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Cardiovascular Anesthesia > trial > Flashcards

trial Flashcards

1
Q

What are some signs of venous engorgement when bypass begins?

A

pale and purple face, high CVP, facial edema

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2
Q

What does a high CVP immediately after bypass initiation signify?

A

If Bicaval: cannula could be incorrectly placed, or sinched.

If not Bicaval: cannula against wall or zygus vein.

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3
Q

What should CVP initially be after bypass initiation?

A

around 5

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4
Q

Who controls the inhalation gas during bypass?

A

perfusion. Make sure its on.

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5
Q

How much volume is the pump prime?

A

800-1200mL

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6
Q

What happens to O2 delivery if your patient is anemic before bypass and then the pump prime is infused?

A

DO2 decreases

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7
Q

What is the goal Hgb/Hct during bypass?

A

8

>20%

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8
Q

What is the goal urine output during bypass?

A

1mL/kg

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9
Q

What does hypothermia do to metabolic demands?

A

decreases

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10
Q

How fast should the patients core temperature be raised after bypass?

A

0.3 C/minute

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11
Q

What are complications of coming off of bypass cold?

A

V-fib, bleeding issues

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12
Q

What is the blood glucose goal during bypass?

A

<180

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13
Q

Which type of bypass pump moves blood by sequential compression of tubing by a roller.

A

Roller Pump

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14
Q

How is CO on a roller pump determined?

A

SV of each revolution

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15
Q

What are advantages of roller pump?

A

simple and effective, low priming volume.

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16
Q

Is CO on roller pump afterload independent or dependent?

A

independent

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17
Q

What does a clamped arterial line on a roller pump lead to?

A

high pressure and rupture

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18
Q

What does an obstructed inflow cannula on roller pump cause?

A

microbubbles

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19
Q

Which type of bypass pump leads to damage to blood components and potential for massive air embolus?

A

roller pump

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20
Q

Is CO on centrifugal pump afterload independent or dependent?

A

dependent

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21
Q

If your patients SVR is high with a centrifugal pump how is CO affected?

A

CO is decreased

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22
Q

What happens to blood flow if a centrifugal pump is off and not clamped?

A

flows backward through the pump

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23
Q

If line becomes occluded, on centrifugal the pumps will/will not generate excessive pressure?

A

will not generate excessive pressure

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24
Q

Does inflow obstruction on a centrifugal pump cause cavitation or microbubbles?

A

No, not enough negative pressure is generated

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25
Q

What is the most commonly used cardioplegia solution?

A

buckberg

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26
Q

What is a disadvantage of buckberg cardioplegia solution?

A

poor myocardial recovery

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27
Q

Poor myocardial recovery with buckberg cardioplegia is due to accumulation of these ions?

A

sodum and calcium

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28
Q

Cardioplegia delays which phase of the myocardial action potential?

A

phase 3

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29
Q

What is the blood:crystalloid mixture of buckberg cardioplegia?

A

4:1

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30
Q

What is the final Hct of buckberg cardioplegia?

A

16-20%

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31
Q

How much potassium does high and low buckberg solution contain?

A

high 100 mM KCl

low 50 mM KCl

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32
Q

Does Del Nido cardioplegia increase or reduce energy consumption?

A

reduce

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33
Q

One disadvantage of Del Nido cardioplegia is that is results in what?

A

hemodilution

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34
Q

What is the blood:crystalloid mixture of Del Nido cardioplegia?

A

1:4

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35
Q

Besides blood and crystalloid, what does Del Nido cardioplegia contain?

A

mannitol, potassium, lidocaine, magnesium

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36
Q

How often are buckberg and Del Nido cardioplegia delivered?

A

buckberg 20-25 minutes

Del Nido 40-80 minutes

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37
Q

Antegrade cardioplegia is delivered to the myocardium through the coronary arteries via the ____?

A

ostia

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38
Q

What is the perfusion pressure for integrade cardioplegia?

A

70-100mmHg

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39
Q

Which delivery of cardioplegia is contraindicated with AV regurg?

A

antegrade

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40
Q

In the absence of collateral vessels, uneven distribution of cardioplegia may occur due to what?

A

severe CAD

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41
Q

Retrograde cardioplegia is delivered through the coronary veins via the ____?

A

coronary sinus

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42
Q

What pressure is retrograde cardioplegia delivered at?

A

40mmHg

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43
Q

Which route of cardioplegia may be not adequately protect the RV due to catheter placement?

A

retrograde

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44
Q

What is the potassium concentration of cardioplegia?

A

8-10mEq/L

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45
Q

During cardioplegia b/c the concentration of potassium remains ____ in the ___ space, the membrane remains ____.

A

elevated
extracellular
depolarized

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46
Q

Do we want cardiac arrest to occur in diastole or systole?

A

diastole

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47
Q

What is the single best indicator of body temperature?

A

core

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48
Q

Accuracy of bladder temperature decreases with what?

A

low urine output

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49
Q

Gases are ___ soluble in a ___ solution.

A

more

colder

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50
Q

What does warming too quickly cause?

A

gaseous emboli

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51
Q

During weaning of CBP what are the C’s to remember?

A

cold, conduction, calcium, CO, cells, coagulation

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52
Q

During weaning of CBP what are the V’s to remember?

A

ventilation, vaporizer, volume expanders, visualization

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53
Q

During weaning of CBP what are the P’s to remember?

A

previous abnormality, protamine, pressure, pressors, pacer, potassium

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54
Q

Where can air collect during weaning of bypass?

A

pulmonary veins, LA and LV

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55
Q

Recall is common during sternal split and ____?

A

rewarming

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56
Q

What is a normal/goal calcium during weaning CBP?

A

4.6-5mg/dL

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57
Q

What is the goal Hgb/Hct during before terminating CBP?

A

Hgb >8g/dL

Hct 22-25%

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58
Q

How do you perform recruitment when reinflating the lungs?

A

30cm pressure for 15-20 seconds

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59
Q

When is protamine administered?

A

not until venous cannula and root vent is clamped

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60
Q

When first refilling the heart after CBP, where will pulsatilla be noticed first?

A

PAC

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61
Q

What is goal SBP for terminating bypass?

A

> 90

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62
Q

What is the goal CI following bypass termination?

A

> 2-2.2

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63
Q

What is the order of cannula removal?

A

venous, root vent, give protamine, aortic

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64
Q

How fast should protamine be given?

A

over 10-15 minutes

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65
Q

What does protamine cause that you should be aware of?

A

hypotension

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66
Q

Patients that separate from CBP easily with little/no support usually have what?

A

good pre-op LV function and few comorbidities

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67
Q

How do you treat a patient with significant LVH and diastolic dysfunction after coming off pump?

A

Crystaolloid to maintain adequate LVEDV
Low does vasoconstrictor
May need vasodilator to keep SBP within appropriate ranges

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68
Q

Patients with persistent hypotension in the post-CBP period may have what?

A

vasoplegic syndrome

69
Q

Patients with persistent hypotension in the post-CBP period should be treated with what?

A

vaso, epi, methylene blue

phenylephrine/levo on pump

70
Q

How are patients that come off of pump with LV failure treated?

A

inotropes and afterload reduction

71
Q

How are patients that come off of pump with RV failure treated?

A

nitric oxide, milrinone, epinephrine

72
Q

How are patients that come off of pump with biventricular failure treated?

A

mechanical support like ECMO

73
Q

Does hypothermia have a direct or indirect relationship with metabolism rates?

A

direct

74
Q

What should venous saturations be for circulatory arrest?

A

> 95%

75
Q

nasopharyngeal temperature should be around what temperature during cooling for circulatory arrest?

A

18 Celcius

76
Q

Describe blood flow during retrograde cerebral perfusion?

A

arterial blood through SVC

blood empties into the aortic arch

77
Q

What are the normal flow rates and pressure in retrograde cerebral perfusion?

A

300-500mL/min

pressure of 20-25

78
Q

How do you reinitiate brain perfusion prior to rewarming after circulatory arrest?

A

low flow cold blood

79
Q

To prevent formation of gas emboli what should the temperature gradient be during rewarming after circulatory arrest?

A

<10 celsius

80
Q

During rewarming after circulatory arrest temperature should not exceed what?

A

36 celsius

81
Q

transgastric mid papillary short axis view gives you great visualization of …?

A

global ventricular systolic function. Function post bypass.

82
Q

IABP reduces ___ and increases ____

A

reduces afterload

increases diastolic coronary perfusion

83
Q

What are the five indications for IABP?

A 
Cardiogenic shock
MI
Intractable angina 
Arrhythmias 
Help wean CPB/ECMO
84
Q

What are the four contraindications for IABP?

A

Sepsis
Descending aortic disease
Severe PVD
Severe aortic regurgitation

85
Q

What two gases fill a IABP?

A

helium or CO2

86
Q

Where should the tip of the IABP be on x-ray?

A

2cm distal to left subclavian artery. 2nd intercostal space.

87
Q

IABP inflates when the aortic valve opens or closes?

A

closes

88
Q

What signifies aortic valve closure on A-line?

A

dicrotic notch

89
Q

IABP inflation:
____ coronary artery perfusion
____ myocardial O2 delivery

A

increases both

90
Q

IABP deflates at what wave of the EKG?

A

R wave

91
Q

What lab value should be monitored during IABP use?

A

platelets

92
Q

What is the air used to remove CO2 from the blood on ECMO?

A

sweep

93
Q

Which lab specifically looks at heparin?

A

Anti 10a

94
Q

What anesthetic is best for ECMO?

A

TIVA

95
Q

What standard monitor is helpless in VADs?

A

BP cuff

96
Q

What is the #1 limiting step in LVAD?

A

driveline infection

97
Q

LVADs are very ___ and ____ dependent?

A

preload and HR

98
Q

LVADs have a fixed ____?

A

CO

99
Q

Which fluid should you infuse to a VAD patient?

A

NS

100
Q

What console parameters give you an indication for volume status?

A

power and speed

101
Q

If your patient has an AICD what function should be turned off for surgery?

A

defibrilator

102
Q

If your patient is dependent on their pacemaker which mode should be programmed for surgery?

A

asynchronous

103
Q

Lithotrpsy, TUR and uterine hysteroscopy, MRI, ECT, Nerve stimulator testing/therapy all cause pacemaker ___?

A

interference

104
Q

What three pacemaker letters indicate asynchronous mode?

A

DOO or VOO

105
Q

The pacing chamber is which of the three pacemaker setting letters?

A

1st

106
Q

The sensing chamber is which of the three pacemaker setting letters?

A

2nd

107
Q

The response to sensing is which of the three pacemaker setting letters?

A

3rd

108
Q

If the pacemaker is set to DDD @60. Will you see pacemaker spikes if their HR is 70?

A

no

109
Q

If your patient has a pacemaker what is the preferred method of cautery?

A

bipolar for short bursts

110
Q

Where are pacemaker leads placed if its a biventricular pacemaker?

A

coronary sinus

111
Q

If you increase the sensitivity on the pacemaker, it is ___ likely to fire?

A

less

112
Q

On pacemakers, are you adjusting sensitivity to their intrinsic rate or the pacemaker settings?

A

intrinsic

“increasing sensitivity to their intrinsic rate?

113
Q

If you decrease the sensitivity on the pacemaker, it is ___ likely to fire?

A

more

114
Q

A pacemaker spike without a corresponding beat is called?

A

failure to capture

115
Q

Cautery interference in a patient that is pacemaker dependent, not set to asynchronous mode will lead to what?

A

over-sensing and under pacing

116
Q

When your pacemaker is firing when it shouldn’t be is called?

A

under sensing, over pacing

117
Q

How do you treat under sensing, over pacing?

A

increase the sensitivity

118
Q

If your pacemaker is set to AV pace but you are only seeing some of the V beats come through, what is going on?

A

failure to capture

119
Q

How do you treat failure to capture?

A

increase the mV.

120
Q

What does TEG measure?

A

ability to form a hemostatic plug

121
Q

Your patient is a little oozy (EBL 3L), and your R time on TEG is prolonged, what is the treatment?

A

give more protamine

122
Q

What does the R time on TEG represent?

A

time to begin forming a clot

123
Q

What does the K time on TEG represent?

A

time until clot has achieved fixed strength

124
Q

What does the alpha angle on TEG represent?

A

speed of fibrin accumulation

125
Q

What does the MA on TEG represent?

A

highest vertical amplitude, clot strength

126
Q

What does the A60 on TEG represent?

A

height of the vertical amplitude 60 minutes after max amplitude

127
Q

What TEG values alert to a problem with coagulation factors?

A

R time

128
Q

What TEG values alert to a problem with fibrinogen?

A

K time, alpha angle

129
Q

What TEG values alert to a problem with platelets?

A

MA

130
Q

What TEG values alert to a problem with excess fibrinolysis?

A

A60

131
Q

How do you treat a TEG with an Increased R time?

A

FFP

132
Q

How do you treat a TEG with a decreased alpha angle?

A

cryo

133
Q

How do you treat a TEG with a decreased MA?

A

platelets (DDAVP)

134
Q

How do you treat a TEG with an increased A60 (fibrinolysis)?

A

Txa

135
Q

Which layers of blood vessels made of collagen?

A

tunica externa or tunica adventitia

136
Q

Which blood vessel layer is made of smooth muscle cells and elastin?

A

tunica media

137
Q

Which blood vessel layer is made of endothelial cells?

A

tunica intima

138
Q

Which type of HTN has an identifiable cause?

A

2ndary

139
Q

How is HTN diagnosed?

A

2 reading taken 5 minutes apart, sitting

140
Q

The risk of CVD ______ with each increment of 20/10mmHg above 115/75mmHg.

A

doubles

141
Q

What is normal, preHTN, stage 1 and stage 2 HTN?

A

normal 120/80
pre up to 140/90
stage 1 up to 160/100
stage 2 over 160/100

142
Q

What does the juxtaglomerular apparatus secrete to maintain normal intravascular volume?

A

renin

143
Q

What causes vascular stiffness in the intima?

A

collagen and metalloproteinases

144
Q

intraoperative cardiac morbidity increase when DBP is greater than what?

A

110

145
Q

HTN shifts the auto regulatory curve to the ____

A

right

146
Q

HTNive patients are ___volemic and ___dynamic

A

hypovolemic and hyperdynamic

147
Q

Atherosclerosis can be caused by which other disease?

A

diabetes

148
Q

Atherosclerosis is an ____ disorder.

A

inflammatory

149
Q

What are the three phases of atherosclerosis?

A
  1. fatty streak
  2. plaque progression
  3. plaque disruption
150
Q

What are the biggest risk factors for atherosclerosis?

A

DM and cigarettes

151
Q

What is the most effective medical therapy for atherosclerosis?

A

smoking cessation

152
Q

What is the gold standard for diagnosing atherosclerosis and PAD?

A

angiography

153
Q

What is the single best initial screening for suspected PAD?

A

ankle-brachial index

154
Q

What ankle brachial index indicates a normal index?

A

> 1

155
Q

An ankle brachial index of ____ indicated limb threatening ischemia?

A

< 0.4

156
Q

Patients who develop ___ have 4-5x increase in post-op mortality

A

kidney injury

157
Q

What is the most predictive factor of post-op renal function?

A

preop function. GFR, BUN, creat

158
Q

What is the most effective way to prevent post-op lung complications?

A

post-op lung expansion

159
Q

AA surgery is an independent risk factor for what?

A

delirium

160
Q

Does intraoperative MI or stroke lead to worse outcomes?

A

MI

161
Q

monocular blindness caused by emboli traveling into the internal carotid artery and eventually limiting flow through the ophthalmic artery.

A

amaurosis fugax

162
Q

Common comorbidities for pt undergoing Carotid Endarterectomy ?

A

CVA, CAD, Diabetes, Renal disease

163
Q

CBF is constant between a MAP of

A

60-160

164
Q

What is the rate of CBF?

A

50ml/100g/min

165
Q

what is the most sensitive and specific measure of adequate CBF?

A

awake patient

166
Q

what is the gold standard for identifying neurological deficits?

A

EEG

167
Q

What are the anesthetic goals during CEA?

A

maintain cerebral blood flow and decrease cerebral ischemia

168
Q

what should be avoided during CEA? 4

A

Hyperglycemia
Hemodilution
Hypercarbia
Large swings in blood pressure

169
Q

Which anesthetic agent does not impair cerebral auto regulation?

A

propofol

Cardiovascular Anesthesia (4 decks)

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