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Anestesiologia - Pontos ME1 ME2 + Miller > 42 CEC - Cardiopulmonary Bypass > Flashcards

42 CEC - Cardiopulmonary Bypass Flashcards

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1
Q

What are typical CPB temperatures?

A

28°C to 34°C

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2
Q

Quais os principais componentes do circuito da CEC? (6)

A
  • Tubulacoes sanguineas
  • Reservatorios venosos
  • Bombas arteriais
  • Trocadores de Calor
  • Oxigenador
  • Filtro de linha arterial
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3
Q

Qual a sequencia usual de eventos da CEC? (6)

A
  • Selecao de circuito e priming
  • Anticoagulacao
  • Canulacao
  • Inicio e manutencao da CEC
  • Protecao miocardica
  • Desmame e saida da CEC
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4
Q

Qual a principal funcao dos reservatórios venosos e onde estao posicionados? (2)

A
  • Facilitam o deslocamento de grandes volumes de sangue para fora da circulação em momentos estratégicos da cirurgia
  • Posicionados entre a linha venosa e a bomba arterial
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5
Q

What are the adverse effects of hypothermia? (7)

A
  • Coagulopatia por disfuncao planetaria, ↓síntese e cinetica de enzimas de coagulação
  • HipoCalcemia - ↓metabolismo de citrato
  • ↑infeccao
  • ↑Afinidade de O₂ a Hb
  • ↑BNM
  • Arritmias
  • ↓contratilidade cardiaca
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6
Q

Why is hypothermia used for patients on CPB?

A
  • ↓metabolismo e demanda de O₂
  • Prevencao de lesao miocardica e SNC

Systemic oxygen demand decreases 9% for every degree of temperature drop. Hypothermia, therefore, allows for a lower CPB pump flow, while providing adequate oxygen delivery to vital organs. The main concern with CPB is the prevention of myocardial and central nervous system injury, along with renal and hepatic protection.

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7
Q

Fatores de risco para Lesao Renal Aguda no periodo peribypass (4)

A
  • Insuf Renal previa
  • idade avançada
  • FE < 40%
  • Duracao da CEC

Outros:

  • DM
  • Hemodiluicao na CEC
  • Mulheres
  • Uso de balas intra-aortico
  • Cirurgias cardiotoracicas complexas

Urine output is also monitored during CPB as an indi- cator of perfusion flow and pressure. However, poor urine production during CPB has not been shown to predict post- operative renal insufficiency.

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8
Q

Quais os sitios de canulacao de CEC? (2)

A
  • Sangue venoso pelo AD
  • Sangue arterial: Aorta proximal ascendente
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9
Q

Qual o fluxo em L/min/m² ou mL/kg/min usual da CEC?

A
  • 2.4-3.0 L/min/m²
  • 60 a 70 mL/kg/min

The calculated flow is then compared with the rated flow for the components of the ECC circuit. This flow rating represents the highest blood flow rate at which the component can perform its function within the acceptable range of hydraulic forces (pressure and shear stress) without causing an unacceptable amount of blood trauma.

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10
Q

Quais considerações na tecnica anestesica para cirurgias que envolvem CEC? (4)

A
  • Grau de disfuncao sistolica
  • Extensão de doença coronariana
  • Magnitude da doenca Valvular
  • Tolerancia ao exercicio
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11
Q

Como calcular o Hematocrito Resultante do paciente apos a mistura de volume prime?

A
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12
Q

An adult patient’s intravascular volume of distribution will increase by 20% to 35% when CPB is initiated.

  • Quais as implicacoes? (2)
A
  • Diluicao de proteinas plasmaticas e elementos do sangue
  • Niveis plasmáticos de drogas
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13
Q

The initiation of CPB is often associated with a period of ___1___, which can be managed with the administration of an ___2___ into the venous reservoir of the ECC circuit

A
  1. hypotension
  2. α-agonist (e.g., phenylephrine)
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14
Q

Blood samples should be taken at least every ___1___. Arterial blood gas is drawn to assess the performance of the oxygenator and to monitor the patient for the development of acidosis.

Base deficit values of −5.0 mmol/L or less can be corrected with ___2___, but the underlying cause of the acid production should ultimately be addressed.

A
  1. 30 minutes
  2. Sodium bicarbonate
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15
Q

Por que pacientes em CEC eram considerados de alto risco para consciência intra-op?

A
  • Tecnica com uso elevado de Opioides

The conduct of cardiac anesthesia has moved away from such techniques of the past, which involved high-dose opioid and long-acting neuromuscular blocking agents, as they were associated with prolonged time to extubation in the intensive care unit and delayed ambulation.

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16
Q

O que sao tecnicas fast-tracking? (2)

A
  • BNM e opioides com cuidado e doses mais baixas
  • Multimodal: acetaminophen, ketorolac, dexmedetomidina, ketamina, bloqueio regional (paraesternal)
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17
Q

In general, the anesthesiologist should visually follow progress on the field from sternotomy through cannulation, as this can be a time of significant blood loss and hemodynamic shifts.

  • Quais os principais 4 periodos de canulacao?
A
  1. Esternotomia
  2. Canulacao Aortica
  3. Canulacao Venosa
  4. Cateterizacao de Serio Coronariano
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18
Q

What steps does an anesthesiologist need to take during conventional cannulation?

  • Esternotomia:
  • Canulacao aortica:
  • Canulacao venosa:
  • Cateterizacao de seio coronariano
A
  • Esternotomia: pausar ventilacao
  • Canulacao aortica: evitar hipertensao, PAs < 120
  • Canulacao venosa: VC baixo
  • Guiar com ECO-TE

In general, the anesthesiologist should visually follow progress on the field from sternotomy through cannulation, as this can be a time of significant blood loss and hemodynamic shifts.

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19
Q

Quando e como a Parada Circulatoria é usada em Cirurgias de Arco Aórtico, por exemplo?

A
  • Fluxo é interrompido quando o paciente for resfriado para temperatura desejada (↓metabolismo) e o cirurgiao esta pronto para colocar o enxerto Aortico.
  • Neste momento, o fluxo é interrompido pelo circuito de bypass.

Circulatory arrest can be accompanied by isolated cerebral perfusion or no cerebral perfusion. Isolated cerebral perfusion may be antegrade or retrograde, unilateral or bilateral. Antegrade cerebral perfusion is often delivered via a catheter in the axillary artery or innominate artery that directs blood up the carotid artery, as opposed to retrograde cerebral perfusion delivered via a catheter in the superior vena cava.

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20
Q

What are additional anesthetic considerations associated with circulatory arrest? (4)

A
  • Coagulopatia
  • Sequela neurologica
  • Falencia Renal
  • Disfuncao Pulmonar

Packing the head in ice and administering lidocaine and steroids may also be neuroprotective.

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21
Q

Oxygenators are designed to allow gas exchange in a manner similar to the human lung. There are multiple types of oxygenators available for use, such as the following: (4)

A
  1. Contato direto
  2. Membrana
  3. Microporo
  4. Fibras ocas plasma-tight
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22
Q

Qual a funcao do filtro de linha Arterial (ALF)?

A
  • Remover microembolos particulados e gasosos

To remove bubbles from the blood path effectively, arterial line filters must be continuously “purged” by allowing a small amount of blood to recirculate from the top of the filter back into the venous reservoir.

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23
Q

What is meant by “pump prime”?

A

“Pump prime” involves priming solutions (i.e., crystalloid, colloid, or blood) that are used to fill the CPB circuit.

The solution used to prime the CPB circuit is generally a balanced electrolyte solution containing normal plasma concentrations of many of the standard blood ions. Various drugs may be added to the solution to attenuate the dilu- tional effect of CPB on those ions (e.g., albumin, heparin, bicarbonate) or to discourage edema formation or encour- age diuresis of the prime fluid by the patient (e.g., mannitol).

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24
Q

What is the usual hemodynamic response to initiating bypass? (2)

A
  • ↓PAM
  • ↓[Hb]

Ocorre devido a hemodiluição do sangue circulante do paciente com a solucao “prime” da CEC.

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25
Why is systemic anticoagulation necessary?
* Trombose devido ao contato com as superficies sintéticas do circuito da CEC *Following separation from the CBP machine, protamine is used to bind heparin and reverse the anticoagulant effect.*
26
How is the adequacy of anticoagulation measured before and during bypass?
* Tempo de coagulacao ativado (ACT) 3-4min depois da administracao de heparina e cada 30min no CEC * ACT _>_ 400s
27
O que mede o ACT?
* Efeitos anticoagulantes da Heparina e outros anticoagulantes *The ACT test is not used to monitor heparin levels but to monitor the anticoagulant effects of heparin and other anticoagulants. Thus, elevated ACT measurements taken before, during, or after CPB may be influenced by variables other than heparin (e.g., hypothermia, hemodilution, coag- ulopathy, and anticoagulants).*
28
Em que situacoes o tempo de coagulacao estará normal apesar de concentracao de heparina elevada? (2)
* Resistencia a heparina (infusas pre-op de heparina) * Def de Antitrombina III
29
O que deve ser corretamente monitorado e checado antes de colocar o paciente em CEC? (5)
* **Canulacoes adequadas e posicionadas** * **Anticoagulacao adequada (ACT > 400s)** * PAI * Temperatura central * Plano anestesico adequado *Se usado, posicionamento adequado da canula retrograda de cardioplegia*
30
Por que usar um dreno no VE? (2)
* Prevenir distensao de VE durante a CEC, por insuficiencia aortica ou do fluxo fisiologico normal de sangue pelas veias bronquiais ou Thebesianas * facilitam descompressão e retirada de ar do coracao *A distensao é problematica porque pode elevar a pressao intraventricular (ex tensao de parede miocardica(, levando a isquemia por impedir a distribuicao de cardioplegia subendocardial.*
31
Provided the venous cannula is adequately draining the venous return to the heart, right-sided heart pressure (CVP and PAP) should decrease to **___1___** and the arterial blood pressure should reach a **___2___**.
1. 0 mm Hg, 2. Normal mean pressure (50-90 mm Hg) while also becoming nonpulsatile.
32
The arterial trace usually becomes nonpulsatile as the heart is emptied and the pumping force is changed from the ventricle to the nonpulsatile heart and lung machine. However, patients with **___1___** continue to have a pulsatile arterial trace despite complete venous drainage (CVP and PAP = 0 mm Hg) because of **___2___**.
1. Aortic insufficiency 2. Regurgitation of blood from the arterial cannula across the incompetent aortic valve and back into the LV.
33
Once full flow has been achieved, the function of the heart and lungs will have been completely transferred to the CPB machine; the anesthesiologist then can turn off the ventilator, and **______** of the patient can be initiated.
hypothermia
34
What are the characteristics of cardioplegia?
Manter o potencial transmembrana em repouso * Cristaloide ou hemo-baseada * Intermitente ou continua
35
Qual o mecanismo de cardioplegia principal?
* **Hiper-K** Outros: * HipoCalcemia * ↑Adenosina/Lidocaina/Mg * Abertura de canais ATP-K *To provide a motionless field for the surgeon, the heart is arrested in diastole by the administration of a potassium- enriched cardioplegia solution.*
36
Once the surgical procedure is com- pleted, myocardial arrest can be reversed by **___1___** with **___2___**.
1. reperfusing the coronary arteries 2. Warm normokalemic blood
37
Quais as possiveis vias de administração da cardioplegia? (2)
* Anterograde: raiz da aorta (ostio coronario) * Retrograda: cateter no seio coronariano do AD *The most complete technique for myocardial protection involves both antegrade and retrograde delivery. In fact, it is not uncommon for cardioplegia to be delivered simultaneously in both antegrade and retrograde fashion.*
38
*Antegrade cardioplegic delivery is the most physiologic approach*. * Em que situacoes utilizar a abordagem retrograda?
* Doenca coronariana grave * Insuficiencia Aortica *When the patient has pronounced CAD or aortic valve insufficiency, antegrade administration may not reach the coronary arteries uniformly and thus will not adequately deliver cardioplegia to the myocardium. In these instances, retrograde cardioplegia is used.*
39
Quais as limitacoes da abordagem retrograda?
* Parede livre do VD e 1/3 posterior do Septo IV (distribuicao da ACD) tem perfusao pobre por esta via * Areas microvasculares do coracao que sao perfudindas pela via retrograda soa menos capazes de sustentar metabolismo energético miocárdio normal
40
Como é administrada a solucao de cardioplegia?
* Inicio: 1000-1500ml de solucao HiperK * Periodicamente 200-500mL de solucao "low-K* to deliver nutrients to the cells and maintain the potassium concentration.
41
Intraoperative evaluation of the adequacy of myocardial protection is empirical and based on the quiescence of the (3)
* ECG, * Time since the last dose was administered, * Temperature of the heart.
42
To reinstitute the electromechanical activity of the heart, **___1___** is infused into the coronary arteries. This may be done by administering a “hot shot” through the cardioplegia cannulas or by simply removing the cross-clamp.
1. warm, normokalemic blood
43
Quais elementos devem ser aplicados para otimizar a proteção miocardica na CEC? (4)
* Cardioplegia adequada * Hipotermia 12-15°C * Dreno VE * Evitar re-aquecimento . * Resfriamento topico do Coracao com salina gelada * Superficie de isolamento termico no Coracao posterior par impedir aqueciment odo fluxo mediastinal * Minimizar fluxo colateral de vasos bronquiais
44
What is the function of an aortic cross-clamp?
* Isolamento do coracao e circulação coronariana *This isolation of the heart from the systemic circulation allows for prolonged cardioplegia activity, diastolic arrest of the heart, and profound myocardial cooling.*
45
Efeitos protetores da Hipotermia (4)
* Equilibrio favoravel entre a demanda oferta de O₂ * ↓liberacao de neurotransmissores excitotoxicos * ↓Permeabilidade barreira hemato-encefalica * ↓resposta inflamatoria
46
Respostas fisiológicas a CEC (6)
* ↑Hormonios de stress (catecolaminas, cortisol, angiotensina, vasopressina) * Ativacao de Complemento e cascata da coagulacao * Resposta inflamatória sistemica * Disfuncao plaquetaria * Hemodiluicao * ↓perfusao renal e hepatica, com ↑[ ] serica de drogas por infuso continua *Hemodilution associated with onset of CPB decreases the serum concentrations of most drugs but decreased hepatic and renal perfusion during CPB will eventually increase the serum concentration of drugs administered by continuous infusion*
47
What are the differences between pH-stat and 𝛂-stat methods of atrial blood gas measurement?
* pH-stat: corrigido conforme a temperatura (em normograma) e adicionado CO₂ * 𝛂-stat: nao corrigido pela temperatura
48
Quando usar métodos pH-stat ou 𝛂-stat para gasometria?
* Adults: α-stat management tends to show better neurologic outcomes and is the method most commonly used. * Pediatric: pH-stat management tend to show better neurologic outcomes and is the most common method used for this population. *It is unclear which strategy is superior in adults when deep hypothermia is used with or without circulatory arrest. The clear trend in pediatric CPB is to use pH-stat alone or in combination with α-stat (i.e., to use pH-stat during cooling and α-stat during rewarming) when deep hypothermia is used.*
49
Numerous clinical approaches have been shown to reduce the inflammatory response measurably in cardiac surgical patients. These approaches can be loosely grouped into three primary categories: (3)
* Modification of surgical and perfusion techniques, * Modification of circuit components, * Pharmacologic strategies.
50
Por que a parada circulatoria por hipotermia profunda é utilizada em cirurgias de reparo de Aorta?
É o unico metodo que seguramente apresenta neuroprotecao durante isquemia global
51
Drogas utilizadas na cirurgia cardíaca que diminuem a resposta inflamatoria e Fib-Atrial, sem reduzir mortalidade (2)
* Corticoides * Estatinas
52
Qual o alvo de Ht durante a hipotermia profunda 18°C?
* Hemodiluicao para Ht 18-20%
53
Durante o periodo de hipotermia profunda, por que o fluxo de gas ao oxigenado deve ser interrompido?
Prevenir Hipocapnia profunda
54
Por que o risco de lesao neurologica apos cirurgia cardiaca que envolve Hipotermia Profunda se extende ao periodo pos-op? (3)
* ↑Resistencia vascular cerebral * ↓FSC * Hipertermia devido a resposta inflamatoria
55
In an effort to reduce the period of cerebral ischemia dur- ing circulatory arrest, selective cerebral perfusion techniques have been developed. Selective antegrade cerebral perfusion can be accomplished by directly cannulating the:
* Carótida comum Esquerda ou Direita
56
During delivery of selective antegrade cerebral perfusion, cold arterial blood from the extracorporeal circuit should be delivered to maintain the cerebral blood pressure between **______**
30 and 60 mm Hg.
57
Selective retrograde cerebral perfusion is delivered through a snared cannula introduced into the **___1___** and advanced into the **___2___**; this type of perfusion can be initiated after the patient’s systemic perfusion is discontinued.
* Right atrium * SVC;
58
Qual tecnica de perfusão cerebral seletiva é superior?
* Anterograde é superior
59
Checklist para sair da CEC (7)
1) Checar labs * Gaso-A: *pH, Base Deficit e PaCO₂ neutros* * Hb e eletrolitos 2) Reaquecimento sistemico 3) Recalibrar transdutores 4) Ritmo e FC adequados 5) ECG: ritmo e isquemia 6) ECO-TT: sinais de isquemia, avaliacao de valvas 7) Ventilar pulmoes
60
Qual a dose de Heparina?
* 300-400U/kg * ou curva de Dose-Resposta
61
Como reverter o efeito da Heparina?
* Protamina * 0.8-1mg / 100U heparina * Monitorar pelo ACT *Protamine, a positively charged protein molecule, binds the negatively charged heparin molecule and this complex is removed from the circulation by the reticuloendothelial system.*
62
Como age a Protamina?
* Inativa heparina por se ligar irreversivelmente com a molecula acida da heparina e formar um sal estavel sem efeito anticoagulante
63
*The administration of protamine to the patient is a sentinel event that must be communicated clearly by the anesthesiologist to the perfusionist and surgeon.* * Por que isso é importante?
* O retrorno de sangue contendo protamina de volta para o circuito pode provocar coagulo e deixar o circuito inutilizável caso seja necessario reinstitui-lo.
64
Quais as potenciais complicacoes da reversao da heparina? (2)
* HIpotensao sistemica por reação anafilactoide ou anafilattica verdadeira * Hipertensão pulmonar por liberação anafilactoide de tromboxano
65
Fatores de risco para complicacoes da Protamina (3)
* Hipertensao pulmonar preexistente * DM insulinodependente * Bolus rapido de protamina
66
Why is cardiac pacing frequently needed after bypass? (3)
* Insulto isquemico * Cardioplegia residual * HIpotermia
67
What are some of the things to consider if a patient has difficulty weaning from CPB? (2)
* Procedimento chirurgico adequado * ECO-TE para anormalidades de parede ou competencia valvular *From a surgical standpoint, the adequacy of the surgical procedure (whether it be coronary artery bypass, valve replacement, or otherwise) should be reconsidered. TEE can evaluate regional wall motion abnormalities and valvular competency. The right and left ventricular filling pressure should be assessed by both TEE and invasive monitors. Other hemodynamic variables, such as cardiac index, mixed venous oxygen concentration, pulmonary artery pressure, pulmonary artery occlusion pressure, and systemic vascular resistance should be assessed.*
68
Desenhar um circuito de CEC Tipico
* *Simply stated, venous blood is intercepted as it returns to the right atrium and is diverted through the venous line of the CPB circuit to a venous reservoir.* * *The arterial pump functions as an artificial heart by withdrawing blood from the reservoir and propelling it through a heat exchanger, an artificial lung (the oxygenator), and an arterial line filter before returning it through the arterial line to the patient’s arterial system.* * *Additional pumps and components are used to assist in the operation to manage shed blood (the pump sucker), decom- press the heart (vent), and deliver the cardioplegia solution.*
69
Qual o mecanismo da Hipertensão Pulmonar causada pela Protamina?
Liberação anafilactoide de tromboxano
70
Qual a diferenca de CEC para ECMO/Cardiopulmonary Support (2)
* CEC tem reservatório, filtro de linha arterial e bombas auxiliares (succcao, vent, cardioplegia) * ECMO e CPS sao considerados circuitos fechados
71
Vantagem de crciutos fechados (ECMO, CPS) (2)
* menor area de circuito * menor dose de anticoagulacao
72
Desvantagem de circuitos fechados (ECMO, CPS) (2)
* menos aptos a aprisionar émbolos * Evitar estase e periodos de baixo fluxo, devido a menor dose de anticoagulantes

Anestesiologia - Pontos ME1 ME2 + Miller (127 decks)

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