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Pathophysiology > Peripheral Vascular disease/Valvular disease > Flashcards

Peripheral Vascular disease/Valvular disease Flashcards

1
Q

What is Peripheral Vascular disease?

What causes it?

A
  • A compromised blood flow to the extremities
  • Ankle-brachial index of less than 0.9
    • Ratio of SBP in ankle vs SBP in brachial artery
  • Causes:
    • Atherosclerosis- most common
    • arterial embolism
    • vasculitis
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2
Q

How prevalent is atherosclerosis?

A
  • 2 million Americans are symptomatic
  • associated with aging
  • exceeds 70% in ppl over the age of 75
  • increases with risk factors
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3
Q

What are the risk factors of atherosclerosis?

A
  • DM
  • advanced age
  • male gender
  • ovesity and physical inactivity
  • sedentary lifestyle
  • essential HTN
  • smoking
  • dyslipidemia
  • family Hx
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4
Q

What are the signs and symptoms of atherosclerosis?

A
  • Intermittent claudication (angina of the legs)- most common
  • cool/cold feet to touch
  • pain while laying flat and relieved by a sitting position
  • loss ofpulses in legs or feet, pale color when legs are raised
  • dependent rubor (redness)
  • shiny skinn, loss of hair
  • thickened toenail (fungal infections)
  • Critical limb ischemia (rest pain)- lack of O2 to the limb/leg at rest
    • associated with non-healing ulcers and gangrene
    • most severe symptom
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5
Q

What is the treatment for atherosclerosis?

A
  • Identify and treat the risk factors
    • exercise, lifestyle change, wt loss, smoking cessation
  • lipid lowering therapy (statins)
  • Vitamin C and E and Folate supplements
  • Anti-platelet therapy
  • Revascularization procedures
  • amputation
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6
Q

What

A
  • After donor and recipient arteries are exposed, tunnel is created and graft is passed
  • Graft may be saphenous vein or a prosthesis
    • usually prosthesis b/c if one vein is so bad they need a graft, the saphenous vein probably isnt much better
  • Heparine IV given (note time)
  • Anastomosis are constructed
  • Arteriogram to confirm adequate flow
  • heparin not likely to be reversed b/c it is probably a small dose
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7
Q

Pt with PVD has _____ greater risk of MI, stroke, and death

A

3-5x

These pts probably also have CAD

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8
Q

What are the preferred anesthesia techniques for peripheral revascularization surgeries?

A
  • Regional Anesthesia:
    • increased graft blood flow
    • less increase in SVR with cross-clamping
    • postoperative pain relief
    • less activation of the coagulation system
  • Regional Vs General
    • assess for coagulopathy
    • If regional, spinal may be best to avoid hematoma
    • No difference in cardiopulmonary complications btw RA and GA
    • Significantly fewer graft occlusion complications with RA
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9
Q

What should you consider for the anesthesia management of a peripheral revascularization surgery?

A
  • Consider co-morbidities
  • Medication Hx and impact on anesthesia delivery
  • end organ perfusion and oxygenation- may want foley
  • blood gases to not electrolyte and pH changes
  • Cross clamp- heparin administration
    • record time
    • reversal?
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10
Q

How should you monitor a pt during peripheral revascularization surgery?

A
  • Pts typically have CAD, DM, HTN
  • Make sure pt takes BBs and other chronic meds
  • Art line
  • CVP or catheter- to monitor intravascular volume
  • EBL
  • estimated third space
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11
Q

What is the definition of Mitral Stenosis?

A
  • Normal mitral valve orifice is 4-6 cm2
  • Considered stenotic when the orifice is <1-1.5 cm2
  • a mean left atrial pressure of about 25 mmHg is necessary to maintain an adequate resting cardiac output (normal 8-10)
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12
Q

What is almost always the cause of mitral valve stenosis?

A
  • Almost always caused by fusion of the mitral valve leaflets at the commissures during the healing process from rheumatic fever
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13
Q

What is the root of the problem you are dealing with stenosis?

What is the root problem with regurgitation?

A
  • Stenosis = pressure problem
  • regurgitation = volume problem
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14
Q

What is the pathophysiology of mitral stenosis

A
  • Fusion of valves from rheumatic fever
  • increased pressures in LA requires to move blood through the tiny mitral opening
    • this causes LA enlargement
  • LA enlargement predisposes to atrial fibrillation
    • blood stasis in bil LA predisposes the formation of thrombi–this is why pts with mitral stenosis may be on chronic anticoagulation therapy
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15
Q

What are the symptoms of Mitral valve stenosis?

A
  • dyspnea on exertion when CO is increased
  • Severe mitral stenosis leads to pulmonary hypertension and CHF
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16
Q

What are the goals when managing the anesthesia of a pt with mitral stenosis?

A
  • Goals: slow, tight, full
  • Avoid tachycardia or rapid ventricular response rate during afib (slow)
  • avoid marked increases in central blood volume that could be caused by over transfusion or head-down position
  • Avoid drug-induced decreases in SVR (tight)
  • Avoid events such as arterial hypoxia and/or hypoventialtion that may exacerbate pulmonary HTN and evoke right ventricular failure
17
Q

How should you induce a pt with Mitral stenosis?

A
  • With drugs that are unlikely to increase HR (avoid ketamine) or abruptly decrease SVR
  • Ex. etomidate with balanced technique
18
Q

How should you try to manage the maintenance of anesthesia in a pt with Mitral stenosis?

A
  • Use drugs that have minimal affect on HR,SVR, PVR, and myocardial contractility
    • may need BBs and CCBs, phenylephrine
  • Monitoring:
    • need for invasive monitoring depends on the complexity of the procedure and magnitude of impairment caused by MS
19
Q

What are the two factors associated with the development of Aortic stenosis?

A
  • Aging- degeneration and calcification of the aortic leaflets
    • incidence is increasing as population is aging
  • Presence of a bicuspid aortic valve (BAV), which is a common congenital valve abnormality
    • b/c of abnormal shape, fibrosis and calcification more likely
20
Q

What are the measurements that cause hemodynamically significant aortic stenosis?

What are the characteristic symptoms of AS?

A
  • Aortic valve orifice area < 1 cm2 (normal 2.5-3.5 cm2)
  • transvalvular pressure gradient >50 mmHg
  • Symptoms
    • angina in the absence of ischemic heart disease
    • dyspnea on exertion
    • syncope
21
Q

What are the goals when managing anesthesia for a patient with Aortic stenosis?

A
  • Avoid any events that would further decrease CO
  • Maintain NSR- properly times atrial contraction will produce an optimal LVEDV
  • avoid bradycardia or tachycardia
  • avoid hypotension- avoid decrease in SVR, very difficult to bring BP back up
  • Optimize intravascular fluid volume to maintain venous return ad left ventricular filling
  • **CPR is typically ineffective in pts with AS b/c it is impossible to get enough pressure to move blood through the small opening with compressions
22
Q

General anesthesia or Neuraxial anesthesia in pts with Aortic stenosis?

A
  • General anesthesia preferred because of the sympathetic block that causes decrease in SVR
23
Q

What are some of the causes of mitral regurgitation?

A
  • Usually due to rheumatic fever (book says this is uncommon) and is almost always associated with mitral valve stenosis
  • Can be associated with ischemic heart disease or papillary muscle dysfunction
24
Q

What is the pathophysiology of mitral regurgitation?

A
  • A portion of every stroke volume is regurgitated through the incompetent mitral valve back into the LA
  • This causes LA volume overload and pulmonary congestion
  • The amt that regurgitates depends on:
    • size of mitral valve orifice
    • heart rate, which determines the duration of ventricular ejection
    • the pressure gradient across the mitral valve
  • Pharmacological changes in SVR have a major impact on the regurgitation fraction
25
Q

How is mitral regurgitation noted on a pulmonary arterial occlusion pressure waveform (PAOP)?

A
  • Regurgitant flow causes an exaggerated V wave
  • Size of V wave correlates with magnitude of regurgitant flow
  • Pic below shows normal wave (about 12), will go to 20 or 25 with regurgitation
26
Q

What are the goals for management of anesthesia in a pt with mitral regurgitation?

A
  • Goals: fast, full, forward
  • Avoid events that may further decrease cardiac output
  • Avoid sudden decreases in HR
  • avoid sudden increases in SVR
  • monitor the size of the V wave as a reflection of regurgitant flow
  • minimize drug-induced myocardial depression
  • Ex. Etomidate or high dose opioid for induction
27
Q

What influences the how you will manage the maintenance phas of anesthesia for a pt with mitral regurg?

Monitoring?

A
  • Maintenance anesthesia is influenced by the degree of LV dysfunction
  • If not severe:
    • N2O and volatile agent (Iso, des, or sevo b/c of minimal negative inotropic effects)
  • If severe:
    • Use of high opioid technique minimizes drug induced myocardial depression- be aware that it might cause bradycardia
  • Use of invasive monitoring depends on the complexity of procedure and magnitude of regurg
28
Q

What are the causes of aortic regurgitation?

A
  • Diseased leaflets:
    • endocarditis*, rheumatic fever, BAV
  • Problems with aortic root:
    • idiopathic aortic root dilation, aortic dissection*, marfan syndrome, ankylosing spondylitis
  • *acute
29
Q

What is the problem caused by aortic regurgitation?

A
  • decrease in CO d/t regurgitation of part of the SV back into the LV during diastole
  • Causes combined pressure and volume overload on LV
  • Magnitude of regurgitation depends on:
    • HR- amt of time available for the backward flow to occur
    • SVR-pressure gradient across the aortic valve
30
Q

What are goals for anesthesia in a pt with Aortic regurgitation.

A
  • Avoid sudden decreases in HR
  • Avoid sudden increases in SVR
  • minimize drug induced myocardial depression
  • Induction- use drugs likely to maintain forward left ventricular SV
  • Maintenance:
    • No LV dysfunction- N2O plus VA (Iso)
    • LV compromise- consider opioid alone
31
Q

How should you manage the fluid for a pt with mitral regurgitation?

monitoring?

A
  • Prompt replacement of blood loss is important to maintain forward LV SV
  • Bradycardia may require prompt treatment with atropine
  • monitoring:
    • based on complexity of surgery and severity of regurgitation

Pathophysiology (26 decks)

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