Module 3: Anesthetic Management for Patients with Cardiovascular Disease Flashcards
Coronary Artery Disease
Preventing myocardial Ischemia
Avoid factors known to increase ______
Principle determinants of MVO2:
- MVO2
Wall tension
Contractility
Myocardial O2 balance with CAD
- Typically __________ at rest
- Exercise/stress increases MVO2
- Ischemic symptoms develop
- O2 requirements greater than existing __________
- Coronary vascular reserve is _______.
- Ischemic symptoms develop:
- asymptomatic
- coronary blood flow; exceeded
- Angina
- Alterations in electrophysiology, metabolism, function
Myocardial O2 balance with CAD
Obstructions
* ________ conductance vessels
* Normally, the resistance is almost ______
As the percent of stenosis increases, the ________ across the stenotic area increases
1. Resistance begins to increase when lumen is reduced by > ______%
1. Further _______, resistance increases dramatically
1. 80-90% stenosis, resistance across stenosis _________.
1. Small changes in vessel diameter can dramatically _______ resistance and ______ CBF.
Obstructions
* Large epicardial
* zero
resistance.
1. 50
2. restrictions
3. triples
4. increase; decrease
Remember Laplace’s Law
- Wall tension is _______ proportional to intracavity pressure and radius
- Wall tension in _______ proportional to wall thickness
Can decrease MVO2 by:
* ______ intraventricular pressure
* Preventing or promptly treating _________.
- directly
- inversely
- Decreasing
- ventricular distention
Preload and Afterload
Myocardial Oxygen Supply
The only way to meet increasing myocardial O2 demands is by increasing ___________.
CBF
Coronary Blood Flow
Critical factors/modifiers:
What area of the heart is most vulnerable to ischemia?
- Perfusion pressure
- Vascular tone of the coronary circulation
- Heart rate (time available for perfusion)
- Severity of intraluminal obstructions
- Presence of collateral circulation
Subendocardium of the LV
Myocardial O2 balance with CAD: Compensatory Mechanisms
Collateral circulation
* Develops and matures over time
* Physiologic bypass of the obstructed vessels
Resting CBF maintained by progressive _______ at the microcirculation
* As proximal stenosis increases, _______ seeks to preserve flow
* Basal flow can increase ___-__ times with maximal vasodilation
Coronary vascular reserve progressively decreases and flow becomes ________.
vasodilation
- autoregulation
- 4-5
- pressure dependent
Hemodynamic Goals for Coronary Artery Disease
Goals:
Define risk
Determine need for further testing
Form a safe anesthetic plan
Need for additional medications (beta blockers or anti-hypertensives)
Interventional therapies
Surgery
Recognize the S & S of:
uncontrolled HTN,
myocardial ischemia,
CHF,
valvular heart disease, and
cardiac dysrhythmias
What are the risks of a perioperative event?
Goldman Cardiac Risk Index
Studied over 4,000 patients aged 50 years or older who were having elective, major noncardiac procedures
Found 6 independent predictors of complications
Complications increased with number of risk factors present
1
2
3
4
5
6
Patients with Symptomatic CAD
- Preoperative Evaluation may show changes in frequency or pattern of angina symptoms
- Some patients may have more atypical or undiagnosed (silent) features: (3)
- _________ is associated with high perioperative risk of MI
- Perioperative period associated with __________ state an increase in endogenous catecholamines (increasing risk of MI)
Elderly
Women
Diabetics
/—-/
Unstable angina
/—-/
hypercoagulable
Preoperative Evaluation: HISTORY of CAD
HTN: severity and duration, medications
Smoking
High cholesterol
Symptoms of any conditions
* Myocardial ischemia
* Ventricular failure
* PVD
* Diabetes (higher incidence of CAD, silent MI and ischemia)
* Chest pain, exercise tolerance, SOB
* Edema
Valvular Disease s/s:
Cardiac stents, implantable devices
Angina, dyspnea, syncope, CHF
PHYSICAL EXAM
HEART SOUNDS
1. MURMURS
1. PMI LATERAL TO NORMAL (_______)
1. S4 GALLOP (______)
1. CAROTID BRUITS (_________)
LUNG SOUNDS
1. Pulmonary RALES AND S3 GALLOP (____)
BLOOD PRESSURE MEASUREMENT (SUPINE AND STANDING)
ORTHOSTATIC CHANGES
(VOLUME DEPLETION, HEMORRHAGE, EXCESSIVE VASODILATION)
One study showed: Admission BP and HR was the best predictor of response to laryngoscopy (anxiety?)
HEART SOUNDS
1. CARDIOMEGALY
2. LVH
3. VASCULAR DISEASE AFFECTING CORONARY CIRCULATION
LUNG SOUNDS
1. CHF
Electrocardiogram
Provides info on state of the _____ and _________
Rate, Bundle branch blocks, lv
Old injuries/infarcts
Pacer spikes
Conduction abnormalities
myocardium and coronary circulation
Abnormal “Q” waves
- Highly suggestive of _____.
- 30% of myocardial infarctions occur without symptoms (silent MI) with highest incidence in ____ and _____.
- Presence of Q wave on preoperative EKG in a high risk patient = high indication of ______ and ______.
- past MI
- diabetics and hypertensives
- increased perioperative risk and possible active ischemia
Preoperative Evaluation might include:
CXR
________ results : (LVH, DIASTOLIC AND SYSTOLIC FUNCTION ESPECIALLY IN HEART FAILURE)
Cardiac tests
LABORATORY FINDINGS
RENAL: SERUM CREATININE AND BUN LEVELS
POTASSIUM (DIURETICS, DIGOXIN OR RENAL IMPAIRMENT, EKG CHANGES/ECTOPY)
Magnesium
Hemoglobin/Hematocrit
ECHO
Surgical Procedure Risk
Major _______ procedures associated with highest incidence of complications
ACC/AHA risk stratification
Other high risk procedures:
- vascular
/—–/ - Abdominal
- Thoracic
- Orthopedics
2014 ACC/AHA guidelines
Importance of Exercise Tolerance
Exercise tolerance is one of the most important determinants of perioperative risk and the need for further testing and invasive monitoring
Good exercise tolerance suggests that the myocardium can be stressed without failing (climbing two flights of stairs or walking 4 blocks)
Assessed with a questionnaire that assesses daily activity
(hip/knee issues?)
Treadmill testing
Choice of Anesthetic - Regional (CAD)
Regional anesthesia
Dense analgesia
Blockade of afferent and efferent nerve conduction (catecholamine release is _________)
Major disadvantages
1. __________ from sympathetic block
1. Increase in wall tension with ________ could precipitate subendocardial ischemia w/CAD
* Alpha-agonist may be better
* Large volume loads may be problematic after return of vascular tone
- suppressed
Major disadvantages
1. Hypotension
2. volume loading
Choice of Anesthetic: General (CAD)
General anesthesia with ______
- Lack of myocardial depression (desirable in patients with markedly impaired ____________)
- Suppression of stress response
- Reduction of HR
- Hemodynamic stability
Can supplement with volatile anesthetics
Muscle relaxants
Emergence: relatively comfortable and _________ avoidance.
- Opioids
- ventricular function
- hypothermia
Selection of Anesthetic (CAD)
There is _____ ideal anesthetic for patients with CAD
Opioids
Advantages: lack of myocardial depression, stable hemodynamic state and reduction of heart rate
High dose valuable only in the patient with severe __________.
Inhalational
Dose-dependent hemodynamic changes, reversible, titratable myocardial depression, suppression of sympathetic responses to surgical stress
Protect the myocardium from______and ________ and reduces _______ size
Disadvantages:
- ______.
Adjuncts: propofol, midazolam, dexmedetomidine
- no
Opioids:
myocardial dysfunction
Inhalational:
- ischemia and reperfusion injury; infarct
- systemic hypotension
**Treatment of Intraoperative Problems ** (CAD)
Sinus tachycardia
* Increase anesthesia
* Beta blockers
Increase PCWP
* _________.
* Restrict fluids
* Volatile anesthetic with good LV function
HTN
* Anesthesia,
* vasodilators,
* beta blocker if tachycardia
Hypotension
*___________, if transient and not hypovolemic
* Volume, if hypovolemic
Inotrope
* Associated with increase PCWP and decrease CO
* Increase MVO2 offset by increased CPP and decreased ventricular size
- _________: Maintains perfusion pressure and keeps heart small
Increase PCWP
- Ntg (add inotrope or alpha agonist if decrease in BP
Hypotension
* Alpha agonist
* Neo/NTG
Pathophysiology of Valvular Heart Disease
- Causes chronic ______ and _______ overload
- Ventricular Hypertrophy: increased __________.
- _________ overload: Concentric (_______ ventricular wall thickness, ________ chamber size)
- ________ Overload: Eccentric (_________ wall thickness and _________ cardiac chamber)
- volume and pressure overload
- increased left ventricular mass
- Pressure overload: Concentric (increase in ventricular wall thickness, normal chamber size)
- Volume Overload: Eccentric (normal wall thickness and dilated cardiac chamber)
Valvular Heart Disease
- Should have a high index of suspicion if patient has a history of:
- Exercise tolerance usually decreased
- Exhibit signs/symptoms of heart failure to include:
- Angina can occur in patients with:
1._______ often accompanies enlargement of the atria
- rheumatic fever, IV drug abuse, genetic disorders (i.e., Marfans), heart surgery as a child, or heart murmurs
- –
- dyspnea, orthopnea, fatigue, pulmonary rales, jugular venous congestion, hepatic congestion, or edema
- hypertrophied left ventricle
- A-Fib
Concetric vs. Eccentric HF
Tests to evaluate valvular heart disease:
Echocardiography with doppler can:
EKG: Evidence of ischemia, arrhythmias, atrial enlargement, ventricular hypertrophy
CXR:
Cardiac Cath:
ECHO:
* Measures size and function of the chambers
* Pressure gradients of the valves
* Valve area measurements
* Severity of disease determined
CXR
* enlargement of chambers,
* pulmonary HTN,
* pulmonary edema and effusions
Cardiac Cath:
* used before surgery to diagnosis CAD,
* measurement of heart pressures in the chambers and pressure gradients across valves
Transesophageal Echocardiography (TEE)
- Can be used in the OR during valve surgery
- Evaluate severity of valvular disease, structural and functional changes
- Evaluation of the valve repair or function of artificial valves
- ______ and ______ function of the Left and right ventricles before and after bypass
- Determines postsurgical management
- Systolic; diastolic
Pressure-Volume Loops
- Plots LV pressure against volume through one complete cardiac cycle
- Each valvular lesion has a unique profile that suggests compensatory physiologic changes by the left ventricle
P-V Loops: Valve disease
A = normal
B = mitral stenosis
C = aortic stenosis
D = mitral regurgitation (chronic)
E = aortic regurgitation (chronic)
Aortic Stenosis (AS)
- Most common valvular disease in the U.S.
- Normally, composed of _____ semilunar cusps
- Classified as ______, _______, or ________ obstruction
- _________ hypertrophy develops:
- -
- 3
- valvular, subvalvular, or supravalvular
- Concentric: thickened ventricular wall with normal chamber size
Pathophysiology of Aortic Stenosis
- Decreasing LV _______ accompanies _______ LV end-diastolic pressure
- ______ and _________ can be maintained until late disease process
- Atrial contraction account for ______ of the ventricular filling (normally _____)
- Clinical factors associated with AS:
- Causes:
- compliance; elevated
- Contractility and ejection fraction
- 40%, 20%
- Older, male, smoker, HTN, Hyperlipidemia
- Rheumatic fever (more common in developing countries)
- Calcification of tri-leaflet
- Congenital bicuspid valve
Presentation of Aortic Stenosis
Angina
* Angina can occur in the absence of CAD
* Thickened myocardium is susceptible to ______ and elevated ___________ that decrease coronary perfusion pressure
Syncope
CHF
Tighter AS, __________ increases to a level where LV hypertrophy can not normalize the wall tension so the heart starts to _______ with symptoms of systolic dysfunction and decreasing cardiac output
Life expectancy with symptoms of:
Angina: ____ years
Appearance of syncope: ___-__ years
Appearance of CHF: ___-__ years
Angina
- CAD
- ischemia; LV end-diastolic pressure
CHF
- LV systolic pressure
- dilate
- 5
- 3 - 4 years
- 1 - 2 years
Aortic Stenosis
P-V loop for Aortic Stenosis
- Left ventricle is working at higher _________ to generate normal SV
- Elevated wall tension stimulated parallel replications of _______
- So… ______ and ______.
- Increased _________ to accomplish the pressure work
- intraventricular pressure
- sarcomeres
- myocardial thickening and LV hypertrophy
- contractility
Anesthetic/Hemodynamic goals: AS
Preload:
Afterload:
Contractility:
Preload:
full to fill the noncompliant ventricle
Afterload:
maintain coronary perfusion gradient, reduction in BP with decrease CPP risk of subendocardial ischemia and sudden death
Contractility:
maintained to overcome the high-pressure gradient through the valve
Anesthetic/Hemodynamic Goals: AS
Rate:
Rhythm:
MVO2:
Rate:
NORMAL: avoid bradycardia (decreases CO with fixed stroke volume) and tachycardia (ischemia with limited diastolic time for coronary perfusion)
Rhythm:
sinus (important in atrial contraction in LV filling); cardioversion if hemodynamic compromise and arrhythmia
MVO2:
avoid tachycardia and hypotension (ischemia is big risk)
Anesthetic Management: Aortic stenosis
Monitoring:
Standard, 5-Lead, A-Line, PA/TEE depends on type of surgery, defibrillator handy
Induction:
Regional: SAB is relatively ________ in severe AS (sympathectomy)
General:
Maintenance:
Maintain HR, treat tachycardia immediately
Treat arrhythmias with cardioversion
Treat hypotension immediately
- contraindicated
- heavy opioid/benzo technique, volatiles fine
“The Death Spiral in AS”
In severe or critical AS,
* Any drop in SBP for any reason can result in the viscous cycle
* Chest compressions are ineffective (difficult to generate enough mechanical force to create adequate SV across the stenotic valve
* Resulting in sudden death
Aortic valve
Pathophysiology of Aortic Insufficiancy (AI)
- ________, ___________, ________, and _________ are among the most common causes of AI
- Acute AI causes:
- Chronic AI:
- ___________ hypertrophy:
- Rheumatic fever, aortic root dilation, congenital bicuspid aortic valve, and infective endocarditis
- infective endocarditis, aortic dissection (Marfan syndrome), after balloon valvotomy or failed surgical valve repair
- LV diastolic volume overload (Stroke volume regurgitates back across the valve in diastole.)
- Eccentric : (dilated LV with normal or thickened wall)
aortic regurgitation
P-V Loop in “acute” AI
- EDV and ESV _______
- Contractility __________ (myocardium overstretched)
- ______ may be increased, decreased or normal
- LV volume _________ during isovolumetric relaxation (D-A segment)
- EDP (A-B segment, B point) is _____
- increase
- decreased
- SV
- increasing
- high
P-V Loop in “chronic” AI
- _____, _______ and _____ enlarged
- Cardiac output ______
- Contractility _______
- LV volume __________ during isovolumetric relaxation (D-A segment)
- EDP (A-B segment, B point) _______
- Diastolic reserve ______
- EDV, ESV, SV
- normal
- decreased
- increasing
- normal
- intact
Anesthetic/Hemodynamic goals in AI
Preload:
Afterload:
Contractility:
Rate:
Rhythm:
MVO2:
Preload:
Increase slightly, necessary for forward flow
Afterload:
Reduction augments forward flow; increase anesthetic depth or vasodilators (to decrease regurgitant fraction)
Contractility:
Usually adequate; maintain with beta-agonists; dobutamine is ideal (does not increase afterload)
Rate:
Increase→ improves forward flow by decreasing diastolic duration and decreasing regurgitant flow and increasing EF
Also improves coronary perfusion
Rhythm:
Usually sinus
MVO2:
Usually not a problem
Anesthetic Management in AI
Monitoring and preop management same as aortic stenosis
Induction:
* Regional:
- General:
Maintenace:
Phenylephrine or Ephedrine to treat hypotension?
- Regional: may have an advantage of decreasing SVR and therefore afterload
- General: Ketamine/Pancuronium may be useful to increase HR
Pathophysiology of Mitral Stenosis
- causes:
- Symptoms:
- Worsened in conditions that need increased _______.
- Blood stasis in left atrium (dilated LA) risk of:
- _______ years before critical stenosis manifests (normal = ___-___ cm2; stenosis = ______cm2)
- Develop:
- causes: **Rheumatic disease **(80-90%), infective endocarditis (3.3%), mitral annular calcification (2.7%)
- fatigue, dyspnea on exertion, hemoptysis, diastolic murmur
- CO (pregnancy, anemia, exercise)
- thrombus formation and SVT/A-Fib
- 20+/////4-6////1.5
- hoarseness
Rheumatic fever/heart disease
Rheumatic fever:
_______ issue, usually in underdeveloped/developing countries where antibiotics are not routine
Rheumatic heart disease:
Cardiac inflammation and scarring triggered by an autoimmune reaction to infection with _______________.
Acute stage: consist of ________.
Chronic stage: ___________.
Stenosis usually starts in females and up to _______ years after rheumatic heart disease diagnosis (progressive calcification and fusion of leaflets)
- Childhood
- group a streptococci
- pancarditis (inflammation of the myocardium, endocardium, and epicardium)
- valvular fibrosis (stenosis and/or insufficiency); 2
Mitral Stenosis
Anesthetic/Hemodynamic goals: MS
Preload:
Afterload: prevent _____; _______ RV afterload due to pulmonary vasoconstriction (hypoxia and _______); vasopressors for systemic hypotension
Contractility: _______ for adequate filling of lv (atrial contraction contributes _____% of SV)
Rate: Maintain at __________; avoid and treat __________.
Rhythm: Control ventricular response in ___________.
Mvo2:
Preload: good intravascular volume to maintain flow across stenotic valve, avoid overhydration
Afterload: prevent increase; increase RV afterload due to pulmonary vasoconstriction (hypoxia and hypercarbia); vasopressors for systemic hypotension
Contractility: sinus rhythm for adequate filling of lv (atrial contraction contributes 30% of SV)
Rate: Maintain at low end of normal; avoid and treat tachycardia
Rhythm: Control ventricular response in atrial fib
Mvo2: Not a problem usually
Anesthetic/hemodynamic goals: MS
Objective
Maintain NSR, avoid ________ and large increases in ________ (both hypovolemia and fluid overload)
Monitoring
_________ to help guide perioperative management (fluids)
Invasive monitoring dependent on type of surgery
Choice of agents
1. Sensitive to vasodilating effects of:
- Vasopressors to maintain vascular tone (neo? Ephedrine?)
- Avoid intraoperative _________.
- Adequate level of anesthesia to avoid:
Objective
tachycardia; CO
Monitoring
TEE
Choice of agents
1. SAB or epidural (pregnancy?)
2. ?
3. tachycardia (beta blockers, opioids)
4. sympathetic stimulation (SVR, PVR increases)
P-V Loop in Mitral Stenosis
- _____ and _______ small (limited flow into the left ventricle)
- LV generates _________.
- Contractility is _________ (chronic _______ of the LV)
- EDV, SV
- low BP
- decreased; decreased;
Etiology of Mitral Regurgitation (MR)
- Results from any process that distorts the:
Organic MR
* _______.
* _______.
* _______.
* _______.
Functional MR
* May have normal:
* Often occurs from:
- mitral leaflets,
- chordae tendineae,
- papillary muscles,
- valve annulus or
- left ventricular geometry
Organic MR
* Mitral valve prolapse (most common),
* rheumatic heart disease,
* mitral annular calcification,
* endocarditis
Functional MR
May have normal mitral leaflets and chordal structures
Often occurs from ischemic heart disease (IHD) or dilated cardiomyopathy
Etiology of MR
Secondary to abnormalities of chordae tendineae (3)
Papillary muscle dysfunction (2)
- Rupture with acute myocardial ischemia or infarction
- Bacterial endocarditis
- Mitral prolapse
- Ischemia of the posterior papillary muscle (blood supply from RCA)
- Endocarditis
Etiology of MR
Acute MR
* Typically presents in _______.
* Significant regurgitation into the LA with __________.
* Precipitous increase in ____ and _______
* ______________ may develop rapidly.
Chronic MR
* __________
* Regurgitant volume over time causes atrial and ventricular ______ and __________.
Acute MR
1. Typically presents in pulmonary edema
1. Significant regurgitation into the LA with normal compliance
1. Precipitous increase in LAP and PCWP
1. Cardiogenic shock may develop rapidly
Chronic MR
* Progressive
* enlargement and annular dilation
Pathophysiology of Acute MR
- Sudden large volume overload into an uncompensated LA and LV causing severe pressure increase in _______ with_________.
- Volume overload increases _______, modest increase in ___________.
- Clinical presentation of_______ heart failure despite normal myocardial function
- both chambers with severe pulmonary edema
- LV preload; LV stroke volume (Frank-Starling)
- left-sided
Pathophysiology of Chronic MR
Volume overload:
* Ventricular and atrial volume overload
* Compensatory LA and LV enlargement (eccentric hypertrophy) to permit extra volume
LV and RV issues:
* prolonged overload leads to________ which creates a viscous cycle
* Leads to SV ______, filling pressure ______.
* Pulmonary edema, pulmonary HTN and _____.
Volume overload:
* Ventricular and atrial volume overload
* Compensatory LA and LV enlargement (eccentric hypertrophy) to permit extra volume
LV and RV issues:
* LV dysfunction
* decrease, rises.
* RV failure
Anesthetic/hemodynamic Goals: MR
Preload:
Afterload:
Contractility:
Rate:
Rhythm:
Mvo2:
Preload:
* Maintain adequate preload for good forward flow
* Do not overload (dilate both LV and worsen MR/pulmonary congestion)
Afterload:
* decrease SVR,
* arterial vasodilators (dobutamine);
* afterload reduction augments forward flow and decreases regurgitation
Contractility:
* May be depressed; titrate myocardial depressants carefully
Rate:
* Increase slightly; avoid bradycardia which can increase regurgitant flow decreasing the ejected flow in the aorta
Rhythm:
If atrial fib, control the ventricular response
Mvo2:
Compromised if MR coexists with ischemic heart disease
Anesthetic Considerations **MR **
Preop
Versed for anxiety to prevent increase in ____ or _____
Monitoring
Standard, 5-lead, ________,_______,________.
Induction
Regional (careful with abrupt decrease in ______)
General (avoid ________)
Maintenance
Preload, normal EtCO2
Severe dysfunction may need ______.
Preop
SVR or PVR
Monitoring
Standard, 5-lead, aline, CVP/PA, TEE
Induction
Regional: Preload
General (avoid bradycardia)
Maintenance
- dobutamine
P-V loop in Mitral Regurgitation
Acute
* EDV _______ with _______ EDP
* ESV _________, SV ________.
* Ejected volume into the aorta is ______ depending on the regurgitant volume
Chronic
* EDV ________ with ______ EDP due to myocardial remodeling
* ESV ________.
* Markedly __________ SV
Acute
* EDV increases with high EDP
* ESV normal or decreased, SV increased
* Ejected volume into the aorta is small depending on the regurgitant volume
Chronic
* EDV increased with normal EDP due to myocardial remodeling
* ESV normal or increased
* Markedly increased SV
Myocardial Remodeling
Myocardial remodeling: **Ventricular remodeling(orcardiac remodeling) **refers to the changes in size, shape, structure, and function of the heart.
This can happen as a result of ________ OR _____________
exercise (physiologicalremodeling) or after injury to the heart muscle (pathologicalremodeling).
Pathophysiology of Tricuspid Stenosis (TS)
Etiology:
- TS leads to ___________.
- _________ dependence
- ___________ system disease
- Physiology resembles the restriction to ________ into the heart as seen in ___________.
Etiology:
* Congenital,
* rheumatic heart disease, or
* mechanical due to thrombus
- right atrial enlargement
- PRELOAD dependence
- Conduction system disease (A-Fib/flutter, SVT)
- Physiology resembles the restriction to venous return into the heart as seen in cardiac tamponade
Anesthetic/hemodynamic Goals of TS
Monitors:
Preload:
Rate:
Rhythm
Monitors:
A-line, CVP and TEE
Preload:
Maintain normal
Rate:
Normal range
Rhythm
Normal sinus
Pathophysiology of Tricuspid Regurgitation (TR)
Primary (TR with __________)
Causes:
Secondary (more common)
* RV _________ and annular ________.
* Associated with longstanding ____________
* Most common in patients with _________
Isolated TR:
________ for many years
S/S:
Primary (TR with abnormal valve)
* Rheumatic heart disease,
* infective endocarditis,
* carcinoid syndrome,
* trauma
Secondary (more common)
* RV enlargement and annular dilation
* Associated with longstanding pulmonary HTN
* Most common in patients with MV disease
Isolated TR:
asymptomatic for many years
* Pulsatile neck veins,
* Pansystolic murmur
* generalized weakness,
* early fatigue,
* fullness in RUQ
Anesthetic Management for TR
- Maintain intravascular volume and CVP in the ______ range
- Avoid Increased _______
- Avoid hypoxia, hypercarbia, acidosis
- Avoid ______ and _______, which can reduce venous return and increase RV afterload
- high normal
- PVR
- -.
- PEEP and high airway pressures
Valvular Disease and Murmurs
type of murmur and disease:
- Aortic area
- pulmonic area
- left sternal border
- tricuspid area
- mitral area
