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Anesthesia and Co-Existing Diseases > Oral Review: Cardiac > Flashcards

Oral Review: Cardiac Flashcards

1
Q

What are some factors that influence the heart’s O₂ demand?

A
  1. HR
  2. SVR
  3. Filling pressures
  4. Preload and afterload
  5. Contractility
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2
Q

What are some factors that influence the heart’s O₂ supply?

A
  1. HR
  2. CO
  3. Coronary perfusion pressure (MAP - CVP)
  4. O₂ carrying capacity (Hgb)
  5. FiO2
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3
Q

What is the most important factor for supply and demand in IHD/CAD pts?

A

HR; affects both supply and demand

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4
Q

Compare and contrast stable, unstable, and prinzmetal angina:

A
  • Stable: at least 60 days no ∆ in frequency, duration or other factors; associated with a fixed narrowing (usually 75%+); relieved by rest, NTG
  • Unstable: becoming more frequent, longer, or more severe; occuring at rest or with less exertion; associated with an unstable plaque/thrombosis; signals impending MI
  • Prinzmetal: coronary vasospastic disease
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5
Q

What is our fundamental goal for IHD/CAD pts?

A

Balancing O₂ supply with O₂ demand

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6
Q

Discuss regional anesthesia in IHD/CAD patients:

A
  • Regional anesthsia is acceptable as long as we treat ⇣ in SBP to keep within 20% of baseline. Sympathectomy can actually help, but we need to make sure fluids counteract hypovolemia leading to hypotension.
  • Good drugs for this include ephedrine and phenylephrine
  • Especially phenylephrine: no inotropy/chronotropy = does not affect O₂ demand at all
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7
Q

Discuss opioids’ effects on cardiac function:

A
  • Cause dose-dependent bradycardia and vasodilation
  • No independent ⇣ in CV function
  • When used with N₂O or benzos, cause ⇣ CO and ⇣ BP
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8
Q

Discuss induction in an IHD/CAD patient:

A

• Blunt SNS outflow as much as possible prior to laryngoscopy, using lidocaine, fentanyl, and/or esmolol, and keep it short (

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9
Q

Cardiovascular goals for IHD/CAD patients:

A
  • Avoid tachycardia!! Low-normal HR needed to ⇣ O₂ demand.
  • Maintain normal preload; preload needed to stretch ventricle and ⇡ contractility/SV (Frank-Starling)
  • Maintain normal afterload; afterload needed to maintain diastolic pressure and ⇡ O₂ supply to coronaries
  • Decrease contractility if LV function is normal; this will ⇣ O₂ demand.
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10
Q

Four cardiac effects of all volatile agents:

A
  1. Dose-dependent ⇣ in contractility
  2. Dose-dependent ⇣ in SVR
  3. Dose-dependent ⇡ in CBF
  4. Sensitization of the heart to epinephrine
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11
Q

IA of choice in cardiac anesthsia is usually:

A

Isoflurane

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12
Q

Emergence and post-op considerations for IHD/CAD patients:

A
  • Shivering and pain will ⇡ O₂ demand; minimize them
  • Supplemental O₂ will ⇡ O₂ supply
  • Smooth emergence and consider low-end dosing of anticholinergic w/ reversal agent
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13
Q

EKG leads and what they evaluate:

A
  • II, III, aVF: RCA ⇢ R atrium, R ventricle, SA node, AV node ⇢ inferior wall MI
  • I, aVL: Circumflex ⇢ lateral L ventricle ⇢ lateral wall MI
  • V3-V5: LAD ⇢ anterolateral L ventricle ⇢ anterior wall MI
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14
Q

Three factors that determine LV outflow obstruction in IHSS:

A
  1. Contractility
  2. Preload
  3. Afterload
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15
Q

What is our fundamental goal for IHSS patients?

A

• Decreasing the LV outflow tract obstruction (which is worsened by ⇡ contractility and ⇣ preload/afterload)

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16
Q

Discuss regional anesthesia for IHSS patients:

A

• Okay to do, but be cautious to offset ⇣ preload/afterload with good fluid management otherwise you can worsen the LV outflow tract obstruction

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17
Q

Anesthetic/cardiovascular goals for IHSS patients:

A
  • Maintain high preload; the heart needs the volume
  • Decrease HR to ⇣ O₂ demand
  • Decrease contractility to ⇣ O₂ demand
  • Normal to high-normal SVR to counter the high ejection velocity and preserve coronary perfusion
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18
Q

Discuss induction in IHSS patients:

A
  • Heavy premedication to ⇣ SNS outflow and strong SNS blunting before laryngoscopy
  • Consider use of VAs and esmolol before intubation
  • Etomidate is drug of choice
  • Avoid sudden ⇣ in SVR i.e. from propofol, STP
  • Avoid ketamine and sympathomimetics (pancuronium) and histamine releasers (miva, atra)
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19
Q

Maintenance drugs to use in IHSS patients:

A
  • Volatiles: deep (1-1.5 MAC) of any of the drugs, just watch the SVR; deepen VA for hypertension or junctional rhythm
  • Opioids: do not use as sole anesthetic d/t ⇣ SVR without myocardial depression; use with VAs or benzos to produce myocardial depression without sigificant ⇣ SVR
  • Phenylephrine a good choice - ⇡ SVR without inotropic/chronotropic effect
  • Fluids are huge; hypotension usually = hypovolemia for these patients
  • Use propranolol or esmolol for persistant tachycardia
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20
Q

Maintenance drugs to avoid in IHSS patients:

A

Inotropes
Calcium agonists
Beta agonists (ephedrine, dopamine, dobutamine)
NTG/NTP (will ⇣ SVR)

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21
Q

Signs/symptoms of forward vs. backwards failure:

A
  • Forward failure (think ⇣ CO, ⇣ end organ perfusion): fatigue, hypotension, oliguria, RAAS activation
  • Backwards failure: ⇡ filling pressures, LV dilation, mitral regurgitation
22
Q

Anesthetic/cardiovascular goals for DC patients:

A
  • Normal to high-normal HR: CO is HR dependent… SV will be small
  • Normal to high-normal preload: if SVR ⇡ too much, pulm edema is a risk
  • Normal (NOT ⇡) afterload: don’t ⇣ SVR too much, though, or it will ⇣ preload too
  • Increase contractility: heart is weak and needs as much force as it can get
23
Q

Discuss induction in DC patients:

A
  • Be careful with opioids + benzos as the combination can ⇣ myocardial contractility
  • Etomidate is drug of choice
  • Choose NMB with minimal CV side effects (vec, roc, cisat)
  • Avoid sympathomimetics (ketamine, pancuronium)
24
Q

Maintenance drugs to use and avoid in DC patients:

A
  • Treat tachycardia with esmolol (not at high doses though - loses selectivity, depresses myocardium)
  • Use filling pressures to guide fluids
  • Treat hypotension with ephedrine or phenylephine (go slow on phenylephrine; will ⇡ SVR)
25
Q

Four stages of pericardial disease:

A
  1. Dry stage / acute pericarditis
  2. Effusion stage
  3. Cardiac tamponade
  4. Absorption stage / constrictive pericarditis
26
Q

Discuss regional anesthesia for pericardial disease patients:

A

• Not usually an option due to the emergent nature of the surgery and existing hypotension. Pericardiocentesis can be done under local anesthesia, however.

27
Q

Anesthetic/cardiovascular goals for pericardial disease:

A
  • Normal to high-normal HR: avoid bradycardia, CO is going to depend much more on HR than SV
  • Normal to high-normal preload: need the volume to make SV as large as possible
  • Maintain inotropy: can’t fill as well as it wants, but we can keep it squeezing
  • Avoid myocardial depression
28
Q

Discuss induction in patients with pericardial disease:

A
  • No pre-op meds! Need as much SNS outflow as possible
  • Ketamine is good - ⇡ contractility, ⇡ SVR, ⇡ HR
  • Might need low dose propofol + ketamine + LMA until the effusion is drained, before turning on VAs
  • Pancuronium if you need an NMB, but that’s unlikely
  • Keep in mind that PPV can cause hypotension in the presence of tamponade
29
Q

Pre-op evaluation for mitral stenosis:

A
  • Exercise tolerance
  • S/s of CHF
  • Compensatory SNS ⇡ like anxiety, diaphoresis, resting tachycardia
  • Cardiac dysrhymias like a-fib
  • Angina from ⇣ O₂ supply
30
Q

Discuss regional anethesia for mitral stenosis pts:

A

• Not a good choice; they are pre-load dependent and need to maintain SVR. Will need good fluid management if necessary

31
Q

Anesthetic/cardiovascular goals for mitral stenosis:

A
  • Slow - Tight - Full
  • Slow: avoid tachycardia to allow for diastolic filling
  • Tight: maintain SVR to preserve diastolic pressure and coronary filling
  • Full: maintain preload to ensure enough volume for diastolic filling
  • Avoid hypoxemia/hypoventilation to prevent pulm HTN and right heart failure
32
Q

Discuss induction in patients with mitral stenosis:

A
  • Avoid drugs that ⇡ HR or abruptly ⇣ SVR: ketamine, pancuronium, and all histamine-releasing drugs (miva, atra)
  • Be sure to blunt laryngoscopy reflexes (lido, opioids, induction agent)
33
Q

Maintenance drugs to use and avoid in mitral stenosis patients:

A
  • Low dose VAs titrated slowly upwards
  • IV fluids and phenylephrine to counteract VA vasodilation
  • Inotropes like dobutamine to ⇡ contractility if needed
  • Avoid desflurane - can really ⇣ ⇣ SVR and ⇡ HR (reflexive) esp if rapid ⇡ in concentration
34
Q

Pre-op evaluation for mitral regurg:

A
  • Exercise tolerance
  • S/s of CHF
  • Compensatory SNS ⇡ incl. anxiety, diaphoresis, resting tachycardia
  • Cardiac dysrhythmias, esp. a-fib
  • Angina d/t insufficient O₂ supply
35
Q

Discuss regional anesthesia for mitral regurg patients:

A

• Okay, but make sure to keep fluid volume up to avoid ⇣ SVR

36
Q

Anesthetic/cardiovascular goals for mitral regurg:

A

• Fast - Full - Forward
• Fast: keep HR high-normal (80-90bpm) - CO is going to be very HR dependent for them
• Full: keep preload high to fill the tank and ⇡ SV as much as possible
• Forward: maintain low-normal SVR in order to promote forward flow of SV and minimize backwards flow
o V-wave will reflect regurgitant flow
• Minimize myocardial depression

37
Q

Drugs to use and avoid in patients with mitral regurg:

A
  • Use NMB with stable CV profile or pancurionium which will ⇡ HR
  • For HTN, use hydralazine - no HR effect, and will ⇣ afterload more than preload
  • Isoflurane is VA of choice d/t hemodynamic effects
  • N₂O + low dose VA to minimize myocardial depression; for severe dysfxn, opioid or TIVA technique
  • Inotropes if ⇡ contractility needed (dobutamine, isoproterenol)
  • Avoid high dose opioids (will ⇣ HR), beta blockers (will ⇣ HR)
38
Q

Pre-op evaluation for aortic stenosis:

A
  • Exercise tolerance
  • S/s of CHF
  • Compensatory SNS ⇡ incl. anxiety, diaphoresis, resting tachycardia
  • Cardiac dysrhythmias, esp. a-fib
  • Angina d/t insufficient O₂ supply
39
Q

Discuss regional anesthesia in aortic stenosis patients:

A

• Not a good choice; sympathectomy ⇣ SVR which leads to ⇣ venous return and ⇣ perfusion pressure and heart with AS is already susceptible to ischemia d/t ⇡ O₂ demands

40
Q

Anesthetic/cardiovascular goals for aortic stenosis:

A
  • Maintain HR, SVR, preload, and avoid ⇣ CO at all costs
  • Maintain NSR; these pts absolutely need atrial kick for LVEDV (remember more volume = more force)
  • Maintain high-normal HR, but not tachycardic
  • Maintain SVR; need the pressure to perfuse and keep valve open as much as possible
41
Q

Induction drugs to use/avoid in aortic stenosis patients:

A
  • Avoid pre-medication - patients need SNS outflow
  • Avoid high-dose opiates (bradycardia)
  • Etomidate is drug of choice
  • NDMR: Vec, roc, cis (no CV effects)
42
Q

Maintenance drugs to use/avoid in aortic stenosis patients:

A
  • N₂O + low dose VA; if LV dysfxn severe, consider N₂O + opioids
  • Avoid halothane: SA node depression, can put pts in junctional rhythm
  • Esmolol for tachycardia
  • Lido for ventricular dysrhythmias
43
Q

Pre-op assessment for aortic regurg:

A
  • Exercise tolerance
  • S/s of CHF
  • Compensatory SNS ⇡ incl. anxiety, diaphoresis, resting tachycardia
  • Cardiac dysrhythmias, esp. a-fib
  • Angina d/t insufficient O₂ supply
44
Q

Discuss regional anesthesia in aortic regurg:

A

• Discouraged due to unpredictability of ⇣ SVR reponse

45
Q

Anesthetic/cardiovascular goals for aortic regurg:

A
  • Maintain forward flow
  • High-normal HR; will keep CO up even if SV is small
  • Maintain normal SVR and avoid sudden ⇡ to promote forward flow and coronary perfusion
  • Minimize myocardial depression
46
Q

Induction drugs to use/avoid in aortic regurg patients:

A
  • Etomidate is drug of choice
  • Ketamine may be useful to provide ⇡ HR
  • High opioid + pancuronium for long cases
47
Q

Maintenance drugs to use/avoid in aortic regurg patients:

A
  • Isoflurane better for long cases (minimal cardiac depression, maintains CO, preserves baroreceptor reflex)
  • Sevoflurane for shorter cases
  • Opioid + benzo for severe LV dysfxn
  • NTP intra-op for hypertension to keep SVR from getting too high
  • Atropine for bradycardia (promptly)
48
Q

Describe hypertensive crisis:

A
  • DBP is acutely > 130
  • Can be from MH, thyroid storm, pheochromocytoma, eclampsia, etc
  • Can result in encephalopathy, CHF, SAH, renal insufficiency
49
Q

Treatment for hypertensive crisis:

A

o NTP 0.5 - 10 μg/kg/min - drug of choice d/t short DoA
o NTG 5 - 200 μg/kg/min
o Labetalol 40 - 80mg q10min
• ⇣ DBP by 20% in first 2 hours then gradually to baseline over 24-48 hours

50
Q

Pre-op evaluation for HTN:

A
  • Is it controlled well enough for surgery?
  • Review medications and consider anesthetic implications
  • Evaluate for evidence of end-organ damage
51
Q

Induction drugs to use/avoid in HTN:

A
  • Lidocaine, opioids, or VA to make sure patient is deep before laryngoscopy
  • Consider 100-200mg esmolol prior to laryngoscopy
  • Avoid ketamine
52
Q

Maintenance drugs to use/avoid in HTN:

A
  • Keep phenylephrine and ephedrine handy
  • Use easily titratable VA (sevo/des)
  • Balanced technique to keep VA concentration low
  • Intra-op hypertension: usually from pain, ⇡ VA and use opioids or antihypertensives
  • Intra-op hypotension: ⇣ VA concentration, supplement fluids if needed, check rhythm, consider sympathomimetics

Anesthesia and Co-Existing Diseases (3 decks)

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