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principles 2 cardiac anesthesia > Part 1 > Flashcards

Part 1 Flashcards

1
Q

normal cardiac anatomy = ________ chambers, ____ valves, ______ pulmonary arteries, and & _______ pulmonary veins

A

4, 4, 2, 4

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2
Q

which has a thicker muscle layer? (atrium or ventricle)

A

ventricle

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3
Q

pulmonary arteries carry ______________ blood to the lungs, and the pulmonary veins carry ______________ blood back to the heart

A

deoxygenated; oxygenated

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4
Q

describe the flow of blood through the heart, coming in from the body

A

body –> SVC/IVC –> R. atrium –> tricuspid valve –> R. ventricle –> pulmonic valve –> pulmonary artery –> lungs –> pulmonary vein –> left atrium –> mitral valve –> left ventricle –> aortic valve –> aorta –> body

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5
Q

the heart is located __________ between the lungs in the _________________

A

medially; mediastinum

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6
Q

the heart is separated from other mediastinal structures by the _______________, and sits in its own space called the __________________

A

pericardium; pericardial cavity

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7
Q

the _____________ side of the heart is deflected anteriorly; and the __________ side of the heart is deflected posteriorly

A

right; left

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8
Q

the ________________ surface of the heart sits deep to the sternum and costal cartilages

A

dorsal

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9
Q

the great veins (SVC/IVC) and the great arteries (aorta and pulmonary trunk) are attached to the _________________ surface of the heart, which is referred to as the ___________

A

superior; base

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10
Q

the base of the heart is located at the level of the ________________ costal cartilage

A

3rd

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11
Q

the inferior tip of the heart is called __________________

A

apex

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12
Q

the apex of the heart lies to the ____________ of the sternum between the junction of the ______&_________ ribs near their articulation with the costal cartilages

A

left; 4;5

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13
Q

the slight deviation of the apex of the heart to the left side is reflected in a depression in the medial surface of the inferior lobe of the left lung, which is called the _________________

A

cardiac notch

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14
Q

the ________________ is what divides the heart into chambers

A

septum

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15
Q

the septum of the heart are physical extensions of the ________________ lined with ____________

A

myocardium; endocardium

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16
Q

what are the 3 different septums of the heart

A
  1. interatrial
  2. interventricular
  3. atrioventricular
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17
Q

which cardiac septum includes the valves?

A

atrioventricular

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18
Q

which cardiac septum divides eh heart horizontally

A

atrioventricular septum

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19
Q

in a normal adult heart the interarterial septum bears an oval shaped depression known as the _________________

A

fossa ovalis

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20
Q

the fossa ovalis is a remnant of an opening in the fetal heart known as the __________________

A

foramen ovale

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21
Q

what is the purpose of the foramen ovale in the fetal heart?

A

allows blood to pass directly from the right atrium to the left atrium, by passing the pulmonary circuit

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22
Q

after birth a flap of tissue known as the ________________ (which previously acted as a valve) closes the foramen ovale establishing typical cardiac circulation patterns

A

septum primum

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23
Q

which septum of the heart is the thickest?

A

interventricular

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24
Q

why is the interventricular septum thicker than the interatrial

A

ventricles generate far greater pressure when they contract than the atria

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25
Q

T/F: The interventricular septum has an opening during fetal development, which closes after birth

A

false; interventricular septum once formed remains in tact

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26
Q

the _________________ septum is marked by the presence of four openings that allow blood to move through the chambers

A

atrioventricular

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27
Q

valves between the atria and ventricles are called _________________ valves, and those leading to the pulmonary trunk and aorta are known collectively as _____________ vavles

A

atrioventricular; semilunar

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28
Q

the valves/openings of the atrioventricular septum structurally weaken the AV septum, therefore; the remaining tissue is heavily reinforced with dense connective tissue called ____________________

A

cardiac skeleton

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29
Q

what is the cardiac skeleton

A
  • 4 rings of dense connective tissue that surround the openings between the atria and ventricle and openings to the pulmonary trunk and aorta.
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30
Q

which valves are semilunar valves?

A

aortic and pulmonic

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31
Q

______________ valves operate passively with changes in pressure

A

semilunar (Aortic and pulmonic) - they open with RV/LV ejection

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32
Q

what are your AV valves

A

mitral and tricuspid

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33
Q

_______________ valves ensure unidirectional blood flow from the atria to the ventricles

A

AV valves (mitral and tricuspid)

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34
Q

all valves are ______________ leaflet, except _________________, which is __________ leaflet

A

tri; mitral; bi

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35
Q

pulmonic valve leaflets are identified by ________________

A

anatomic position

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36
Q

what are the leaflets of the pulmonic valve

A

right; left; anterior

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37
Q

aortic valve leaflets are identified r/t ____________________

A

coronary ostium

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38
Q

what are the leaflets of the aortic valve?

A
  1. right coronary cusp (attached to right coronary artery [ostium])
  2. left coronary cusp (attached to left coronary artery)
  3. non-coronary cusp (not attached to a coronary artery)
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39
Q

which valves are smaller and thicker?

A

semilunar (aortic and pulmonic)

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40
Q

which valves handle HIGH velocity

A

semilunar (aortic and pulmonary)

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41
Q

what is normal aortic valve area

A

3-4 cm^2

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42
Q

severe aortic stenosis is defined as a valve area < _________ cm^2

A

1

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43
Q

What is a possible congential heart defect of the aortic valve

A

bicuspid aortic valve defect

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44
Q

what are the leaflets of the tricuspid valve

A
  1. anterior
  2. posterior
  3. septal
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45
Q

what are the leaflets of the mitral valve

A
  1. anterior
  2. posterior
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46
Q

how are the leaflets of the mitral valve SUBdivided?

A

A1-3 & P1-3

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47
Q

on the mitral valve leaflets A1/P1 are ____________ side and A3/P3 are ___________ side

A

lateral; medial

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48
Q

with a ______________ MI you can have a chordae tendineae rupture

A

transmural

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49
Q

what are the small fibrous strings which attach from the AV valves to the papillary muscles

A

chordae tendineae

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50
Q

which valves are described as: large, thin, and filmy?

A

AV valves

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51
Q

normal valve area of the tricuspid valve

A

7 cm^2

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52
Q

tricuspid stenosis occurs when valve area is < _________ cm^2

A

1.5

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53
Q

normal valve area of the mitral valve

A

4-6 cm^2

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54
Q

mitral valve stenosis occurs when valve area is < ______________ cm^2

A

2

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55
Q

what is the function of the papillary muscle?

A

keeps valves from prolapsing backward into the atria

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56
Q

ruptured chordae tendineae (esp with mitral valve) causes what

A

pulmonary edema

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57
Q

when an AV valve is OPEN: the chordae tendineae is _____________ and the papillary muscles are _______________

A

slack; relaxed

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58
Q

when the AV valve is CLOSED: the chordae tendineae is _____________ and the papillary muscles are _______________

A

taut; contracted

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59
Q

what is the leading cause of aortic valve regurgitation in younger (peds) patients?

A

bicuspid aortic valve (CHD)

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60
Q

coronary ostia is in the ________________________

A

sinus of valsalva

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61
Q

_______________ is when valve opening narrows and restricts blood flow

A

stenosis

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62
Q

_______________ is when blood leaks backwards through a valve d/t incomplete closure

A

regurgitation

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63
Q

________________ is when valve leaflets do not close smoothly; they buldge upward into the atrium

A

prolapse

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64
Q

what are the common causes of valvular dz

A
  1. endocarditis
  2. rheumatic fever
  3. congenital defects (bicuspid AV)
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65
Q

if your valve is stenotic, you will have a ______________ gradient

A

higher

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66
Q

what is valve gradient

A

the difference in pressures on each side of the valve

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67
Q

severity of regurgitation is reported on a ______________ scale

A

0 - 4+

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68
Q

right dominant is when the posterior descending artery (PDA) is supplied from the __________, and “left dominant” is when the PDA is supplied from the _________________

A

right coronary artery; left circumflex

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69
Q

in reference to the posterior descending artery, what percentage of the population is “right dominant” and what percentage is “left dominant”

A

85% = right

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70
Q

if there is a left main coronary artery occlusion in a left dominant heart, you will lose circulation and oxygenation to which walls of the heart?

A

anterior, lateral, AND posterior

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71
Q

the right coronary artery orginates at the ___________________

A

right aortic sinus

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72
Q

___________ arteries arise off of the PDA

A

septals

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73
Q

the PDA supplies the:

A
  1. inferior wall of the heart
  2. cardiac septum
  3. posteriormedial papillary muscle
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74
Q

the anterior right ventricle is supplied by what artery?

A

the right ventricular branches (i.e. acute marginal) - which branch off the RCA

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75
Q

in 60% of people blood to the SA node is supplied via

A

sinus node artery which branches off the RCA

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76
Q

in most people, if they have an infarction of the ____________ artery; they will lose automaticity of the SA node

A

right coronary

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77
Q

the right coronary artery (RCA) supplies ________-____% of blood supply to the left ventricle

A

25-35

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78
Q

which coronary artery is described as the “widow maker”

A

left coronary artery

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79
Q

branches of the left coronary artery

A
  1. left anterior descending (LAD) - (aka anterior interventricular branch)
  2. left circumflex
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80
Q

the __________________ artery comes off the left main and travels down the interventricular groove to the apex

A

LAD (aka anterior interventricular branch)

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81
Q

____________ and ___________ arteries branch off the LAD and supply the lateral wall of the LV

A

septals and diagonals

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82
Q

30% of the population has an arterial branch off the LAD that looks like the 1st diagonal. This artery is called ____________________

A

ramus intermedius

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83
Q

the LAD provides blood supply for ______-______% of the LV

A

45-55

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84
Q

which arteries provide blood supply to the left ventricle (list from greatest supply to least)

A

LAD > RCA > left circumflex

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85
Q

which coronary artery travels downward and left through the AV groove

A

left circumflex artery

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86
Q

which artery supplies the posteriolateral portion of the left ventricle

A

left circumflex

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87
Q

in about 38% of the population the SA node blood supply originates from the ________________

A

left circumflex artery

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88
Q

the left circumflex artery (in right dominant heart) provides ___ -____% of blood supply to the left ventricle. in the left dominant heart, the left circumflex artery supplies about _______% of blood supply to the left ventricle

A

15; 25; 50

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89
Q

a left main artery occlusion would have EKG changes in what leads

A

V1-V6 (entire left ventricle

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90
Q

LAD occlusion would have EKG changes in what leads

A

V1-V4 (anterior LV)

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91
Q

circumflex occlusion would have EKG changes in what leads

A

I, aVL, V5, V6 (lateral)

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92
Q

RCA occlusion would have EKG changes in what leads

A

II, III, aVF (RV, posterior LV)

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93
Q

T/F: coronary circulation is continuous

A

false; it cycles

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94
Q

coronary circulation peaks during __________ and ceases during ____________

A

diastole; systole

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95
Q

what are the surface arteries of the heart that are most superficial and follow the sulci

A

epicardial arteries

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96
Q

there are _______ dilations in the wallof the aorta just superior to the aortic valve. 2 of these dilations give rise to the ___________________

A

3; 1 to the left coronary artery and 1 to the right coronary artery

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97
Q

what vein initially runs parallel with the LAD but eventually runs to the posterior side of the heart (with the circumflex)

A

great cardiac vein

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98
Q

what coronary vein runs parallel with the left marginal artery (branch of circumflex)

A

posterior cardiac vein

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99
Q

which coronary vein runs parallel with the PDA

A

middle cardiac vein

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100
Q

which vein parallels the right coronary artery and drains blood from the posterior surfaces of the right atrium and ventricle

A

small cardiac vein

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101
Q

what coronary vein parallels the small cardiac arteries and drains the anterior surface of the right ventricle

A

anterior cardiac veins

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102
Q

which coronary vein bypasses the coronary sinus and drains directly into the right atrium

A

anterior cardiac vein

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103
Q

coronary veins drain into the ___________, which empties directly into the right atrium

A

coronary sinus

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104
Q

describe the flow of blood through the coronary vasculature

A

aorta –> coronary arteries –> epicardium –> endocardium –> coronary veins –> coronary sinus –> R. atrium

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105
Q

there is a small amount of venous return to the heart from bronchial circulation through the ___________ veins; this acts as a physiological shunt

A

thesbian

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106
Q

what is normal coronary sinus SVO2

A

35% (meaning large O2 extraction with little reserve in times of ischemia

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107
Q

T/F: there is blood flow to the epicardium during the entire cardiac cycle (systole and diastole)

A

TRUE

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108
Q

blood flow to the _________________ layer of the heart occurs mainly during diastole making it the most vulnerable to ischemia

A

endocardium

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109
Q

which muscle layer of the heart is the most vulnerable to ischemia

A

endocardium

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110
Q

at rest, ________% of CO passes through the coronaries

A

4-5 (225mL/min)

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111
Q

what layer of the heart extracts 65-70% of the DO2 (delivered O2)?

A

myocardium

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112
Q

formula for coronary perfusion pressure

A

CPP = ADBP - LVEDP

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113
Q

what is a normal CPP

A

15-70 mmHg

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114
Q

what is a normal LVEDP

A

12-15 mmHg

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115
Q

coronary blood parallels what?

A

myocardial metabolic demand

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116
Q

hypoxia causes the coronaries to ____________

A

vasodilate (to increase supply of O2 to the heart)

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117
Q

volatile anesthetic gases cause the coronary artery ___________________

A

vasodilation (may enhance recovery of stunned myocardium)

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118
Q

according to Coronary STEAL, when SVR is low 2/2 dilation what is happening in the coronaries?

A

decreased flow to the coronaries

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119
Q

what is the chief cell type in the heart

A

cardiomyocyte

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120
Q

______________ cells are primarily involved in the contractile fuction of the heart

A

cardiomyocytes

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121
Q

each myocardial cell contains ____________ which are specialized organelles consisting of long chains of _____________

A

myofibrils; sarcomeres

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122
Q

what are the fundamental contractile units of muscle cells

A

sarcomeres

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123
Q

T/F: cardiomyocytes are highly resistant to fatigue

A

TRUE

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124
Q

a sarcomere bundle contains what?

A
  1. myosin
  2. tropomyosin-actin-troponin complex
  3. z-disc
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125
Q

when a cardiac action potential is generated calcium moves into the cell causing the ___________________ to release more calcium (inside the cell) –> interaction with troponin tropomyosin complex to initiate cardiac contraction

A

sarcoplasmic reticulum

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126
Q

Calcium-induced calcium release (CICR)

A

The movement of Ca2+ through the plasma membrane, including the membranes of the T tubules, into cardiac muscle cells stimulates the release of Ca2+ from the sarcoplasmic reticulum –> cardiac muscle contraction

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127
Q

for a cardiac myocyte to relax, what has to happen?

A

Calcium has to be actively transported back into the SR across cellular membrane (requires energy and O2)

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128
Q

when calcium is released from the SR how does this lead to muscle contraction of the cardiac myocyte

A

calcium binds to troponin –> conformational change of tropomyosin exposing the active binding site –> interaction with actin and myosin –> contraction

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129
Q

T/F: ATP and O2 are required for both relaxation and contraction of the cardiomyocyte

A

TRUE

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130
Q

what is the ideal sarcomere length

A

1.8 - 2.2 um

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131
Q

actual sarcomere size is dependent on ______________

A

preload

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132
Q

_____________ sarcomeres end-to-end comprise a myocyte

A

6

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133
Q

what is between myocytes to prevent overstretching and damage and allow them to move as “one”

A

collagen

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134
Q

in a cardiac myocyte cell, what is the function of the intercalated discs

A

they create gap junctions –> increased spread of depolarization –> cardiac muscle contracting in sync

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135
Q

__________% of ATP in the cardiac myocyte is used for myosin linking

A

75

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136
Q

_________________ is an internodal pathway that connects the right and left atrium allowing them to contract at the same time

A

Bachmann’s Bundle

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137
Q

Describe the normal electrical conduction flow of the heart

A

SA –> AV –> Bundle of His –> L/R Bundle branches –> purkinje fibers

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138
Q

the __________________________ prevents atrial depolarization from entering into the ventricular tissue

A

fibrous cardiac skeleton

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139
Q

depolarization rate of SA node is _________; however, ANS innervation brings it down to about ____________

A

90; 60-70

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140
Q

how is action potential of the SA node generated?

A

spontaneously

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141
Q

what is described as the pacemaker of the heart

A

SA node

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142
Q

phases of the Pacemaker (SA) action potential

A
  1. phase 4 - spontaneous depolarization to threshold (-30 mV) (K efflux and Na influx) from resting membrane potential (-60mV) - slow- Na influx
  2. phase 0 - slow depolarization d/t calcium influx (L-type)
  3. phase 3 - repolarization d/t K efflux
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143
Q

electrical conduction from SA to AV node rests for ________________ seconds before AV node is depolarized

A

0.1 - 0.13

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144
Q

the pause of electrical depolarization at the AV node allows for what

A

filling of chambers and coordinated contraction btwn atria and ventricle

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145
Q

AV node depolarizes at ________________

A

40-60 bpm

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146
Q

if AV node becomes primary pacemaker, what type of rhythm will you see on EKG

A

junctional rhythm (40-60 bpm; no p waves bc atria are not depolarizing)

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147
Q

His-Purkinje fibers depolarize at __________ bpm

A

20-40

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148
Q

the Fastest conduction velocity in the heart is performed by….

A

His-Purkinje (longest to travel but does so the fastest in sync)

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149
Q

what is the final backup in the event of SA and AV node failure

A

His-Purkinje system

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150
Q

what type of rhythm will you see if His-Purkinje system is the pacemaker

A

agonal rhythm

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151
Q

Anesthetic gases effect on SA nodal activity

A

depresses SA nodal automaticity and contractility

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152
Q

what is the mechanism on how volatile anesthetic gases depress contractility?

A

they decrease the entry of calcium into cells during deopolarization

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153
Q

phases of ventricular action potential

A
  1. phase 0: rapid depolarization (Na influx)
  2. Phase 1: intial repolarization (Na channels close)
  3. phase 2: plateau (calcium influx)
  4. phase 3: repolarization (K efflux)
  5. phase 4: Na-K pump restores restiming membrane potential
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154
Q

what is resting membrane potential of the ventricular action potential

A

-90 mV

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155
Q

phase 2 (plateau) ventricular action potential allows time for __________ contraction, and prevents _____________

A

ventricular; tetany

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156
Q

duration of Action potential in atrial muscle __________ s; duration of action potential in ventricular muscle ________ s

A

0.2; 0.3

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157
Q

________________ time is relatively fixed in duration, therefore at times of high heart rate ________________ time is sacrificed

A

systole; diastole

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158
Q

tachycardia decreases _________________ & _________________

A

ventricular filling and coronary filling

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159
Q

describe the process of excitation-contraction coupling in the cardiac cell

A
  1. Calcium from plateau phase of action potential enters the cell at the via DHP receptor
  2. calcium triggers the RYR receptor of the SR to release calcium (calcium induced calcium release)
  3. calcium binding to troponin –> conformational change of tropomyosin exposing the active site –> contraction
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160
Q

_________ % of ATP is used for Calcium transport into the SR at muscle relaxation

A

25

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161
Q

describe the process of when cardiac muscle completes contraction and is resting/relax

A
  1. calcium release from troponin and some is actively transported via atp back into SR ; other Calcium is actively pumped out of the cell via the Na/Ca exchanger (which requires ATP, K, Na pump)
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162
Q

how do PDE inhibitors (like milrinone) effect contractility of the heart?

A

prevents the breakdown of intracellular calcium –> increased contraction

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163
Q

how does digitalis affect contractility of the heart?

A

blocks the Na-K-ATPase which indirectly inhibits the Na/Ca exchanger, increasing intracellular calcium –> increased contraction

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164
Q

how does glucagon affect contractility of the heart

A

increases intracellular cAMP –> increases intracellular calcium –> enhances contractility

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165
Q

how does acidosis affect the contractility of the heart

A

slows calcium channels, slows contractility

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166
Q

how does N2O affect contractility of the heart

A

reduces the availability of intracellular calcium –> decreasing contractility

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167
Q

sympathetic innervation of the heart orginiates from _____________ and travels through the ________________

A

T1-T4; stellate ganglion

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168
Q

if you do a spinal block above T1, what cardiac effects would you expect to see

A

bradycardia and Hotn (block SNS innervation to heart)

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169
Q

B1 activation in the heart –> increased activation of ___________ –> ___________, which opens more ________ channels

A

cAMP; Ca; Ca

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170
Q

B1 activation of the heart causes positive ______________, ______________, and ____________ response

A

chronotropy; dromotropy; ionotropy

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171
Q

________________ innervation is widely distributed throughout the heart, but __________________ innervation is only present in atria and conduction tissues

A

SNS; PNS

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172
Q

muscarinic activation in the heart causes negative _______________, ____________, and ______________ response

A

chronotropic; dromotropic; ionotropic

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173
Q

T/F: parasympathetic innervation can decrease CO to nearly zero (esp in peds)

A

TRUE

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174
Q

SNS and PNS effects ________________ time between action potentials

A

latency (does not actually change the action potential)

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175
Q

SNS response on the heart increases _____________ via ________________

A

automaticity; NE

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176
Q

PNS response on the heart decreases _______________ via ____________

A

automaticity; Ach

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177
Q

SNS/PNS innervation on cardiac action potential is primarily d/t effects on ____________ and ___________ INFLUX

A

sodium; calcium

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178
Q

________________ from closure of mitral valve to closure of aortic valve

A

systole

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179
Q

isovolumic contraction occurs during ________________, and isovolumic relaxation occurs during _______________

A

systole; diastole

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180
Q

T/F: diastole is an energy requiring process

A

TRUE

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181
Q

during an isovolumetric contraction, how does pressure differ between atria, ventricle, and Ao (place from highest pressure to lowest)

A

AoP > LVP > LAP

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182
Q

describe the process of systolic ejection

A

LVP > AoP –> rapid ejection, then slow ejection

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183
Q

diastasis = _______________

A

passive filling

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184
Q

rapid filling =

A

suction of blood through open MV

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185
Q

atrial systole provides _______% of ventricular filling in normal pt; and ____% of filling in htn/AS pts

A

20; 40

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186
Q

EDPVR (end diastolic pressure volume relationship) refers to _____________, which is also ______________

A

compliance (stiffness); preload

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187
Q

ESPVR (end systolic pressure volume relationship) gives you ________________

A

contractility

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188
Q

if the EDPVR line is increased from baseline (higher on graph) what does this mean?

A

decreased compliance; decreased preload (i.e. filling) - diastolic HF

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189
Q

if your slope of your ESPVR is steeper than baseline; what does this mean

A

contractility is increased

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190
Q

how do you calculate stroke volume from a pressure volume loop

A

EDV - ESV

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191
Q

how do you calculate EF from a pressure volume loop?

A

SV / EDV

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192
Q
  1. S1 and S2 heart sounds
A

refer to hand out for checking answers

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193
Q

if your preload is increased, what parts of your pressure volume loop would also be effected?

A

increased EDV, LVEDP, SBP/DBP, and SV

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194
Q

independent effects on pressure volume loop of increase afterload

A
  1. isovolumic contraction is prolonged (d/t increased aortic pressure)
  2. smaller SV
  3. increased ESV
  4. increased SBP/DBP
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195
Q

independent effects of increased inotropy on the pressure volume loop

A
  1. increased SV and EF
  2. decreased ESV
  3. increased slope of ESPVR
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196
Q

CO = ____________x _________

A

HR; SV

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197
Q

ventricular systolic function is equated with ________________

A

CO

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198
Q

what is normal CO

A

4-6 L/min

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199
Q

what is the formula for CI

A

CO/BSA

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200
Q

what is normal CI

A

2.5- 4.2 L/min/m2

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201
Q

manipulation of HR will directly affect ____________

A

CO

202
Q

__________ is an intrinsic fx of the SA node, but is affected by ANS, humoral and local factors

A

HR

203
Q

T/F: HR decreases with age

A

true (r/t sns outflow

204
Q

what are the main determinants of SV

A

preload, afterload, and contractility

205
Q

________________ IS end diastolic volume (EDV) which is dependent on ________________

A

preload; ventricular filling

206
Q

T/F: typically the heart pumps all the blood returned to it

A

TRUE

207
Q

what is the primary determinant of preload

A

venous return

208
Q

if you the heart more volume (preload) you _____________ the blood returned to the heart

A

increase

209
Q

if you have too much preload (i.e. overdistension) what is the consequence

A

the heart cannot deliver a contraction that is strong enough (d/t sarcomeres being pulled too far apart)

210
Q

when HR is constant ____________ is directly proportional to preload in both the right and left heart

A

CO

211
Q

increase HR causes ___________ in diastolic time and impairs ______________

A

decrease; filling

212
Q

T/F: LV output is higher than RV output over time

A

false; RV and LV outputs should be equal

213
Q

venous compliance is _______x higher than arteriole

A

10

214
Q

75% of blood resides in the ___________ (arteries or veins?)

A

veins - why venous compliance is 10x higher than arteriole

215
Q

what is the bainbridge reflex

A

rise in atrial volume (gives increase in atrial pressure) causes the HR to increase by 10-20%

216
Q

T/F: an empty heart cannot pump blood

A

TRUE

217
Q

factors that can affect preload

A
  1. intrathoracic pressure (PPV, thoracotomy)
  2. positioning during surgery (t-burg)
  3. pericardial pressure (pericardial dz/tamponade)
  4. loss of atrial systole
218
Q

_______________ establishes the length of each myocyte immediately before isovolumic contraction

A

preload

219
Q

_____________ is what pulls the sarcomeres apart

A

preload

220
Q

the steep part of the EDPVR line on a pressure volume loop represents what

A

preload reserve

221
Q

as preload reserve increases ______________ increases but at slower rate for any given increase in pressure

A

SV

222
Q

once preload reserve (steepest slope of EDPVR) - is steep ____________ cannot increase anymore to compensate; this means _______________ is exhausted

A

SV; preload reserve

223
Q

_______________ is the load opposing the shortening of muscle fibers (i.e. what the heart is pumping against)

A

afterload

224
Q

what are the factors that influence afterload

A
  1. ventricular wall tension (law of laplace: T (tension) = pressure x radius)
  2. Arterial impedance to rejection: HTN, arteriosclerosis, SVR, PVR
  3. physical properties of blood vessels and/or blood viscosity
225
Q

formula for SVR

A

80 x (MAP-CVP)/CO

226
Q

what is a normal SVR

A

900 - 1500 dynes/sec/cm-5

227
Q

formula for PVR

A

80 x (mPAP - PWAP/CO)

228
Q

normal PVR

A

50-150 dyn · s cm-5

229
Q

formula for compliance

A

change in volume/change in pressure

230
Q

CO and SV are ________________ related to afterload

A

inversely

231
Q

which ventricle is more sensitive to afterload? why?

A

RV more sensitive; bc LV has 6x muscle mass than RV allowing it to withstand changes in afterload

232
Q

Failing hearts are sensitive to changes in _________________

A

afterload

233
Q

with LVF _______________ can greatly improve stroke volume

A

vasodilators

234
Q

T/F: contractility is independent of preload and afterload

A

TRUE

235
Q

what is the most important factor that can alter contractility

A

calcium concentration

236
Q

formula for contractility (i.e. elastance) =

A

pressure/volume

237
Q

contractility is dependent on the ______________ environment

A

chemical

238
Q

factors that affect contractility

A
  1. calcium concentration (primary)
  2. Mg
  3. O2
  4. acidosis
239
Q

methods to assess ventricular function

A
  1. frank starling curves (SV/EDV)
  2. pressure volume curves
  3. systolic fx (change in pressure/change in time)
  4. EF = (EDV-ESV)/EDV
  5. diastolic function via TEE measuring flow over MV during diastole
240
Q

what is a normal EF

A

68%

241
Q

what is the most accurate method to assess cardiac function?

A

TEE

242
Q

what is the most commonly used monitoring method to assess the CV system

A

blood pressure

243
Q

what is the gold standard for CV pressure monitoring

A

intra-arterial BP

244
Q

what is the vessel of choice for placing an arterial line

A

Radial artery

245
Q

why is the right radial artery the site of choice for Aline placement in cases of chest trauma

A

cross clamping of descending aorta can occlude l-subclavian artery

246
Q

which artery provides the majority of blood flow to the hand in 90% of humans

A

ulnar, why it is not the preferred choice for ABP

247
Q

using the allens test, you know the artery is sufficient to cannulate for ABP if the refill is ________________s

A

5-10

248
Q

when doing an allens test, if refill is greater than _________ s you know that site is NOT appropriate to cannulate for ABP

A

15

249
Q

_____________ is the change in the amount of blood ejected from the heart each beat

A

Stroke volume variation (SVV)

250
Q

_____________ is a number that can be obtained from a vigileo, and helps guide fluid resusitation

A

SVV

251
Q

if your SVV is > ________% it is appropriate to fluid challenge your pt

A

13

252
Q

Factors that influence your site choice for ABP monitoring

A
  1. site of surgery
  2. position of patient (decreased flow to certain areas)
  3. hx of ischemia in limb prior to surgery
  4. previous cutdowns or arterial harvests
  5. dz processes (DM, PVD, raynauds)
253
Q

contraindications to Aline placement

A
  1. infection
  2. coagulopathy
  3. proximal occlusion
  4. Raynauds (for certain sites)
254
Q

if a patient has raynauds what site would be appropriate of aline placement

A

femoral or axillary; larger and have less risk for spasm/ischemia

255
Q

considerations with brachial artery for ABP placement

A
  1. large artery, more proximal
  2. decreased chance for compromised circulation
  3. catheter easily kinked with patient movement
256
Q

considerations of axillary artery for ABP placement

A
  1. nerves are close in proximity and risk for damage
  2. increased risk of hematoma (decreased ability to compress area)
257
Q

if the axillary artery is used for a line placement what side should it be placed on to reduce risk of cerebral emboli

A

left

258
Q

considerations for femoral a line placement

A
  1. high risk of infection
  2. risk of pseudoaneurysm formation
  3. not desirable site if pt has PVD
259
Q

T/F: collateral circulation exists in the foot with the dorsalis pedis artery just like with the hand

A

TRUE

260
Q

if use the dorsalis pedis for a line placement, the SBP will be ____________ mmHg higher, and the DBP will be _____________ mmHg lower

A

10-20 mmHg; 15-20 mmHg

261
Q

which arterial cannulation site for aline placement has a high incidence of failure

A

dorsalis pedis

262
Q

complications with aline placement

A
  1. infection
  2. thrombosis and distal ischemia
  3. hemorrhage
  4. skin necrosis
  5. emboli
  6. hematoma
  7. nerve injury
  8. inaccurate pressure measurements
263
Q

_________________ measures filling pressures of the right ventricle and gives assessment of intravascular volume and RV fx

A

CVP

264
Q

where does the distal tip of a CVP sit?

A

either in one of the large intrathoracic veins or in the RV

265
Q

what can increase CVP?

A
  1. heart failure
  2. blood volume increase
  3. venoconstriction
266
Q

sites for CVP

A
  1. IJ
  2. EJ
  3. Subclavian
  4. Antecubital vein
  5. femoral
267
Q

indication for measuring CVP

A

assessing fluid volume status

268
Q

accuracy and reliability of CVP is dependent on what factors?

A

LV and RV fx

269
Q

the A wave on a CVP waveform represents what

A

atrial contraction (causes rise in atrial pressure)

270
Q

when would you expect to lose your A wave on your CVP tracing

A

afib/aflutter

271
Q

what does the C wave on your CVP tracing represent

A

tricuspid valve closure (and bulge into right atrium causing increased atrial pressure)

272
Q

T/F: C wave should always be present on your CVP tracing

A

FALSE

273
Q

what does the x descent on a CVP waveform represent

A

atrial relaxation

274
Q

what does the v wave on the CVP waveform represent

A

refilling of atrium (increasing atrial pressure) during ventricular contraction

275
Q

what does the Y wave represent on the CVP waveform tracing

A

atrial emptying/early ventricular filling d/t tricuspid opening in early ventricular diastole

276
Q

what are some absolute contraindications to CVP

A
  1. superior vena cava syndrome
  2. obstruction in the SVC
277
Q

what are some relative contraindications to CVP (not absolute, weight pros and cons)

A
  1. infection
  2. coagulopathy
  3. newly inserted pacer wires (wait 4-8 wks)
  4. past carotid endarectomy or needed carotid endarectomy
278
Q

complications with inserting CVC

A
  1. arterial puncture
  2. hemothorax
  3. pneumothorax
  4. pericardial effusion/tamponade
  5. embolism
  6. nerve injury
  7. arrhythmias
279
Q

what nerves are at risk for injury during CVC placement

A
  1. brachial plexus
  2. stellate ganglion
  3. phrenic
280
Q

pneumothorax 2/2 CVC placement occurs most commonly with what stie

A

subclavian

281
Q

what is the purpose of pulmonary arterial pressure monitoring

A

estimate the pressures on the left side of the heart

282
Q

what is normal PCWP

A

10-12 mmHg

283
Q

normal CVP

A

8-10 mmHg

284
Q

normal PAP

A

15-30/5-15

285
Q

PAP systolic and diastolic numbers reflect the pressures where?

A

inside the lungs

286
Q

low PAP most likely indicates ______________; high most likely indicates ___________________

A

hypovolemia; hypervolemia

287
Q

if your PAP numbers are 50-60/30s what would you suspect?

A

pulmonary HTN

288
Q

with cardiogenic shock; SVR is ______________ and CO is _____________

A

high; low

289
Q

PCWP estimates _____________ and ____________

A

left atrial pressures (LAP); LVEDP

290
Q

what are some factors that alter the accuracy of PCWP numbers

A
  1. PVD
  2. MV dz
  3. PEEP
291
Q

ideal placement of the PA catheter when measuring PCWP is in __________________

A

west lung zone III

292
Q

if your PA catheter is in lung zone 1 or 2 when shooting a PCWP, what does this represent?

A

reflects the alveolar pressures instead of the LAP

293
Q

distance to the right atrium from:
1. Subclavian vein = __________
2. right EJ = ______________
3. right IJ = _____________
4. Femoral = _______________

A
  1. 10 cm
  2. 10-15 cm
  3. 15-20 cm
  4. 25-40 cm
294
Q

absolute contraindications to placing a PA catheter

A
  1. tricuspid or pulmonic valvular stenosis
  2. RA/RV mass (tumor)
  3. tetralogy of Fallot
295
Q

what are some relative (not absolute) contraindications to placing a PA catheter (weight risk vs benefit)

A
  1. severe arrhythmias (LBBB, heart block)
  2. coagulopathy
  3. newly inserted pacer wires
296
Q

if you place a PA catheter in a pt with a LBBB, this could lead to ____________; so you should have _____________ readily available

A

RBBB (ultimately causing a now complete heart block) ; external pacer

297
Q

complications of placing a PA catheter

A
  1. arrhythmias
  2. endobronchial hemorrhage
  3. pulmonary infarction
  4. catheter knotting/entrapment
  5. valvular dammage
  6. thrombocytopenia
  7. thrombus formation
  8. balloon rupture
298
Q

risk factors for endobronchial hemorrhage with PA catheter placement

A
  1. elderly
  2. female
  3. pulmonary HTN
  4. mitral stenosis
  5. coagulopathy
  6. distal placement of catheter
  7. balloon hyperinflation
299
Q

if you have a PA catheter in, and your patient is about to undergo hypothermic cardiopulmonary bypass, what should you do?

A

pull the catheter back, for hypothermia can cause stiffening and migration of catheter

300
Q

if you inflate your balloon to shoot a PCWP, and you start to see bright red blood in the ETT what do you suspect has happened

A

endobronchial hemorrhage 2/2 inflating the balloon inside the distal Pulmonary artery

301
Q

inflating the balloon (to shoot PCWP) inside the distal PA has a mortality risk of _____________

A

50-70%

302
Q

what is the normal range of SVO2

A

60-80%

303
Q

formula for cardiac resting energy expenditure (REE) =

A

CO x hgb x (SaO2 - SVO2) x 95.18

304
Q

how is SvO2 calculated

A

from differential absorptionof various wavelengths of light by saturated and desaturated Hgb

305
Q

according to Ficks equation, changes in SvO2 should reflect changes in ______________

A

CO

306
Q

causes of decreased SvO2

A
  1. anemia
  2. hypoxemia
  3. decreased CO
307
Q

causes of increased SvO2

A
  1. shunting
  2. intracardiac VSD
  3. left shift of oxyhbg curve
  4. cell death
  5. sepsis
308
Q

SvO2 < _____________ is treated

A

50%

309
Q

use of an intraaortic balloon pump

A
  1. perfuse coronary arteries with ischemia
    2.tx of shock (at least one of the following malfx: contractility, preload, afterload)
310
Q

how does an IABP aid in decreasing afterload

A

when you deflate balloon at beginning of systole –> lower pressure in aorta –> blood being sucked out of LV (aids LV emptying)

311
Q

with an IABP balloon is inflated at ____________ and deflated at ____________

A

diastole; end-diastole (beginning of systole)

312
Q

how do you know your IABP is working in reducing your afterload?

A

blood pressure (systolic) is coming up and are able to wean gtts (like dobutamine)

313
Q

inflation of IABP at beginning diastole causes what

A

back pressure along aortic arch (bc the aortic valve is closed) which causes filling of the coronaries and diastolic pressure to increase

314
Q

how do you know your intra-aortic balloon pump is working in tx ischemic coronary arteries

A

when chest pain goes away

315
Q

with IABP the balloon is filled with _______________

A

helium

316
Q

why is the IABP filled with helium

A

it has lower density and is easier to push and pull in and out of the balloon

317
Q

the IABP is typically filled to what inflation volume ________ cc

A

40

318
Q

IABP decreases workload of the heart, ____________ ventricular performance (SV), and ______________ myocardial perfusion

A

increases; increases

319
Q

contraindications to IABP

A
  1. aortic aneurysm
  2. aortic insufficiency
  3. PVD (unable to cannulate the femoral artery without ischemia to limbs)
  4. non-viable myocardium and non-transplantable pt
320
Q

the IABP is distal to the ________________ and superior to the __________________

A

left subclavian artery; renal arteries

321
Q

the IABP uses the __________________ to trigger and is inflated following closure of the _____________ and deflated just prior to _____________

A

R wave ECG; aortic valve; systole

322
Q

with inflation of a 40 mL IABP, __________ mL of blood is dispaced to cerebral and coronary perfusion

A

10-30

323
Q

T/F: IABP forward displacment of blood improves renal, mesenteric and systemic blood flow

A

TRUE

324
Q

________________ is a pacer where a pacing wire is threaded down the jugular vein with an introducer where it makes contact with the RV, and wire is attached to generator box

A

transvenous

325
Q

_______________ pacers use external pacing pads connected to device

A

transcutaneous

326
Q

_______________ pacers use epicardial wires inserted during surgery and the leads go outside of the chest to a control box

A

transthoracic

327
Q

pacers essentially do 2 things, what are they?

A
  1. sense (the electrical activity of the heart)
  2. send out electrical signals
328
Q

what is pacer signal amplitude

A

how much “juice” the box puts through the wire with every pulse (measured in mA)

329
Q

what is pacer pulse width

A

how long each pulse lastws

330
Q

what is pacer capture threshold

A

minimum amount of electricity (mA) the box has to emit to pace the heart

331
Q

a _____________ pacemaker is a control box and a single output wire that leads to the inner wall (v wire)

A

temporary

332
Q

which pacer providers simple rate control by pacing the ventricles

A

temporary pacer

333
Q

describe permanent pacers

A
  1. some have 1 wire leading ot RV
  2. some have 2 wires leading to RA and RV
334
Q

indications for a pacemaker

A
  1. complete heart block
  2. symptomatic bradycardia
  3. CHF
  4. Asystole > 3 s
  5. arrhythmia suppression
  6. CAD
  7. valvular heart disease
  8. cacification of conduction system
  9. 2nd Degree AVB
  10. MI
  11. Sick sinus syndrome
335
Q

pacers are identified by three letter acronyms:
1st letter = _______________
2nd letter = _______________
3rd letter = __________________

A

chamber paced; chamber sensed; response pacer makes to a sensed intrinsic beat

336
Q

what is a DDD pacer

A

dual paced (A + V); Dual sensed (A + V); Dual pacing response (trigger and inhibited)

337
Q

permanent pacemakers also have 4th and 5th letters, what do these represent?

A

4th = programmability
5th = arrhythmia control

338
Q

AOO pacer

A

atrium paced, no chamber sensed; no chamber pacer response to sensed intrinsic beat

339
Q

Asynchronous pacing mode ______________ sensitivity of the box; synchronous pacing mode _____________ sensitivity of the box

A

decreases; increases

340
Q

which type of pacing mode has no sensing to detect intrinsic R waves, but can compete with pt HR and cause VT/VF

A

asynchronous

341
Q

which type of pacing mode detects the intrinsic heart depolarization causing the pacer to be either activated or inhibited

A

synchronous

342
Q

if your pacer is failing to capture, what should you do

A

increase the mA

343
Q

ventricular pacing increases ______________ by increasing ____________, but does not preserve _________________

A

CO; HR; atrial kick

344
Q

Atrial pacing CV effect

A

preserves atrial kick which can be very impt with heart failure pts

345
Q

when is AV sequential pacing tupically used?

A
  1. when atrium is not contracting but can with electrial stimulation
  2. when atria and ventricular contractions are dissociated
346
Q

anesthesia considerations for pt coming into surgery with pacer

A
  1. know what kind of pacer
  2. call rep and tell them pt is going to surgery
  3. have magnet in OR
  4. have external pacer unit on standby
347
Q

T/F: AICD can act as a pacer and defibrillator

A

TRUE

348
Q

if using a bovie in the OR and pt has a AICD what should you do

A

place magnet on pts chest to shut off cardioverter - still allows pacer to fx but will not pick up interference from bovie, thus will not give un-needed shock to pt

349
Q

how do you know if a temporary pacer is capturing

A
  1. check pulse
  2. check a line
  3. do not assume activity of the pacer on the monitor is generating a pulse
350
Q

with spontaneous breathing LV filling and SV is reduced during ______________; but with mechanical ventilation LV filling and SV is lower during _______________; (this is 2ndary to increase in intrathoracic pressure)

A

inspiration; expiration

351
Q

systolic blood pressure typically fluctuates with spontaneous breathing by about ______________ mmHg

A

5-10

352
Q

pulsus paradoxus is when systolic BP fluctuates with breathing by > ___________ mmHg

A

10

353
Q

___________________ occurs during controlled mechanical ventilation when arterial pressure rises during inspriation and falls during expiration 2/2 changes in intrathoracic pressure 2/2 PPV

A

reverse pulsus paradoxus

354
Q

with pulsus paradoxus (spontaneous breathing) SBP increases during _______________

A

expriation

355
Q

with reverse pulsus paradoxus (mechanical ventilation) SBP increases during __________________

A

inspiration

356
Q

formula for SVV

A

(SVmax - SVmin)/ SVmean over a respiratory cycle

357
Q

SVV > _______% suggests that the pt is fluid responsive as it indicates the SV is sensitive to fluctuations in preload 2/2 respiratory cycle

A

10

358
Q

formula for pulse pressure

A

SV / arterial compliance

359
Q

causes of increased SVV

A
  1. hypovolemia
  2. tamponade
  3. constrictive pericarditis
  4. LV dysfx
  5. massive PE
  6. bronchospasm
  7. dynamic hyperinflation
  8. pneumothorax
  9. raised intrathoracic pressure &/or intraabdominal pressure
360
Q

SVV > 10-13% what should you do?

A

fluid challenge

361
Q

SVV < 10% but SV is normal, what should your intervention be

A

pressors

362
Q

SVV < 10%, but SV is low, what is your intervention

A

inodilator

363
Q

SVV < 10% but SV is high what is your intervention

A

diuretic

364
Q

T/F: Swan and CVP monitors have been proven to improve outcomes

A

FALSE

365
Q

limitations to arterial based monitoring (flotrac, vigelio)

A
  1. pt must be intubated, sedated, paralyzed
  2. severe arrhythmias (do not get adequate information)
  3. have to have a pulse rate (IABP, ventricular assist device)
366
Q

cerebral oximetry is based on ____________ technology

A

near infared spectroscopy (NIRS)

367
Q

NIRS should be kept at least ____________% of baseline saturation

A

70-75

368
Q

NIRS should be placed ________________ forehead

A

midline

369
Q

what is rSO2

A

regional oxygen saturation; what the NIRS will typically be set to monitor

370
Q

if doing a “body” NIRS in peds, what type of O2 monitoring will you set the monitor to

A

regional cerebral tissue oxygen saturation (SctO2)

371
Q

healthy rSO2 on NIRS

A

58-82%

372
Q

intervention threshold for rSO2 number with NIRS monitoring

A

~20% from baselin

373
Q

Critical threshold for rSO2 number with NIRS monitoring

A

~25% from baseline

374
Q

interventions to improve Cerebral rSO2 (NIRS)

A
  1. rule out mechanical cause (head position, cannula position)
  2. increase supply (O2 delivery): increase CO, BP, DO2, PaCO2, Hgb/Hct
  3. decrease demand: increase anesthetic, decrease temperature
375
Q

_________________ is the leading cause of death in the US

A

coronary artery disease

376
Q

risk factors for CAD

A
  1. obese
  2. sedentary life style
  3. smoking
  4. HTN
  5. DM
377
Q

______________ is the most stressful event for the CV system

A

exercise

378
Q

during exercise CO can be increased by______________x 2/2 increased HR and contractility

A

2.5-7

379
Q

at rest the coronary sinus Po2 is __________

A

27%

380
Q

ischemia of the myocardium occurs when __________________ exceeds ______________

A

O2 demand; supply

381
Q

formula for O2 content of blood

A

hgb x 1.34 x SpO2 + (0.003 x PAO2)

382
Q

what is the normal O2 content of blood

A

20 mL / 100 mL

383
Q

what is the primary determinant of O2 content of blood

A

hgb

384
Q

coronary perfusion pressure is “autoregulated” btw ____________ - _______ mmHg

A

50-150

385
Q

CPP is completely dependent on ___________, if it is outside of the autoregulation pressure (50-150mmHg)

A

HR

386
Q

ways to optimize coronary perfusion pressure (CPP)

A
  1. normal to high ADBP
  2. Low LVEDP
  3. Low HR
387
Q

formula for Coronary blood flow

A

CBF = coronary perfusion pressure (CPP)/Coronary vascular resistance (CVR)

388
Q

normal Coronary blood flow value?

A

225-250

389
Q

what influences Coronary vascular resistance (CVR)

A
  1. metabolic factors
  2. ANS
  3. hormonal
  4. endothelial factors
  5. anatomic factors
  6. blood viscosity
390
Q

how does ANS influence coronary vascular resistance

A
  1. alpha-1 constriction, mainly epicardial arteries
  2. beta-1 dilation, mainly intramuscular arteries
391
Q

what metabolic factors influence coronary vascular resistance

A
  1. pH
  2. CO2
  3. lactate
  4. O2
  5. adenosine
392
Q

what hormones influence coronary vascular resistance

A
  1. vasopressin
  2. angiotensin
  3. prostacyclin
  4. TXA
393
Q

what anatomic factors influence coronary vascular resistance

A
  1. capillary recruitment
  2. collateral artery development.
394
Q

what increases Coronary vascular resistance

A
  1. increased O2
  2. decreased CO2
  3. increased pH
  4. increased alpha-adrenergic tone
  5. increased cholinergic tone
  6. increased vasopressin
  7. increased angiotensni
  8. increased TXA
395
Q

what decreases coronary vascular resistance

A
  1. decreased O2
  2. increased CO2
  3. decreased pH
  4. lactate
  5. adenosine
  6. increased Beta-adrenergic tone
  7. increased prostacyclin
  8. increased nitric oxide
  9. increased endothelium derived hyperpolarizing factor
  10. increased prostaglandin I2
396
Q

___________________ vessesl are already maximally dilated; therefore they cannot respond to increase in demand (and are most susceptible to ischemia)

A

subendocardial

397
Q

_______________ is the MOST susceptible to ischemia

A

subendocardium

398
Q

coronary stenosis ___________ CVR and __________ CBF

A

increase; decrease

399
Q

T/F: sequential lesions/plaques in the coronaries are additive

A

true; LAD + circ occlusion is a left main equivalency

400
Q

coronary blood flow is reduced with coronary stenosis based on ______________ law

A

poiseuilles

401
Q

if you have a 50% decrease in coronary diameter 2/2 stenotic lesion, that area of the heart is now only receiving _______________ of flow

A

1/16

402
Q

why do young individuals with an MI have worse outcomes than older individuals with MI

A

younger individuals have not developed collateral flow

403
Q

what are the 3 main determinants of myocardial oxygen consumption (MVO2)

A
  1. HR
  2. contractility
  3. wall stress
404
Q

formula for myocardial oxygen consumption (MVO2)

A

MVO2 = CBF - (CaO2 - CvO2)

405
Q

what is the MOST important determinant of myocardial oxygen demand

A

HR

406
Q

doubling the heart rate ___________________ the myocardial oxygen demand

A

more than doubles

407
Q

increased contractility causes ______________ myocardial oxygen demand

A

increased (d/t needing more energy and more O2)

408
Q

clinical measurement of contractility

A
  1. visually during open heart
  2. briskness of upstroke on arterial waveform tracing
  3. echocardiogram (*most accurate)
409
Q

cardiac wall stress is dependent on ________________, ________________, and ________________

A

afterload; chamber size (preload), and thickness

410
Q

what law helps explain wall stress

A

law of laplace: tension(wall stress) = (P x radius)/(2x wall thickness)

411
Q

MAP = _______________

A

MVO2

412
Q

doubling MAP, ________________ myocardial oxygen demand (MVO2)

A

doubles

413
Q

clinically to decrease myocardial O2 demand, what do you want to decrease?

A

SVR

414
Q

MVO2 is increased by an increase in…

A
  1. HR
  2. preload
  3. contractility
  4. afterload
  5. temperature
  6. hgb
415
Q

T/F: ECG is the least sensitive method for monitoring for myocardial ischmeia

A

TRUE

416
Q

ST depression = ______________, elevation = _________________

A

ischemia; infarction

417
Q

flattening or inversions of T waves indicate __________________

A

ischemia

418
Q

ST changes will occur on ECG ____________ after ischemia occurs

A

1-2 min

419
Q

what leads are the most sensitive for ischemia monitoring?

A

an inferior lead (II, III, or aVF) + V5

420
Q

_____________% of ischemic events are captured if an inferior lead (II, III, aVF) + V5 are used to monitor

A

90

421
Q

Sudden increase in PAP indicates what

A

decrease in cardiac function

422
Q

if there is a new onset of prominent V wave on PCWP waveform, this indicates what

A

papillary muscle dysfunction

423
Q

____________________ precedes ECG and PAP changes with myocardial ischemia

A

regional wall motion abnormalitiy (detected with TEE)

424
Q

gold standard for myocardial ischemia montioring

A

TEE

425
Q

_________________ monitoring assess preload, contractility, Reigonal wall motion abnormality, valvular fx, antatomy, and presence of pericardial effusion

A

TEE

426
Q

on TEE you see lack of movement of wall, this is called _________________

A

akinesis

427
Q

on TEE you see decreased regional wall movement, this is called _______________

A

hypokinesis

428
Q

on TEE you see paradoxical movement during systole this is called ____________________

A

dyskinesis

429
Q

dyskinesis is typically d/t __________________, and this is an emergency situation

A

ventricular aneurysm

430
Q

ideal induction agent for cardiac patients

A

etomidate

431
Q

ketamine effects on CV

A
  1. increase SVR
  2. increase preload
  3. increase contractility
  4. increase HR
432
Q

what is the perfect induction agent for a pt with cardiac tamponade

A

ketamine

433
Q

__________________ is not an ideal induction agent for pts with cardiac ischemia

A

ketamine; d/t increased MVO2

434
Q

propofol CV effects

A
  1. decrease BP
  2. Decrease SVR
  3. decrease contractility
435
Q

BZ effect on CV

A

minimal HD effects

436
Q

opioids effect on CV

A

decrease myocardial demand, without decreasing contractility

437
Q

CV effects of precedex

A

hypotension and bradycardia

438
Q

volatile anesthetics effects on MVO2

A
  1. all decrease contracility
  2. all decrease afterload
  3. minimal change in preload
  4. HR increase (esp with des)
  5. vasodilation of normal coronary vasculature decrease perfusion to ischemic areas
439
Q

which anesthetic gas is a very poor choice for pts in RV failure or pts with pulmonary HTN

A

nitrous oxide

440
Q

effects of nitrous oxide on MVO2

A

decreases contractility and increases PVR

441
Q

___________ HR, _______________ contractility, ________________ SVR, ______________Preload, & _____________ SNS stimulation

A

decrease; minimal effect, decrease, decrease, decrease

442
Q

succinylcholine effect on MVO2

A

bradycardia especially with repeated doses

443
Q

pancuronium effect on MVO2

A

increases HR by 20%

444
Q

how can you attenuate the increased HR (and thus increased MVO2) with pancuronium administration

A

high dose narcotics

445
Q

vecuronium and rocuronium effect on MVO2

A

minimal CV effect (thus minimal MVO2 effect)

446
Q

cisatracurium effect on MVO2

A

no CV effect (thus no MVO2 effect)

447
Q

what muscle relaxants are the best choice for cardiac cases

A

vec, roc, or nimbex

448
Q

treatments for CAD (surgical)

A
  1. angioplasty
  2. stents
  3. CABG
449
Q

what is “fast track” cardiac anesthesia

A
  1. driven by desire to reduce cost
  2. accomplished by better drug selection/dose, new surgical techniques, warmer bypass temps
  3. early extubation and hemostatic control = essential
450
Q

anesthetic approach for myocardial revascularization procedures

A
  1. fast track anesthesia
  2. ERAS cardiac
  3. off bypass revascularization
  4. MIDCAB, port access, redo CABG
451
Q

which heart failure is more common (systolic or diastolic)?

A

systolic

452
Q

systolic HF is more common in _____________________, where diastolic HF is more common in ________________

A

middle aged men (2/2 CAD); elderly women (2/2 obesity, htn, DM postmenopause)

453
Q

T/F: heart failure is primarily a disease of the elderly

A

TRUE

454
Q

T/F: HF spends more healthcare dollars than any other dz

A

TRUE

455
Q

most common cause of RV failure?

A

LV failure

456
Q

causes of systolic HF

A
  1. CAD
  2. Dilated CM
  3. chronic pressure overload (AS, HTN)
  4. chronic volume overload (valve insuff, high output failure)
457
Q

sx of systolic HF

A
  1. decreased EF
  2. ventricular dysrhythmias are common (risk of sudden death)
  3. S3 heart sound
458
Q

s/sx of diastolic HF

A
  1. normal EF, but sx of failure
  2. S4 heart sound
  3. increased LVEDP (classic sign)
459
Q

hallmark sign of systolic HF

A

decreased EF

460
Q

classic sign of diastolic HF

A

increased LVEDP

461
Q

which HF is age dependent? increased incidence in 50+; > 50% in those > 70 years of age

A

diastolic

462
Q

______________ HF is an inability to pump; where ______________ HF is an inability to fill

A

systolic; diastolic

463
Q

causes of diastolic HF

A
  1. ischemic heart disease
  2. chronic HTN
  3. progressive aortic stenosis
  4. age
464
Q

T/F: diastolic HF may coexist with Systolic HF

A

TRUE

465
Q

inotropes effect on PV loops

A

shift loop left

466
Q

diuretics and vasodilators effect on PV loops

A

decrease LVEDP

467
Q

vasopressors effect on the PV loop

A

*shift loop up

468
Q

_________________ = acute or worsening imbalance of myocardial oxygen supply to demand

A

acute coronary syndrome

469
Q

most common cause of ACS

A

focal disruption of atheromatous plaque –> partial/complete occlusion of coronary

470
Q

3 categories of ACS

A
  1. STEMI
  2. NSTEMI
  3. Unstable angina
471
Q

ST segment depression/nonspecific ECG changes with elevated cardiac biomarkers = _______________

A

NSTEMI

472
Q

ST depression/nonspecific ECG changes with normal cardiac biomarkers = __________________

A

unstable angina

473
Q

________________ occurs when coronary blood flow decreases abruptly

A

STEMI

474
Q

5 common pathophysiologic process that causes NSTEMI

A
  1. rupture/erosion of coronary plaque that leads to non-occlusive thrombosis
  2. dynamic obstruction d/t VC
  3. worsening coronary luminal narrowing due to progressive atherosclerosis, instent restenosis, or narrowing of CABG
  4. inflammation
  5. myocardial ischemia due to demand increase
475
Q

Basic set up for CABG

A
  1. std monitors + ABP/PAP/CVP, cerebral oximetry, BIS, TEE
  2. emergency meds: inotrope (epi), vasopressor (neo), vasodilator (cardene)
  3. routine induction meds: etomidate, paralytic, narcotics, heparin
  4. at least 2 units blood ready
  5. temporary pacer checked, and battery is working
  6. infusions are set up and ready
476
Q

what is the purpose of giving versed and fentanyl prior to CABG

A

decrease unwanted SNS response 2/2 anxiety

477
Q

pt coming in for CABG who should you caution premedication of versed and fentanyl with ?

A

CHF, low CO, and pulmonary HTN pts

478
Q

pre-bypass goals

A
  1. keep pt at baseline
  2. do not start correcting numbers until surgical correction has been made
  3. do no harm
479
Q

periods of increased stimulation (pre-bypass CABG)

A
  1. incision
  2. sternotomy & retraction
  3. sympathetic nerve dissection (at LIMA)
  4. pericardiotomy
  5. aortic cannulation
480
Q

inadequate anesthesia during times of increased stimulation with CABG (prebypass) can result in…

A

increased circulating catecholamines –>
1. HTN
2. dyrhythmias
3. tachycardia
4. ischemia
5. HF

481
Q

pre-bypass CABG, periods of decreased stimulation (“slump”)

A
  1. preincision
  2. peripheral graft harvest (from leg)
  3. IMA dissection
  4. venous cannulation
482
Q

periods of decreased stimulation (“slump”) with prebypass CABG - what are the risks?

A
  1. Hotn
  2. bradycardia
  3. dysrhythmias
  4. ischemia
483
Q

what is teh most stimulating part of the induction period for CABG pt?

A

laryngoscopy

484
Q

what is your first line tx for hypotension for the pt on pump

A

neosynephrine (not fluids, need to avoid hemodilution)

485
Q

autologous blood removal for CABG

A

taking 1 unit of blood prior induction via gravity.

486
Q

risks with autologous blood removal

A
  1. Hotn 2/2 hovolemia
  2. decreased O2 carrying capacity (will be reflected through mixed venous sat)
  3. infection
487
Q

autologous blood is stored in a bag with _________________ (similarly to banked blood)

A

citrate phosphate dextrose solution

488
Q

relative c/i to autologous blood removal

A
  1. left main dz
  2. LV dysfx (cannot handle hovol with losing 1 unit blood
  3. anemia with hgb < 12
  4. emergent surgery
489
Q

when would you expect there to be a high risk of major structure accidently being cut during CABG?

A

redo sternotomy 2/2 adhesions and scar tissue

490
Q

if a major structure is accidently cut during CABG (specifically with sternotomy) what do you do

A
  1. put on bypass immediately
  2. have blood products checked and ready for administration
491
Q

prolonged sternotomy dissection for CABG increases the risk of _______________ redo surgery

A

dysrhythmias

492
Q

what are the vessels that could be used for coronary bypass

A
  1. LIMA/RIMA
  2. saphenous vein
  3. radial artery
493
Q

endoscopic vein harvest for CABG is typically done if which vein is used

A

saphenous

494
Q

what is the preferred agent for anticoagulation with CPB

A

unfractionized heparin

495
Q

initial dose of unfractionized heparin for anticoagulation prior to CPB

A

300 units/kg

496
Q

retrograde autologous priming

A

draining blood out of pt through aortic cannula to prime CPB circuit

497
Q

what is the most common arterial access site for aortic cannulation

A

distal ascending aorta

498
Q

before aortic cannulation, ACT must be greater than ___________

A

400 s

499
Q

if the distal ascending aorta is not an arterial access option for aortic cannulation, what are the other arterial access sites that can be used?

A

femoral artery

500
Q

what is the number one complication from aortic cannulation (CABG)

A

embolic phenomena 2/2 air or atherosclerotic plaque dislodgement

principles 2 cardiac anesthesia (2 decks)

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