Size isn't everything, some like 'em small- PVD Flashcards
What
- 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
Pt with PVD has _____ greater risk of MI, stroke, and death
3-5x
These pts probably also have CAD
What are the preferred anesthesia techniques for peripheral revascularization surgeries?
- 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
What should you consider for the anesthesia management of a peripheral revascularization surgery?
- 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?
How should you monitor a pt during peripheral revascularization surgery?
- 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
What are the goals when managing the anesthesia of a pt with mitral stenosis?
- 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
How should you induce a pt with Mitral stenosis?
- With drugs that are unlikely to increase HR (avoid ketamine) or abruptly decrease SVR
- Ex. etomidate with balanced technique
How should you try to manage the maintenance of anesthesia in a pt with Mitral stenosis?
- 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
What are the goals when managing anesthesia for a patient with Aortic stenosis?
- 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
General anesthesia or Neuraxial anesthesia in pts with Aortic stenosis?
- General anesthesia preferred because of the sympathetic block that causes decrease in SVR
How is mitral regurgitation noted on a pulmonary arterial occlusion pressure waveform (PAOP)?
- 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
What are the goals for management of anesthesia in a pt with mitral regurgitation?
- 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
What influences the how you will manage the maintenance phas of anesthesia for a pt with mitral regurg?
Monitoring?
- 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
What are the causes of aortic regurgitation?
- Diseased leaflets:
- endocarditis*, rheumatic fever, BAV
- Problems with aortic root:
- idiopathic aortic root dilation, aortic dissection*, marfan syndrome, ankylosing spondylitis
- *acute
What are goals for anesthesia in a pt with Aortic regurgitation.
- 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