Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

!!!!!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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

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

A

HR; affects both supply and demand

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Compare and contrast stable, unstable, and prinzmetal angina:

A
  1. Stable:
    • at least 60 days no ∆ in frequency,
    • duration or other factors;
    • associated with a fixed narrowing (usually 75%+)
    • relieved by rest, NTG
  2. Unstable:
    • becoming more frequent, longer, or more severe
    • occuring at rest or with less exertion;
    • associated with an unstable plaque/thrombosis;
    • signals impending MI
  3. Prinzmetal:
    • coronary vasospastic disease
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is our fundamental goal for IHD/CAD pts?

A

Balancing O₂ supply with O₂ demand

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Discuss regional anesthesia in IHD/CAD patients:

A
  1. Regional anesthsia is acceptable as long as we treat ⇣ in SBP to keep within 20% of baseline.
  2. Sympathectomy can actually help, but we need to make sure fluids counteract hypovolemia leading to hypotension
  3. Good drugs for this include ephedrine and phenylephrine
    • Especially phenylephrine: no inotropy/chronotropy = does not affect O₂ demand at all
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Discuss opioids’ effects on cardiac function:

A
  1. Cause dose-dependent bradycardia and vasodilation
  2. No independent ⇣ in CV function
  3. When used with N₂O or benzos
    • cause ⇣ CO and ⇣ BP
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Discuss induction in an IHD/CAD patient:

A
  1. Blunt SNS outflow as much as possible prior to laryngoscopy,
    • using lidocaine, fentanyl, and/or esmolol,
  2. and Keep it SHORT
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Cardiovascular goals for IHD/CAD patients:

A
  1. Avoid tachycardia!!
    • Low-normal HR needed to ⇣ O₂ demand.
  2. Maintain normal preload;
    • preload needed to fill ventricle and maintain SV (Frank-Starling)
    • ⇡ preload = increase demand
    • ⇣ preload = decreased coronary profusion
  3. Maintain normal afterload;
    • afterload needed to maintain diastolic pressure and ⇡ O₂ supply to coronaries
  4. Decrease contractility if LV function is normal;
    • this will ⇣ O₂ demand.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Four hemodynamic effects of all volatile agents:

A
  1. Dose-dependent ⇣ in contractility
  2. Dose-dependent ⇣ in SVR
  3. Dose-dependent ⇡ in CBF
  4. May Sensitize heart to epinephrine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

IA of choice in cardiac anesthsia is usually:

A

Isoflurane

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

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

A
  1. Shivering and pain will ⇡ O₂ demand; minimize them
  2. Supplemental O₂ will ⇡ O₂ supply
  3. Smooth emergence
    1. consider low-end dosing of anticholinergic w/ reversal agent
    2. lidocaine prior to extubation
    3. extubate deep if possible
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

EKG leads and what they evaluate:

A
  • II, III, aVF:
    • ​RCA ⇢ inferior wall MI
      • R atrium, R ventricle,
      • SA node, AV node
  • I, aVL:
    • Circumflex ⇢ lateral wall MI
      • lateral L ventricle
  • V3-V5:
    • ​LAD ⇢ anterior wall MI
      • ​⇢ anterolateral L ventricle
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Three factors that determine LV outflow obstruction in IHSS:

A
  1. Contractility
  2. Preload
  3. Afterload
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Discuss regional anesthesia for IHSS patients:

A
  1. Okay to do
    • but be cautious to offset ⇣ preload/afterload with good fluid management otherwise you can worsen the LV outflow tract obstruction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Anesthetic/cardiovascular goals for IHSS patients:

A

GOAL: minimize LV outflow obstruction

  1. Decrease HR = ⇣ O₂ demand
  2. High preload = the heart needs the volume
  3. Normal to high afterload = normal SVR to counter the high ejection velocity and preserve coronary perfusion
  4. Decrease contractility to ⇣ O₂ demand
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Discuss induction in IHSS patients:

A
  1. Heavy premedication to ⇣ SNS outflow and strong SNS blunting before laryngoscopy
  2. Consider use of VAs and esmolol before intubation
  3. Etomidate is drug of choice
  4. Avoid sudden ⇣ in SVR
    • i.e. from propofol, STP
  5. AVOID
    • ketamine
    • sympathomimetics (pancuronium)
    • histamine releasers (miva, atra)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Maintenance drugs to use in IHSS patients:

A
  1. Volatiles:
    • deep (1-1.5 MAC) of any of the drugs, just watch the SVR;
    • Deepen VA for hypertension
    • Lighten VA junctional rhythm
  2. 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
  3. Phenylephrine a good choice
    • ⇡ SVR without inotropic/chronotropic effect
  4. Fluids are huge
    • hypotension usually = hypovolemia for these patients
  5. Use propranolol or esmolol
    • for persistant tachycardia

(Treat hypotension first with fluids and then with phenylephrine!)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Maintenance drugs to avoid in IHSS patients:

A
  1. Inotropes
  2. Calcium agonists
  3. Beta agonists (ephedrine, dopamine, dobutamine)
  4. NTP (will ⇣ SVR)
  5. NTG (will ⇣ Preload)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Signs/symptoms of forward vs. backwards failure:

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

Anesthetic/cardiovascular goals for Dialated Cardiomyopathy patients:

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

Discuss induction in Dialated Cardiomyopathy patients:

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

Maintenance drugs to use and avoid in Dialated Cardiomyopathy patients:

A
  1. Treat tachycardia with esmolol
    1. Use filling pressures to guide fluids
  2. 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
  1. Normal to high-normal HR:
    • AVOID bradycardia,
    • CO will depend much more on HR than SV
  2. Normal to high-normal preload:
    • Give fluids!
    • need the volume to make SV as large as possible
  3. Maintain inotropy:
    • can’t fill as well as it wants, but we can keep it squeezing
  4. Avoid myocardial depression
28
Q

Discuss induction in patients with pericardial disease:

A
  1. No pre-op meds!
  2. Need as much SNS outflow as possible!
  3. Ketamine is good - ⇡ contractility, ⇡ HR
    • Might need low dose propofol + ketamine + LMA until the effusion is drained, before turning on VAs
  4. Pancuronium if you need an NMB, but that’s unlikely
  5. Keep in mind that PPV can cause hypotension in the presence of tamponade (decreased venous return)
  6. Keep in mind that once theeffusion is draind they are likely to become HYPERtensive!!! Be ready for it!
29
Q

Pre-op evaluation for mitral stenosis:

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

Discuss regional anethesia for mitral stenosis pts:

A
  1. Not a good choice;
    • they are pre-load dependent and need to maintain SVR.
    • Will need good fluid management if necessary
31
Q

Anesthetic/hemodynamic 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
  1. Avoid drugs that ⇡ HR or abruptly ⇣ SVR:
    • ketamine, pancuronium, and all histamine-releasing drugs (miva, atra)
      1. Be sure to blunt laryngoscopy reflexes
        1. (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 (less increase in HR)
  • Avoid desflurane - can really ⇣ ⇣ SVR and ⇡ HR (reflexive) esp if rapid ⇡ in concentration
34
Q

Pre-op evaluation for mitral regurg:

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

Discuss regional anesthesia for mitral regurg patients:

A

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

36
Q

Anesthetic/hemodynamic goals for mitral regurg:

A

Fast - Full - Forward

  1. Fast: keep HR high-normal (80-90bpm)
    • CO is going to be very HR dependent for them
  2. Full: keep preload high
    • to fill the tank and ⇡ SV as much as possible
  3. Forward: maintain low-normal SVR
    • in order to promote forward flow of SV and minimize backwards flow
    • V-wave will reflect regurgitant flow
  4. Minimize myocardial depression
37
Q

Drugs to use and avoid in patients with mitral regurg:

A

USE

  1. NMB with stable CV profile or pancurionium which will ⇡ HR
  2. For HTN, use hydralazine - no HR effect, and will ⇣ afterload more than preload
  3. Isoflurane is VA of choice d/t hemodynamic effects
    • N₂O + low dose VA to minimize myocardial depression
    • for severe dysfxn, opioid or TIVA technique
  4. Inotropes if ⇡ contractility needed
    • dobutamine, isoproterenol

AVOID

  1. high dose opioids (will ⇣ HR), beta blockers (will ⇣ HR)
38
Q

Pre-op evaluation for aortic stenosis:

A
  1. Exercise tolerance
  2. S/s of AS
    1. Syncope, Angina, Dyspnea on exertion
  3. Cardiac dysrhythmias
39
Q

Discuss regional anesthesia in aortic stenosis patients:

A

NOT A GOOD CHOICE

  • sympathectomy ⇣ SVR which leads to ⇣ venous return and ⇣ perfusion pressure
  • the heart with AS is already susceptible to ischemia d/t ⇡ O₂ demands
40
Q

Anesthetic/hemodynamic goals for aortic stenosis:

A

Maintain HR, SVR, preload, and avoid ⇣ CO at all costs

  1. Maintain NSR
    • these pts absolutely need atrial kick for LVEDV (remember more volume = more force)
    • AVOID junctional and a-fib (they will be hard to get back)
    • AVOID tachycardia
  2. Maintain preload and afterload;
    • Adequate SVR → need the pressure to perfuse coronaries (avoid sudden decreases)
    • Maintain preload to maintain venous return and optimize LV filling
41
Q

Induction drugs to use/avoid in aortic stenosis patients:

A
  • BP is HR dependent
    • if they become bradycardic treat with atropine or glyco
  • Etomidate = drug of choice
  • Phenylephrine = if BP drops
  • Opoids are gread because they will decrease the HR
  • NDMR: Vec, roc, cis (no CV effects)
42
Q

Maintenance drugs to use/avoid in aortic stenosis patients:

A
  1. Anestheisa maintained with
    • N2O + opioids
    • or if they have significant LV dysfunction a High Opioid Technique
  2. NMB - w/o CV side effects (Roc, Vec, Cis-atra)
    • Bad Choice = Pancuronium - stimualtes Ganglion and increases HR
  3. Hypotension:
    • treat with an alpha agonist
    • Phenylephrine (it DOES NOT increase HR)
  4. Treat Junctional Rhythm/Bradicardia
    1. ​(Glycopyrolate, Atropine, Esmolol) →BP is HR dependent
  5. SVT - treat promptly with cardioversion
  6. Aortic Senosis has a propensity to develop ventricualar arrythmias
    1. ​ALWAYS have Lidocaine and Amioderone
    2. ALWAYS have a Defibrilator Availible
43
Q

Discuss regional anesthesia in aortic regurg:

A

• Discouraged due to unpredictability of ⇣ SVR reponse

44
Q

Anesthetic/cardiovascular goals for aortic regurg:

A

Maintain forward flow

  1. High-normal HR;
    • will keep CO up even if SV is small
  2. Maintanin normal preload
    • caution…too much = pulmonary edema
  3. Maintain normal SVR
    1. ​avoid sudden ⇡ to promote forward flow and coronary perfusion
  4. Minimize myocardial depression
45
Q

Induction drugs to use/avoid in aortic regurg patients:

A
  1. Etomidate is drug of choice
  2. Ketamine may be useful to provide ⇡ HR
  3. High opioid + pancuronium for long cases
46
Q

Maintenance drugs to use/avoid in aortic regurg patients:

A
  1. Isoflurane better for long cases
    1. (minimal cardiac depression, maintains CO, preserves baroreceptor reflex)
  2. Sevoflurane for shorter cases
  3. Opioid + benzo for severe LV dysfxn
  4. NTP intra-op for hypertension to keep SVR from getting too high
  5. Atropine for bradycardia (promptly)
47
Q

Describe hypertensive crisis:

A

DBP is acutely > 130

  1. Can be from:
    • MH
    • thyroid storm
    • pheochromocytoma
    • eclampsia, etc
  2. Can result in:
    • encephalopathy
    • CHF
    • SAH
    • renal insufficiency
48
Q

Treatment for hypertensive crisis:

A
  • SNP 0.5 - 10 μg/kg/min
    • ​drug of choice d/t short DoA
  • NTG 5 - 200 μg/kg/min
  • Labetalol 40 - 80mg q10min

(⇣ DBP by 20% in first 2 hours then gradually to baseline over 24-48 hours)

49
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
50
Q

Induction drugs to use/avoid in HTN:

A
  1. Lidocaine, opioids, or VA to make sure patient is deep before laryngoscopy
  2. Consider 100-200mg esmolol prior to laryngoscopy
  3. AVOID ketamine
51
Q

Maintenance drugs to use/avoid in HTN:

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

!!!!!Anesthesia and Co-Existing Diseases !!!!! (3 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions