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CV Anesthesia > Test 1 > Flashcards

Test 1 Flashcards

1
Q

Major branches of left coronary artery

A

LAD

  • diagonal
  • septal perforator
  • intermediate

Circumflex
- obtuse marginal

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2
Q

Major branches of RCA

A

Acute marginal

PDA (in most)

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3
Q

3 most effective monitors to detect myocardial ischemia

A

ECG (detects ischemia 80% of the time)

PAC

TEE

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4
Q

2 factors which decrease myocardial oxygen supply and increase demand

A

Heart rate

Filling pressures (PCWP)

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5
Q

2 factors affecting coronary perfusion pressure

A

DBP (diastolic blood pressure)

LVEDP (Left ventricle end diastolic pressure)

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6
Q

Formula for coronary perfusion pressure

A

CPP = DBP - LVEDP

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7
Q

Role of HR management in optimizing myocardial oxygen supply and demand

A

LV fills during diastole

Total time in diastole key in perfusion

Modest increase in demand (HR) has major effect on supply

as heart rate foes up, filling time goes down

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8
Q

Hemodynamic variable most commonly associated with myocardial ischemia

A

Heart rate

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9
Q

Four factors that may adversely affect ventricular wall tension

A

Systolic BP

Afterload

LV filling volumes

Myocardial ischemia

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10
Q

Myocardial ischemia effect on wall tension

A

Changes compliance and will have higher pressures for same volume

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11
Q

Effect of IABP on myocardial oxygen supply

A

Augmentation of diastolic pressure resulting in increased coronary perfusion

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12
Q

Effect of IABP on myocardial oxygen demand

A

Reduction in afterload

  • decreased cardiac work, oxygen consumption
  • increased cardiac output
  • decreased hemodynamic abnormalities associated with mechanical defects
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13
Q

Most commonly associated complication associated with CABG

A

A-Fib or rhythm disturbances

MI

Post op bleeding

Stroke

ARF

Post-perfusion syndrome (pump head)

Respiratory failure

Sternal wound infection

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14
Q

Predictors of morbidity/mortality with CABG

A 
Age
Prior MI
MI location
Coagulopathies
CHF
Dysrhythmia
HTN
DM
PVD
cerebrovascular disease
Valvular heart disease
Smoking
Lung disease
ECG abnormalities
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15
Q

Time period most associated with morbidity mortality after MI

A

Within 1 month 35% have repeat MI

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16
Q

2 test measuring ventricular function in pt presenting for CABG

A

TEE

PAC

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17
Q

3 commonly used home meds in pt with CAD presenting for CABG

A

Beta blockers

Calcium channel blockers/ ACE inhibitors

Diuretics/thiazides

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18
Q

6 indications for placement of PAC

A
  • LV dysfx
  • angina w/i 48 hours
  • symptomatic valve disease
  • severe HTN w/ hx of angina
  • large operation with anticipated intravascular volume changes
  • vascular surgery with clamp of major arter
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19
Q

4 uses of PAC data during CABG

A

Measure CO

Detect, to, and trend myocardial ischemia

Measure and optimize ventricular preload and volume

Detect, treat, and trend valve dysfx

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20
Q

Clinical uses of intraoperative TEE during CABD

A

Ventricular function (EF, wall motion)

Wall motion abnormalities

Valve dysfunction

Stenosis or regurgitation

Chamber size may be indicative of dysrhythmia and dysfunction

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21
Q

Phenylephrine dose for CABG

A

30-60 mcg/min vs bolus

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22
Q

Dose for sedative hypnotics for CABG

Midazolam

Propofol

Etomidate

A

Midazolam 3-5 mg

Propofol 20-200mg

Etomidate. 10-20 mg

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23
Q

Opiod induction sequence dosage

Fentanyl

Sufentanil

A

Fentanyl 3-25 mcg/kg

Sufentanil 0.5-1.5 mcg/kg

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24
Q

Effect of fentanyl on volatile agent requirement

Dose of 25 mcg/kg, 50 mcg/kg, 75 mcg/kg, 100 mcg/kg

A

Increasing dosage of fentanyl results in decrease in MAC of volatile

25 mcg/GI = 40% decrease MAC

50 mcg/kg = 55% decrease MAC

75 mcg/kg = 65% decrease MAC

100 mcg/kg = 70% decrease MAC

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25
Q

With high dose fentanyl anesthesia resulting changes in hemodynamics

Vs inhalation anesthetic

A

Increase in HR, MAP, CI, MVO2

Inhalation results in decreased HR, CI, MVO2, MAP

26
Q

Dose of epinephrine associated with extrasystoles when using Isoflurane

A

7 mcg/kg

27
Q

6 causes of Myocardial ischemia during anesthesia

A
  • coronary artery occlusion
  • tachycardia
  • high PCWP/CVP (>12-15)
  • hypotension
  • severe hypertension
  • increased workload or high CO (sepsis)
28
Q

6 signs of myocardial ischemia

A
  • ST segment abnormality
  • dysrhythmia
  • conduction abnormality
  • PA waveform abnormality
  • decreased myocardial performance (low CI or BP)
  • wall motion abnormality( echo, visual)
29
Q

Intervention of Nitrates for myocardial ischemia

A

Decreases wall tension better than anything else

30
Q

Intervention of beta blockers for myocardial ischemia

A

Decreased contractility and HR

use esmolol not metoprolol

31
Q

Intervention of calcium channel blocker drugs for myocardial ischemia

A

Just drop BP

Not helpful with anything else

32
Q

5 patient subgroups requiring higher perfusion pressures

A
  • Acute MI/ongoing ischemia
  • renal/cerebral insufficiency
  • Left main/left main equivalent
  • aortic stenosis
  • chronic hypertension
33
Q

4 potential sources of conduit for bypass grafts for CABG

A
  • LIMA
  • RIMA
  • radial
  • saphenous veins
  • gastroepiploic
34
Q

Blood pressure maintenance during arterial cannulation

A

Maintain SBP <100

if higher can dissect aorta

35
Q

6 sources of rhythm disturbances associated with surgical manipulation CPB

A
  • atrial cannulation/vent stitch
  • RFG catheter (retrograde cardioplegia)
  • pericardiotomy
  • lap under heart to explore distal
  • myocardial ischemia
  • dissecting out heart for redo/pericarditis
36
Q

Heparin dose in prep for CPB

Goal ACT after periocardiotomy and prior to aortic cannulation

A

300 units/kg

Goal ACT >400 second

37
Q

Hemodynamic consequences of “mixing” or “RAPing”

A

Decreases viscosity and circulating norepinephrine levels

decreases SVR

38
Q

4 goals of cardiopulmonary bypass

A
  • oxygenation of blood and elimination of carbon dioxide (ventilation)
  • circulation of the blood
  • systemic cooling and rewarding
  • diversion of blood from heart to provide bloodless surgical field
39
Q

Cross clamp strategies for distal anastomoses

A

Distals done with cross clamp on

Mammary done last to avoid twisting IMA

40
Q

Cross clamp strategy for proximal anastomoses

A

Cross clamp removed, partial clamp of aorta for proximal

At risk for ischemia until proximal completed

41
Q

Protamine dosing after separation of CPB

A

10mg test dose after satisfied with heart performance

Then 25 mg every minute

Typical dose 250 mg

remove aortic cannula with 1/2 protamine dose is in*

42
Q

On CPB blood pressure is

A

Flow X SVR

43
Q

To reduce flow and separate from CPB (hemodynamics)

A

SVR is increased

44
Q

Prior to CPB what should you do with PAC

A

Pull PAC back 2 cm bc easier to perf RA when volume lost to go on CPB

45
Q

Law relating to wall tension

A

LaPlace’s Law

46
Q

Difference in collateral flow and natural flow r/t perfusion of heart

A

Collateral flow doesn’t reach subendocardial as well as epicardial

47
Q

5 advantages of OPCAB

A

Less neuropsychological impairments

Fewer inotrope, dysrhythmia postop

Improved hemostasis

Less need for transfusion and fluids

Less postop renal insufficiency

48
Q

6 pt subgroups most likely to benefit from OPCAB

A 
>70 yrs old
Low EF
Redo CABG
Significant comorbidities
Calcified aorta
Pt refusing blood products
49
Q

Role of intracoronary shunts for distal anastomoses

A

Placed after arteriotomy

Decreased bleeding

CBF maintained though reduced

50
Q

4 methods of display ante of heart for distal anastamosis

A

Laps
Towel
Deep pericardial sutures
Suction stabilizer devices

51
Q

Effects of displacement on

CO/SV and BP

A

Decreased RV filling but elevated filling pressures rt RA compression

Decreased RV output = underfilled LV = lower SV/CO

Decreased CO = decreased BP

52
Q

Effects of displacement on valve function

A

Vertical position = distortion of MV and TV

Significant regurgitation

53
Q

Myocardial ischemia manifestations during OPCAB

A

Elevated PA **
Deterioration in heart performance

ST elevation

New RWMA

54
Q

Target vessel positioning associated with biggest decrease in SV and increase in CVP

A

Circumflex positioning

55
Q

4 strategies to manage Herat rhythm disturbances during OPCAB

A 
Lidocaine (esp RCA)
Magnesium 2gm (keep K4.0)
Nitro during distal anastamosis for spasm
56
Q

Heaprin dose

ACT goal

A

1.5-2mg/kg (usually 10,000-15,000 units)
—1/2 full CBP dose)

3000 units if vein taken prior to bolus for revascularization

Keep ACT >250

57
Q

Usefulness of TEE monitoring

A

RWMA

CI superior to TEE with displacement

58
Q

Order of grafting

A 
Colalteralized 
LAD w. LIMA
Proximal before distal
Diagonals
RCA
PDA
Circ
2nd and 3rd OM
PLA
OM
Ramus intermediate
59
Q

Inferior wall exposure surgical maneuver fo limit hemodynamic compromise

A

Table flat and retraction sutures relaxed

Decreases compression of RA/RV

60
Q

Surgical maneuvers to manage hemodynamic changes

A
  • Order of grafts based on hemodynamic consequences
  • OR graft most diseased first
    -close communication with anesth
  • DPS to bring great vessels and chambers into same plane
  • open R pleura for lat grafts to avoid compression
  • lift R sternum to make more space
    (Towel under R side of retractor)
  • remove pleurocardial fat

CV Anesthesia (4 decks)

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