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Vascular > Vascular PP1a > Flashcards

Vascular PP1a Flashcards

1
Q

recent MI, preferred waiting time for surgery

percentage of vascular patients that have normal coronaries?

percentgae of vascular patients that have CAD?

A

preferred to wait 60 days

<10%

>50%

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2
Q

what is MACE

A

major adverse cardiac event

MI, new onset of HF, arrythmias, ST elevation, Death,

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3
Q

what are the take offs from the aorta

A

R: innominate(brachiocephalic), right common CA: internal and external CA, R subclavian

L: L common CA and L subclavian

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4
Q

what is the patho of Atherosclerosis

what happens when it dislodges

where are the most common areas of build up

A

macrophages start sticking to the endothelial lining of the vessels

they build up over time and make foam cells (fatty streaks)

more macrophages come. inside core is filled w lipids and outside has calcium build up and is (fibrous plaque)

if dislodges becomes an emboli: MI or ischemic stroke

medium and large vessels most prone or where areas of branching are

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5
Q

what is a simple way of testing for PVD

A

ankle brachial index

SBp of ankle/SBP of arm. if less than .9 this is abnormal

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6
Q

what are the three types of atherosclerosis morbidity

A
  1. stable plaque. remodeling of the internal lumen. decrease in supply and demand
  2. plaue rupture and thrombus formation - MI, Stroke, TIA, unstbale angina
  3. Atrophy of vessel wall and dilation created an aneurysm
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7
Q

what are the risk factors for atherosclerosis

A

smoker, obses, poor health, DM, HTN, HLD, renal insufficiency, chronic inflammation

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8
Q

what is the MOA of statins

what are the other medical managments of atherosclerosis

A

statins will decrease

LDL, VLDL, cholesterol synthesis, mevalonic acid —> decrease cholesterol

stop smoking, lose weight, healthy eating, exercise, glucose control, control HTN (BB ACEI),

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9
Q

what are the preoperative guidelines for vascular surgery

A

review preop meds

type of procedure

level of risk of procedure

is patient optimized, do we need additional evals

clinical hx

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10
Q

what are the effects of chronic drug therapy

aspirin, plavix, statins, ACEI, Diuretics, CCB, hypoglycemis drugs, BB

A

aspirin - increased bleeding, decreased GFR,

plavix - bleeding

statins - liver dysfunction and rebound inflammation

Diuretics - hypovolemia

CCB - hypotension

hypoglycemic drugs - decrease BG/ metformin —> lactic acidosis

BB: decreaesd HR, BP, bronchospasms

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11
Q

how long to hold

plavix

xarelto

LMWH

5000u heparin

A

plavix 3 days or 7 days

xarelto 5 days

LMWH 12 hr

heparin 2 hrs

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12
Q

what drugs should you take day of surgery and not take

A

Take: statins, BB,

dont take: AceI, CCB, aspirin, antiPLT

dont start new BB day of surgery

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13
Q

day of surgery ACEI

why not take them

how to txt

A

hpotension, not responding to phenyl, ephedrine

what to fluid optimise pt

pat can have refactory vasoplegia

txt: methylene blue, hydroxy cobalamin B12, Vasopressin

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14
Q

day of surgery anti PLT therapy

considerations

DES, BMS

A

should weight the benefits of surgical bleeding vs thrombotic risk

DES - 6 months

BMS - 30 days

team decision on whether to proceed

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15
Q

how long to hold

plavix, warfarin, fondaparinox, LMHW, dabigatran, DES, BMS, urgent surgery w DES

A

plavix: 3-7 days
warfarin: until INR is normal
fondaparinox: 48 hrs

LMWH: 12 hrs

dabigatran: 5-7 days

DES: 6 months or 3 months if urgent

BMS: 30 days

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16
Q

Day of surgery Alpha 2 agonist

considerations

A

clonidine: if stopped after chronic use could have profound rebound hypertension
seen: hypertension, tachycardia, diaphoreis, pulm edema

Recommendations says its not needed to prevent MACE

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17
Q

what type of labs do you want for a vascular patient

A

cbc, bmp, coags, renal , EKG, troponin, echo

18
Q

when to order a repeat echo

A

worsening symptoms

unknown reasons for DOE

known LV dysfunction

no echo done is the past yr

19
Q

what are the steps to determine if advanced cardiac testing is needed

A
  1. urgency of surgery
  2. ACS or othr patho present?
  3. will the test results change your plan
20
Q

what are the 6 steps to know if additional cardiac testing is needed for vascular surgery

A
  1. urgency of surgery
  2. ACS present
  3. MACE (if <1% proceed)
  4. MET score >4
  5. if METS <4, get stress testing
  6. will these results change my anesthestic plan
21
Q

when is it recommended get a CABG or PCI before surgery

if not getting surgery, what medications should they be on

A

only if the left main coronary artery is disrupted. if not, no indication

should be on statins, BB, aspirin

22
Q

dicuss Ambulatory EKG

what is it, pro and cons

A

a tool is detect and measure arrythmias

pro: cheap, 1/3 cost of thallium testing
cons: no detection of intensity of arrythmias, cant tell if pt has pacemaker, cant tell LBBB

23
Q

DTI: thallium imaging

what is it. pros and cons

A

the most non invasive screening

can be used during exercise or stress testing

thallium will block adenosine to the coronary arteries. now will be able to detect areas of stenosis

24
Q

what can an echo tell you

A

bleeding, decreased preload, stenosis or regurg of valves, emboli, lesions, LVADS, EF

25
Q

which test is the best at prediciting cardiac morbidity with a 90% predication

A

ischemic stress test followed by DTI and AEKG

26
Q

types of intraoperative monitoring for patients with vascular disease

when to use R heart cath

when to use A line

A

EKG, temp, BP, Aline (severe atherosclerosis), TEE, CVP, PA cath (PHTN, RV failure),

27
Q

what is the importance of EKG leads and catching ischmia

A

lead II - 75%

Lead V - 80%

lead V4 - 100%

28
Q

what are the general guidelines to preventing an MI

A

decrease workload of heart: decrease HR, decrease afterload, Bp within 20% of baseline

keep warm

treat anemia

keep euvolemic

29
Q

what is the trauma triad

A

hypercoag, hypothermia, metbolic acidosis

30
Q

guidelines to transfuse during vascular surgery

if starting to bleed, what 4 questions to ask

A

keep to a hbg of 8, no studies show benefit of greater amount

rate, cause, how much, control

31
Q

what are the negative to a hypothermic patient (6)

A

L shift of curve

coagulopathy

cardiac depressent

viscocity increase of blood

shivering increasing metabolic demand

increase adrenergive tone —>postop MI

32
Q

what are some key questions when doing CEA surgery

A

do we have collaterals

what does perfusion on the contralateral neck look like

has the pt had previous CEA?

33
Q

TIA

discuss

A

transient ischmic attack

focal deficit lasting 24 hrs

15% a stroke will be preceeded by a TIA

87% of strokes are ischemic

34
Q

function and location

chemoreceptors

baroreceptors

A

both are located in the aortic bodies and carotid bodies

checmoreceptors will respond to changes in CO2 and O2. —> tachycardia and HTN. after CEA, carotid bodies dont work as well, wont see tachycardia

baroreceptors respond to pressure changes.—> bradycardia and hypotension

35
Q

why may the surgeon use a shunt? risk?

A

to devert blood around the plaque

not used very often, can have dissection, bleeding, hypotension, dislodge plaque, introduce air, infection

36
Q

carotid endarderectomy

treat the patient like they have what

what drugs should they not stop taking (3)

when is it beneficial for them to have this procedure, %age of stenosis occured

what is a common reason of having a MI event intraop

A

treat CEA patient like they have CAD

dont stop taking BB, statin, ASPIRIN - dont want them to thrombos during sxg

when its great thatn 70% stenosis

thombosis which leads to a supply and demand issue

37
Q

what are some preoperative considerations w CEA

A

smoker, obese, DM, HTN, HLD, renal insuffienceny, heart health, medication therapy

38
Q

CEA intraop monitoring and lines

type of neuro monitoring

arm position

A

A line, BP cuff contralaterial arm, 5 lead EKG, temp, 2 large bore IVs, phen drip hanging, are we dont SSEP, MEP

noth arms are tucked, make sure IVs are running well

39
Q

shunting in CEA

why use it, indicator to use

location

%age say its unnecessary

risks for placing

A

help w collateral flow when intraop. when clamp if ipsilateral changes are noticed on EEG then place shunt or increase BP to feed collaterals

common carotid and internal carotid

85% say its uncecessary

plaque loosen, air embolism, bleeding, infection, hypotension, dissection, long term stenosis

40
Q

what are some considerations with CEA

hemodynamics

benzos

Co2 level

gluose levels

fluids

heparin

A

hemodynamics: during clamping, increase BP to perfuse collaterals. do tachycardia, no increased workload on heart
benzos: light use. want a good neuro exam on wake up

normocapnia no hypocapnia

BG <200

avoid fluid overload, no hypotonic solutions to prevent cerebral edema

10000u of heparin drawn up for act 200

41
Q

what is cerebral steal and what can make it worse

A

ischmic part of the heart and other vessels will dilate and devert blood flow.

if hypercapnia/hypoventilation can make cerebral steal worse

42
Q
A

Vascular (4 decks)

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