Lectures 9 & 10

Question 1

What medications are usually continued up to the time of surgery?

Answer 1

Most cardiac meds (including beta-blockers)

Systemic glucocorticoids

Statins

Some anti-hypertensives

Question 2

What medications are often held on the day of surgery

Answer 2

Insulin

Oral hypoglycemic agents

Diuretics

High dose ASA and NSAIDs

Question 3

Meds that are held on a case-by-case basis

Answer 3

ACEi/ARBs

Long acting insulin

Low dose ASA

Antiplatelets

Question 4

Which two medications have protocols in regards to surgery?

Answer 4

Beta-blockers and statins

Question 5

What are active cardiac conditions?

Answer 5

List of cardiac conditions which, if present, indicate that you don’t do elective surgery without first evaluating, treating and stabilizing:

Unstable coronary syndromes (unstable angina, recent MI)

Decompensated HF

Significant dysrhythmias

Severe/poorly compensated valvular disease

Question 6

Cardiac clinical risk factors

Answer 6

H/o heart disease

H/o HF

H/o cerebrovascular disease

Diabetes

Renal insufficiency (creatinine > 2)

Question 7

What is hypotension

Answer 7

Just a number

We use it as a surrogate measurement because we have no objective indicator of cardiac output and only partial measures of tissue perfusion

Question 8

DDx of Hypotension

Answer 8

Hypovolemic

Distributive

Cardiogenic

Obstructive

*Obstructive and cardiogenic are essentially the same thing (in terms of PCWP, CO, and SVR) but they differ in etiology (i.e., rhythm problem vs tension pneumo)

Question 9

Vasopressor commonly used in anesthesia

Answer 9

Phenylephrine and Ephedrine

Question 10

True/False

Phenylephrine is 100x more potent than ephedrine

Answer 10

True

Note: the idea of potency is not that important for this comparison since they are not drugs in the same class

Question 11

Phenylephrine

Answer 11

Direct vasoconstrictor and acts as a peripheral alpha adrenergic agonist to increase peripheral vascular tone (venous more than arterial)

Minimal inotropic effects

No direct effect on HR

Question 12

Ephedrine

Answer 12

Releases catecholamines which stimulate beta receptors, commonly causing an increase in HR

BP increase is partly d/t increased cardiac pumping

Question 13

What is the effect of ephedrine on SVR?

Answer 13

Unpredictable

Released NE may stimulate alpha receptors more (increased SVR) or beta receptors more (decreased SVR)

Question 14

Choosing ephedrine vs phenylephrine?

Answer 14

Think ephedrine for heart and phenylephrine for pipes

Ephedrine: slower HR, less worried about myocardial perfusion, younger patient

Phenylephrine: faster HR, worried about myocardial perfusion, patient is older