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3rd Quarter > Principles of Anesthesia Quiz #1 > Flashcards

Principles of Anesthesia Quiz #1 Flashcards

1
Q

What is the blood pressure goal for cardiac patients in OR regarding baseline vitals and blood pressure?

A

Goal is to stay within 10-20% of ischemic free range of baseline pressure

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2
Q

Which heart implant will indicate to you that you have a very sick ventricle?

A

AICD, do not over load patient with fluid.

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3
Q

When should a new MI case be cancelled with an elective procedure

A

Postpone elective non-cardiac procedures if MI < 1 month prior to procedure Wait 6 months after MI

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4
Q

List high risk cardiac surgical procedures

A

Emergent Procedures
Aortic/vascular procedures
Peripheral vascular
Prolonged procedures with blood loss/fluid shifts

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5
Q

List intermediate risk cardiac surgical procedure

A

Carotid endarterectomy
Head/neck procedures
intraperitoneal
intrathoracic

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6
Q

List low risk cardiac surgical procedures

A

Superficial
cataract
Breast
Endoscopic

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7
Q

List the two most important perioperative cardiac risk factors

A 
Urgency of procedure (complications 2 to 5 times more likely)
Operative site (major thoracic, abdominal, vascular)
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8
Q

Intraoperative hypotension can be related to what day of surgery drug?

A

ACEI

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9
Q

Possible cancellation of procedure if DBP > ___ with evidence of ___

A

110, organ damage

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10
Q

Changes in retinal vasculature ___ the severity and progression of arteriosclerosis and hypertensive damage in other organs

A

parallel

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11
Q

What is normal ejection fraction?

A

65%

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12
Q

List the two main coronary arteries

A

LMCA (left ventricle) and RCA (SA node, AV node, PDA)

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13
Q

MR AS Systolic

A

Sound is restricted forward flow

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14
Q

MS AR Diastolic

A

Sound is unrestricted backward flow

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15
Q

What is the conduction rate of the SA node

A

100-110

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16
Q

Vagal tone brings the resting heart rate to about ___. Located in the junction of the ___ and ___.

A

60-80 bpm, RA, SVC

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17
Q

What carries electrical impulses to the LA

A

Bachmann’s Bundle

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18
Q

What is the intrinsic rate of the AV node

A

40-60 bpm

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19
Q

For leads I, V1, and V6, name differences in left and right bundle blocks.

A

Lead I - left rabbit ear, right biphasic
Lead V1 - left downward, right rabbit
Lead V6 - left upward, right biphasic

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20
Q

What has the fastest conduction velocities in the heart?

A

Purkinje Fibers

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21
Q

List responses of the sympathetic nervous system

A 
Acceleratory response
Norepinephrine
Increase heart rate
Increase force of contraction
Increase conductivity
Peripheral vasoconstriction
Innervates all chambers of heart
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22
Q

List parasympathetic responses

A 
Inhibitory response
Acetylcholine
Decreased heart rate
Mild decrease in force of contraction
Slows conduction through AVN
Fibers exist in atria and ventricles (pronounced effects on atria, minimal effects on ventricles)
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23
Q

What is the equation of Coronary Vessel Perfusion

A

CPP = DBP - PAWP

Greatest during diastole when ventricle is relaxed, the wall is slightly softer, and blood flow is generous

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24
Q

What drug relaxes the heart wall allowing increased blood flow?

A

Nitro

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25
Q

What actions supply the heart?

A 
Heart rate
Perfusion pressure
O2 content
LVEDP
CAD
O2 extraction
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26
Q

What are the demands of the heart?

A 
Heart rate
Cardiac output
PCWP (LAP)
Systolic blood pressure
Preload/Afterload/Contractility
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27
Q

Discuss the increase in heart rate and coronary perfusion

A

As heart rate increases, there is less time for coronary blood flow and perfusion. Systolic contraction pressures also occlude blood flow by applying pressure (10mmHg to 120mmHg). The subendocardium of the LV is most vulnerable.

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28
Q

___ is the biggest indicator of CAD.

A

Unstable angina. Poorly controlled by medications at this point, and carries a significant risk of MI

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29
Q

When damage to the heart’s endothemlium occurs, it produces less ___ and less ___

A

NO, Prostacyclin

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30
Q

“Critical stenosis” is a ___ decrease in diameter of a large distributing artery.

A

75%

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31
Q

What are goals for treatment of CAD

A

Restore normal coronary perfusion
Normalize O2 supply/demand ratio
Stent/CABG/Interventions
Antianginals/BB/CCB/Nitrodilators

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32
Q

What are pharmacological treatments for stable angina pectoris

A

Aspirin, plavix, beta blockers, CCB, nitrates, ACEI, risk reduction

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33
Q

Define unstable angina

A

Rest angina >20 minutes, often due to acute event i.e. rupture of small plaque

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34
Q

Ischemic heart disease, discuss

A

caused by supply/demand imbalance
Unstable angina - No damage or biomarker release
Non STEMI - Positive necrosis and biomarker release
STEMI - Biomarker release and ST changes

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35
Q

Discuss the four laboratory biomarkers for myocardial infarction (injury)

A

CK - simple, fast, skeletal muscle not specific to myocardial injury
CK-MB - Cardiac muscle, 3-4 hours post injury, peaks 24 hr, normal 36hr
Troponins - Gold standard, 3-12 hr post MI, elevated 5-10 days for trop I, 2 wks for trop II
BNP - heart failure marker

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36
Q

Insufficient blood supply to the myocardium results in:

A

Ischemia
Injury
Infarct
Depends on length of time blood supply is inefficient, degree of insufficiency, availability of collateral circulation

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37
Q

Ischemia increased by ___% in patients whose heart rate is >99 bpm preop

A

40

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38
Q

Most ischemic episodes are r/t ___

A

Hemodynamic instability

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39
Q

What medications do you avoid with ischemia?

A

Inotropes - increased contractility = increased demand = ischemia

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40
Q

What identifies ischemia intraoperatively?

A

ST segment depression of greater than 1 mm provides evidence of ischemia

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41
Q

List interventions for myocardial ischemia

A 
Anesthesia 
Nitrates
Beta blockers
Calcium channel blockers
Increased perfusion pressure
Positive inotropes
Initiate CPB, cardioplegia for protection, revascularize
IABP
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42
Q

75% of myocardial injury is caused by ___

A

Occlusive intracoronary thrombus

43
Q

With MI, how does the Q wave change?

A

Q wave 0.04 seconds wide. ST segment elevation indicates acute injury.

44
Q

What are the interventions for MI

A

Minimizing demand and optimizing supply
Heart basal O2 consumption: 8-10ml O2/100g/minute
***The most important factor and primary determinant of myocardial O2 consumption is Heart Rate
Slow heart rate

45
Q

Nitroglycerin, discuss

A

Acts as substrate for formation of NO
Dilates veins>arteries (peripheral and coronaries)
**Relaxes wall tension - increased blood flow through subendocardium

46
Q

Sodium Nitroprusside (Nipride)

A

Not for AS/hypotension/hypovolemia
Decreases BP
Decreases SVR

47
Q

Contraindications for beta blockers

A 
Contraindications for beta blockers Marked 1st degree AVB
2nd or 3rd degree AVB
Asthma COPD
LV dysfunction
HR < 50 bpm
hypotension
48
Q

Effects of beta blockers on supply

A

Increased diastolic filling time

increased myocardial flow redistribution (epicardial to endocardial)

49
Q

Effects of beta blockers on demand

A

Decreased heart rate
Decreased contractility
Decreased systolic wall tension

50
Q

Calcium channel blockers

A

causes coronary artery dilation in normal and constricted coronaries
Anti-coronary artery spasm properties
Nifedipine, Verapamil, Diltiazem

51
Q

When to use calcium channel blockers?

A

Helpful for ischemia disease

  • decreases MVO2
  • decreased inotropy
  • relieves ischemia
52
Q

Contraindications for calcium channel blockers

A 
EF < 30%
SBP < 90 mmHg
SSS
2nd or 3rd degree AVB
Atrial fib/flutter
53
Q

Effects of calcium channel blockers on supply

A

decreased coronary vascular resistance
decreased heart rate
decreased wall tension

54
Q

Effects of calcium channel blockers on demand

A

decreased heart rate
decreased contractility
decreased wall tension

55
Q

What is the most sensitive lead to detect ischemia?

A

Lead 5

56
Q

All agents are safe to use if pacemaker is ___ weeks old

A

All agents are safe to use if pacemaker is ___ weeks old >2

57
Q

No N2O if ___ days old. Expands pocket, and may displace anode.

A

<2

58
Q

Avoid ___ for fasiculations and K increase

A

succinylcholine

59
Q

Aortic stenosis, where is murmur

A

Systolic murmur best heard in 2nd right intercostal space with transmission into the neck

60
Q

Aortic stenosis

A

Narrowed pulse pressure
Small or absent dicrotic notch
Exaggerated A and V waves
Harsh low pitched murmur

61
Q

Causes of aortic stenosis

A

Rheumatic disease
Senile calcification
Congenital malformations
- bicuspid AV is most common

62
Q

What is the aortic stenosis triad of symptoms

A

Angina pectoris
- usually the first symptom
Syncope
CHF

63
Q

Pathophysiology of aortic stenosis

A

Chronic pressure overload of LV d/t fixed mechanical obstruction (tight aortic valve)

64
Q

Natural progression of aortic stenosis

A

Normal AV opening ~3cm
Mild AS >1cm
Moderate AS 0.7-0.9 cm
Severe/critical AS 0.5-0.7 cm

65
Q

Hemodynamic goals in aortic stenosis

A

Maintain preload - volume dependent (easy with NTG)
NSR with HR 50-70
High afterload - coronary perfusion (early Neo)
Maintain constant contractility - judicious use of BB

66
Q

Anesthetic techniques with aortic stenosis

A

AS patients will drop their BP badly and quickly
Avoid tachycardia, disastrous, can’t tolerate, precipitates ischemia
Normal atrial kick - 25%, AS atrial kick - 40%

67
Q

Rheumatic Heart Disease

A 
Rheumatic Heart Disease 
d/t Rheumatic fever
Streptococcal infection
Initial pancarditis (inflammation of all layers of heart)
Resolves in weeks
Permanent heart valve damage
MV and AV often damaged
68
Q

Signs of good LV

A 
No history of s/s of CHF
Hypertension
Normal Cl and LVEDP
Echo WNL
EF >40%
69
Q

Signs of poor LV

A 
S/S CHF with SOB
Recent/multiple MI
Low Cl, High LVEDP
Abnormal Echo
EF < 40%
70
Q

What is protected left main disease

A

At least one functional graft to either the LAD or Circumflex
Can sometimes intervene safely in CVL

71
Q

What is unprotected Left Main Disease

A

No graft supplying area distal to lesion at left heart

Accepted treatment = CABG

72
Q

Patient’s requiring higher perfusion pressures

A 
Acute infract from CVL
Acute MI
Renal/cerebral insufficiency
Left main/left main equivalent
Aortic Stenosis
Chronic hypertension
73
Q

Cardiac catheterization

A

Gold standard for diagnosis of cardiac pathology

74
Q

Benzos and receptors occupied

A

<20% - anxiolysis
30-50% - sedation
60 or more - unconciousness

75
Q

Etomidate

A

Maintains best CV stability

Stable BP

76
Q

Ketamine

A

Generalized CV stimulation

Avoid in patient with CAD, CHF, aneurysms

77
Q

The most important cellular components of vessel walls are ___ and ___

A

Endothelium and vascular smooth muscle

78
Q

What are some high-risk vascular surgical procedures?

A

Open aortic aneurysm repair

Lower extremity revascularization

79
Q

What are some intermediate-risk vascular surgical procedures?

A

Carotid endarterectomy

Endovascular aortic aneurysm repair

80
Q

What is the gold standard for carotid revascularization?

A

Carotid Endarterectomy (CEA)

81
Q

What is the most common cause of morbidity/mortality associated with CEA?

A

Myocardial ischemia

82
Q

What is the 2nd most common cause of morbidity/mortality associated with CEA?

A

Stroke

83
Q

What much of the brain’s blood supply is supported by the carotids? Vertebrals?

A

Carotids supply 80-90%

Vertebrals supply 10-20%

84
Q

What is the most common site of atherosclerosis leading to TIA or stroke?

A

Carotid bifurcation (origin of the internal carotid artery)

85
Q

List indications for CEA

A

TIA’s associated with ipsilateral severe carotid stenosis (>70%)
Severe ipsilateral stenosis in patient with incomplete stroke
30-70% occlusion in patient with ipsilateral symptoms
Asymptomatic significantly stenotic lesions (>60%)

86
Q

Contraindications for CEA

A

Acute profound strokes
Progressing strokes
Severe intracranial disease
Other severe generalized disorders (cancer)

87
Q

What are the advantages of using regional anesthesia for CEA?

A

Awake patient provides sensitive and specific monitor of cerebral perfusion, better than EEG can

88
Q

What will cancel your CEA case?

A

Uncontrolled HTN, DM, or CAD

89
Q

What is the goal of anesthesia for CEA?

A 
To maintain adequate cerebral perfusion without stressing the heart
Avoid tachycardia (esmolol)
No Nitrous oxide
No glucose in IVF
ETT taped to contralateral side
Use Iso
90
Q

No monitoring is as effective as what?

A

An awake patient

91
Q

Stump pressure, What are you measuring when you clamp?

A

Mean arterial pressure cephalad to cross clamp.
Generated by back pressure from circle of willis
>60 mmHg is adequate

92
Q

Expect profound ___ with manipulation of carotid baroreceptor

A

bradycardia

Protamine can drop pressure

93
Q

What is at greatest risk for injury due to aortic cross clamping?

A

Kidneys

94
Q

Describe an aneurysm

A

Enlargement of artery twice normal size

Aortic resection - elective if >4cm

95
Q

What is a common complaint of aortic aneurysms

A

Intense back and upper abdominal pain

96
Q

What are three types of classifications of aortic aneurysms

A

DeBakey - Types 1-3 (type 2 is confined to the ascending aorta)
Standford - Types A or B
Crawford - Types 1-4

97
Q

What is an indication for an aortic dissection?

A

Sharp pain in chest, neck, or between shoulders indicates dissection

98
Q

During cross clamp of descending aorta, where is the blood pressure monitoring performed?

A

Right radial and left femoral artery, allows for cerebral perfusion and kidney pressures.

99
Q

What do you want to keep your blood pressure at while an aortic clamp is being performed?

A

MAP around 100 mmHg in upper body, above 50 mmHg distal to clamp

100
Q

How do you calculate spinal cord perfusion pressure?

A

MAP - CSF = SCPP

101
Q

Cross clamping of ___ aorta decreases renal blood flow significantly

A

infrarenal

102
Q

List three drugs used in renal protection

A

Mannitol
Dopamine
Fenoldopam

103
Q

Mesenteric traction may release ___ and cause hypotension

A

prostacyclin

3rd Quarter (22 decks)

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