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Anesthesia MM/TL > Orals: cardiac > Flashcards

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
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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

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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

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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

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5
Q

How do you treat stable narrow SVT?

A 
Vagal maneuvers
Ice
Beta blockade
CCB
Adenosine
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6
Q

How do you treat unstable narrow, regular SVT?

A

Synchronized cardio version at 50-100 J

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7
Q

How do you treat Vfib or unstable V tach?

A 
Defibrillation at 200 J (biphasic)
360 J (Monophasic)
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8
Q

How do you treat wide regular unstable VT.

A

Synchronized cardio version at 100 J

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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

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10
Q

How do you treat stable irregular narrow tachycardia?

A

Beta blockade (esmolol drip or metoprolol)
CCB (diltiazem)
Amio drip

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11
Q

What are the causes of deceased oxygen delivery?

A

Anemia

Decreased cardiac output

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12
Q

What are the relative causes of hypovolemia?

A 
h's and T's:
Tamponade
Pneumothorax
PE
MI
PEEP
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13
Q

When you see a tachycardia or bradycardia, what should you ask yourself?

A

Is it primary or secondary

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14
Q

What are the causes of primary bradycardia?

A

Sick sinus syndrome
Heart block
MI causing heart block

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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

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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

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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
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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
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19
Q

What are the 5 ASA monitors?

A 
EKG 
Pulse oximetry
Oxygen analyzer
Temperature monitor
NIBP
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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)

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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)

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22
Q

ESV is a function of what?

A

afterload and contractility

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23
Q

EDV is a function of what

A

Preload

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24
Q

Stroke volume is influence by what

A

Preload
Afterload
Contractility

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25
Q

What is the cause of ALI/ARDS?

A

Oxidant radicals
Inflammatory destruction of alveolar membrane
Release of proteinaceous material

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26
Q

What is the cause of respiratory failure in shock?

A

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

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27
Q

What kind of monitors can you use to assess for fluid status?

A

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

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28
Q

What additional monitors can you use for someone with shock?

A

PAC=
SvO2
CO

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29
Q

What can be calculated on echocardiography to assess stroke volume?

A

Velocity time intravascular (VTI) of the subaortic flow

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30
Q

What are the treatments on sepsis?

A

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

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31
Q

Why is norepinephrine the vasopressor of choice in sepsis?

A

Because it corrects for splanchnic ischemia and improves organ function

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32
Q

What’s on the differential for hypoxia (Board stiff question)?

A

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

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33
Q

How do you trouble shoot hypoxia?

A

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?

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34
Q

What is on the differential for hypercapnea?

A

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)

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35
Q

How do you assess airway in preop?

A

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?

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36
Q

What are signs of a difficult airway?

A 
Large or loose teeth
Big tongue
Short thyroid talk distance
Thick neck
Mallampati >2
Decreased neck mobility 
Obesity
Beard
Masses/ radiation scars
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37
Q

What are the questions you want to ask a patient for airway assessment?

A 
Any trouble in the past? Chipped tooth?
History of surgery or radiation?
Last time they ate?
Have they been vomiting?
Do they have OSA?
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38
Q

Name steps for awake intubation

A

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?)

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39
Q

How will you decide to extubate someone?

A

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

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40
Q

How do you deal with difficult airway in a child?

A

Keep them breathing spontaneously - sevoflurane
Use fiber optic for attempts
Ventilate frequently and between attempts

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41
Q

How do you deal with a difficult airway in an uncooperative adult?

A

Induce and maintain in-line stabilization
Take a look and attempt with boogie and video
If cannot get it - cric!

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42
Q

If patient unable to tolerate awake fiber optic?

A

Induce - incubating LMA

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43
Q

Would you use cricoid pressure? Why or why not?

A

No, because it has not been proven to prevent aspiration and can make ventilation and intubation more difficult

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44
Q

What did the Metoprolol CR/XL randomized intervention trial in CHF show?

A

BB are suitable and improve survival for patients with CHF class II to IV and EF < 40%

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45
Q

What are the factors of Revised Cardiac Risk Index?

A
  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
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46
Q

When should beta blockers be continued perioperatively?

A

When a patient has been on beta blockers chronically

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47
Q

When should you start a beta blocker on a patient?

A

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

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48
Q

When should you get an echo on someone with clinically suspected valvular disease of moderate - severe degree?

A
  1. No echo within a year
  2. New significant symptoms or exam findings

Class 1 evidence ***

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49
Q

Is valve repair for elective surgery effective in lowering periop risk?

A

Yes, if the patient has moderate-severe disease with symptoms

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50
Q

What do the ACC/AHA guidelines say about noncardiac surgery in patients with asymptomatic severe aortic stenosis, MR, AR with normal EF?

A

With appropriate intraoperative and postoperative monitoring and hemodynamic management may be reasonable

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51
Q

What do the ACC/AHA guidelines say about targeted pulmonary therapy?

A

They should be continued unless contraindicated or not tolerated

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52
Q

What do the ACC/AHA guidelines say about seeing a pulmonary hypertension specialist preoperatively?

A

Beneficial but not required

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53
Q

What are the risk factors for increased periop risk in patients with PAH?

A
  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
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54
Q

What is the value of severe mean PAP on echo or RHC.

A

mPAP > 55 mm Hg

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55
Q

What is the mPAP for mild PH?

A

> 25-40 mm Hg

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56
Q

What is the RVSP above which signifies PH?

A

> 35

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57
Q

What is the mPAP that is considered moderate PH?

A

41-55

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58
Q

What is the recommendation for cardiac assessment on a patient with greater than 1% RCRI, but METS > 4?

A

No further testing, proceed to surgery

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59
Q

What are the recommendations for patients with RCRI >1% and METS < 4?

A

Ask yourself - will further testing impact decision making or periop care?

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60
Q

What do the ACC/AHA guidelines say about preoperatively ECG?

A

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

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61
Q

What do the guidelines say about assessing LV function preoperatively?

A

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
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62
Q

What do you do about patients with elevated RCRI and unknown functional capacity?

A

According to the ACC/AHA guidelines, it is reasonable to perform a stress test for functional capacity if it will change management

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63
Q

Which beta blockers have been shown to reduce mortality?

A

Metoprolol
Bisoprolol
Carvedilol

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64
Q

Who should have a beta blocker?

A

All patients with:
LV dysfunction (EF<40%) with HF
Prior MI

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65
Q

How long should beta blockers be continued for patients with normal LV function and prior MI/ACS?

A

For 3 years

But reasonable to continue

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66
Q

How long should you wait for surgery after MI?

A

At least 60 days

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67
Q

What does a fixed perfusion defect on radionuclide scan indicate risk-wise?

A

Low positive predictive value for perioperatively cardiac events, but predicts long term cardiac events

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68
Q

What does a reversible perfusion defect indicate risk-wise?

A

Predicts high probability of perioperatively cardiac events

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69
Q

How long after bare metal stent placement should elective noncardiac surgery be?

A

30 days

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70
Q

How long after balloon angioplasty should elective noncardiac surgery be?

A

14 days

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71
Q

How long after a DES should elective noncardiac surgery be?

A

1 year

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72
Q

If a patient has had a DES and needs surgery sooner than 1 year, what’s the earliest you can consider?

A

6 months

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73
Q

If a patient needs stunting, but also needs elective noncardiac surgery within the year, what can you do?

A

BMS + 4-6 weeks of DAPT, then continue aspirin perioperatively

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74
Q

If the noncardiac surgery is time sensitive (2-6weeks) or high risk of bleeding, what is the PCI option?

A

Ballon angioplasty or BMS

Or CABG

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75
Q

What are the adverse outcomes associated with preoperatively beta blockade?

A

Bradycardia
Stroke
Higher rate of death from noncardiac events

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76
Q

What do the ACC/AHA guidelines say about starting a beta blocker perioperatively on a patient with moderate-high ischemic risk?

A

It is reasonable, but should consider the patient’s risk of stroke and other contraindications (uncompensated HF)

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77
Q

What do the guidelines say about starting a patient on beta blockade who has clear long term indication for it but low RCRI?

A

Unknown benefit

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78
Q

What do the guidelines say about starting a statin postoperatively?

A

It is reasonable in patients undergoing vascular surgery

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79
Q

What do the guidelines say about starting alpha 2 agonist perioperatively?

A

It is not recommended for prevention of cardiac events

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80
Q

What are the recommendations for CCB perioperatively?

A

No formal recommendations

They have been shown to reduce risk of death/MI/arrythmia

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81
Q

What are the recommendations for ACEi periop?

A

Continuation is reasonable

If held, restart ASAP

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82
Q

When is the risk of stent thrombosis for DES and BMS the highest?

A

4-6 weeks after stent implantation

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83
Q

What if a patient had a DES 5 months ago, but needs urgent surgery?

A

Try to continue DAPT, if not stop PGY inhibitor and continue ASA, restart PGYi immediately

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84
Q

What test would you order to monitor for bleeding risk after dabigatran?

A

aPTT

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85
Q

What test would you order to monitor for bleeding risk with apixaban or rivaroxaban?

A

PT

Or Xa level

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86
Q

If you have a patient with a pacemaker, would do you do?

A

Interrogate the device

Is the patient dependent? If so, turn to asynchronous mode

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87
Q

What if a pacemaker begins oversensing during a procedure?

A

Tell them to stop all electrical activity!

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88
Q

Which patients do you reprogram a pacer in?

A

A patient that needs higher cardiac output and has an insufficient underlying rhythm and rate
Mono polar electrocautery
Minute ventilation sensor

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89
Q

Going into a CABG, a patient’s ACT doesn’t rise after giving heparin, what do you do?

A

Give FFP for antithrombin deficiency

90
Q

What do you do to check that you have not placed a line in the carotid?

A 
Color comparison with radial arterial line
Look for pulsation
Check with ultrasound
Hook to IV tubing
Transduce
91
Q

How do you place a TEE?

A

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
Q

What are the steps to going on pump?

A

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
Q

What is aminocaproic acid?

A

Inhibitors the activity of plasminogen/plasmin by binding to lysine sites on the complex to inhibit plasmin from lysing fibrin clots

94
Q

How do you assess for arterial cannula malposition?

A

Systemic hypotension
Unilateral blanching of the face
Asymmetry of BP in arms
Decreased carotid pulse on ipsilateral side

95
Q

How do you assess for venous cannula malposition?

A

Increased CVP

Head/facial swelling

96
Q

If the pressures on PAC go up, what should that tell you?

A

Inadequate LV venting –> increased LV dissension, wall tension and therefore oxygen demand
Also, myocardial rewarming

97
Q

What do the vents in the LV drain?

A 
Bronchial veins
Thebesian veins
Persistent left SVC 
Shunt
Aortic regurgitate
98
Q

Why do you need an atriotomy in bicaval cannulation?

A

Because it will not drain the coronary sinus which empties into the RA

99
Q

How do you assess arterial inflow?

A

Flow
Reservoir level
Patient’s pressure

100
Q

What are the dangers of arterial cannulation?

A

Emboli
Dissection
Malposition (too proximal cutting off coronaries)
Aneurysm

101
Q

What are the signs that bypass is achieved!

A

Nonpulsatile

Low CVP and PAP

102
Q

How do you get a patient off bypass?

A
  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
Q

What is levosimendan?

A

Increases calcium sensitivity of myocytes by binding troponin C
Increases inotropy, decreases preload and afterload

104
Q

How does milrinone work?

A

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
Q

What are signs of aortic dissection?

A

Hypotension
Increased arterial line pressure
Decreasing reservoir

106
Q

What are the signs of reversed cannulation?

A

Increased CVP

Facial engorgement

107
Q

What if a patient has history of HIT? How will you get on pump?

A

Can use bivalirudin

Ecarin clotting time for monitoring (ECT)

108
Q

What are the contraindications to TEE?

A

Esophageal surgery
Zenker’s
Varicose

109
Q

What are the goals for an off pump CABG?

A

“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
Q

What are the essential monitors for doing a mini mitral case?

A

Pacing swan
Pacing box
cerebrox/ BIS
AC fibrillator

111
Q

How is a LV vent placed?

A

Thru upper pulmonary vein, thru the mitral valve

112
Q

What is a Benthall procedure?

A

Aortic root replacement with a composite valve-graft conduit

113
Q

What is the Cameroon technique?

A

Aortic root replacement with coronary artery reimplantation

114
Q

What monitors are needed for deep circulatory arrest?

A

EEG, cerebrox, Jugukar bulb venous O2
TEE
Bilateral arterial lines

115
Q

What are the indications for retrograde cardioplegia?

A

Severe AI
LVH
Severe CAD

116
Q

When is ante grade cerebral perfusion used?

A

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
Q

What are the concerns regarding an LVAD?

A
  1. Right heart function and support

Dec. PVR, maintain afterload and preload, keep NSR, MAP 70-80

118
Q

What do you do if there is suck down with LVAD?

A

Give fluid! Maintain preload

Give vasopressin or phenylephrine to push septum back over

119
Q

What monitor should you have to monitor BP intraoperatively?

A

Doppler Us

120
Q

What are the complications of VADs?

A 
Mediastinal bleeding
GIB
Intracranial bleed
Vwf syndrome
Stroke
RV failure
121
Q

How does an IABP work?

A

Inflates during diastole to increase coronary perfusion

Deflates during systole which provides a suction effect to increase forward flow

122
Q

Where does an IABP go?

A

Up the femoral artery to the junction of the subclavian

123
Q

What happens if a IABP inflates too late?

A

You lose the effect of increased diastolic perfusion

124
Q

What happens if it inflates too soon?

A

Increased afterload and strain on the heart

125
Q

What happens if you turn the IABP off?

A

Clot formation!

126
Q

What happens if the balloon ruptures?

A

Helium embolus! Which absorbs quickly, but then it has to be replaced

127
Q

What is Eisenmenger’s syndrome?

A

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
Q

What blood product do you want most in setting of IABP?

A

Platelets because IABP chews these up

129
Q

How long should you wait to come off bypass from time of unclamping?

A

At least 20 minutes

130
Q

Every time the surgeons lifts the heart, the IABP can’t pick up. What’s the diagnosis?

A

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
Q

What do you do if the pacing wires aren’t capturing?

A

Increase amps
Check monitors and pacing box (batteries?)
Communicate with surgeons it may need to be moved

132
Q

After closing, you see a regional wall motion abnormality on TEE, what does that mean? What do you do?

A

Suggests ischemia possibly from a kinked grafted, clotted graft, dissected or stitched graft.

Reopen chest and look

133
Q

Is it necessary to place a PAC preoperatively? Why or why not?

A

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
Q

Why do you look for on TEE in a valve repair?

A

Filling and function of ventricles

Peri valvular leak

135
Q

What are the consequences of mtp?

A 
Dilution all coagulopathy
Hypocalcemia
Hypothermia
Hyperkalemia
Immune reactions
TRALI
Fluid overload
136
Q

What are the downsides of fem-fem bypass?

A

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
Q

What it THAM? When would you use it?

A

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
Q

What are the side effects of THAM?

A

Tissue irritation and venous thrombosis at site of administration
Hypoglycemia
Respiratory suppression

139
Q

What is the dosing of THAM?

A

0.3 mol/L

Max dose = 15 mmol/kg (3.5 L in 70 kg)

140
Q

What are the consequences of bicarbonate?

A

High sodium content
Hypertonicity causing rapid intravascular volume –> intracranial bleed
Hypercapnea
Hypokalemia
Ionized hypocalcemia
Increased acidosis secondary to shift of oxygen dissociation curve?

141
Q

What are the implications of perivalvular leak?

A

Not seated correctly
Not sewn in perfectly

Go back on bypass and fix!

142
Q

What monitors do you want for a patient with an LVAD?

A

Cerebral oximetry
Doppler for BP
Intermittent ABG/VBB

143
Q

What do you do if a patient with an LVAD desaturates?

A

Check flow rate - increase flow or RPM

Increase FiO2

144
Q

What are the anesthetic goals of HOCM.

A

Increased preload
Maintain afterload
Avoid tachycardia
Avoid inotropy

Tax: fluids and phenylephrine

145
Q

What are sgarbossa’s criteria?

A
  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
Q

What is R in T phenomenon?

A

When there is electrical stimulation of the heart during its repolarization or refractory period that can lead to V fib

147
Q

What would you do if a patient has PVCs intraoperatively?

A

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
Q

What is the new guideline on newer generation DES and elective noncardiac surgery?

A

May consider surgery after 3 months if risk of further delay outweighs the risk of stent thrombosis

149
Q

Who needs SBE prophylaxis?

A
  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
Q

What conditions is SBE no recommended for?

A

MVP
Bicuspid AV
HOCM
GU or GI procedures

151
Q

What would you administer for SBE ppx?

A

Amoxicillin 2 g (50 mg/kg in kids) 1 hour before procedure

152
Q

What would give for SBE ppx in someone who is allergic to PCN?

A

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
Q

What would you give for SBE prophylaxis in someone who can’t take po?

A

Ampicillin 2 g (50 mg/kg in kids)

Cefazolin 1 g

154
Q

What is the transvalvular gradient of severe aortic stenosis?

155
Q

What is the velocity of aortic jet in severe aortic stenosis?

156
Q

What is the velocity of aortic jet, mean transvalvular gradient and aortic valve area in mild aortic stenosis?

A

Less than 3
Less than 25 mm Hg
1.5-2.0

157
Q

What is a normal AV area?

158
Q

What are the concerns with anterior mediastinum mass?

A

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
Q

What are the risk factors for periop cardiopulmonary complications in anterior mediastinal mass?

A
  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
Q

How would you evaluate a patient for airway compression?

A

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
Q

When would you perform a upright and supine TEE.

A

Anterior mediastinal mass

Pericardial effusion

162
Q

When does CKMB elevate after MI? How long does it stick around? When does it peak?

A

Elevates within 4-6 hours
Peaks 12-24 hours
Returns to baseline in 2-3 days

Not as specific for cardiac tissue

163
Q

When does troponin peak?

A

12-24 hours

164
Q

How long does it stick around?

165
Q

When does troponin elevate?

166
Q

What is the therapeutic digoxin level?

A

0.5-2.0 NG/ml

167
Q

What are the symptoms of digoxin toxicity?

A 
EKG changes: mild ST depression, 
Arrythmia 
Fatigue
Salivation
Confusion 
Nausea vomiting 
Visual disturbances
168
Q

What factors potentiates digoxin toxicity?

A

Hypokalemia
Hypomagnesemia
Hypercalcemia

169
Q

What does it mean if troponin is elevated by CKMB is not?

A

MI occurred within the last few days, but there a

Has been no recurrence because CKMB drops off around 2-3 days

170
Q

What monitors to do you want for a CABG?

A

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
Q

A patient Bp drops after initiation of bypass, what do you think k is going on?

A

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
Q

What might be wrong if the pacing wires are not capturing?

A 
Dislodged
New MI - significantly increases energy required to depolarization 
Insufficient amps 
Pacemaker malfunction 
Acid-base disturb 
Electrolyte abnormalities 
Abnormal antiarrythmic drugs levels
173
Q

When is a patient at highest risk for recall in a cardiac case?

A

During rewarming –> give benzodiazepine before this!

174
Q

What is a side effect of cyclosporine in heart transplant patients?

A

HTN

Treat with CCB or ACEi

Avoid beta blockers and nifedipine

175
Q

What are the signs of cardiac transplant rejections?

A 
Fever
Arrythmias
Dyspnea
Accelerated atherosclerosis 
Myocardial dysfunction
176
Q

What is unique about a transplanted heart?

A

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
Q

What are the best vasopressors to use for a transplants heart?

A

Isoproterenol
Epinephrine
Dobutamine

178
Q

Would you still administer an anti muscarinic with neostigmine in a patient with a cardiac transplant?

A

Yes due to peripheral muscarinic effects and sometimes bradycardia in the transplanted heart due to partial innervation after 6 months that can occur

179
Q

What are the effects of aortic regurgitation?

A

Increased myocardial oxygen demand
Decreased coronary perfusion secondary to reduced aortic diastolic pressure and increased LVEDP
Pulmonary edema due LVEDP

180
Q

Why would you administer beta blocker therapy for aortic dissections?

A

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
Q

What are the contraindications to acute normovolemic hemodilution?

A 
Anemia (Hct <33%)
Impaired renal function
Aortic stenosis
Significant pulmonary disease
Coagulopathy
182
Q

How do you do acute normovolemic hemodilution?

A

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
Q

What are the effects of acute normovolemic hemodilution?

A

Deceased SVR 2/2 decreased blood viscosity

Increased CO

184
Q

How do roller pumps work?

A

By partial compression of tubing
Not sensitive to afterload or preload
Delivers flow based on speed
Delivers pulsatile flow

185
Q

What are the disadvantages of a roller pump?

A

More damage to RBCs

More entrainment of air

186
Q

What are the characteristic of a centrifugal pump?

A 
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
Q

Would you use alpha stat management if employing moderate hypothermia?

A

Yes, because there is evidence that it improves neurological outcome in patients

(No addition of CO2)

188
Q

What does the c wave represent in PCWP tracing?

A

The elevation of the mitral valve during early ventricular systole

189
Q

What does the v wave reflect on PCWP tracing?

A

Venous return against a closed mitral valve

190
Q

What does the X descent represent on PCWP tracing?

A

Downward displacement of the atrium during ventricular contraction

191
Q

What does the y descent represent in a PCWP tracing?

A

Decline in atrial pressure as mitral valve opens during systole

192
Q

What are the surgical steps to going on bypass?

A

Ascending Aortic cannulation “low flow” from surgeon
Venous cannulation (IVC, RA)
LV vent placed

193
Q

How do you monitor temperature in CPB?

A

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
Q

What would you do if the perfusionist said the venous reservoir level was decreasing ?

A

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
Q

Why do you inflate the lungs following CPB?

A

To de- air the left heart and prevent end organ damage from embolization
Recruit collapsed alveoli

196
Q

When trying to come off of bypass pulmonary pressures increase while SVR decreases, what would you suspect?

A

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
Q

How does recent mitral valve replacement contribute to risk of left ventricular failure coming off bypass?

A

Results in loss of low resistance outflow tract into the LA which may unmask LV dysfunction

198
Q

When should IABP inflate?

A

Middle of the T wave

Dicrotic notch

199
Q

Can you use IABP with s pacermaker?

A

Yes, just use the arterial wave form for triggering

200
Q

Explain the difference between central aortic pressure and radial arterial pressure after CPB?

A

Peripheral vasodilation during rewarming causes a significantly lower pressure at radial arterial line (about 30 mmHg)

This resolves in about 45 minutes

201
Q

What is pulses paradoxus?

A

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
Q

How would you manage tamponade?

A

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
Q

What are the indications for cardiac ablation

A

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
Q

What is a normal valve area for mitral valve?

205
Q

What is an severe mitral valve area for stenosis?

A

Less than 1.0

206
Q

What is a moderate valve are for MS?

207
Q

What is the energy used for synchronized cardio version with a Monophasic defibrillator?

A

200 joules

208
Q

What are the anesthetic goals for a patient with mitral regurgitation?

A 
Maintain preload and forward flow
Judiciously reduce afterload 
Keep HR high normal 
Minimize cardiac depression
Avoid increases in PVR
209
Q

What are the anesthetic goals for patients with MR occurring secondary to MVP?

A

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
Q

When a patient had MVP, what else should you be worried about ?

A

Mitral regurg

PFO

211
Q

What is the differential for an unsuccessful rise in ACT after heparin?

A 
Antithrombin III deficiency
IV infiltration
Wrong med
ACT measurement malfunction 
Heparin resistance
212
Q

What are the causes of hypotension and increased pulmonary pressures after protamine?

A

Histamine release

Type III resection with protamine-heparin complexes leading to release of TXA2 in pulmonary circuit

213
Q

How would you evaluate a patient’s pacemaker?

A 
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
Q

How would you position the return plate (bovid pad)?

A

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
Q

What are the potential reasons for pacemaker failure intraoperatively?

A 
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
Q

What see the indications for postoperative pacemaker interrogation?

A 
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
Q

Who should not get a dobutamine stress test?

A

Severe HTN
Arrythmia
Hypotension

218
Q

Who should not get adenosine?

A

Asthma
Critical carotid disease
Intolerance for discontinuation of theophylline

219
Q

What can statins do?

A

Decrease risk of death in vascular patients with renal impairment

220
Q

What can PAC cause in LBBB?

A

Total heart block

221
Q

How would you treat a Type III protamine reaction?

A

Epinephrine or milrinone for inotropy
Consider nitric oxide
Consider low dose heparin to break up complexes and reduce production of TXA2

Anesthesia MM/TL (36 decks)

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