Campbell Flashcards
1
Q
Preload definition
A
- the pressure applied to fill the heart
- the degree to which the myocardium is stretched before it contracts
2
Q
Preload is represented by:
A
the “passive” pressure-volume curve
3
Q
Preload and _____ are the same clinically
A
end diastolic pressure
4
Q
Typical LVEDP values:
A
4-5 mmHg
5
Q
Starlings law of the heart:
A
Heart contracts more forcefully due to enhanced thick and thin filament overlap, contracts to the same ESV (end systolic volume)
6
Q
Preload has to do with what valve? systole or diastole?
A
mitral
diastole
7
Q
Increased preload –> increased
A
SV, CO, and PAP (?)
8
Q
when preload is decreased, what happens to SV, BP, EDV, and HR?
A
SV decreased
BP decreased
EDV decreased
HR increased
9
Q
What does lasix do to preload?
A
decrease
10
Q
What does nitroglycerin do to preload?
A
decrease
11
Q
when preload is increased, what happens to SV, BP, EDV, and HR?
A
SV increases
BP increases
EDV increases
HR decreases
12
Q
What does IVF do to preload?
A
increase
13
Q
What does blood transfusion do to preload?
A
increase
14
Q
Afterload definition:
A
the pressure in the aorta throughout the ejection phase
15
Q
Afterload is associated with which valve?
A
aortic
16
Q
A sudden increase in MAP causes 3 things to happen:
A
- pressure in the ventricle must rise to a higher level during the isovolumetric contraction phase before the aortic valve will open
- ejected volume goes down
- SV and CO will decrease
17
Q
a decrease in afterload does what to SVR, BP, LV volumes?
A
decrease SVR
decrease BP
decrease LV volume
18
Q
a decrease in afterload does what to time for the LV to empty, O2 demand, resistance to forward flow?
A
decrease time for LV to empty
decrease O2 demand
decrease resistance to forward flow
19
Q
a decrease in afterload does what to contractility, HR, stroke volume?
A
increase contractility
increase HR
increase stroke volume
20
Q
what does nitroprusside do to afterload?
A
decreases
21
Q
an increase in afterload does what to SVR, BP, LV volumes?
A
increase SVR
increase BP
increase LV volume
22
Q
an increase in afterload does what to time for the LV to empty, O2 demand, resistance to forward flow?
A
increase time for LV to empty
increase O2 demand
increase resistance to forward flow
23
Q
an increase in afterload does what to contractility, HR, stroke volume?
A
decrease contractility
decrease HR
decrease stroke volume
24
Q
what does phenylephrine do to afterload?
A
increases afterload
25
What happens with a sustained increase in MAP: (3 things)
a. the increased ESV plus normal venous return volume leads to increased EDV
b. due to the increased EDV the heart contracts more forcefully (Starlings Law of the Heart)
c. SV, CO and PA are increased
26
An increase in MAP shifts the pressure volume curve which way (at steady state)?
right
| reserve is diminished
27
contractility definition:
Altered contractile force due to change in the rate or quantity of calcium delivered to the myofilaments, or a change in the affinity of the filaments for calcium.
28
A sudden increase in contractility causes: (3 things)
a. the heart to contract more forcefully from any initial length
b. the heart to contract more forcefully during the ejection phase, leading to a reduced ESV and increased SV
c. increased SV increases CO and PA
29
decreased contractility causes what change in: BP, SV, LV volume
decrease BP
decrease SV
increase LV volume
30
CHF does what to contractility?
decrease
31
increased contractility causes what change in: BP, SV, LV volume
increase BP
increase SV
decrease LV volume
32
what does digitalis do to contractility?
increase
33
what does calcium do to contractility?
increase
34
The short-term blood pressure regulators are those that respond to rapid changes in MAP and attempt to rapidly return the MAP back to normal range
baroreceptors and hormones such as angiotensin and vasopressin
35
what is the time frame of short term BP regulators? (how rapid are they)
within 30 min
36
long term BP regulation is maintained by what system?
Renal homeostasis of blood pressure occurs as the kidneys preferentially excrete sodium and water to maintain a normal fluid balance.
37
Do the left ventricular diastolic volume (LVDV) and the left ventricular diastolic pressure (LVDP) have a predictable relationship?
No
38
Increase in contractility causes the same shift in ventricular function curve as (increase/decrease) in afterload
decrease
39
increase in contractility or decrease in afterload cause what shift in ventricular function curve?
upward and to the left shift
| reflects increase in SV and decrease in LV chamber size
40
decrease in contractility or increase in afterload cause what shift in ventricular function curve?
downward and to the right
| reflects decrease in SV and increase in LV chamber size
41
contractility and afterload have a (direct/inverse) relationship
inverse
42
DAPT + ASA and P2Y12 inhibitor is standard for _____ weeks after ____ stent
6 weeks after bare metal stent
3-6 months after MI
12 months after drug eluding stent
43
Chronic constrictive pericarditis results from
pericardial thickening and fibrosis
44
most common cause of pericardial constriction (in past and currently):
past: Tb
currently: idiopathic in nature and can occur following cardiac surgery, neoplasia, uremia, radiation therapy, and rheumatoid arthritis
45
What do you want with HR/contractility in chronic constrictive pericarditis anesthesia management?
PRESERVE HR and contractility
46
chronic constrictive pericarditis anesthesia management drug/ventilation concerns?
- ketamine good
- bradycardia is bad
- careful with VA (worry about vasodilation)
- preserve HR, preload, afterload, contractility
- caution with PPV- decreases CO and venous return to heart
47
Concentric goes with regurgitation or stenosis?
stenosis
48
Eccentric goes with regurgitation or stenosis?
regurgitation
49
Mitral regurg/insufficiency hemodynamic goals:
- Decreasing regurgitant blood flow to enhance CO by decreasing afterload, maintaining or increasing preload, and maintaining cardiac contractility.
- Bradycardia or dysrhythmias that cause a loss of atrial kick can result in pulmonary congestion, left atrial and left ventricular overload, and a significant decrease in CO
50
mitral regurgitation HR goal:
increase/avoid bradycardia
51
mitral regurgitation rhythm goal:
NSR
52
mitral regurgitation afterload goal:
decrease
53
mitral regurgitation PVR goal:
avoid increase
54
mitral regurgitation preload goal:
normal or increased
55
mitral stenosis peak systolic pressure:
lower than normal
56
in mitral stenosis, a reduced left ventricular preload causes a:
decrease in LVEDP and stroke volume
57
best drug for mitral stenosis:
phenylephrine (low HR ok/somewhat desirable)
58
mitral stenosis goal HR:
low, normal
59
mitral stenosis goal rhythm:
NSR
60
mitral stenosis goal afterload:
maintain normal
61
mitral stenosis PVR goal:
avoid increases
62
mitral stenosis goal preload:
normal to increase
63
What value should should alert the anesthetist to the presence of mitral or aortic insufficiency or primary coronary artery disease?
increased LVEDV in patients with mitral stenosis
| LVEDV normal in approx 85% patients with just mitral stenosis
64
mitral stenosis causes what PA Cath waveform changes?
a prominent a wave and a decreased y descent
65
aortic regurgitation/ insufficiency anesthesia management goals:
- increase forward flow and decrease the degree of regurgitation
- HR maintained 80 to 100 bpm
- decrease afterload (especially diastolic pressure)
- avoid myocardial depression
- maintain normal sinus rhythm
- maintain/increase preload
(regurg- still full fast forward)
66
regional in aortic regurgitation?
- neuraxial blockade, spinal and epidural are appropriate
| - decrease SVR due to sympathetic blockade may be advantageous for aortic regurgitation
67
Drugs/anesthesia in aortic regurgitation:
paralytic?
gas?
- GA can be done with a variety of agents
- Pancuronium is desirable
- Caution with Succs ie bradycardia
- Isoflurane increases HR (want to maintain 80-100) and decrease SVR (we want to decrease afterload)
- For ventricular dysfunction- opioid based technique
68
aortic regurgitation HR goal:
moderate increase
| 80-100
69
aortic regurgitation goal rhythm:
NSR
70
aortic regurgitation afterload goal:
decrease
71
aortic regurgitation PVR goal:
maintain
72
aortic regurgitation preload goal:
normal to increase
73
mitral valve prolapse anesthesia considerations:
- Stimulation of SNS worsens MVP
- Avoid anticholinergics (make valves worse)
- Reduce Pre-op anxiety
- Regional and GA is acceptable
- Maintain SVR above normal even with sympathetic blockade
- Maintain preload
- DO NOT use Ketamine (because increases HR)
74
Antibiotics in mitral valve prolapse:
- ABX prophylaxis due to endocarditis
- only patients with prosthetic valves, patients with prior endocarditis, heart transplant patients with a valvuloplasty, and certain congenital heart disease patients now require endocarditis prophylaxis.
75
mitral valve prolapse preload goal:
maintain or increase
76
mitral valve prolapse afterload goal:
maintain
77
mitral valve prolapse contractility goal:
maintain
78
mitral valve prolapse HR goal:
maintain
79
mitral valve prolapse rhythm goal:
NSR
80
Most distinguishing characteristic of aortic stenosis pressure volume loop:
The extremely high systolic pressure rise is the most distinguishing characteristic
81
when see aortic stenosis in history, look at echo for:
size of valve
82
what drug must be avoided in aortic stenosis (if critical/severe):
propofol
83
severe aortic stenosis is an aortic valve area less than:
1 cm2
84
aortic valve area less than ____ is associated with sudden death
0.7 cm2
85
regional in aortic stenosis?
no spinal, increase drop in BP and increase HR and sympathetic response
epidural is better than spinal
86
can you do CPR/resuscitate pt with aortic stenosis:
successful CPR is near impossible
87
best drug for all stenosis:
phenylephrine
88
best drug for all regurgitation:
ephedrine
89
aortic stenosis anesthesia considerations:
- Caution the use of medications with histamine release (increase HR)
- Avoid profound hypotension and decreased SVR
- Opiate induction technique preferred
- Avoid Ketamine
- Etomidate good choice
- propofol not a great idea
90
treating hypotension in aortic stenosis:
phenylephrine or a-agonist
91
treating bradycardia (<60) or junctional rhythm in aortic stenosis:
ephedrine, atropine or glyco
92
treating tachycardia (>110) in aortic stenosis:
B-blocker (esmolol)
93
how to treat SVT in aortic stenosis:
cardioversion
94
aortic stenosis goal HR:
low to normal
95
aortic stenosis goal rhythm:
NSR
96
aortic stenosis goal afterload:
maintain/increase
97
aortic stenosis goal PVR:
maintain
98
aortic stenosis goal preload:
increased
99
valve summary:
preload
contractility
rhythm
always maintain, maintain, NSR
100
regurgitation memory trick:
full fast forward
101
stenosis HR:
decrease
102
a repeatedly reported complication following TAVR, and affects 10% to 50% of patients, with a higher incidence in CoreValve use:
AV block requiring permanent pacemaker placement
103
before induction for a TAVR, what should be placed on pt?
pacer/defib pads
104
Hypertrophic Cardiomyopathy AKA HCM/ IHSS comes from:
genetically transmitted
105
Hypertrophic cardiomyopathy AKA HCM/ IHSS is the most common cause of:
pediatric and young adult death
106
Hypertrophic cardiomyopathy preload goal:
increase
107
Hypertrophic cardiomyopathy afterload goal:
increase
108
Hypertrophic cardiomyopathy contractility goal:
decrease
109
Hypertrophic cardiomyopathy HR goal:
maintain
110
Restrictive Cardiomyopathy anesthesia considerations
- Diuretics
- Na and H2O restriction
- Anticoagulation
- Tx dysrhythmias
- Maintain preload
- Minimal myocardial depression
- High dose narcotic with titration
111
what is Takotsubo Cardiomyopathy
elevated endogenous catecholamine concentrations cause myocardial toxicity leading to myocardial inflammation and dysfunction
aka stress cardiomyopathy, broken heart syndrome, etc.
112
Takotsubo Cardiomyopathy presents as:
MI
| angiogram reveals nothing
113
Takotsubo Cardiomyopathy patients usually regain cardiac function in:
4-8 weeks
114
absolute contraindications to TEE:
- Strictures
- Diverticula
- Tumors
- Traumatic interruption
- Recent suture lines
115
allows pacemaker to switch from synchronous to asynchronous pacing with a magnet:
reed switch
| inactivates the sensing circuit causing it to be asynchronous
116
asynchronous mode:
cardiac pacing mode set independent of the hearts intrinsic rate
117
inhibited definition (for pacemaker):
when the patient demonstrates an intrinsic heartbeat, the pacemaker will not deliver a paced beat
118
threshold definition (for pacemaker):
the minimum output that will cause the myocardial chamber (atrium or ventricle) to consistently contract or capture
119
how often should ICD be routinely assessed?
6 months
120
how often should pacemaker be routinely assessed?
every year*
121
magnet on pacemaker:
asynchronous pacing
122
magnet on ICD:
disables shock
123
magnet on pacemaker and ICD:
disables shock only
124
Radiofrequency catheter ablation
Modification of the sinus node or atrioventricular (AV) node
| - SVT, a flutter, atrial tachycardia, afib
125
before radiofrequency catheter ablation is chosen as therapy, what must be done?
EPS study to determine the origin and pathway of the arrhythmia and MOA
126
after radiofrequency catheter ablation, will the patient need meds?
pt will no longer need meds after RCFA
127
what is now being used prior to RCFA?
Cryoablation
128
how does cryoablation work?
- Liquid Nitrous is used through a catheter and the arrhythmia is frozen/ permanently destroyed by “ice mapping”
- causes less discomfort and safer
- best used for iatrogenic AV Block
129
RCFA procedural complications:
- Bleeding
- ECG changes
- Cerebrovascular accidents
- Cardiac tamponade
- Damage to the aortic valve
130
Vtach ablation, most patients on amiodarone which:
causes pulmonary toxicity, hypothyroidism* and hypotension during anesthesia
