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6902 - Kronus > Seperation from CBP > Flashcards

Seperation from CBP Flashcards

1
Q

sequence of events coming off CBP

A
  • rewarming
  • removal of cross clamp and placement of partially occluding cross clamp
  • proximal anastomosis of SVG/radial artery grafts
  • establish rythm
  • wean from CPB
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2
Q

getting ready for separation from bypass

A
  • temperature
  • cardiac rate and rhythm
  • adequate hematocrit
  • -blood products in the room
  • ventilation w 100% 02
  • anesthetics
  • pressors and inotropes
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3
Q

ratio of blood prodcuts at VA and evidence

A

VA: 4uPRBS: 1 FFp & 6 pk plts

evidence 1:1:1 ratio or 1:1.15

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4
Q

CVP mnemonic for C

A 
cold
conduction
calcium
cardiac output
cells
coagulation
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5
Q

CVP mnemonic for V

A

Ventilation
Vaprizer
Volume Expansion
Visulization (TEE)

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6
Q

CVP mnemonic for P

A 
Predictors
Protamine
Pressure
Pressors
Pacer
Potassium
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7
Q

As a patient is rewarmed the surgeon will as for NTG and low dose dopamine what does this do

A

promotes vasodilation and rewarming, prevents vasopasm of coronary arteries, promotes flow in coronary arteries

inotropes help stunned myocardium recover

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8
Q

predictors of difficulty separating from CPB

A

EF

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9
Q

weaning from cbp

A

-gradually allow the heart to fill and begin ejecting blood

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10
Q

what is considered optimal preload in weaning

A

the lowest value that will provide adequate cardiac output

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11
Q

What are the effect of high preload

A

increased wall tension
decreased CPP
decreased CO
precipitates pulmonary edema

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12
Q

how can you prepare for vascular instability

A

manipulate vasoactive drugs and blood products/colloids, table position

may have pump blood to give back

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13
Q

how can we monitor preload

A

monitor with PAP, TEE

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14
Q

how can we control rate and rythm

A

higher rate is ok
pacer options
atrial kick

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15
Q

how can we control contractility

A

inotropes

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16
Q

how can we control afterload low vs high

A

typically a low SVR
-increase SVR with levophed, neo and PDE3 inhibitors
hight SVR
-inhalation anesthetics, narcs, vasodilators

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17
Q

Post bypass CV collapse

A
  • profound hypotension, low CO that is unresponsive to inotropes and vasopressors
  • go back on pump
  • give full dose of heparin if protamine is already in
  • rest the heart IABP, LVAD,RVAD?
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18
Q

Diagnosis of LV failure after bypass 3 causes of ischemia

A

graft failure
inadequate coronary blood flow
myocardial ischemia leading to damage

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19
Q

causes of graft failure (ischemia r/t LV failure after bypass)

A 
clot
distal suture causing constriction
kinking of graft
air in graft 
graft swen in backwards
poor IMA flow
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20
Q

causes of inadequate coronary blood flow (ischemia r/t LV failure after bypass)

A 
incomplete revascularization
inadequate CPP
emboli in native coronary arteries
coronary vasospasm
tachycardia (less filling time)
increased myocardial 02 demand
surgical injury to native cornary artery
21
Q

causes of myocardial ischemia leading to damage (ischemia r/t LV failure after bypass)

A

poor myocardial preservation during CPB

evolving MI

22
Q

LV failure after bypass due to valve failure with a prosthetic valve

A

sewn in backwards
perivavlular leak
mechanical obstruction to outflow

23
Q

LV failure after bypass due to valve failure with a native valve

A

acute mitral regurg due to ischemia of papillary muscles

24
Q

LV failure after bypass due to valve failure with a gas exchange problem

A 
Hypoxemia
-inadequate fi02
-atelectasis
-mechanical ventilator failure
-airway disconnect
-severe bronchospasm
-pulmonary edema
Hypoventialtion
25
Q

Diagnosis of LV failure after bypass due to preload

A

inadeaquate preload
-hypovolemia
-no atrial kick
excessive preload

26
Q

differential dx of LV failure after bypass

A

ischemia, valve failure, preload, reperfusion injury, VSD, medications, acidemia, electrolyte imbalances, pre-existing LV failure

27
Q

Interventions for LV collapse: Rate

A

High HR: evaluate pain, light anesthesia

Low HR: pacer

28
Q

Interventions for LV collapse: rhythm

A

dx type and cause, treat, amiodarone

29
Q

Interventions for LV collapse: preload

A

High preload: NTG, phlebotomy, Rev T-berg

Low Preload: volume

30
Q

Interventions for LV collapse: contactility

A

High contractility: inhalation anesthetics, beta blocker, turn off inotropes
low contractility: catecholamines, PDE3 inhibitors, IABP

31
Q

Interventions for LV collapse: afterload

A

high afterload: vasodilators milrinone

low afterload: vasoconstrictors

32
Q

zebras (haha) to LV collapse

A 
pneumothorax
hemothorax
migration of ETT
obs of tracheobroncial tree
increase in dead space
intracardiac shunt (PFO)
protamine reactions
anaphylaxis
33
Q

risk factors for RV failure post bypass

A 
pior pulmonary hypertension
mitral vavle disease
left to right shunt
massive PE
air emobli
acute or chronic MR
diastolic LV dysfunction
34
Q

treatment for RV failure post bypass

A 
treat ischemia
increase preload
intrope support
hyperventialtion to decrease PVR
nitric oxide 10-40 PPM
PGE! infusion through RA line w NE via LA line
sildenafil
RVAD
35
Q

what to avoid in RV failure post bypass

A

hypoxia
acidemia
hypothermia

36
Q

inotrope support in RV failure

A

milrinone, dobutamine and isoproternial

incrase RV contractility and decrease PVR

37
Q

pulmonary vasodilators for RV failure in post bypass

A

NTG and Nipride

38
Q

decannulation

A

after patient is stable
keep SBP low
start protamine at surgeons request
blood products as needed

39
Q

Protamine dosing

A

10mg protamine for every 1000 units of heparin

40
Q

protamine side effects

A

hypotension, cv collapse, anayphlaxsis

41
Q

risk factors for hypersensitivty to protamine

A

prior protamine exposure
-give test dose
pulmonary HTN
-vasoconstriction, RV failure and death

42
Q

what should you do if a protamine reaction occurs

A 
stop the infusion
ventilate with 100% 02
turn down inhalation agents
volume and pressors
antihistamines
corticosteroids
catecholamine infusion (epi)
go back on pump (last resort)
43
Q

residual heaprin effects

A

incomplete heparin neutralization (check ACT)
heaprin rebound
(occurs 4-6 hrs post-op when heparin dissociates from proten binding sites)
give addition 25-50 of protamine

44
Q

pharmacologic agents for blood conservation

A

amicar
aprotinin
ddavp

45
Q

what does DDAVP cause? when is it useful?

A

causes release of von willebrand’s factor and factor 8

useful in patients with uremia, cirrhosis, recent ASA use

46
Q

management of post-bypass bleeding

A 
supportive therapy
-normothermia
-keep up with blood loss
-treat hypertnetion promptly
treat hemostatic disorder
-neutralize heparin
replace factors and platelets
47
Q

causes of hemodynamic deterioration with chest closure

A

tamponade
myocardial edema
kinked graft
protamine reaction

-treat cause, leave chest open

48
Q

fast track recovery

A 
minimize narcotics and benzos
rely more on inhalation agent
propofol at end of case
minimize muscle relaxant use at end of case
goal: early extubation and activity

6902 - Kronus (8 decks)

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