Mod2: PERIOPERATIVE MANAGEMENT FOR THE PATIENT UNDERGOING CARDIOPULMONARY BYPASS SURGERY Flashcards

1
Q

PREOPERATIVE EVALUATION

Anesthesia for cardiovascular surgery that will utilize CPB requires an undestanding of

A

Pt’s history and disease processes, and

Impact of history and disease processeson on the anesthetic plan and the surgical plan

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2
Q

PREOPERATIVE EVALUATION

T/F: The provider must always recognize that the anesthetic plan must be individually tailored to each pt, and it must remain fluid throughout the whole perioperative process

A

True

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3
Q

PREOPERATIVE EVALUATION

Prior to the day of surgery, the pt should have had an adequate cardiovascular evaluation which will include:

A

Lab testing

Imaging

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4
Q

PREOPERATIVE EVALUATION

Prior to the day of surgery, the pt should have had an adequate cardiovascular evaluation which will include lab testing and imaging

However, a full anesthetic assessment and chart evaluation must still be completed. Why?

A

To cover all the basis

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5
Q

PREOPERATIVE EVALUATION

Cardiovascular surgery also requires constant communication between which providers?

A

Anesthesia team

Surgeon/Surgical team

Perfusionist

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6
Q

PREOPERATIVE EVALUATION

What are the goals of preoperative evaluation?

A

Quantify & reduce perioperative cardiovascular risk factors influencing perioperative morbidity & mortality

Determine ventricular function

Prompt identification & treatment of ischemia

Identify & evaluate comorbid diseases effecting cardiopulmonary bypass

Patient/family education

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7
Q

PREOPERATIVE EVALUATION

Integration of preoperative data/information leads to appropriate selection of:

A

Monitors and

Anesthetic techniques

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8
Q

CARDIAC EVALUATION

By the time the anesthesia provider is consulted, a definitive cardiac diagnosis has already been established

However, things that support the diagnosis and require that the anesthesia provider pays close attention to in the chart have to do with:

A

Cardiac history

Physical signs & symptoms

Invasive & noninvasive diagnostic test

Pulmonary history

Renal

Diabetes Evaluation

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9
Q

CARDIAC EVALUATION

Cardiac history, including: Previous MI, active chest pain/pressure, Exercise tolerance/ Stress test, CHF symptoms are important to evaluate, why?

A

You don’t want to exacerbate their symptoms during the preoperative preparatory phase and cause further myocardial damage

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10
Q

CARDIAC EVALUATION

Physical signs & symptoms that are relevant to cardiovascular surgery include?

A

Vital signs

JVD

Apical pulses (displaced?!)

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11
Q

CARDIAC EVALUATION - Invasive & noninvasive diagnostic test

Make sure to pay close attention to the diagnostic tests that have already been performed. Why?

A

Could give a clue into which technique to use for induction

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12
Q

CARDIAC EVALUATION

Results from which test will be available for a diagnosis of Multi-vessel disease?

A

Cardiac catheterization

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13
Q

CARDIAC EVALUATION

Results from which test will provide information regarding Ventricular Function or Valvular Function?

A

TTE or Prior TEE

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14
Q

CARDIAC EVALUATION

If the pt has Carotid artery disease or a hx of Stroke, which operation may they require prior to their cardiac procedure?

A

Carotid endarterectomy

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15
Q

CARDIAC EVALUATION

And at minimum, if their carotid artery stenosis is more than 50% on either side, what additional monitor would you want to consider?

A

Cerebral oximetry

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16
Q

CARDIAC EVALUATION - T&S/T&C, CMP, PT, PTT/INR

Some surgeons may only require a T&S if the surgical repair isn’t expected to be extensive. However, if it’s a complex case, make sure there is a

A

T&C on the chart, and

Make sure there are NO antibodies

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17
Q

CARDIAC EVALUATION - T&S/T&C, CMP, PT, PTT/INR

What if there are antibodies?

A

Make sure the surgical team is aware of how long it will take to have the blood available for the pt

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18
Q

CARDIAC EVALUATION - Pulmonary history

If Smoker of history of COPD, what’s the minimum period of time before surgery they should go without smoking?

A

2 weeks before/day of surgery

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19
Q

CARDIAC EVALUATION - Pulmonary history

If Smoking history or COPD, and unable or unwilling to stop smoking at least 2 weeks before/day of surgery, when should education regarding smoking cessation should occur?

A

Within the 24hr prior to surgery

(This is a national quality measurement)

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20
Q

CARDIAC EVALUATION - Pulmonary history

Other pulmonary assessment prior to cardiac surgery include:

A

Dyspnea/SOB

Pulmonary function test/ Chest X-ray

Recent URI

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21
Q

CARDIAC EVALUATION - Pulmonary history

What do you do if Recent URI (within 2 weeks)?

A

Postpone elective surgery

22
Q

CARDIAC EVALUATION - Renal

If the pt has a history of renal insufficiency, this may be something to have a discussion with the surgeon and the perfusionist about; Why?

A

This may necessitate a change in treatment plan

23
Q

CARDIAC EVALUATION - Renal

How could treatment plan change If the pt has a history of renal insufficiency?

A

Pt may require hemofiltration after bypass, or

Dosing of medication may need to be altered

In addition, pts with renal disease often have lower HCT and Hgb, and may require blood transfusion while on bypass

Other considerations may include Volume overload from priming, or Hyperkalemic cardioplegia solution

24
Q

CARDIAC EVALUATION - Diabetes Evaluation

During bypass, Insulin requirements are higher for both diabetics and non-diabetics; why?

A

Surgical stressandnon-physiological state of bypass cause and increase in glucose levels

25
Q

CARDIAC EVALUATION - Diabetes Evaluation

Pts taking NPH insulin may produce antibodies to which drug? Why is that?

A

Protamine

Because NPH insulin contains protamine moiety

This could cause an increased risk for allergic reaction with the administration of protamine when it’s time to reverse the heparin

26
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY

For preparation, how long ahead of time will the anesthesia provider typically arrive?

A

At least one hour before the pt comes in the room

This time can varry depending on the complexity of the case

27
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY

T/F: A Routine anesthesia machine check is completed

A

True

28
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY

Airway should be gathered depending on?

A

what’s available at the institution

29
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY

Why should you consider and ETT designed for possible extended intubation?

A

Because a lot of cardiac surgery pts may require prolonged ventilatory support

30
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY

What’s the best ET tube for extended intubation and Why?

A

SealGuard ETT, or

Any ETT designed for prolonged intubation

SealGuard have an ET cuff with better seal at lower intracuff pressures

Also has a suction port that sits above the balloon for subglotic suctioning

This suction port has been associated with a reduction in ventilator acquired pneumonia

31
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY

Other Airway equipments include:

A

Nasal cannula for supplemental O2

End-tidal CO2 monitor

32
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY

Intravenous Access:

A

Usually two large-bore IV’s (14-18g-gauge)

Central line

PA catheter

33
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY

What features must a central line used during cardiac surgery have?

A

Hemostatic valve

Type of central line will varry depending on institution

Typivally a 9Fr introducer that has a hemostatic valve for PA catheter placement

Ultimately, you want a multilumen central catheter that would allow for mutiple drugs to be infused while simultaneously being able to measure hemodynamic parameters, and also with the ability to infuse large volumes of fluid in case of an emergency

One port should always only be dedicated to drug infusion and nothing else

34
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY

Standard ASA monitors used in cardiac surgery

A

5 lead EKG

Temperature

CVP, PA, Arterial BP

(Transduced, leveled and zeroed)

Cardiac Output

TEE

Multiple infusion pumps

35
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Pre-drawn Medications

Benefit of Pre-drawn Medications, and when to draw them?

A

Will save you in an emergency

Should be drawn up prior to bringing the pt to the OR

36
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Pre-drawn Medications

Heparin is one of the very important drugs to have pre-drawn up. Why? What’s its predraw dose?

A

The las thing you want to have to do draw up heparin to crash on bypass

Heparin predrawn dosed 400 units/kg

37
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Pre-drawn Medications

Other drugs to predraw include?

A

Induction medications

“Uppers”

Neo, Levo, Epi

“Downers”

NTG, Cardene

in 10cc syringe IVP, for immediate tx of hypo or HTN

Antibiotics

38
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion

How do you prepare infusion drips and pumps for cardiac surgery?

A

Infusion drips should be pre-spiked and

pumps should be pre programmed for the pt’s weight

39
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion

Which drips should be readied for cardiac surgery?

A

Phenylephrine, Norephrine, Epinephrine, Dopamine, Vasopressin, Dobutamine, Amiodarone***, Milrinone, Insulin, NTG, Cardene, etc.

40
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion

Amiodarone should be confirmed with the surgeon; why?

A

Because it is costly and not always required

41
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion

T/F:

Amiodarone must also have its own dedicated line with an in-line filter

A

True

42
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion

A pacemaker with extra batteries should always be available in the OR for cardiac surgery; why?

A

Intrinsic rhythm sometimes take a while to come back, or

They may even have complete heart block

43
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion

If the pt is asystole under the pacemaker, what must you consider having?

A

Backup pacemaker

44
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion

Blood products available/in room?

A

????

45
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY

Current Drug Therapy for cardiac surgery pts typically includes which classes of drugs?

A

Beta-blockers

Calcium channel blockers

ACE inhibitors

Digitalis preparations

Diuretics

46
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY

Pts are Usually instructed to continue Current Drug Therapy until time of surgery; with the exception of

A

Diuretics

47
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY

For Pre induction, when and where are A-line, central line typically placed ?

A

Prior to induction

either in the pre-op area or the OR

48
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY

Sometimes, pts are unable to tolerate line placement prior to induction, so it will be important to do a thourough pre-op evaluation to assess their

A

Tolerance

This would include anxiety level, ability to lie flat while awake, chest pain/pressure they are currently experiencing, restless leg syndrome

Will need opioids and benzodiazepines for sedation for invasive line placement

49
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY

T/F: Sedative tend to make restless leg syndrome more active

A

True

and they will not be able to lie still for line placement

50
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY

Pre-induction, why is O2 administration required for sedation?

A

You want to increase O2 content by increasing delivery

While reducing consumption

51
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY

Why is it important to evaluate their current drug therapy? Are they in-patient, and are already on heparin, NTG, Insulin?

A

NTG and insulin requirements may change prior to induction

This is something to take into consideration

52
Q

ANESTHETIC PREPARATION FOR CARDIAC SURGERY

Why is it important to have a pressor and a “downer” readily available at induction?

A

They may require additional support

Sedation could cause hypotension requiring a vasopressor, or HTN requiring Nicardipine?