Cardiac Flashcards

Question

Post op HTN treatment?

Answer 1

* Pain adeuqately controllw? * if yes, then HTN treat with * hydralazine 2.5-10 mg IV q 10-20 min * labetalol 5-20 mg IV q 10 min * Nipride 0.5-10 mcg/kg/min

Answer 2

* Preop: * *Assess HTN and CAD r/f for PAD* * *Exercise tolearance, pain, claudication with exercise? blood thinners?* * *Intraop:* * After donor and recipient arteries exposed, tunnel is created and graft is passed * graft may be saphenous vein or prothesis * *own vessel doesn't work that well because probably also atherosclerosed* * Heparin IV given * *typically give 3,000-5,000 units* * Anastomosis are constructed * arteriogram to confirm adequate flow- *doppler peripherally to confirm adequate flow* * **maintain good BP in these pts! * heparin is not likely to be reversed * Principle risk during reoncstructive sx is associated with **atherosclerosis**, especially **IHD** * **Pt with PVD has 3-5greater risk of MI, stroke and death!** * *need good exercise tolerance! cleared by cards, stress test, etc* * *have to manage both PVD and CAD!* * **CABG operations are usually performed before sx on peripheral vasculature pt who experience angina and claudication**

Answer 3

skill and experience of anesthesia provider, including the ability to monitor hemodynamics and respond quickly, are far more important than a specific agent used

Answer 4

* Regional anesthesia: some perceived advantages of regional anesthesia 1. increased graft blood flow * *sympathectectomy below level of regional* 2. less increase in SVR with cross clamping 3. Postop pain relief- *this also protects SNS outflow* 4. Less activation of coag system * *decrease plt activation* * *decrease resistance in blood flow* * *preferrable mechanism- consider anticoag/antiplt meds pt on!* * *Regional vs General* * assess for coag * if consideration regional, spinal may be best, to avoid hematoma * studies have shown no diff b/w RA and GA in terms of CARDIOPULMONARY complications * *no diff in MI, death, myocardial ischemia outcomes b/w regional and GA* * sig difference in complication rate in terms of GRAFT OCCLUSION * *pt c reigonal do better with graft and graft sx outcome* * *surgeons want regional*

Answer 5

* Consider co morbiidties- biggest CAD * CVA, renal, etc? * medication hx- impact on anesthetic delivery * *anticoag--\> if increased INR, no regional* * end organ perfusion and oxygenation-- maintain * *kidney, brain* * blood gases- electolyte and pH changes * cross clamp- hep admin/record time/reversal? * give heparin (3-5000 max) * record time--\> heparin peaks 3-5 min after, let surgeon know and they'll cross clamp * typically no reversal needed unless higher doses given

Answer 6

* Pt typically present with CAD, DM, HTN * *tight BG control* * Preop- make sure pt takes BB and/or other chronic meds * intraop a line- *useful if labile BP and bypassing large vessels, long case* * ability to monitor intravascular volume by either CVP and CO or urinary catheter * *esp is underlying cardiac issues* * *foley with longer cases esp.* * EBL- *keep eye on blood loss. if not clamping adequately, may get quite a bit of bleeding* * estimated third space * *wounds can be large OR sometimes small incisions* * *keep eye on third spacing*

Answer 7

**_Goals (slow tight full)_** 1. Avoid sinus tachycardia or rapid ventiruclar response rate during a fib * *Stoelting- treat afib c rvr with amiodarone, bb, ccb* 2. avoid marked increases in central blood bolume as associated with over transfusion or head-down position * *no rapid transfuion or head down* * *dont' want drop or sudden increase in prelaod!* 3. avoid drug induced decreases in SVR * *use etomidate- any decrease in SVR, hypotension is very difficult to manage, need to treat adequately with phenylephrine* 4. Avoid events such as arterial hypoxemia and/or hypoventilation that may exacerbate pulmonary HTN and evoke RV failure * *will easily back up into pulmonary system!* * *100% o2 prudent on these pt* * *Stoelting- events that increae pulm HTN=* * *Hypoxemia* * *hypercarbia* * *lung hyperinflation* * *increase lung water*

Answer 8

* Most often accomplished with drugs admin intravenously that are unlikely to increase HR (avoid ketamine) or abruptly decrease SVR (*want to maintain tight system)* * *ideal- etomidate, high narcotic technique*

Answer 9

* Is intended to minimize the likelihood of marked and sustained changes in HR, SVR, PVR and myocardial contractility * useful drugs * beta blockers * ccb * phenylephrine * Use of invasive monitoring depends on complexity of the operative procedure and the magnitude of physiologic impairment produced by mitral stenosis * *aline useful----degree of invasive monitoring depends on procedure and sx impairment* * *if very severe MS and non-cardiac related procedure, is the procedure worth doing before valvular replacement?* * *If sx needs to be done and MS isn't so severe* * *aline* * *CVP line useful* * *if bigger procedure--\> cardiac consult esp if mitral stenosis severe*

Answer 10

* Sinus tachycardia or rapid ventricular response during atrial fib * *BP will instantly drop* * marked increase in central blood volume, as associated with overtransfusion or head down positon * drug-induced decrease in SVR * *If Bp drops, hard to get blood flow back* * hypoxemia and hypercarbia that may exacerbate pulmonary HTN and evoke RV failure

Answer 11

* Important goal-- avoid events that would further **decrease CO** Goals (*slow, tight, full like MS??)* 1. maintain NSR 2. AVOID bradycardia or tachycardia * hr 60-90 hr DEPENDENT on BP 3. avoid hypotension * *If lose BP, like MS, will get into trouble* 4. optimize intravascular fluid volume to maintain venous return and LV filling * *need good venous return! help with SV and forward flow* * *don't overload either!*

Answer 12

* General anesthesia is often selected in preference to epidural or spinla anesthesia * this minimies the likelihood of an undesirable decrease in SVR * *sympathemectomy with spinal causes lots of issues with AS!* * Use of a-line and PA catheter depends on magnitude of sx and the severeity of the aortic stenosis * *BIG procedure, severe AS and can't replace before urgent/emergent sx, make sure you have PA, a line and moniroting (TEE may also be useful)*

Answer 13

* Important goal is to avoid events that may further decrease CO GOAL : **FAST FULL FORWARD** 1. Avoid sudden decrease in HR * HR 80/85 beneficial 2. Avoid sudden increase in SVR * *need good forward flow* * *if you decrease BP, hard time getting them back* * *also avoid sudden increases* 3. Monitor the size of the V wave as a reflection of regurgitant flow 4. minimize drug induced myocardial depression * *want balanced technique, with opioid, some VA, nsaids, tyneol etc.* * *no high VA*

Answer 14

Keep in mind the importance of avoiding excessive and abrupt changes in SVR or decrease in HR * *Keep those things in mind when choosing drugs* * *Etomidate is best bet- no change in BP/HR*

Answer 15

* Maintenance of aneshtesia- is influenced by degree of LV dysfunction * If LV dysfunction **_not_** severe: * N2O plus VA (isoflurance is attractive choice because of hemodynamic effect) * LV dysfunction severe: * use of opioid technique- minimizes likelihood of drug-induced myocardial depression, may be a consideration * Use of invasive monitorign- depends on: * compelxity of procedure * magnitude of physiologic impairment with MR

Answer 16

Goals: * avoid sudden decrease in HR (high normal) * avoid sudden increase in SVR - *blood will go back* * minimize drug induced myocardial depression

Answer 17

* Use drugs considered likely to maintain forward LV stroke volume * *etomidate- cardiac stable*

Answer 18

* If no severe LV dysfucntion * N2O plus VA (isoflurane attractive choice d/t minimla hemodynamic effects) * When myocardial function compromised * use of opioid alone may be considered

Answer 19

* **_Prompt_** replacement of blood loss important to maintain forward LV stroke volume * *if losing blood, repalce blood!* * bradycardia may require prompt treatment with atropine (or glyco) * Monitoring is dictated by * complexity of sx * severeity of aortic regurg

Answer 20

Goal is to prevent and avoid myocardial depression 1. HR- normal to elevated 2. Preload- normal to high! * *if drop preload, then low SV* 3. Afterload- low * *don't want open-wide system, if drop BP too much, hard time getting back* * *also want to decrease afterload to decrease workload on heart* 4. Contractility- increase

Answer 21

* Maintain med therapy- esp BB * Hypotension treated with: * ephedrine * phenylephrine * vasopressin * GA doses may be decreased (VA, induction) * PPV beneficial in decreasing pulmonary congestion * regional anesthesia ok * *if regional and decrease in afterload, be careful because if BP dropped too much, hard time getting it back up* * Avoid fluid overload * +/- arterial line * *depends on severity of dx and procedure*

Answer 22

* VA good - *decrease contractility* * *these hearts are too muscular and VA is helpful in decreasing contractility* * A-line **MUST HAVE** * Treat hypotension with alpha adrenergic agonists (phenylephrine) and VOLUME! * Beta adrenergic agonists are **contraindicated** * ***I****f hypotensive, avoid beta agonists because if they are hypotensive, they're usually hypovolemic!!! Beta agonists will just make hypertrophy worse!!* * prompt replacement of blood and fluids * avoid vasodilators * maintain NSR

Cardiac Flashcards

(46 cards)