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6902- Cullen > Vascular PP > Flashcards

Vascular PP Flashcards

1
Q

2 aspects that the extent of perioperative monitoring should be based on?

A

type of surgery and presence of coexisting disease

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2
Q

3 ways to assess cardiac function in vascular surgery patients?

A

TEE, EKG, PA cath

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3
Q

Does PAC monitoring affect length of stay or mortality in vascular patients?

A

no

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4
Q

When comparing vascular patients who had a PA cath versus those who did not, the PA cath group had higher rates of what 3 complications?

A

pulmonary embolism, pulmonary infarction, and hemorrhage

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5
Q

What procedures warrant routine use of PACs according to the ASA?

A

none

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6
Q

Patients with HTN or angiopathology rely on what to perfuse their vital organs>

A

increased mean arterial pressures

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7
Q

Patients with HTN or angiopathology require lower or higher pressures to maintain autoregulation?

A

higher

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8
Q

What is the most common cause of occlusive disease in arteries of lower extremities?

A

atherosclerosis

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9
Q

The short and sweet 3 step pathophysiology summary of how plaques affect arteries?

A
  1. plaque formation 2. thrombosis 3. aneurysm formation
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10
Q

4 symtpoms associated with peripheral occlusive disease?

A

gangrene, impotence, ulcers, claudication

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11
Q

Plaque is made up of what substances?

A

cholesterol, fat, Ca, fibrin, cellular waste products

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12
Q

Mortality rates for PVD at 5 years and 10 years, respectively?

A

30%; 70%

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13
Q

The extent of disability in PVD patients is influenced?

A

collateral blood flow

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14
Q

What is responsible for activating the clotting system in PVD?

A

inflammatory process

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15
Q

Target heart rate for beta blocker therapy in PVD patients?

A

50-60

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16
Q

Beta blocker therapy is recommended for PVD patients at risk for what 2 things?

A

MI, ischemia

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17
Q

5 effects on the pulmonary system that epidurals have?

A

Decreased effect on FVC, FEV1, and PEFR, Decreases ventilation perfusion mismatch, Improves atrioventricular oxygen differentiation, Decreases pulmonary postoperative complications, Decreased incidence of thromboembolism

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18
Q

2 effects that epidurals have on the renal system?

A
  • Increases blood flow in the renal cortex

* Decreases renovascular constriction

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19
Q

2 effects that epidurals have in the geriatric population?

A

decreased stress and improved post op mental function

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20
Q

In regards to extubation and pain control how does epidural anesthesia affect those 2?

A

earlier extubation and improved pain control

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21
Q

What effects does epidural anesthesia have on the heart?

A

Decreases MVO2 demand & afterload, increases endocardial blood flow at ischemic zones, increased hemodynamic stability (?), Decreases GA medication usage, improves blood flow to lower extremities

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22
Q

7 things inhibited by epidurals?

A

surgical stress response, epinephrine & cortisol release (not sure if good or bad), hyperglycemia (good), lymphopenia, inflammatory mediator release, nitrogen sparing, blocks sympathetic tone

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23
Q

3 risks possible when having surgery on the aorta?

A

large intraop blood loss, renal failure, paralysis

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24
Q

An EF less than what percentage proves to be risky when having aortic surgery?

A

30

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25
Q

3 screening tools to diagnose AAA?

A

MRI, CT, ultrasound

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26
Q

Primary goal of preoperative period for AAA?

A

restore intravascular volume/fluid load

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27
Q

Blood products to have available for AAA surgery?

A

PRBC x 2, FFP, platelets

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28
Q

When does heparinization occur during AAA repair?

A

before occlusion

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29
Q

Renal prophylaxis during AAA repair can be completed with?

A

mannitol

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30
Q

Abdominal aortic aneurysm repair can be done using which 2 approaches?

A

transperitoneal or anterolateral

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31
Q

For an abdominal aortic aneurysm repair, what are the 3 locations the clamp can be placed?

A

supraceliac, suprarenal, infrarenal

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32
Q

There is less effect on LV afterload when the clamp is placed where in AAA surgery?

A

farther distally

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33
Q

The aortic cross clamp causes what to happen to BP above and below clamp?

A

above- HTN; below- hypotension

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34
Q

What happens to MAP and SVR during aortic cross clamping? What happens to PAW?

A

increase; increase PAW

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35
Q

What affect does aortic cross clamping have on afterload and wall tension?

A

increases both

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36
Q

Why may aortic cross clamping cause issues in the ischemic heart?

A

because aortic cross clamping increases afterload and wall tension

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37
Q

The hemodynamic effects of aortic cross-clamping depend on what 3 things?

A

the application site along the aorta, the patient’s preoperative cardiac reserve, and the patient’s intravascular volume

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38
Q

Most common site for aortic cross clamping?

A

infrarenal

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39
Q

What two systems are involved with aortic cross clamping?

A

SNS, RAAS

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40
Q

5 metabolic changes which occur from aortic cross clamping?

A

increased lactic acid, release of arachidonic acid, thromboxane A2, cyclo oxygenase inhibitors, increased epi and norepi levels

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41
Q

How do beta blockers help w the metabolic changes associated with aortic cross clamping?

A

as a result of aortic cross clamping, epinephrine and norepinephrine release are increased and stimulate myocardial β1-receptors that can increase heart rate and myocardial oxygen demand

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42
Q

This is a metabolic change associated with the decrease in myocardial contractility and cardiac output during aortic cross clamping?

A

thromboxane A2

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43
Q

5 symptoms common with mesenteric traction syndrome?

A

decreases in blood pressure and SVR, tachycardia, increased cardiac output, and facial flushing

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44
Q

These mediators are thought to be responsible for the tachycardia, elevated temp, leukocytosis, and fluid sequesteration during surgery?

A

TNF, IL-6, catecholamines, cortisol

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45
Q

The hemodynamic instability that may ensue after the release of an aortic cross-clamp is called?

A

declamping shock syndrome

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46
Q

What happens to the SVR, vessel tone, afterload, preload, CO, and myocardial tone in declamping shock syndrome?

A

all decrease and the vessel tone dilates and blood is directed to the dilated vasculature

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47
Q

This is paramount in providing circulatory stability before release of the aortic clamp?

A

Restoration of circulating blood volume

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48
Q

What three things influence the magnitude of circulatory instability after undoing the aortic cross clamp?

A

site and duration of cross-clamp application, gradual release of the clamp

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49
Q

What does decreased myocardial contractility do to total body oxygen consumption? What can the CRNA do to counteract decreased myocardial contractility during AAA repair?

A

increase; decrease vasodilators

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50
Q

What does decreased CVP do to prostaglandin levels?

A

decrease

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51
Q

What is a major complication of clamping the thoracic aorta?

A

spinal cord ischemia and paraplegia

52
Q

At what spinal level is the Artery of Adamkiewitcz located?

A

T8-L2

53
Q

Where does the spinal cord receive its blood supply from?

A

vertebral arteries and thoracic and abdominal aorta

54
Q

Classic deficit of spinal cord ischemia? These deficits are also commonly known as?

A

loss of motor function and pinprick sensation but preservation of vibration and proprioception; anterior spinal artery syndrome

55
Q

There is an increased incidence of renal failure following aortic surgery associated with what 3 events?

A

emergency procedures, prolonged cross clamp period, prolonged hypotension

56
Q

What is the dose of mannitol to infuse prior to cross clamping to preserve renal function?

A

0.5g/kg

57
Q

What infusion can treat renal vascular HTN?

A

fendoldopam

58
Q

5 indications for aortic surgery?

A

dissection, aneurysm, occlusive disease, trauma, coarctation

59
Q

What are the 4 specific site lesions requiring aortic surgery?

A

ascending aorta, aortic arch, distal to left subclavian artery and above diaphragm, below diaphragm

60
Q

The 6 etiologies of thoracic aortic aneurysms?

A

degenerative (arteriosclerotic), mechanical (dissection, trauma), connective tissue syndrome, inflammatory, anastomatic (postarteriotomy), infectious

61
Q

A true aneurysm involves which layers, whereas a false aneurysm involves this layer?

A

true involves all, false involves only adventitia

62
Q

Thoracic aneurysms are classified based on what three things?

A

location, shape, type

63
Q

This type of aneurysm has a spindle shape and results in dilation of the aorta?

A

fusiform

64
Q

These aneurysms are spherical dilations and are generally limited to only one segment of the vessel wall?

A

saccular

65
Q

Aortic dissection is the result of a spontaneous tear within what layer that permits the flow of blood through a false passage along the longitudinal axis of the aorta?

A

intima

66
Q

Thoracoabdominal aortic aneurysms (TAAA) are classified using the ___________ classification?

A

Crawford

67
Q

A Type A Type I Aortic Dissection occurs where?

A

entire length of aorta

68
Q

A Type A Type II Aortic Dissection occurs where?

A

ascending aorta

69
Q

A Type B Aortic Dissection occurs where?

A

distal to subclavian artery

70
Q

A Type A Aortic Dissection is also known as? A Type B Aortic Dissection is also known as?

A

proximal; distal

71
Q

What can an aortic aneurysm do to the trachea or bronchus?

A

compression or deviation

72
Q

What type of valve irregularity can an aortic aneurysm produce?

A

aortic regurgitation

73
Q

Normal adult aorta is how many cm?

A

2-3 cm

74
Q

Operative mortality rate of aortic aneursym? if leaking occurs?

A

2-5%; > 50%

75
Q

What does a chest x ray show in aortic trauma?

A

wide mediastinum

76
Q

Which artery is recommended for monitoring BPs for surgery on the ascending aorta?

A

left radial artery bc of proximity of inominate artery to where you put clamp

77
Q

What is unique about the surgical technique for ascending aorta surgeries?

A

uses median sternotomy and cardiopulmonary bypass

78
Q

A good drug to use during ascending aorta surgeries?

A

nitroprusside

79
Q

Descending thoracic aorta: What approach is used if limited to descending aorta?

A

left thoracotomy

80
Q

Descending thoracic aorta: what approach is used if the abdominal aorta is involved?

A

thoracoabdominal

81
Q

Descending thoracic aorta: One or two lung ventilation?

A

one

82
Q

Descending thoracic aorta: arterial pressures measured from which artery?

A

right radial

83
Q

Descending thoracic aorta: where is aorta cross clamped?

A

above and below the lesion

84
Q

Descending thoracic aorta: HD instability likely to occur following release of the cross clamp due to what 3 reasons?

A

abrupt decrease in afterload, bleeding, release of vasodilating acid metabolites

85
Q

Descending thoracic aorta: 3 therapeutic considerations for releasing the cross clamp?

A

decrease anesthetic depth, volume load, partial or slow release of the cross clamp

86
Q

Descending thoracic aorta: 3 good drugs to treat hypotension after releasing cross clamp?

A

CaCl, bicarb, vasopressors

87
Q

Some early complications of thoracic aortic surgery?

A

MI, CHF, resp failure, paraplegia, embolism, bowel ischemia, renal failure, CVA, vocal cord paralysis, sexual dysfunction

88
Q

Which artery is the guidewire threaded through for an EVAR repair?

A

femoral artery to iliac artery

89
Q

When is heparin given during an EVAR?

A

prior to manipulation of catheter

90
Q

Advantages of EVAR versus the open repair?

A

no aortic cross-clamping, improved hemodynamic stability, decreased incidence of embolic events, decreased blood loss, reduced stress response, decreased incidence of renal dysfunction, and decreased postoperative discomfort

91
Q

Is local anesthesia versus general anesthesia more beneficial for patients undergoing EVAR?

A

no

92
Q

Some factors contributing to morbidity during carotid endarterectomy?

A

operative timing, hyperglycemia, history of stroke, surgery w or w/out a shunt, ulcerative lesion, age

93
Q

The greatest contribution to overall morbidity related to carotid endarterectomies is?

A

MI

94
Q

How do you calculate cerebral perfusion pressure?

A

difference between MAP and ICP

95
Q

During CEA, what plays a predominant role in regulating CPP?

A

MAP

96
Q

When MAP is maintained between __ and __ CBF remains constant?

A

60-160

97
Q

Chronic systemic hypertension shift the patient’s cerebral autoregulatory curve to which direction?

A

right

98
Q

Why should MAP be higher during a CEA?

A

Chronic systemic hypertension shift the patient’s cerebral autoregulatory curve to the right so a higher MAP is required to maintain CPP

99
Q

Normal CBF?

A

50mL/100 g/min

100
Q

Neuronal function is generally maintained at CBF levels greater than?

A

25 mL/100 g/min

101
Q

Cellular death occurs at CBF levels less than?

A

6 mL/100 g/min

102
Q

Cerebral ischemia leads to disruption of autoregulation and therefore what does the vasculature do? Therefore the blood flow becomes dependant on?

A

dilate; pressure

103
Q

What is the major objective during carotid artery revascularization?

A

maintain CBF and decrease cerebral ischemia

104
Q

How can cerebral ischemia be prevented during CEA?

A

increasing collateral flow (placement of intraluminal shunt) or by decreasing cerebral metabolic requirements (pharmacologic adjunct)

105
Q

4 interventions for preserving cerebral protection?

A

avoiding hyperglycemia, hemodilution, maintenance of normocarbia, and tight control of arterial blood pressure

106
Q

What is the risk associated with shunting during a CEA?

A

shedding of debris in to cerebral vasculature

107
Q

What medications should the patient receive prior to CEA?

A

all of his/her usual medications

108
Q

Superficial and deep cervical plexus blocks block which nerves?

A

C2-C4

109
Q

Advantages of superficial and deep cervical plexus blocks during CEA?

A

LOC, speech, contralat hand grip can be assessed and examined intraop

110
Q

Disadvantages of superficial and deep cervical plexus blocks during CEA?

A

airway not secured, full cooperation of pt required

111
Q

What is common for BP to do during carotid surgery?

A

HTN

112
Q

What should the goal be for CO2 during CEA?

A

normocapnia

113
Q

How should emergence and extubation be after a CEA?

A

smooth and uneventful

114
Q

T/F: It has now been determined the incidence of stroke resulting from CAS is similar to the CEA results for all age

A

True

115
Q

The most common complication associated with carotid artery stenting?

A

stroke

116
Q

Some complications associated with carotid artery stenting?

A

MI, bradycardia, hypotension, stroke, Horner syndrome, cerebral hyperperfusion syndrome, carotid artery dissection/rupture

117
Q

What does increased arterial BP above the clamp mean? And what is our intraoperative intervention?

A

decreased O2 consumption; nitro, milrinone, inhaled anesthetics (reduce afterload), shunt and aorta to fem bypass

118
Q

What does decreased arterial BP below the clamp mean for us? And what is our intraoperative intervention?

A

Decreased total body CO2 production; reduce preload/nitroglycerin, atrial to femoral bypass

119
Q

How will increased wall motion abnormalities and left ventricular wall tension be manifested during aortic surgery? And what is our intervention?

A

increased mixed venous O2 sat; renal protection/fluid admin, mannitol, lasix, dopamine, mucomyst, sodium bicarb

120
Q

What does a decreased EF and CO mean for us during aorta surgery? What are interventions done to help w that?

A

decreased total body O2 extraction; hypothermia, decrease minute ventilation, sodium bicarb

121
Q

What does decreased RBF do to catecholamine release?

A

increase

122
Q

Acid base imbalance from increased pulmonary occlusion pressure?

A

respiratory alkalosis

123
Q

Acid base imbalance from increased CVP?

A

metabolic acidosis

124
Q

Vascular patients receiving what 3 types of surgery should be considered high risk for an ischemic event?

A

open AAA repair, visceral arteries, and lower leg revascularization,

125
Q

In what 2 ways can coronary ischemia occur in vascular patients?

A

plaque becomes loose and subsequent vessel thrombosis or supply demand mismatch exacerbated by tachycardia and HTN

126
Q

What is another contributing factor increasing cardiac risk in patients undergoing major arterial repair?

A

fluid shifts caused by blood loss and HTN

6902- Cullen (10 decks)

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