Test 1: NORA Cath Lab Interventional Cardiology - PACU/ER/ICU Flashcards
What are the most common procedures done in the Cath Lab?
- Electro-Physiology procedures
- Cardio-version
- TEE (Transesophageal Echocardiography)
- TAVR (Transcatheter aortic valve replacement)
What is Electro-Physiology Study (EPS) / Electro-Physiology Ablation (EPA)
The identification and ablation of dysrhythmias caused by aberrant (abnormal) conduction pathways.
What are the pros of EP ablation?
- Minimally invasive
- 60-85% curative on 1st attempt
What are the cons of EP ablation?
- Often lengthy (2-6 hours)
- Often uncomfortable
- Isoproteronol (Isopruel) may be used induce arrhythmias (V-tach/V-fib)
Anesthesia considerations for EP ablation
- Sedation vs General
- External defibrillation pads (must have)
- Non-magnetic equipment
- Anti-arrhythmic meds held
- Specific catheter concerns (may induce arrhythmias)
- Foley catheter (long procedure)
- X-Ray protection
TEE/ Cardioversion is often done on patients with what heart conditions?
- Atrial flutter
- Atrial fibrillation
Common comorbidities for these patients include CHF, valvular disease, and HTN prior to cardiothoracic surgery
What are the current guidelines of performing a TEE?
- TEE is most successful with AF < 7 days duration
- TEE is used to rule out mural thrombus
- Cardioversion (if a thrombus exist, don’t cardiovert, put them on Coumadin)
Vitamin K Antagonist
Action:
Labs to Monitor:
Food interaction:
Reversal Agent
Vitamin K Antagonist
Action: Antagonizes vitamin K, decreases factors II, VII, IX, X
Labs to Monitor: INR
Food interaction: Cabbage, cauliflower, leafy greens
Reversal Agent: Vitamin K, FFP
Direct thrombin inhibitor: Dabigatran (Pradaxa), Bivalrudin, Argatroban, Hirudin
Action:
Labs to Monitor:
Food interaction:
Reversal Agent
Direct thrombin inhibitor: Dabigatran (Pradaxa), Bivalrudin, Argatroban, Hirudin
Action: Antagonizes thrombin to prevent fibrinogen from forming fibrin
Labs to Monitor: dTT, last dose of the drug
Food interaction: N/A
Reversal Agent: D/C, prothrombin complex
Factor Xa inhibitor: Xarelto, Eliquis, Savaysa, Heparin
Action:
Labs to Monitor:
Food interaction:
Reversal Agent
Factor Xa inhibitor: Xarelto, Eliquis, Savaysa, Heparin
Action: Prevents cleavage of prothrombin to thrombin
Labs to Monitor: Specific anti-X assays, last dose of the drug
Food interaction: N/A
Reversal Agent: D/C, prothrombin complex
Targets for Bivalirudin, Agatroban, and Hirudin?
- Thrombin
Targets for Heparin and LMWH?
- Thrombin
- Factor Xa
Target for Fondaparinux
- factor Xa
What are anesthesia considerations for TEE?
- Nasal cannula used sufficient
- Bite block, Cetacaine spray, or preop care
- Use Propofol w/o lidocaine
- Versed/ Ketamine as alternatives
- Be prepared for multiple cardioversion
As Na+ channel blocker lidocaine has the potential to cause bradycardia/ asystole after cardioversion
Use of cetacaine spray can lead to what complications?
- Methemoglobinemia
When is a Transcatheter Aortic Valve Replacement (TAVR) indicated?
- Indicated as an option to surgical aortic valve replacement for patients with aortic stenosis.
- Symptomatic pt of any age with high surgical risk
- symptomatic pt with predicted post-TAVR survival > 12 months
- symptomatic pt >80 years
- Younger patients with life expectancy <10 years
Anesthesia considers for TAVR
- GA or conscious sedation
- Transapical vs transfemoral approach
- Use of ventilation control, TEE, and muscle relaxants
- Standard monitor, large bore IV, A-line
- Defibrillator
- Typed and crossed
- Heparin/ACT monitoring/ protamine reversal
What are common endoscopy procedures?
- Esophagogastroduodenoscopy (EGD)
- Colonoscopy
- Endoscopy retrograde cholangiopancreatography (ERCP)
Indications for EGD/ Colonoscopy
- Biopsy
- Foreign body retrieval
- Esophageal varices
- Feeding tubes
- Removal of polyps
- Dx of cancer and GI bleeds
Anesthesia Considerations of EGD/ Colonoscopy
- Lateral position
- Biflow nasal cannula is usually sufficient
- Typically sedation unless there is a foreign object or esophageal obstruction
- Other considerations for GETA include active bleeding/ vomiting
- Versed and Fentanyl upfront can cause drug synergism problem
What is the purpose of an ERCP?
- Dx and treatment of biliary and pancreatic disorder
- ERCPs are common in biliary stenosis, jaundice, common duct stones
Anesthesia Considerations for ERCP
- Extreme comorbidities
- Prone: Head turns to the side
- GETA recommended
What are some medication considerations for the ERCP procedure?
- Glucagon (2 mg) for antispasmodics
- Avoid narcotics, can lead to Oddi spasms
- Have anti-emetics ready
What are the indications for electroconvulsive therapy (ECT)?
- Bipolar disease
- Schizophrenia
- Extreme depression
- Suicidal behavior
What will ECT induce?
- Tonic/ clonic seizure d/t release of neurotransmitters
How often is ECT performed?
- Treatment 3x/week for 12 treatments then weaned
Physiologic responses to ECT
- Initial parasympathetic activity
- 10-20 mins sympathetic stimulation
- Incontinence
- Myalgia (last 2-7 days)
- HA
- Emergence agitation/ confusion
Anesthesia considerations/ implications for ECT
- Pre-op evaluation, pregnancy test
- General Anesthesia (have bite block)
- Caffeine used to increase seizure duration
- Protect extremities
- Avoid hyperventilation (cerebral vasoconstriction)
- Ativan/Haldol on standby
The benefits of ECT are thought to not occur unless a seizure happens during the treatment.
What does hyperventilation do to cerebral blood flow?
Hyperventilation causes cerebral vasoconstriction, which reduces cerebral blood flow and volume and decreases oxygen supply.
What should HTN be treated with during ECT?
- Short-acting B-blockers (esmolol)
