Orals: cardiac Flashcards
1
Q
Differential for Tachycardia
A
Primary: SVT or Ventricular arrythmias Secondary: sympathetic stimulation from sepsis hypoxia hypercapnea pain Anemia Hypovolemia Inotrope running wide open Pheochromocytoma Carcinoid syndrome
2
Q
What are the questions you ask when you see SVT?
A
Stable or Unstable?
Wide or Narrow?
Wide : monomorphic or poly
Narrow: regular or irregular
3
Q
What is the treatment for regular wide monomorphic SVT? What rhythm do you suspect?
A
Re-entrant tachycardia
Tx: 6 mg of adenosine IV push
2nd dose: 12 mg
4
Q
What is the treatment for irregular wide SVT?
A
Amiodarone 150 mg over 10 minutes
IV infusion 1 mg/min X 6 hours
5
Q
How do you treat stable narrow SVT?
A
Vagal maneuvers Ice Beta blockade CCB Adenosine
6
Q
How do you treat unstable narrow, regular SVT?
A
Synchronized cardio version at 50-100 J
7
Q
How do you treat Vfib or unstable V tach?
A
Defibrillation at 200 J (biphasic) 360 J (Monophasic)
8
Q
How do you treat wide regular unstable VT.
A
Synchronized cardio version at 100 J
9
Q
How do you treat unstable irregular narrow SVT? What rhythm is this?
A
A fib, flutter or AVNRT
Synchronized cardio version at 120-200J
10
Q
How do you treat stable irregular narrow tachycardia?
A
Beta blockade (esmolol drip or metoprolol)
CCB (diltiazem)
Amio drip
11
Q
What are the causes of deceased oxygen delivery?
A
Anemia
Decreased cardiac output
12
Q
What are the relative causes of hypovolemia?
A
h's and T's: Tamponade Pneumothorax PE MI PEEP
13
Q
When you see a tachycardia or bradycardia, what should you ask yourself?
A
Is it primary or secondary
14
Q
What are the causes of primary bradycardia?
A
Sick sinus syndrome
Heart block
MI causing heart block
15
Q
What is the treatment for unstable bradycardia?
A
Give oxygen, maintain airway, IV access
0.5 mg atropine every 3-5 minutes up to max of 3 mg
Dopamine 2-10mcg/kg/min
Epi 2-10 Mcg/kg/min
Transcutaneous pacing
16
Q
What are the secondary causes of bradycardia?
A
Beta blockade
CCBs
Digoxin toxicity
Opioids
Volatile anesthetic (junction all rhythm!)
Dexmedetomidine
Anticholinesterases (neostigmine, physostigmine)
Vagal stim - oculocardiac reflex, visceral traction, laryngoscopy, baroreceptor reflex, Betzold-jarisch reflex
17
Q
What is on the differential for HTN?
A
Hypoxemia Hypercapnea Pain Inotrope or pressor running open Pheo or carcinoid Pre-E Increased ICP Autonomic hyperreflexia
18
Q
What is the treatment for high ICP?
A
Hyperventilation to goal of PaCO of 30-35 Elevation of HOB TIVA Normothermia Mannitol Hypertonic saline Lasix CSF drain
19
Q
What are the 5 ASA monitors?
A
EKG Pulse oximetry Oxygen analyzer Temperature monitor NIBP
20
Q
What are the effects of sepsis on the hemodynamic response?
A
Systemic peripheral vasodilation –> decreased preload (decreased cardiac output and therefore oxygen delivery)
- -> decreased afterload therefore decreased coronary perfusion due to lack of coronary perfusion pressure
- -> decreased contractility due to myocardial depressant circulation
Tachycardia causing decreased filling time as well as diastolic time (coronary perfusion time)
21
Q
When asked about hemodynamics, how should you categorize this?
A
Preload (venous return! Amount of blood in the body)
Afterload (SVR)
Contractility (inotropy, chronotropy, lusitropy, valves)
22
Q
ESV is a function of what?
A
afterload and contractility
23
Q
EDV is a function of what
A
Preload
24
Q
Stroke volume is influence by what
A
Preload
Afterload
Contractility
25
What is the cause of ALI/ARDS?
Oxidant radicals
Inflammatory destruction of alveolar membrane
Release of proteinaceous material
26
What is the cause of respiratory failure in shock?
Hypoperfusion and hypoxia cause central medullary respiratory centers and chemoreceptors to increase RR and decrease TV ---> dead space ventilation --> V/Q mismatch--> increased work of breathing
Diaphragm dysfunction due to hypoperfusion
27
What kind of monitors can you use to assess for fluid status?
Arterial line with PPV
Systolic pressure variation
Inferior vena cava diameter and respiratory variability on TTE
LV filling on TEE
Variation in VTI in TEE or TTE after a fluid challenge
Pulse oximetry variation
28
What additional monitors can you use for someone with shock?
PAC=
SvO2
CO
29
What can be calculated on echocardiography to assess stroke volume?
Velocity time intravascular (VTI) of the subaortic flow
30
What are the treatments on sepsis?
Broad spectrum antibiotics within 1 hour
30 ml/kg of fluid bolus
Norepinephrine as first line vasopressor , titration to MAP of 65-70
Low dose steroids (200-300 mg/day of hydrocortisone)
Target Hb of 7-9 in absence of hypoperfusion
31
Why is norepinephrine the vasopressor of choice in sepsis?
Because it corrects for splanchnic ischemia and improves organ function
32
What's on the differential for hypoxia (Board stiff question)?
Wall to ETT:
Check gases - wrong composition, no delivery? (Disconnect, kink, line crossover, forgot to switch it on, someone came behind me and turned it off)
ETT to lungs:
Check tube position - disconnected, kinked, moved?
Listen! Endobronchial or esophageal intubation? Severe bronchospasm? PTX? Subcutaneous intubation?
Chest wall to pleura: Obesity? Flail chest? chest wall weakness from NMB? Undiagnosed neuromuscular disorder? Phrenic nerve damage? Kyphoscoliosis?
Pleura: fluid or air?
Parenchyma: aspiration? Mucus plug? Atelectasis? Bronchospasm? CHF? ARDS? V/Q mismatch from position or one lung vent?
Pulm vasculature: emboli - fat, clot, air, amniotic fluid
Cardiac: R--> L shunt (ASD, Eisenmenger's, ToF, coarctation) , air embolus, MI, valvular do
CNS: Apnea
Damage to respiratory center (stroke, tumor, herniation)
High cervical lesion
33
How do you trouble shoot hypoxia?
Check Gas settings, vent and tubing to ETT checking for disconnections, flipped switches, incorrect gas mixture, kinks, line crossing
Examine ETT and listen to patient
Suction tube, give bronchodilators
Monitor vitals - what do they tell you?
34
What is on the differential for hypercapnea?
Anything that increases metabolism or doesn't allow to get rid of it:
Thyrotoxicosis
Malignant hyperthermia
Sepsis
Hypoventilation - check vent settings
Patient breathing spontaneously and given too much opioid, NMB, anesthetic
Rebreathing (exhausted CO2 absorber, malfunctioning expiration valve, low flows)
35
How do you assess airway in preop?
Have you ever been told you are hard to intubate or they had trouble with your airway?
Anesthesia records
Medical diagnoses
Radiation or surgery to the area?
36
What are signs of a difficult airway?
```
Large or loose teeth
Big tongue
Short thyroid talk distance
Thick neck
Mallampati >2
Decreased neck mobility
Obesity
Beard
Masses/ radiation scars
```
37
What are the questions you want to ask a patient for airway assessment?
```
Any trouble in the past? Chipped tooth?
History of surgery or radiation?
Last time they ate?
Have they been vomiting?
Do they have OSA?
```
38
Name steps for awake intubation
PREOXYGENATE
increase FRC
EQUIPMENT: boogie, cook catheter, suction, cric kit, LMA, ENT surgeon, oral airway/nasal airway
1. Antisialogogue : glycopyrrolate 0.2 mg IV as soon as possible, at least 20 minutes ahead of time
2. Dexmedetomidine bolus + drip, maybe ketamine
3. Lidocaine topicalization : viscous lido, inhaled lido, transtracheal intubation
4. Fiber optic with other tools nearby, Lube! Oxygen on the suction port
5. Drive, twist tube (touch of sux?)
39
How will you decide to extubate someone?
Head down:
Awake, following commands
Adequate oxygenation and ventilation on minimal vent settings
Slow, steady breathing pattern, adequate tidal volumes, generating negative pressure
Hemodynamically stable on minimal support
Leak test
Physical exam does not reveal a swollen airway
Can put in Cook catheter and leave it in while removing the tube
Have all reintubation equipment around
40
How do you deal with difficult airway in a child?
Keep them breathing spontaneously - sevoflurane
Use fiber optic for attempts
Ventilate frequently and between attempts
41
How do you deal with a difficult airway in an uncooperative adult?
Induce and maintain in-line stabilization
Take a look and attempt with boogie and video
If cannot get it - cric!
42
If patient unable to tolerate awake fiber optic?
Induce - incubating LMA
43
Would you use cricoid pressure? Why or why not?
No, because it has not been proven to prevent aspiration and can make ventilation and intubation more difficult
44
What did the Metoprolol CR/XL randomized intervention trial in CHF show?
BB are suitable and improve survival for patients with CHF class II to IV and EF < 40%
45
What are the factors of Revised Cardiac Risk Index?
1. High risk surgery: intraperitoneal, intrathoracic, suprainguinal vascular
2. History of ischemic heart disease
3. History of CHF
4. History of CVA/TIA
5. Insulin
6. Preop Creatinine > 2
46
When should beta blockers be continued perioperatively?
When a patient has been on beta blockers chronically
47
When should you start a beta blocker on a patient?
When the patient has 3 or more risk factors for RCRI
Do NOT start on the day of surgery
Start within 30 days with goal HR between 50-60 bp man
48
When should you get an echo on someone with clinically suspected valvular disease of moderate - severe degree?
1. No echo within a year
2. New significant symptoms or exam findings
Class 1 evidence ***
49
Is valve repair for elective surgery effective in lowering periop risk?
Yes, if the patient has moderate-severe disease with symptoms
50
What do the ACC/AHA guidelines say about noncardiac surgery in patients with asymptomatic severe aortic stenosis, MR, AR with normal EF?
With appropriate intraoperative and postoperative monitoring and hemodynamic management may be reasonable
51
What do the ACC/AHA guidelines say about targeted pulmonary therapy?
They should be continued unless contraindicated or not tolerated
52
What do the ACC/AHA guidelines say about seeing a pulmonary hypertension specialist preoperatively?
Beneficial but not required
53
What are the risk factors for increased periop risk in patients with PAH?
1. Group 1 (idiopathic) Pah
2. Pulm pressures > 70 + moderate RV dilation and/or dysfunction and/or PVR > 3 Woods units
3. Class III-IV CHF 2/2 PH
54
What is the value of severe mean PAP on echo or RHC.
mPAP > 55 mm Hg
55
What is the mPAP for mild PH?
>25-40 mm Hg
56
What is the RVSP above which signifies PH?
> 35
57
What is the mPAP that is considered moderate PH?
41-55
58
What is the recommendation for cardiac assessment on a patient with greater than 1% RCRI, but METS > 4?
No further testing, proceed to surgery
59
What are the recommendations for patients with RCRI >1% and METS < 4?
Ask yourself - will further testing impact decision making or periop care?
60
What do the ACC/AHA guidelines say about preoperatively ECG?
It is reasonable for patients with:
1. Known CAD
2. Significant arrythmia
3. Peripheral artery disease
4. CVA
5. Significant structural heart disease
If low risk surgery and no KNOWN disease: do not get one
Routine ECG is not recommended
61
What do the guidelines say about assessing LV function preoperatively?
Do not do routinely
Reasonable in patients with:
1. Dyspnea of unknown etiology
2. Worsening CHF symptoms
3. Have not been evaluated in a year and have KNOWN LV dysfunction
62
What do you do about patients with elevated RCRI and unknown functional capacity?
According to the ACC/AHA guidelines, it is reasonable to perform a stress test for functional capacity if it will change management
63
Which beta blockers have been shown to reduce mortality?
Metoprolol
Bisoprolol
Carvedilol
64
Who should have a beta blocker?
All patients with:
LV dysfunction (EF<40%) with HF
Prior MI
65
How long should beta blockers be continued for patients with normal LV function and prior MI/ACS?
For 3 years
But reasonable to continue
66
How long should you wait for surgery after MI?
At least 60 days
67
What does a fixed perfusion defect on radionuclide scan indicate risk-wise?
Low positive predictive value for perioperatively cardiac events, but predicts long term cardiac events
68
What does a reversible perfusion defect indicate risk-wise?
Predicts high probability of perioperatively cardiac events
69
How long after bare metal stent placement should elective noncardiac surgery be?
30 days
70
How long after balloon angioplasty should elective noncardiac surgery be?
14 days
71
How long after a DES should elective noncardiac surgery be?
1 year
72
If a patient has had a DES and needs surgery sooner than 1 year, what's the earliest you can consider?
6 months
73
If a patient needs stunting, but also needs elective noncardiac surgery within the year, what can you do?
BMS + 4-6 weeks of DAPT, then continue aspirin perioperatively
74
If the noncardiac surgery is time sensitive (2-6weeks) or high risk of bleeding, what is the PCI option?
Ballon angioplasty or BMS
Or CABG
75
What are the adverse outcomes associated with preoperatively beta blockade?
Bradycardia
Stroke
Higher rate of death from noncardiac events
76
What do the ACC/AHA guidelines say about starting a beta blocker perioperatively on a patient with moderate-high ischemic risk?
It is reasonable, but should consider the patient's risk of stroke and other contraindications (uncompensated HF)
77
What do the guidelines say about starting a patient on beta blockade who has clear long term indication for it but low RCRI?
Unknown benefit
78
What do the guidelines say about starting a statin postoperatively?
It is reasonable in patients undergoing vascular surgery
79
What do the guidelines say about starting alpha 2 agonist perioperatively?
It is not recommended for prevention of cardiac events
80
What are the recommendations for CCB perioperatively?
No formal recommendations
They have been shown to reduce risk of death/MI/arrythmia
81
What are the recommendations for ACEi periop?
Continuation is reasonable
| If held, restart ASAP
82
When is the risk of stent thrombosis for DES and BMS the highest?
4-6 weeks after stent implantation
83
What if a patient had a DES 5 months ago, but needs urgent surgery?
Try to continue DAPT, if not stop PGY inhibitor and continue ASA, restart PGYi immediately
84
What test would you order to monitor for bleeding risk after dabigatran?
aPTT
85
What test would you order to monitor for bleeding risk with apixaban or rivaroxaban?
PT
| Or Xa level
86
If you have a patient with a pacemaker, would do you do?
Interrogate the device
| Is the patient dependent? If so, turn to asynchronous mode
87
What if a pacemaker begins oversensing during a procedure?
Tell them to stop all electrical activity!
88
Which patients do you reprogram a pacer in?
A patient that needs higher cardiac output and has an insufficient underlying rhythm and rate
Mono polar electrocautery
Minute ventilation sensor
89
Going into a CABG, a patient's ACT doesn't rise after giving heparin, what do you do?
Give FFP for antithrombin deficiency
90
What do you do to check that you have not placed a line in the carotid?
```
Color comparison with radial arterial line
Look for pulsation
Check with ultrasound
Hook to IV tubing
Transduce
```
91
How do you place a TEE?
Make sure it is unlocked and slightly ante flexed
Lube
Bite block
Increase anesthetic depth
Use laryngoscopy for placement if there is any trouble
92
What are the steps to going on pump?
Get baseline ABG and ACT
1. Heparinize! 300 u/kg, then 100 u/kg for ACT goal of 400-480s
(If patient has been on heparin the last several days, suspect antithrombin III deficiency and call for FFP early)
START AMICAR
2. Keep MAP below 80 for arterial cannula tigon
3. Get repeat ACT 3 minutes after heparin
4. Pull back PAC catheter
5. Give muscle relaxant
6. Shut off ventilator and vapors when perfusion its says "full flow"
7. TEE in "freeze mode"
8. Turn off Bair hugger
9. Empty Foley for accurate on-pump urine measurement
Communicate with perfusionist and surgeon
93
What is aminocaproic acid?
Inhibitors the activity of plasminogen/plasmin by binding to lysine sites on the complex to inhibit plasmin from lysing fibrin clots
94
How do you assess for arterial cannula malposition?
Systemic hypotension
Unilateral blanching of the face
Asymmetry of BP in arms
Decreased carotid pulse on ipsilateral side
95
How do you assess for venous cannula malposition?
Increased CVP
| Head/facial swelling
96
If the pressures on PAC go up, what should that tell you?
Inadequate LV venting --> increased LV dissension, wall tension and therefore oxygen demand
Also, myocardial rewarming
97
What do the vents in the LV drain?
```
Bronchial veins
Thebesian veins
Persistent left SVC
Shunt
Aortic regurgitate
```
98
Why do you need an atriotomy in bicaval cannulation?
Because it will not drain the coronary sinus which empties into the RA
99
How do you assess arterial inflow?
Flow
Reservoir level
Patient's pressure
100
What are the dangers of arterial cannulation?
Emboli
Dissection
Malposition (too proximal cutting off coronaries)
Aneurysm
101
What are the signs that bypass is achieved!
Nonpulsatile
| Low CVP and PAP
102
How do you get a patient off bypass?
1. Talk to surgeon about possiblity of needing inotropy or vasopressor. Hook it up 10-15 minutes before coming off
2. Check ABG : correct Hct (>24), electrolytes (K, Ca++, Mg+)
3. Send Plt and fibrinogen - send for product accordingly
4. Suction ETT
5. Make sure body temp is 36 C
6. Begin ventilation
7. Make PAC balloon is down
8. Clamp off --> heart starts, make sure R/R is normal
9. Consider NMB, anestheticg
103
What is levosimendan?
Increases calcium sensitivity of myocytes by binding troponin C
Increases inotropy, decreases preload and afterload
104
How does milrinone work?
Increases heart contractility by preventing breakdown of cAMP and therefore increasing release of intracelluar calcium causing better, stronger contraction
In peripheral and pulmonary, it prevents cGMP breakdown resulting in vasodilation
105
What are signs of aortic dissection?
Hypotension
Increased arterial line pressure
Decreasing reservoir
106
What are the signs of reversed cannulation?
Increased CVP
| Facial engorgement
107
What if a patient has history of HIT? How will you get on pump?
Can use bivalirudin
| Ecarin clotting time for monitoring (ECT)
108
What are the contraindications to TEE?
Esophageal surgery
Zenker's
Varicose
109
What are the goals for an off pump CABG?
"Fast and full"
CVP 15-20
HR 70-90
Trendelenburg to increase venous return
Inotropy with dobutamine or epi
Decrease SBP < 100 for aortic cross clamp during proximal grafts
Give 500 albumin while sewing distal grafts in preparation of manipulation of the heart
110
What are the essential monitors for doing a mini mitral case?
Pacing swan
Pacing box
cerebrox/ BIS
AC fibrillator
111
How is a LV vent placed?
Thru upper pulmonary vein, thru the mitral valve
112
What is a Benthall procedure?
Aortic root replacement with a composite valve-graft conduit
113
What is the Cameroon technique?
Aortic root replacement with coronary artery reimplantation
114
What monitors are needed for deep circulatory arrest?
EEG, cerebrox, Jugukar bulb venous O2
TEE
Bilateral arterial lines
115
What are the indications for retrograde cardioplegia?
Severe AI
LVH
Severe CAD
116
When is ante grade cerebral perfusion used?
If aortic root repair is going to be prolonged
Cannula the right axillary, BC, or subclavian artery or left carotid --> need a left radial arterial line
117
What are the concerns regarding an LVAD?
1. Right heart function and support
| Dec. PVR, maintain afterload and preload, keep NSR, MAP 70-80
118
What do you do if there is suck down with LVAD?
Give fluid! Maintain preload
| Give vasopressin or phenylephrine to push septum back over
119
What monitor should you have to monitor BP intraoperatively?
Doppler Us
120
What are the complications of VADs?
```
Mediastinal bleeding
GIB
Intracranial bleed
Vwf syndrome
Stroke
RV failure
```
121
How does an IABP work?
Inflates during diastole to increase coronary perfusion
| Deflates during systole which provides a suction effect to increase forward flow
122
Where does an IABP go?
Up the femoral artery to the junction of the subclavian
123
What happens if a IABP inflates too late?
You lose the effect of increased diastolic perfusion
124
What happens if it inflates too soon?
Increased afterload and strain on the heart
125
What happens if you turn the IABP off?
Clot formation!
126
What happens if the balloon ruptures?
Helium embolus! Which absorbs quickly, but then it has to be replaced
127
What is Eisenmenger's syndrome?
Equalization of left and right sided pressures of the heart due to chronic anatomical left to right shunt
High mortality rate
No cure except heart transplant
128
What blood product do you want most in setting of IABP?
Platelets because IABP chews these up
129
How long should you wait to come off bypass from time of unclamping?
At least 20 minutes
130
Every time the surgeons lifts the heart, the IABP can't pick up. What's the diagnosis?
ECG complex gets too small due to vector change the IABP can't recognize it
The arterial BP drops so low that it doesn't see it
131
What do you do if the pacing wires aren't capturing?
Increase amps
Check monitors and pacing box (batteries?)
Communicate with surgeons it may need to be moved
132
After closing, you see a regional wall motion abnormality on TEE, what does that mean? What do you do?
Suggests ischemia possibly from a kinked grafted, clotted graft, dissected or stitched graft.
Reopen chest and look
133
Is it necessary to place a PAC preoperatively? Why or why not?
No, it is not necessary.
Have preoperatively cardiac numbers does not help guide intraoperative management and use of a PAC does not improve outcome
134
Why do you look for on TEE in a valve repair?
Filling and function of ventricles
| Peri valvular leak
135
What are the consequences of mtp?
```
Dilution all coagulopathy
Hypocalcemia
Hypothermia
Hyperkalemia
Immune reactions
TRALI
Fluid overload
```
136
What are the downsides of fem-fem bypass?
Not in a huge vessel for good drainage
No normal flow pattern (have reversal of flow up the femoral artery into the aorta
Can be hard to adequately perfuse (worry about spinal cord perfusion)
137
What it THAM? When would you use it?
It is a biologically inert amino alcohol with pH of 7.8 which buffers carbon dioxide and acids.
Accepts protons and generates bicarbonate in vivo
Maintains buffering power in hypothermia
Does not need to have an open system to breath off CO2 (unlike bicarbonate)
Use when have severe metabolic acidosis or hypercapnea
138
What are the side effects of THAM?
Tissue irritation and venous thrombosis at site of administration
Hypoglycemia
Respiratory suppression
139
What is the dosing of THAM?
0.3 mol/L
| Max dose = 15 mmol/kg (3.5 L in 70 kg)
140
What are the consequences of bicarbonate?
High sodium content
Hypertonicity causing rapid intravascular volume --> intracranial bleed
Hypercapnea
Hypokalemia
Ionized hypocalcemia
Increased acidosis secondary to shift of oxygen dissociation curve?
141
What are the implications of perivalvular leak?
Not seated correctly
Not sewn in perfectly
Go back on bypass and fix!
142
What monitors do you want for a patient with an LVAD?
Cerebral oximetry
Doppler for BP
Intermittent ABG/VBB
143
What do you do if a patient with an LVAD desaturates?
Check flow rate - increase flow or RPM
| Increase FiO2
144
What are the anesthetic goals of HOCM.
Increased preload
Maintain afterload
Avoid tachycardia
Avoid inotropy
Tax: fluids and phenylephrine
145
What are sgarbossa's criteria?
1. Concordant ST elevation greater than 1 mm in leads with a positive QRS (5 points)
2. Concordant ST depression greater than 1 mm in Precordial leads (3 points)
3. ST elevation or depression of greater than 5 mm with a negative (discordant) QRS (2 points)
Score of greater than 3 is 90% specific, but not sensitive
146
What is R in T phenomenon?
When there is electrical stimulation of the heart during its repolarization or refractory period that can lead to V fib
147
What would you do if a patient has PVCs intraoperatively?
Improve oxygenation, ventilation, electrolyte abnormalities, pull back on CVC, hypotension, check for drug toxicities (QT prolongation), mechanical irritation
Get defibrillator in the room,
Consider anti-arrythmics
148
What is the new guideline on newer generation DES and elective noncardiac surgery?
May consider surgery after 3 months if risk of further delay outweighs the risk of stent thrombosis
149
Who needs SBE prophylaxis?
1. Prosthetic valves
2. Unrepaired CHD
3. repaired CHD with prosthetic device in first 6 months
4. Repaired CHD with residual shunts or valve regurgitate
5. Previous endocarditis
6. Cardiac transplant with valve regurg
7. Prosthetic material used for valve repair : rings, chords
150
What conditions is SBE no recommended for?
MVP
Bicuspid AV
HOCM
GU or GI procedures
151
What would you administer for SBE ppx?
Amoxicillin 2 g (50 mg/kg in kids) 1 hour before procedure
152
What would give for SBE ppx in someone who is allergic to PCN?
Cefazolin (1 g or 50 mg/kg in kids)
Clindamycin (600 mg or 20 mg/kg in children)
Ceftriaxone (1 g or 50 mg/kg in kids)
153
What would you give for SBE prophylaxis in someone who can't take po?
Ampicillin 2 g (50 mg/kg in kids)
| Cefazolin 1 g
154
What is the transvalvular gradient of severe aortic stenosis?
> 40
155
What is the velocity of aortic jet in severe aortic stenosis?
> 4-4.5
156
What is the velocity of aortic jet, mean transvalvular gradient and aortic valve area in mild aortic stenosis?
Less than 3
Less than 25 mm Hg
1.5-2.0
157
What is a normal AV area?
2.5-4
158
What are the concerns with anterior mediastinum mass?
Great vessel and heart compression
Tracheobronchial compression --> V/Q mismatch
Post obstructive pneumonia
SVC syndrome - Impaired drainage of head and neck --> airway edema, impaired cerebral perfusion
Tamponade physiology
Complete airway collapse!
159
What are the risk factors for periop cardiopulmonary complications in anterior mediastinal mass?
1. Tracheal compression > 50%
2. Tracheal compression > 30% + bronchial compression
3. Stridor
4. Orthopnea
5. Cyanosis
6. Pleural effusion
7. JVD
8. SVC syndrome
9. Pericardial effusion
10. Combined obstructive and restrictive pattern in PFTs
160
How would you evaluate a patient for airway compression?
I would perform a detailed history and Physical exam looking for stridor, cyanosis, Orthopnea, tachypnea, wheezing, diminished breath sounds, syncope, presyncope. I would try determine whether this was worse in the supine position.
I would review all imaging to identify the level of airway compression, recognizing that airway compression below the level of the carina may further increase the risk of making passage of an ETT or bronchoscope beyond the area more difficult.
161
When would you perform a upright and supine TEE.
Anterior mediastinal mass
| Pericardial effusion
162
When does CKMB elevate after MI? How long does it stick around? When does it peak?
Elevates within 4-6 hours
Peaks 12-24 hours
Returns to baseline in 2-3 days
Not as specific for cardiac tissue
163
When does troponin peak?
12-24 hours
164
How long does it stick around?
7-10 days
165
When does troponin elevate?
2-6 hours
166
What is the therapeutic digoxin level?
0.5-2.0 NG/ml
167
What are the symptoms of digoxin toxicity?
```
EKG changes: mild ST depression,
Arrythmia
Fatigue
Salivation
Confusion
Nausea vomiting
Visual disturbances
```
168
What factors potentiates digoxin toxicity?
Hypokalemia
Hypomagnesemia
Hypercalcemia
169
What does it mean if troponin is elevated by CKMB is not?
MI occurred within the last few days, but there a
| Has been no recurrence because CKMB drops off around 2-3 days
170
What monitors to do you want for a CABG?
5 lead EKG (lead V5 for ischemia, II for arrythmia)
Arterial line for BP monitoring during induction, intubation, and bypass, frequent lab checks
Central line for fluid and vasopressor administration
Consider PAC for pacing and fluid management, postoperative management of cardiac function
TEE to monitor cardiac function
BIS to monitor anesthetic levels and cerebral oximeter for CPP
171
A patient Bp drops after initiation of bypass, what do you think k is going on?
Hemodilution and deceased SVR
```
Other differential dx:
Aortic dissection
Malposition of arterial cannula
Kinking
Clamping
Inadequate venous return to the pump
Too much anesthesia
Bleeding
Pump malfunction
```
172
What might be wrong if the pacing wires are not capturing?
```
Dislodged
New MI - significantly increases energy required to depolarization
Insufficient amps
Pacemaker malfunction
Acid-base disturb
Electrolyte abnormalities
Abnormal antiarrythmic drugs levels
```
173
When is a patient at highest risk for recall in a cardiac case?
During rewarming --> give benzodiazepine before this!
174
What is a side effect of cyclosporine in heart transplant patients?
HTN
Treat with CCB or ACEi
Avoid beta blockers and nifedipine
175
What are the signs of cardiac transplant rejections?
```
Fever
Arrythmias
Dyspnea
Accelerated atherosclerosis
Myocardial dysfunction
```
176
What is unique about a transplanted heart?
It is unable to respond the acute hypotension with an increase in heart rate due to lack of autonomic innervation
Relies on preload to maintain cardiac output
Does respond to circulating catecholamines due to alpha beta receptors on the transplant. Indirect vasopressors don't work as well due to absence of catecholamine stores in myocardial neurons
177
What are the best vasopressors to use for a transplants heart?
Isoproterenol
Epinephrine
Dobutamine
178
Would you still administer an anti muscarinic with neostigmine in a patient with a cardiac transplant?
Yes due to peripheral muscarinic effects and sometimes bradycardia in the transplanted heart due to partial innervation after 6 months that can occur
179
What are the effects of aortic regurgitation?
Increased myocardial oxygen demand
Decreased coronary perfusion secondary to reduced aortic diastolic pressure and increased LVEDP
Pulmonary edema due LVEDP
180
Why would you administer beta blocker therapy for aortic dissections?
To reduce intramural pressures and aortic shear forces that could lead to propagation or rupture
Can also help with aortic regurgitation by reducing LV afterload
Associated with reduced periop and long term cardiac morbidity/mortality from high risk vascular surgery
181
What are the contraindications to acute normovolemic hemodilution?
```
Anemia (Hct <33%)
Impaired renal function
Aortic stenosis
Significant pulmonary disease
Coagulopathy
```
182
How do you do acute normovolemic hemodilution?
Collect 1-2 units of blood while simultaneously replacing with crystalloid
Reinfuse the blood if indicated in reverse order of collection (1 unit as the highest concentration of coagulation factors and platelets)
183
What are the effects of acute normovolemic hemodilution?
Deceased SVR 2/2 decreased blood viscosity
| Increased CO
184
How do roller pumps work?
By partial compression of tubing
Not sensitive to afterload or preload
Delivers flow based on speed
Delivers pulsatile flow
185
What are the disadvantages of a roller pump?
More damage to RBCs
| More entrainment of air
186
What are the characteristic of a centrifugal pump?
```
Forward flow depends on rotation
Less damaging to RBC
Sensitive to preload and afterload
Stops functioning if a significant amount of air is entrained
Cannot deliver pulsatile flow
```
187
Would you use alpha stat management if employing moderate hypothermia?
Yes, because there is evidence that it improves neurological outcome in patients
(No addition of CO2)
188
What does the c wave represent in PCWP tracing?
The elevation of the mitral valve during early ventricular systole
189
What does the v wave reflect on PCWP tracing?
Venous return against a closed mitral valve
190
What does the X descent represent on PCWP tracing?
Downward displacement of the atrium during ventricular contraction
191
What does the y descent represent in a PCWP tracing?
Decline in atrial pressure as mitral valve opens during systole
192
What are the surgical steps to going on bypass?
Ascending Aortic cannulation "low flow" from surgeon
Venous cannulation (IVC, RA)
LV vent placed
193
How do you monitor temperature in CPB?
Nasopharyngeal or tympanic to monitor core temp
Peripheral temperature monitor
Must monitor temperature gradient because large gradients can lead to formation of gas bubbles in the blood
194
What would you do if the perfusionist said the venous reservoir level was decreasing ?
I would tell the perfusionist to add fluid to the blood volume and slow the pump flows while I look for potential causes of decreased venous return including: elevation of heart by surgeon, kinks or problems with cannula, air lock, malposition, thrombi obstruction
195
Why do you inflate the lungs following CPB?
To de- air the left heart and prevent end organ damage from embolization
Recruit collapsed alveoli
196
When trying to come off of bypass pulmonary pressures increase while SVR decreases, what would you suspect?
LV failure
2/2 MVR and therefore increased afterload, kinked graft, inadequate coronary BF or myocardial preservation, MI, valve failure, inadequate preload, reperfusion injury, electrolyte abnormalities
197
How does recent mitral valve replacement contribute to risk of left ventricular failure coming off bypass?
Results in loss of low resistance outflow tract into the LA which may unmask LV dysfunction
198
When should IABP inflate?
Middle of the T wave
| Dicrotic notch
199
Can you use IABP with s pacermaker?
Yes, just use the arterial wave form for triggering
200
Explain the difference between central aortic pressure and radial arterial pressure after CPB?
Peripheral vasodilation during rewarming causes a significantly lower pressure at radial arterial line (about 30 mmHg)
This resolves in about 45 minutes
201
What is pulses paradoxus?
Exaggeration of drop in systolic BP (>10 mm Hg) with normal breathing
Normally, inhalation causes negative intrathoracic pressure --> increased venous return to right heart --> bulging of inteventricular septum to the left side, impairing LV filling and reducing SV
202
How would you manage tamponade?
Alert surgeon
Administer fluid bolus
Avoid Bradycardia
Maintain spontaneous ventilation
Give inotropes if needed
Treat acid/base disturbance that leads to cardiac depression
Transport to OR for window or perform in ICU at bedside
203
What are the indications for cardiac ablation
Symptomatic AVNRT, WPW, unifocal atrial tachycardia or flutter
Afib with life style impairing symptoms or intolerance of meds
Symptomatic VT
Patient preference
Medication noncompliance
204
What is a normal valve area for mitral valve?
4-6 cm
205
What is an severe mitral valve area for stenosis?
Less than 1.0
206
What is a moderate valve are for MS?
1-1.5
207
What is the energy used for synchronized cardio version with a Monophasic defibrillator?
200 joules
208
What are the anesthetic goals for a patient with mitral regurgitation?
```
Maintain preload and forward flow
Judiciously reduce afterload
Keep HR high normal
Minimize cardiac depression
Avoid increases in PVR
```
209
What are the anesthetic goals for patients with MR occurring secondary to MVP?
Avoid tachycardia, increased contractility or catecholamine release (no ketamine) because can increase MVP and thus the MR due to increased LV emptying
Maintain preload and afterload
210
When a patient had MVP, what else should you be worried about ?
Mitral regurg
| PFO
211
What is the differential for an unsuccessful rise in ACT after heparin?
```
Antithrombin III deficiency
IV infiltration
Wrong med
ACT measurement malfunction
Heparin resistance
```
212
What are the causes of hypotension and increased pulmonary pressures after protamine?
Histamine release
| Type III resection with protamine-heparin complexes leading to release of TXA2 in pulmonary circuit
213
How would you evaluate a patient's pacemaker?
```
Find out:
Indication for placement
Model and type of device
Pacemaker dependency
Intrinsic rate and rhythm
Programmed pacing mode
Behavior of the device when exposed to a magnet
Battery status
Last test date
Integrity of the leads
Pacing threshold
```
214
How would you position the return plate (bovid pad)?
As close to the operative site and as far away from the pacemaker to avoid passage of current through the pulse generator or leads (at least 6 inches away)
215
What are the potential reasons for pacemaker failure intraoperatively?
```
MI (lengthens refractory period and significantly increases the energy requirement to achieve depolarization)
Electrolyte abnormalities
Acid/base disturbance
Lead failure
Abnormal antiarrythmic drug levels
```
216
What see the indications for postoperative pacemaker interrogation?
```
Reprogrammed to no function before
Hemodynamically challenging case
Significant intraoperative event
Emergency surgery above the umbilicus
CT surgery
Procedure that uses EMI
Unable to follow up in 1 month
```
217
Who should not get a dobutamine stress test?
Severe HTN
Arrythmia
Hypotension
218
Who should not get adenosine?
Asthma
Critical carotid disease
Intolerance for discontinuation of theophylline
219
What can statins do?
Decrease risk of death in vascular patients with renal impairment
220
What can PAC cause in LBBB?
Total heart block
221
How would you treat a Type III protamine reaction?
Epinephrine or milrinone for inotropy
Consider nitric oxide
Consider low dose heparin to break up complexes and reduce production of TXA2
