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23 spring anesthesia > Test 3: 30: CV > Flashcards

Test 3: 30: CV Flashcards

1
Q

if pt on ACE inhibitor what to do day of surgery

A

hold
can cause hypotension from reduced afterload

enalapril, benazepril

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2
Q

if pt on beta blocker what to do day of surgery

A

do not withhold- can cause rebound effect

beta blocker are used to decrease HR

atenolol, propranolol

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3
Q

if pt on calcium channel blockers what to do day of surgery

A

ok to continue unless pt is hypotensive or bradycardic

calcium channel blockers are used to decrease BP

amlodipine

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4
Q

if pt on pimobenden what to do day of surgery

A

Do NOT hold day of surgery

pimobendan is used to increase contractility and decrease afterload

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5
Q

if pt on diuretic what to do day of surgery

A

case by case- hold day of surgery unless activly in heart failure

there is increase risk of hypotension and hypokalemia if they remain on the diuretic

furosemide

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6
Q

what are some diagnostics tests for a cardiac workup before anesthesia

A

Bloodwork
* Complete Blood Count
* HCT
* Chemistry Screen
* BUN/Creatinine
* NTpro-BNP
* Troponin?

Other tests
* Blood Pressure
* ECG
* Chest Radiographs?
* Echocardiogram?
* Arterial Blood Gas?

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7
Q

what is La:Ao

A

left atrium size compared to aortic root on echo

if left atrium much bigger can indicate volume overload and left sided heart failure

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8
Q

as a cat ages there is a greater risk for what cardiac issue

A

HCM +/- a murmur

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9
Q

what determines SV

A

stroke volume: ↑contractility, ↑preload ↓afterload

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10
Q

MAP should be kept above —

A

MAP > 60 mmHg

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11
Q

how to prevent exacerbation of cardiac disease during anesthesia

A

↓ fluid use
minimize stress
rapid intervention with ↓BP, HR or arrhythmias

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12
Q

what oral premeds can be used for cardiac anesthetic protocol

A

Gabapentin

  • Mild sedation in cats with mild impact on echocardiographic findings (remained in reference range)
  • May reduce need for other premedications
  • Improved cardiovascular stability in people

Trazodone

  • Improved signs of anxiety in cats with no significant effect on physical exam findings
  • Oral trazodone has minimal cardiovascular impacts in healthy dogs
  • MAC sparing (17%)
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13
Q

use acepromazine for cardiac pt?

A

not usually

  • causes vasodilation via ⍺ blockade
  • NOT reversible
  • Contraindicated in patients with hypertrophic cardiomyopathy
  • Low-dose may be tolerated in patients with mild mitral valve disease

acepromazine: dopamine 2 receptor antagonist and anti ANS(⍺1 and 2, m1, H1, 5HT2) → sedative, ↓BP, ↑spleen size, ↓temp, ↓vomiting

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14
Q

can you use ⍺2 agonist for heart pts

A

⍺2 agonist will increase afterload and can cause reflex bradycardia → ↓ cardiac output

  • should not be used in pt with decrease systolic function (DCM)
  • may be beneficial in cats with HOCM
  • reversible - atipamezole (antisedan)

dexmedetomidine, xylazine: cause sedation, analgesia, ↓SYM: ↓HR ↓BP

peripheral: vasoconstriction: ↑BP, reflex ↓HR
central: ↓SYM: ↓BP and ↓HR (can use atropine to counteract)

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15
Q

can you use opioids for cardiac pt

A

yes- well tolerated

  • Important to treat pain
  • Minimal impacts on blood pressure
  • Can cause vagally-mediated bradycardia- but can be treated with anticholinergics (atropine)
  • MAC sparing
  • Reversible with naloxone
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16
Q

can you use benzodiazepines for cardiac pt

A

yes

  • Minimal impact on cardiovascular function
  • May not offer optimal sedation in most patients (can cause dysphoria) →need to combine with opioid or use as co-induction agent
  • MAC sparing
  • Reversible-flumazenil

diazepam, didazolam

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17
Q

alfaxalone

A

steroid
sedation with no analgesia effect
rapid onset- can be IM for angry animals

can cause excitatory during recovery- give with sedation or analgesia (opioid) to prevent this

less CV effects then propofol
Resp: ↓RR and swallow reflex
Metabolism: liver but safe to use in sighthounds and cats

caution with animals with respiratory problems, CV disease (CHF)

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18
Q

what drug protocol for fractious cardiac pt

A
  • Oral premedication at home (gabapentin/ trazodone)
  • Alfaxalone(sedation) /Butorphanol(opioid) IM
  • Minimal impacts on cardiac output
  • Mild impacts on echo findings in healthy cats and dogs
  • Favorable compared to
    dexmedetomidine/butorphanol in cats

butorphanol: opioid: κ agonist + μ antagonist: minimal analgesia, mild sedation
alfaxalone: IM anesthetic, no analgesia, less CV effects then propofol, use with opioid to prevent excitability

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19
Q

can you use propofol for cardiac pt

A

would not recommend

  • Dose and rate dependent vasodilation → hypotension
  • Dose and rate dependent hypoventilation → hypoxemia
  • Minimize induction dose needed when possible
  • Avoid in severely compromised patients (CHF)
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20
Q

can you use alfaxalone for cardiac pts

A

better then propofol but still not great

  • Dose dependent ↑HR and vasodilation in dogs, can cause ↓HR in cats
  • Cardiac output typically maintained
  • Minimize dose when possible
  • May be preferable over propofol for mild cardiovascular disease
  • Avoid in severe cardiac disease
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21
Q

can you use ketamine in cardiac pt

A
  • Increases sympathetic tone → increases HR, BP, afterload
  • Contraindicated in HCM → increased work causes ↑O2 consumption, O2 runs out and cause ischemia → arrhythmias
  • Direct myocardial depression
  • Analgesic
  • ↑SYM: may be beneficial in mild mitral valve disease

ketamine: dissociative anesthetic: block NMDA(excitatory glutamate receptor) → intense analgesia, light sleep, catalepsy(muscle rigidity), violent recovery, apneustic breathing, can cause ↑HR, CO, MAP in healthy pts, but in sick pts can have negative inotropic and vasodilatory effect →arrhythmia

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22
Q

can you use etomidate for cardiac pts

A

yes- minimal cardiac effects

  • side effect: adrenocortical suppression
  • Always combine with sedation (benzodiazepine + opioid) to avoid muscle twitching
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23
Q

once induced how to maintain anesthesia in cardiac pt

A

Inhalants cause dose-dependent hypotension → vasodilation and decreased contractility. Use lowest amount possible

TIVA with propofol or alfaxalone may cause less hypotension. But is Not as rapidly eliminated as inhaled drugs during cardiac arrest

MAC Sparing protocols
* Locoregional anesthesia when possible
* Opioid CRI →Fentanyl or remifentanil
* Lidocaine CRI →Reduces ventricular arrhythmias

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24
Q

what monitoring is used for cardiac pt during procedure

A

Oxygenation

  • Pulse oximetry and arterial blood gas analysis

Hemodynamics

  • Invasive blood pressure when possible
  • +/- Cardiac output monitoring
  • +/- Transesophageal echo

Other

  • ECG
  • Capnography
  • Temperature
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25
Q

left sided systolic apical murmur usually means

A

mitral valve disease

26
Q

staging for mitral valve disease

A

Stage A: High risk of developing mitral valve disease

Stage B: Structural heart disease but no failure

  • B1: Asymptomatic, no echo/radiographic changes
  • B2: Asymptomatic, echo/radiographic changes, NEED treatment

Stage C: Heart Failure

Stage D: Heart Failure refractory to standard treatment

27
Q

stage A mitral valve disease

A

Stage A: High risk of developing mitral valve disease

28
Q

stage B mitral valve disease

A

Stage B: Structural heart disease but no failure

  • B1: Asymptomatic, no echo/radiographic changes
  • B2: Asymptomatic, echo/radiographic changes, NEED treatment- pimodendan
29
Q

stage C mitral valve disease

A

Stage C: Heart Failure

left sided systolic apical murmur

30
Q

stage D mitral valve disease

A

Stage D: Heart Failure refractory to standard treatment

left sided systolic apical murmur

31
Q

what is the most common heart disease in dogs

A

mitral valve disease → left sided systolic apical murmur

Most common in small breed dogs→ prevalence increases with age (85% by age 13)

32
Q

what drug should a B2 mitral valve disease dog be on

A

pimodendan

B2: asymptomatic but has echo/xray changes

pimobendan can lengthen time to developing symptoms

33
Q

Which of the following would you select as an anesthetic protocol for a 12 year old female toy poodle with B2 mitral valve disease undergoing anesthesia for a mastectomy?

A) Dexmedetomidine, ketamine/midazolam, isoflurane

B) Fentanyl, midazolam, alfaxalone,
epidural, isoflurane +/- fentanyl CRI

C) Acepromazine, hydromorphone,
propofol, isoflurane

D) Etomidate, isoflurane

A

B: alfaxolone has less CV effects, combined with opioid (fentanyl and benzo- midazolam) to prevent excitabolity, then use local epidural, and maintain on iso with CRI opioid-fentanyl as needed

would not use A: dexmedatomidine (⍺2 agonist) counterindicated cause it ↑ afterload, also no opioid used for pain control

C: could use for B1(no echo changes) excitable dog: ace (sedation), hydro (opioid)

D: etomidate is great but needs to be combined with benzo to prevent excitability, also no opioid for pain relief

34
Q

goals for mitral valve disease

A

leaky valve: fast and loose

  • Maintain HR → Avoid bradycardia do not want more diastolic fill time, because when heart contracts that mean even more blood would go backwards
  • Maintain contractility
  • Maintain blood pressure → Avoid increased afterload
35
Q

induction protocol for mitral valve disease pt

A

keep fast and loose

  • Premedicate or co-induce with opioid, benzodiazepine
  • Minimize propofol or alfaxalone dose
  • Minimize inhalant
  • Liberal use of anticholinergics (do not tolerate bradycardia →try to keep HR up)
  • Judicious/↓ use of fluids
  • Support blood pressure with dopamine/dobumatine
36
Q

dilated cardiomyopathy causes

A

Decreased systolic function and left ventricular dilation →mitral annular stretch → mitral regurgitation (most do not have murmur)

can cause arrhythmias: Afib and Ventricular arrhythmia

  • Doberman or grain free, taurine deficiency
37
Q

goals for DCM pts

A
  • Maintain HR and preload
  • Support contractility
  • Maintain sinus rhythm

DCM can cause ↓systolic function and LV dilation → MR → Afib and ventricular arrhythmias

38
Q

protocol for DCM pts

A

very similar to mitral valve disease pts

  • Opioid based premedication
  • Induction with midazolam + alfaxalone/etomidate
  • Dobutamine for inotropic support
  • Lidocaine for sudden onset Afib/ Vtach
  • Consider electro-cardioversion if unresponsive Afib & hemodynamically unstable

DCM can cause ↓systolic function and LV dilation → MR → Afib and ventricular arrhythmias (dobermans and grain free diets)

39
Q

HCM causes

A

ventricular hypertrophy → diastolic dysfunction (can’t relax)

this can lead to LA dilation → CHF and clot formation in the LA, myocardiac ischemia and arrhythmias

can have systolic anterior motion of the mitral valve (SAMI) →HOCM (mitral valve sucked into aorta)

40
Q

— is the most common cardiac disorder in cats

A

HCM (15% increases with age)

HCM: diastolic dysfunction → LA dilation → CHF, clots, iscemia and arrhythmias. Can progress to HOCM

41
Q

Which of the following would you select as an anesthetic protocol for a fractious 13 year old MC DSH with HCM without evidence of heart failure undergoing anesthesia for dental extractions?

A) Dexmedetomidine IM, induce with
ketamine/midazolam, maintain on isoflurane

B) Acepromazine + hydromorphone IM, induce with propofol, maintain on isoflurane

C) Alfaxalone + methadone IM, induce with propofol + midazolam, maintain on isoflurane, perform dental blocks

D) induce with Etomidate, maintain on isoflurane

A

A) Dexmedetomidine IM, induce with
ketamine/midazolam, maintain on isoflurane (NO opioid, dexmed (⍺2agonist) Contraindicated in pts with decreased systolic function because it decreases cardiac output by increasing afterload and reflex ↓HR. Ketamine will cause ↑HR which is bad cause HCM can cause arrhythmias)

B) Acepromazine + hydromorphone IM, induce with propofol, maintain on isoflurane (ace and propofol will drop BP which may decrease perfusion to very thick myocardium →ischemia)

C: Alfaxalone + methadone IM, induce with propofol + midazolam, maintain on isoflurane, perform dental blocks (alfaxalone have ↓CV effects and can be given IM for angry cat, opioid good for pain. prop + midazolam together will not need as much meds and will have less ↓ in BP, use of local blocks will decrease other meds needed)

D: induce with Etomidate, maintain on isoflurane (etomidate needs to be given IV, this is angry cat- will not work, no opioid, need benzo for etomidate to avoid excitability)

HCM: diastolic dysfunction → LA dilation → CHF, clots, iscemia and arrhythmias. Can progress to HOCM

42
Q

goals for HCM

A
  • Minimize stress: sympathetic activation & tachycardia because it increases myocardial oxygen demand
  • Avoid decreased afterload- do not want to vasodilate
  • Avoid volume overload/underload

HCM: diastolic dysfunction → LA dilation → CHF, clots, iscemia and arrhythmias. Can progress to HOCM

43
Q

protocol for HCM pt

A

Premedication with alfaxalone +opioid
* Can consider low dose dexmedetomidine especially if HOCM
* Avoid acepromazine

Induction with:
* Alfaxalone + midazolam
* Etomidate + midazolam
* Propofol +midazolam
* Avoid ketamine/tiletamine cause they cause ↑SYM (↑HR)

Other
* Maintain on inhalant with locoregional when possible, consider MAC sparing opioid
* Low dose IV crystalloids (~3ml/kg/hr)
* Mild bradycardia acceptable, caution with anticholinergics
* Treat hypotension with dopamine/norepinephrine (avoid dobutamine- do not need heart to pump harder, their systolic function is normal okay)

HCM: diastolic dysfunction → LA dilation → CHF, clots, iscemia and arrhythmias. Can progress to HOCM

44
Q

— can have mild bradycardia acceptable, caution with anticholinergics

A

HCM- the lower HR will allow more time for heart to fill

this is opposite to mitral valve disease where lower HR = more blood = more regurg

HCM: diastolic dysfunction → LA dilation → CHF, clots, iscemia and arrhythmias. Can progress to HOCM

45
Q

DCM or HCM you should use dobutamine

A

DCM: dobutamine for inotropic support(↑ systolic). DCM have ↓ systolic function and LV dilation and MR and Afib.

HCM: do not use dobutamine: treat ↓BP with dopamine/NE: HCM have ↓ diastolic function but normal systolic function do not need dobutamine to make it pump harder

46
Q

why avoid ace and ketamine in HCM

A

HCM: diastolic dysfunction → LA dilation → CHF, clots, iscemia and arrhythmias. Can progress to HOCM

Acepromazine- cause vasodilation which decreases blood back to heart, not reversible

Ketamine: increases symp tone (↑HR, BP and afterload) HCM cats have normal systolic function and increased HR will limit filling time → ischemia and arrhythmias

should also avoid dobutamine and anticholinergics in HCM pts

47
Q

why use anticholinergics in Mitral valve disease pts

A

want to prevent bradycardia

if slower HR, then more blood into ventricle and when heart pumps then more blood will regurg.

use atropine to increase HR and avoid bradycardia

mitral valve want to keep fast and loose, avoid bradycardia and increased afterload

48
Q

— is the Most common congenital disease of large breed dogs

A

aortic stenosis

49
Q

Aortic stenosis causes

A

Increased resistance to outflow → left ventricular hypertrophy → myocardial ischemia

syncope, ventricular arrhythmias, sudden death

50
Q

goals of Aortic stenosis

A

similar to HCM cats cause AS causes LV hypertrophy

  • Prevent tachycardia
  • Prevent arrhythmias
  • Maintain adequate blood pressure and cardiac output (coronary perfusion)
51
Q

protocol for Aortic stenosis

A
  • Avoid stress (consider oral premedication if needed)
  • Avoid anticholinergics (unless severe bradycardia) and acepromazine
  • Dexmedetomidine controversial (low dose may be acceptable)
  • avoid ketamine (do not want to increase HR)
  • Opioid, BZD, alfaxalone/propofol/etomidate
  • Lidocaine CRI
  • Opioid CRI
52
Q

pulmonary stenosis can lead to —

A

ventricular arrythmias or RV failure

53
Q

goals for pulmonary stenosis

A
  • Maintain preload/venous return
  • Maintain myocardial contractility
  • Prevent tachycardia or severe bradycardia
  • Avoid increases in pulmonary vascular resistance

PS: ventricular arrhythmias and RV failure

54
Q

protocol for pulmonary stenosis

A
  • Premedicate if needed (opioid)-avoid tachycardia
  • Induce with opioid, benzodiazepine, lidocaine + low dose propofol or alfaxalone or etomidate
  • avoid ketamine (causes ↑HR)
  • Can use higher fluid rates (5ml/kg/hr) to maintain preload
  • Avoid hypercapnia, hypoxia, acidosis, hypothermia, pain
55
Q

PDA causes

A

shunt from descending aorta to pulmonary artery → more blood in left side of heart

Left sided CHF (50% dead in 1 year)

if PDA bad enough pulmonary HTN will cause shunt to reverse → cyanosis

56
Q

if pulmonary HTN too high what direction will blood flow in PDA

A

will reverse. will go from pulmonary artery into the aorta, skipping the lungs → cyanosis

57
Q

goals for PDA

A
  • Maintain CO and HR (want to keep HR ↑ to decrease amount of blood that leaks through during diastole)
  • Minimize reductions in SVR
  • Minimize increases in PVR (shunt can reverse cause hypoxemia)
58
Q

protocol for PDA

A

Premedication with opioid +/- benzodiazepine +/- alfaxalone +/- ketamine

  • Utilize anticholinergic if bradycardic
  • Pre-oxygenate to avoid hypoxemia → increased PVR (want to avoid shunt reversal)

Induce with: benzodiazepine + ketamine or etomidate or
alfaxalone or low dose propofol

  • Maintain HR
  • Treat hypoventilation rapidly, prevent desaturation

Maintain with inhalant + opioid CRI

  • Treat bradycardia
  • Treat hypotension with dopamine

Fluid restrictive (~2ml/kg/hr)
2 pulse oximeters →Caudal pulse oximeter can detect shunt reversal sooner as PDA on descending aorta

59
Q

— is most common congenital defect in cat

A

VSD

60
Q

VSD can cause

A

shunts blood from left to right

if it gets very bad: RV hypertrophy will cause shunt to reverse to right to left →cyanosis and poor prognosis

61
Q

goals for VSD

A
  • Prevent right to left shunting
  • Maintain SVR
  • Avoid increasing PVR (do not want shunt reversing)
62
Q

protocol for VSD

A

Premedication with opioid +/- benzodiazepine
* Avoid acepromazine—systemic hypotension

Pre-oxygenate to avoid hypoxemia → increased PVR

Induce with: benzodiazepine + ketamine or etomidate
or alfaxalone or low dose propofol
* Maintain HR
* Treat hypoventilation rapidly, prevent desaturation

Maintain with inhalant + opioid CRI
* Treat hypotension with dopamine

23 spring anesthesia (40 decks)

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