

Hemodynamic effects of positive inotropes include:

A

Increased contractility with:
Increased SV
Often decreased LVEDP

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15
Q

T/F In the failing circulation, effects of inotropes are likely to be more pronounced.

A

TRUE

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16
Q

Complications of Isoproterenol:

A

Tachyarrythmias

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17
Q

Complications of high dose NE and Epi for prolonged periods with persistent low CO:

A

will decrease perfusion to many tissue beds and contribute to renal failure

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18
Q

Use Digoxin cautiously in patients with:

A

hypokalemia, renal failure, bradycardia, drug interactions

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19
Q

Arrhythmogenic potential of positive inotropes:

A

Dobutamine<Isoproterenol

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20
Q

For Beta agonists cAMP increases Ca influx via slow channels and increases Ca sensitivity of Ca-regulatory proteins. This Increase the force of:

A

contraction and velocity of relaxation

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21
Q

Epinephrine is the prototypical catecholamine that stimulates:

A

Alpha 1, Beta 1, Beta 2

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22
Q

Low dose epinephrine stimulates _____ and is essentially a _______

A

Beta 2, vasodilator

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23
Q

Intermediate dose epinephrine stimulates _____, which ___________

A

Beta 1
which is an inotrope
increases HR and contractility and increases CO and increases automaticity

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24
Q

High dose epinephrine stimulates ____ and is a potent _______.

A

Alpha 1
Vasoconstrictor

Most potent activator of Alpha-1 receptors
Potent vasoconstrictor including cutaneous, splanchnic and renal vascular beds
Used to maintain myocardial and cerebral perfusion
Increases Aortic dBP.
Reflex bradycardia can occur
Vasoconstrictor.

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25
Norepinephrine is primarily an __________
Alpha 1 agonist Beta-1 effects are overshadowed by its Alpha-1 effects Beta-2 effects are minimal
26
T/F: Cardiac output decreases at low doses, but at higher doses may increase because of increased afterload and baroreceptor-mediated reflex bradycardia
FALSE! Cardiac output may INCREASE at low doses, but at higher doses may DECREASE because of increased afterload and baroreceptor-mediated reflex bradycardia
27
NE binds to _________ more readily than ____
Binds to Alpha-1, Alpha-2 and Beta-1 receptors more readily than Beta-2
28
Isoproterenol has ______ receptor effects, No _____ effects.
BETA 1 and BETA 2 NO ALPHA Increases HR , contractility, B.P., and cardiac automaticity Decreases SVR and diastolic BP
29
The net effect of Isoproterenol is
increased CO and decreased MAP
30
Isoproterenol should not be used in patients with
Cardiogenic shock and with ischemic heart disease
31
Uses of Isoproterenol include:
Chemical pacemaker after heart transplant or in complete heart block Bronchospasm management during anesthesia Maybe used to attempt to decrease PVR in patients with pulmonary hypertension and RV failure.
32
Dobutamine is a synthetic catecholamine with structural characteristics of:
Dopamine and Isoproterenol
33
Dobutamine acts primarily on
Beta 1 receptors with small effects on Beta 1 and Alpha 1 receptors No clinically significant vasoconstrictor activity. Small increase in heart rate compared to isoproterenol. Less likelihood of adverse increase in myocardial O2 requirements. Dilates coronary vasculature. No dopaminergic receptor activation. Increases renal blood flow by increasing C.O.
34
Dobutamine has dose dependent increases in _____ and decrease in _______.
HR and CO and decrease in filling pressures Inotropic properties with less dysrhythmogenic activity, doses >10 mcg/kg/min may predispose to tachycardia and cardiac dysrhythmias
35
D1 ultimately ______ cAMP, which results in ______________.
activates Smooth muscle of blood vessels: vasodilatation Naturesis, Diuresis
36
D2 ultimately ______ cAMP, which results is
inhibits Presynaptic: Inhibit NE release and promote vasodilation Attenuate the beneficial effects of DA on renal blood flow
37
Dose dependent effects of Dopamine:
0.5-3 mcg/kg/min dopamine effect (DA1 and DA2) 3-10 mcg/kg/min beta effect 10-20 mcg/kg/min beta and alpha effects Over 20 mcg/kg/min alpha effects Relationship between DA dose and effect is associated with some individual to individual variability.
38
T/F Low dose dopamine is renal protective
FALSE Increases RBF, GFR, Na+ excretion and urine output BUT NOT RENAL PROTECTIVE
39
Dopamine is often used in clinical situations where the patient presents with:
Decreased C.O. Decreased systemic B.P. Increased L.V. end-diastolic pressure
40
________ interferes with the ventilatory response to _______.
Dopamine | hypoxemia
41
High doses of Dopamine ______ release of insulin, which causes
inhibit | hyperglycemia
42
Dopamine and Dobutamine must be mixed in
D5W
43
Phosphodiesterase III inhibitors:
Slow the metabolism of cAMP to 5’-AMP increasing intracellular cAMP concentrations. Increase the Ca sensitivity of contractile proteins Increase Ca influx Antagonize adenosine
44
Inamrinone is a PD3 that has dose dependent increases in ____&___ and decreases in ____&____ after CABG.
Dose-dependent increases in SV and CI and decreases in SVR and PVR after CABG More effective with fewer complications than dobutamine during separation from CPB
45
In patients with poor LV function, Inamrinone is as effective as ______, but both are more superior to either drug alone.
epinephrine | Inamrinone increases intrapulmonary shunting and decreases PaO2.
46
Adverse reactions of Inamrinone include:
``` Thrombocytopenia (10%) Elevated LFTs Arrhythmias Do NOT administer to patients AS May aggravate outlet obstruction in patients with IHSS ```
47
Milrinone is preferred to inamrinone because:
Inotropic and vasodilator properties similar to inamrinone but 15-20 times more potent, with a shorter t½ and without the risk of thrombocytopenia. Decrease dose in renal failure
48
Side effects of milrinone include:
Headache, hypotension, syncope. Ventricular arrhythmias. Increased ventricular response rate in A. Fib/ . Flutter.
49
Effects of glucagon:
Acts at a receptor other than beta to increase cAMP (Glucagon receptor?) Increases CI, HR, BP while decreasing SVR and LVEDP Useful for cardiac failure particularly when precipitated by beta-adrenergic blockade Use is limited due to expense and side effects (N/V, increased blood sugar, increased coronary and pulm. vascular resistance)
50
Effects of digoxin:
Cardiac glycoside: Positive inotrope. Negative dromotrope. Negative chronotrope
51
Direct myocardial action of digoxin:
Inhibits Na-K ATPASE increasing intracellular Na and indirectly intracellular Ca. Ca may bind to troponin-C, increasing inotropy In CHF, dig increases LV shortening and EF Not effective for acute management of LCOS
52
Uses of digoxin:
Positive Inotrope for the treatment of mild to moderate heart failure Often used in combination with a diuretic and ACE Inhibitor. Control of ventricular response rate with chronic A. Fib.
53
The toxic level of digoxin is
Plasma levels > 3ng/mL. Treating CHF keep < toxic level. Treating A. fib. Treat to results (desired ventricular rate)
54
Digoxin toxicity is associated with
decrease in intracellular potassium
55
Predisposing causes of digoxin toxicity:
``` Hypokalemia Hypomagnesemia Hypoxemia Hypercalcemia Hypothyroid ```
56
Presentation of digoxin toxicity:
``` Presentation: Early: anorexia, N/V PVCs Paroxysmal atrial tachycardia with block Most common dysrrhythmia. Mobitz type II A-V- block V. fib. Most frequent cause of death ```
57
Treatment of digoxin toxicity:
Correction of predisposing causes: Supplemental potassium. Supplemental magnesium. Correct hypoxemia. Administration of drugs: Phenytoin or lidocaine to suppress ventricular dysrhythmias. Atropine to increase heart rate. Beta blocker use to suppress increased automaticity may be limited by increased AV node refractoriness when conduction blockade is present. Temporary pacing if complete heart block is present.
58
After administration of Digibind, are digoxin levels accurate?
NO, Do not check levels. Levels are useless for several days
59
Digoxin drug interactions:
``` Drugs Dec Clearance Quinidine Amiodarone Verapamil Propafenone Coreg Cyclosporine Conivaptan ``` ``` Enhance Dig Abs Macrolides PPIs “Conazoles” Ranolazine Dec Dig Abs Resin binders Acarboes/miglitol Kaolin-pectins Reglan Sulfasalazine Sucralfate ```
60
Effects of calcium:
Ca above the normal range, improves contractility of isolated cardiac muscle. Ca increases systemic vascular resistance. Ca interacts with vasoactive drugs. Ca can inhibit Beta agonists by direct inhibition of adenyl cyclase Bolus dosing of Ca has no consistent effect on CO coming off CPB.
61
Catecholamine Complications:
``` Local tissue ischemia from SQ infiltration of inoconstrictors. Increased myocardial oxygen consumption Enhance lipolysis and gluconeogenesis Alter electrolyte concentrations Activate coagulation Override microvascular control mechanisms Alter distribution of CO Increase myocardial work Increase the risk of cardiac arrhythmias ```
62
Therapeutic Plan for Low CO:
Optimize Heart Rate and Rhythm Optimize Preload If BP acceptable after increasing preload, administer an arteriolar dilator to increase SV (Optimize afterload). For low BP, add an Inotrope
63
Positive inotrope selection for Pulmonary and or systemic HTN:
dobutamine, inamrinone or milrinone, isoproterenol
64
Positive inotrope selection for low SVR:
NE, DA, epi
65
Positive inotrope selection for normal SVR and PVR:
DA, epi
66
Positive inotrope selection for Tachycardia:
inamrinone or milrinone, calcium, NE, epi
67
Persistent low CO or myocardial ischemia with maximal medical therapy indicates the need for:
IABP, LVAD
68
ALARM-AF Trial:
Lower in house mortality for patients receiving vasodilator + diuretic (7.6%) vs diuretic alone (14.2%) Greater in house morality for IV inotropes (25.9%) vs No inotropes (5.2%) 1.5 fold increase for patients receiving dopamine or dobutamine, 2.5 fold increase for patients receiving NE or Epi

Pharm II (3 decks)

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