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From Flashcardlet big > Pre-operative work up questions > Flashcards

Pre-operative work up questions Flashcards

1
Q

Name 6 risk factors for post operative renal dysfunction

A 
Age
Hypertension 
Diabetes
Radiologic contrast
complex surgery (AVR + CABG) 
ACE inhibitor
pre-operative renal dysfunction
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2
Q

What type of analgesic should be avoided post op

A

NSAIDs

They interfere with prostaglandin function of the kidney

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3
Q

Name treatments for Hyperkalemia

A

1 gram of Calcium chloride IV
50 meq of Sodium Bicarbonate
10 u of Humulin R IV and 50 ml of D5W
30 gm po Kayexalate

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4
Q

What is malignant hyperthermia

A

Autosomial dominant with variable penetrance genetic disorder that results in increased skeletal muscle metabolism and CO2 production–hyperthermia/VT/renal failure

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5
Q

What agents can trigger Malignant Hyperthermia and what is the pathophysiology

A

Inhaled anesthestics (Halthothane, isoflurane)
Succinycholine
Possible association with ketamine

*impaired reuptake of inonized calcium from cytsol in the SR

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6
Q

List 4 viability scans

A 
Myocardial perfusion imaging
	thallium or technetium
PET
Dobutamine echocardiography 
MRI
CT
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7
Q

What is CHILD classification of liver failure and what is the mortality of patient with CHILD B

A 
Based on 5 parameters
	Ascities 
	PT (INT) 
	Albumin
	Encpalopathy
	Bilirubin 
A is 5-6 
B is 7-9
C 10 to 15 
CHILD A is 0 to 3% 
CHILD B is 40 to 80%
CHILD C is 100%
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8
Q

In patients with cirrhosis of the liver classified as CHILD B what is the mortality associated with a cardiac procedure involved the use of bypass

A

more then 70%

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9
Q

3 findings on stress thallium that an predict benefit of revascularization

A

Large reversible defect (which is also caused moderate-severe inducible ischmie, > 10 % of myocardium
Absence of fixed defects
Presence (and number of segments) of viable myocardium

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10
Q

What are contraindications to Dobutamine

A

Ventricular arrhythmias
Recent myocardial infarctions (1 to 3 days)
Acute coronary syndrome
Hemodynamically significant left ventricular outflow tract obstruction
Aortic aneurysm or aortic dissection
systemic hypertension

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11
Q

What is a dobutamine stress echo

A

Measure inotropic reserve of dysfunctional, but viable myocardium

viable myocardium shows improved regional contractile function

contractile reserve is independent of the severity of the coronary artery disease

mitral inflow pattern—early diastolic deceleration time (DT) of > 150 msec correlates with improvement after CABG and greater survival.

End-diastolic wall thickness of < .6 cm indicates non-viable segment

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12
Q

List 4 viability studies in order of accuracy

A 
PET imaging
	highest sensitivity 
SPECT
	more sensitive than Dom echo
	excellent at predicting benefit from revascularization 
Dobutamine stress echo

Dobutamine MRI

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13
Q

How does thallium myocardial perfusion imaging for viability work

A

Thallium is take up by viable (living) myocytes (requires NA/K ATPase)
reflection of both perfusion and viability
Current protocols image at stress..redistribution..and reinjection (18 to 24 hours)
defect present in stress that recovers at late imaging indicates viability

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14
Q

List myocardial perfusion end points that are adverse predictors of future cardiac events

A

Large defect size > 20 percent of the left ventricle
defects in more than 1 coronary artery territor suggestive of multivessel disease
major nonreversible defects
transient or fixed left ventricular cavity dilation
resting left ventricular ejection fraction < 40 percent
increase lung uptake up thallium

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15
Q

What are risk factors for protamine reactions

A

history of a protamine allergy
Allergy to fish products
Previous exposure to protamine, even without a reaction
Use of NPH insulin
Prior vasectomy (immunologic exposure to sperm proteins after breakeage of the pats blood-sperm barrier.
Any allergy to other meds

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16
Q

What is risk of stroke per degree of carotid stenosis

A

<50% it’s a 2% risk
50 to 80% it’s about 7.5%
> 80% it’s about 11%
Unilateral occlusions it’s about 11%

Poor correlation between degree of audible bruit and the degree of carotid stenosis

17
Q

What is mechanism of peri-operative stroke with carotid stenosis

A

Emboli from carotid plaque
Loss of pulsatile flow or inadequate perfusion pressure on bypass may lead to diminished flow distal to stenosis leading to “watershed stroke”
Prothrombotic state post-op leads to destabilization of previously asymptomatic carotid stensosis (as > 50% of cases occur > 24 hours post op)

18
Q

Who should undergo carotid screening

A 
Age > 65 
Left main disease
Peripheral vascular disease
History of TIA/Stroke
Carotid bruit on exam 
Smoking 
female 
DM 
Prior carotid endarectomy
19
Q

What are the important outcomes from the carotid u/s to understand

A
  1. Peak systolic velocity (PSV)
  2. End-diastolic velocity
  3. Ratio between PSV in the internal carotid artery and the proximal common carotid artery (ICA/CCA ratio)
    This ratio correct for baseline variation in hemodynamics (such as CO)
    a ratio > 4 is equal to > 70%
20
Q

What are options for carotid endarterctomy and CABG

A

Staged: CEA 1st–then 1 to 5 days after CABG (usually for those with less critical coronary disease

Combined: when severe CAD and would not tolerate CEA. Symptomatic for both lesion s

Reverse-staged: CABG then carotid–high rate of stroke (14%) while mortality is the same

21
Q

What are AHA guidelines for CEA before CABG or concomitant

A

Class IIa

Symptomatic carotid artery disease or asymptomatic disease but stenosis of > 80% unilateral or bilateral

22
Q

A patient presenting with MI. What are effects of timing on myocardium

A
  1. < 20 minutes of occlusion: reversible cellular damage and dpressed function with subsequent myocardial stunning
  2. > 40 min but < 3 hours. If reperfusion happens, 60 to 70% of ultimate infarct is salvageable
  3. > 3 hours but < 6 hours: salvageable myocardium decreases to 10%
  4. > 6 hours resulting in trans-myocardial infarction
23
Q

List parameters of cardiogenic shock

A 
SBP < 80 mmHg
PCWP > 18
u/o < 20cc/hr
metal state changes
tachycardia 
peripheral vasoconstriction with cold extremities 
CI < 1.8  
SVR < 200 dyn
24
Q

What is prevalence and outcomes of presenting in SHOCK

A

most common cause of in-hospital mortality following MI
Mortality is 80%
Incidence in MI is 2.4 to 12%
results from loss of at least 40% of left ventricle

25
Q

What is definition of NSTEMI

A 
chest pain > 10 minutes
ST-segment depression > 0.5 mm
ST-segment elevation 0.6mm to 1.0mm
T-wave inversion > 1 mm 
Positive troponin 
or history of unstable angina in a pt with CAD risk factors
26
Q

Classify athersclerosis of the aorta

A

Type 1: circumferential calcification “Porcelain aorta”
Type 2: Diffuse intimal thickening with ragged friable edges. Unreliable palptation, easy to identify on TEE or epiaortic scan
Type 3: Intramural liquid debris. The most difficult to find by palpation or TEE. Best seen on epiaortic scan

An other classification used in TEE or epiaortic
Grade 1: normal or mild,  wall< 2 mm
Grade 2: thickening 2-3 mm
Grade 3: atheromatous protrusion < 5 mm
Grade 4: atheromatous protrusion > 5 mm
Grade 5: mobile plaque
27
Q

What is a grading system for Epi-aortic scanning

A

Normal no intimal thickening
Mild < 3 mm without irregularities
Moderate > 4 mm with diffifuse irregularities and or calcification
Severe > 5 mm intimal thickening and or large mobile debris and ulcerated pla ques and thrombi

28
Q

Describe role for pulmonary function test in preop

A

Help only in highlighting the degree of risk but do not provide definitive risk assessment for post operative complications.
FEV1 that is more than two standard deviations less then predicted is usually associated with a prohibitively high risk for pulmonary complications

29
Q

Patient with post op AVR having hemolysis. What are tests that should be performed

A 
Serum haptoglobin * best test* 
LDH
Indirect bilirubin 
peripheral smear
urine free hemoglobin 
urine hemosiderin
30
Q

What pulmonary function tests are associated with high risk postoperative respiratory failure

A 
P02 < 60 on room air 
PC02 if > 60 
FEV1 < 65% of VC 
FEV 1 < 1 -1.5 L 
DLCO < 50% predicted 
Vo2 max > 10 cc/kg, the best predictor but rarely measured 
Failure to respond to broncho-dilators
31
Q

Interpreting pulmonary function testing

A

The most important spirometric maneuver is the FVC. To measure FVC, the pt inhales maximally, then exhales as rapidly and as completely as possible.
Normal lungs generally can empty more than 80 percent of their volume in six seconds or less. The forced expiratory volume in one second (FEV1) is the volume of air exhaled in the first second of the FVC maneuver. The FEV1/FVC ratio is expressed as a percentage

32
Q

How to distinguish between restrictive and obstructive pulmonary disorders

A

When the FVC and FEV1 are decreased, the distinction between an obstructive and restrictive ventilatory pattern depends on the absolute FEV1/FVC ratio.

If the absolute FEV1/FVC ratio is normal or increased, a restrictive ventilatory impairment

A reduced FEV1 and absolute FEV1/FVC ratio indicates an obstructive ventilatory pattern, and bronchodilator challenge testing is recommended to detect patients with reversible airway obstruction (e.g., asthma).

*use 0.7 as the FEV1/FVC ratio that is “normal”

33
Q

What are parameters of bedside spirometry that indicate high risk

A

FEV1 < 70% predicted

FEVc < 70 % predicted

FEV1/FVC ratio of < 65%

34
Q

What is definition of Cardiogenic Shock

A

BP systolic < 80mmHg mean < 60mmHg
CI < 2 L (with adquate filling)
LAP and/or RAP > 20

Clinical manifestation of low cardiac output
decreased peripheral perfusion (pulses, cool, mottled)
restlessness, confusion, decreased mentation
urine output < 20-30 cc/hr

35
Q

In patients with pre-existing chronic renal failure and dialysis

a. What is the expected in hospital mortality associated with CABG
b. What is the two year survival (including mortality of all causese)

A

8- 13%

50 to 60%

36
Q

In patients with pre-existing chronic renal failure and dialysis
What is the expected in hospital mortality associated withe coronary artery bypass surgery
What is the two year survival (including mortality of all causes)

A

8 - 13%

50 to 60%

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