Valvular lesions - anesthetic management of

Question 1

In all REGURGITANT lesions, avoid __________ (bradycardia/tachycardia) because it can significantly increase regurgitant fraction

Answer 1

Bradycardia

Question 2

3 things that increase regurgitant fraction

Answer 2

1. Bradycardia
2. Increased afterload (SVR)
3. Larger valvular orifice

Question 3

Anesthetic management for REGURGITANT lesions follows “______, _______, ______”

Answer 3

Fast
Full
Forward

Question 4

What kind of lesions does “Fast, Full, Forward” manage?

Answer 4

REGURGITANT

Question 5

Fast, full, forward means?

Answer 5

Fast: Increase HR
Full: Maintain/increase preload
Forward: Decrease afterload

Question 6

In MR, the SV is directed two directions during systole: the _____ and the ______

Answer 6

Aorta, left atrium

Question 7

In MR, chronic dilation is referred to as

Answer 7

eccentric hypertrophy

Question 8

In an acute MR (i.e. papillary muscle rupture), you would expect to see pulmonary ____ and eventual ______ failure

Answer 8

HTN, RV

Question 9

Anesthetic considerations for MR

HR

Answer 9

“Fast”: Avoid bradycardia

(would cause increased regurgitant fraction)

Question 10

Anesthetic considerations for MR

Preload

Answer 10

Maintain or increase

(higher helps compensate for regurgitant volume and increases SV)

Question 11

Anesthetic considerations for MR

Afterload

Answer 11

“Forward”: Decrease afterload

Systemic vasodilators

(promote forward flow; increased SVR increases regurgitant volume)

Question 12

Anesthetic considerations for MR

PVR

Answer 12

Avoid increases in

(PVR increases workload of RV)

Question 13

How to you avoid increases in PVR

Answer 13

Avoid acidosis, hypercarbia, hypoxia, nitrous oxide, Trendelenburg position

Question 14

Anesthetic considerations for MR

Regional anesthesia

Answer 14

Good

(can reduce afterload, overall regurgitant fraction)

Question 15

Aortic Regurgitation (AR) anesthetic considerations

HR

Answer 15

“Fast”: 80-100 bpm

(reduces regurgitant volume)

Question 16

Aortic Regurgitation (AR) anesthetic considerations

Preload

Answer 16

“Full”: Maintain or increase

(more volume to increase SV and CO)

Question 17

Aortic Regurgitation (AR) anesthetic considerations

Afterload

Answer 17

“Forward”: Decrease

(promotes forward blood flow and reduces regurgitant volume)

cautious use with phenylephrine or vasopressin; ephedrine ok

Question 18

Aortic Regurgitation (AR) anesthetic considerations

Regional anesthesia

Answer 18

Good

to reduce afterload

Question 19

What do you want to avoid in STENOTIC LESIONS?

Answer 19

Tachycardia

(will reduce filling time and ejection time = reduce SV and increase O2 demand)

Question 20

In MS, severe disease occurs when MV is < ____cm2

Answer 20

1.0cm2

Question 21

In MS, increased pressure in the LA leads to a chronically _________ LV

Answer 21

underfilled

Question 22

In MS, there is an increased risk for _____________ d/t increased LA pressure/volume

Answer 22

atrial fibirillation

Question 23

Afib leads to loss of atrial kick, which accounts for ____ - _____% of LVEDV

Answer 23

20-30%

Question 24

Mitral stenosis anesthetic considerations

Main goal

Answer 24

Maintain adequate preload

Question 25

Mitral stenosis anesthetic considerations HR

Answer 25

Low-Normal rate Avoid drugs that increase HR (anticholinergics) (tachy = decreased filling times, decreased CO)

Question 26

Mitral stenosis anesthetic considerations Arrythmias

Answer 26

Avoid tachyarrythmias treat with amiodarone, BBs, CCB., CARDIOVERSION

Question 27

Mitral stenosis anesthetic considerations Preload

Answer 27

Maintain (IVF to maintain LVEDV without causing pulmonary congestion)

Question 28

Mitral stenosis anesthetic considerations Afterload

Answer 28

Maintain PHENYLEPHRINE, NE, VASOPRESSION (ephedrine not best choice) (SVR preserves MAP with a lower SV, CO)

Question 29

Mitral stenosis anesthetic considerations PVR

Answer 29

Avoid increases (can further increase workload of RV) Avoid acidosis, hypercapnia, hypoxia, nitrous oxide, Trendelenburg

Question 30

Mitral stenosis anesthetic considerations Regional

Answer 30

Ok if INR <1.5 patients often on anticoagulants d/t afib hx

Question 31

Aortic stenosis anesthetic considerations Main goal

Answer 31

Maintain higher SVR (afterload is fixed on lesion)

Question 32

Aortic stenosis anesthetic considerations HR

Answer 32

Low-Normal (tachy= decreased filling, decreased SV, CO; brady= LV overfilling, subendocardium depression, myocardial ischemia)

Question 33

Aortic stenosis anesthetic considerations Preload

Answer 33

Maintian/increase (need adequate LVEDP to fill non-compliant ventricle)

Question 34

Aortic stenosis anesthetic considerations Afterload

Answer 34

Maintain/increase PHENYLEPHRINE, NE (hypotension = decreased coronary perfusion pressure, myocardial ischemia; SV is fixed by stenotic lesion)

Question 35

Aortic stenosis anesthetic considerations PVR

Answer 35

Maintain

Question 36

Aortic stenosis anesthetic considerations Regional

Answer 36

Contraindicated (sympathectomy = profound hypotension, decreased coronary perfusion pressure, cardiovascular collapse)