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Critical Care GBC > W10 D3 - CV Surgery > Flashcards

W10 D3 - CV Surgery Flashcards

1
Q

What is a CABG? Indications?
What is a conduit?

A

Coronary artery bypass graft surgery
* uses a vein or artery (conduit) to go around an occlusion

Indications
* moderate to severe CAD and…
* chronic, disabling angina or unstable
* triple vessel disease
* chest pain after MI
* failed angioplasty
* coronary artery aneurysm

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2
Q

Differentiate venous and arterial conduits for CABG

A

Venous
* Saphenous vein graft from leg
* vein is long, straight, and easy to access
* long term risk of graft occlusion

Arterial
* right or left internal mammary artery, some others
* tougher, muscular layer provides longer durability and patency of veins
* arterial spasm can occur d/t muscle layer

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3
Q

Explain the prinicples of cardiac surgery

sternotomy, cardiopulmonary bypass, chest tubes, epicardial pacing wires

A

Medical Sternotomy
* midline chest opening

Cardiopulmonary bypass
* the heart is stopped and cooled during surgery
* prevent cardiac events with cardioplegia (++K solution)
* blood is diverted from right side of the heart to a heart/lung machine, oxygenated and returned to circulation

Chest tubes
* mediastinal and pleural are placed to prevent accumulation of blood

Epicardial pacing wires
* on right ventricle and right atrium as needed

Closure of chest wall
* sternal bound is closed with stainless steel wires

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4
Q

How does SIRS happen after most CV surgeries??

A

The cardiopulmonary bypass induces systemic inflammatory response syndrome with possible multiorgan injury/failure:
* d/t the blood circulating outside of the body
* results in massive vasodilation
* usually on norepi

Also at risk for strokes from poking holes in calcification
Risk of bleeding d/t high heparin doses during surgery, deacitivation of platelets on machine

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5
Q

What are possible post op complications of CV surgery?

A

Neuro changes
Arrhythmias
Bleeding
Site infection

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6
Q

What nursing care should be provided after CABG surgery?

A

1. ECG monitoring for 48-72 hours
2. ASA within 48 hours (6 hours if not previously taken) post CABG and daily
3. Afib prophylaxis
4. Statins to reduce rate of graft athlerosclerosis
5. ACE inhibitors, mostly for comorbities

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7
Q

Explain the anatomy of a heart valve

A

Leaflets are the flaps that open inside the valve
Annulus is the ringlike structure that supports the leaflets
Commissure is the line where two leaflets join

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8
Q

Which valve is the only one with only two leaflets?

A

Mitral valve - most complex
All others have 3

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9
Q

Differentiate valve regurgitation (insufficiency) and stenosis

A

Regurgitation
* unable to close properly
* leak of blood backward through a valve into previous chamber

Stenosis
* narrowing of valve
* unable to open properly
* blood accumulates in the previous chamber

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10
Q

Why is valve repair over replacement prefered?

A

Maintains normal geometry and function of the ventricles
* avoids risks w/ prosthetic valve failure and chronic anticoagulation

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11
Q

What are the effects of cardiac function with mitral regurgitiation and or stenosis?

A

Mitral
Regurgitation
* decreased cardiac output, LA enlargment, LV hypertrophy then thinning/dilates, pulmonary HTN
* HOW? blood flows backward into LA during systole and into LV causing hypertrophy and high pressures in pulmonary veins

Stenosis
* decreased CO, LA enlargement, pulmonary HTN, RV hypertrophy, RV failure
* HOW? narrowing of the valve causes accumulation of blood into LA and reduces filling of the LV. This increases pressure in pulmonary veins and backs up fluid into RV eventually causing failure

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12
Q

What are the effects of cardiac function with aortic regurgitiation and or stenosis?

treatments

A

Aortic
Regurgitation
* decreased CO, LV hypertrophy then thinning, dilated LA, high filling pressures, possible pulmonary HTN
* HOW? valve does not close causing blood to flow backward during distaole into LV then LA then pulmonary veins

Stenosis
* decreased CO, hypertrophy LV then thinning, LA enlargement, ventricular dilation and decreased contractility
* HOW? narrow valve causes accumulation of blood in LV which causes hypertrophy and backs up into LA increasing pressures

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13
Q

Differentiate commisurotomy, annuloplasty, valvuloplasty

A

Valvuloplasty - opens a stenotic valve via repair
Commissurotomy - incision through commisures (fused valve leaflets)
Annuloplasty - ring around annulus to pull leaflets together

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14
Q

What are the pros/cons of tissue vs. mechanical prosthetic valves?

A

Mechanical
Pros
* long lasting, does not degrade

Cons
* warfarin for life
* not good for those who fall, kids, pregnant women

Tissue
Pros
* no need for lifetime anticoag.

Cons
* Degrades overtime, will require another surgery

Both
* risk of endocarditis: require lifetime prophylactic antibiotics
* structural valve can deteriorate
* paravalvular leak and hemolysis

Pro
* long lasting

Cons
* take warfarin for life
* Mechanical:
* Tissue valve degrades overtime

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15
Q

What is a transcatheter aortic valve replacement TAVR?

A

Balloon is inserted into the aortic valve to keep it open while a new valve is inserted
* is not sutured in, calcium holds it
* risk of dislodging calcium/emboli

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16
Q

Mitral vs aortic valve replacement risks

A

Mitral valve replacement requires incision in left atria: a high risk or air embolism affecting coronary or cerebral circulation

Aortic valve replacement could cause calcium dislodgement / systemic emboli from the balloon

17
Q

Explain the physiology, therapies, interventions for aortic stenosis

signs on another card

A

Narrowing of the OPENING of the aortic valve
* Compensates by increasing muscle mass / hypertrophy
* which causes diastolic dysfunction as muscle doesnt stretch well
* addtionally, pressure overload from hypertrophy and blood backing up causes left atrial enlargement (full of blood)

AS causes ventricular dilation and decreased contractility if untreated

Treatment
* asymptomatic: monitor, use statins
* symptomatic: repair or TAVI

18
Q

What are severe symptoms of aortic stenosis that indicate treatment is needed?

How do these happen?

A

SAD
Syncope - valsalva, poor EF
Angina - d/t extra muscle (LV hypertrophy) without extra blood flow
Dyspnea - if LA enlarged with high pressures reduce blood flow to pulmonary veins and less systemic circulation = poor oxygenation

19
Q

What does an aortic murmur sound like?

A

Whooshing
* feel a pulse at the same time to determine systolic or diastolic
* whoosh at pulse = systolic

20
Q

What are some post op issues for AVR for AS?

aortic stenosis

A
  1. heart blocks
  2. hypertension/labile
  3. low CO despite PCWP - hypovolemia
  4. ensuring anticoagulation
  5. starting afib prophylaxis
21
Q

Explain the physiology, s&s, treatment for aortic insufficiency

A

The aortic valve cannot close completely; blood flows back into the LV
* compensates by hypertrophy but cannot maintain; LV becomes thin and dilated
* volume overload increases filling pressures, dilates LA, maybe pulmonary hypertension

S&S
* increased pulse pressures
* signs of HF: edema, ascites
* murmur

Treatment
* BP control
* HF medications if indicated
* replacement

22
Q

What does an aortic insufficiency murmur sound like?

A

Diastolic murmur possibly with S3 from fluid overload
* wide pulse pressure d/t blood leaking out in diastole

23
Q

Explain the physiology, s&s, therapies, interventions for mitral stenosis

finish

A

Narrowing of the OPENING of the mitral valve
* leads to reduced filling of the LV
* blood backs up into LA causing enlargement
* backs up into pulmonary veins causing pulmonary hypertension ALWAYS
* eventually RV failure d/t hypertrophy

S&S
* general fatigue, SOB
* distaolic murmur over apex

Treatment
* Na restriction, diuretics for pulmonary edema
* anti-arrhythmic agents
* anticoagulation
* repair or replacement

24
Q

List potential post op complications for mitral valve replacment

A
  1. Air emboli
  2. heart blocks
  3. may require higher filling pressures and inotropes
  4. RV dysfunction d/t pulmonary hypertension
  5. anticoags
  6. a fib prophylaxis
25
Q

Explain the physiology, s&s, therapies, interventions for mitral insufficiency

A

Cannot close completely so blood backs up during systole from LV to LA
* left atrial enlargement from extra blood
* LV initially hypertropies then thins and dilates
* pulmonary hypertension

S&S
* pulmonary edema
* signs of HF
* systolic murmur at apex

Treatment
* afterload reductions via meds
* repair or replacement
* mitraclip

26
Q

What are the most common CV post op complications to look out for?

A
  1. Heart blocks
  2. Arrhythmias
  3. MIs - watch STs, ischemia
  4. Bleeding - hypotension
  5. Cardiac tamponade - low CO, BP
27
Q

Describe an aortic aneurysm and its repair

A

Dilation of the aorta greater than 50%
* intervention once they are at increased risk for rupture, enlarge too fast, or have persistent pain
* thoracic = above kidneys
* abdominal = between / below kidneys

Types of tears
* type A = ascending aorta or arch, emergency
* type B = descending aorta, BP managment no surgery

Repair
* repair of aneurysm
* replace descending thoracic aorta
* endovascular aortic repair

Critical Care GBC (33 decks)

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