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AS - N934 Advanced Principles II > Cardiac Anesthesia > Flashcards

Cardiac Anesthesia Flashcards

(89 cards)

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1
Q

Preop Evaluation

A

Cardiac history - disease severity & hemodynamic status
- EKG, stress ECHO, cardiac catheterization
- Baseline status (EF, LVEDP, pulmonary HTN, valvular or congenital lesions, CHF)
Past surgical history - previous sternotomy (scarring), vascular surgery, graft sites, or Protamine administration
Angina presentation
Dysrhythmias
METs (exercise tolerance)
Past medical history - TIA or CVA (carotid studies before CV surgery to preserve CBF)
Comorbidities: HTN, COPD, T2D (infection risk), vascular disease, renal or liver insufficiency
Medications - anticoagulants, antianginal, β blockers, insulin, ACEi, ARBs

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2
Q

What’s the mortality percentage after an intraop MI?

A

50%

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3
Q

Cardiac Catheterization

A

Locates potential blockage(s)

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4
Q

EKG

A

Recent MI

Assess rate & rhythm

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5
Q

ECHO

A 
EF %
Valve function
Wall abnormalities
Aorta calcification
Atrial thrombus
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6
Q

Coagulation Studies

A

PTT/PT
Baseline ACT
Platelet number & functionality
TEG (thromboelastogram)

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7
Q

Chest X-ray

A

Aorta calcification
Cardiomegaly
Edema

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8
Q

Renal Function

A

Decreased function ↑postop mortality

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9
Q

Liver Function

A

Cardio-pulmonary bypass ↓liver perfusion

↑hypoperfusion risk d/t ↓splanchnic flow on CPB

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10
Q

What medications to continue leading up to cardiac surgery?

A

Antiarrhythmics
Ca2+ channel blockers
β blockers
Nitrates

Ø antiplatelet/anticoagulants

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11
Q

Cardiac Anesthesia Goals

A
  1. ↓cardiac oxygen utilization (MVO2)
  2. Maintain O2 supply
  3. Anticoagulation
  4. Normotensive w/in 20% baseline
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12
Q

↓MVO2

A

Anesthesia ↓SNS
Hypothermia - alters platelet function & ↓fibrin enzyme function, inhibits thrombin formation, & ↓metabolic demand, ↑ischemia tolerance
Cardioplegia K+ continuous admin during cross-clamping → electrical & mechanical activity ceases (renal patients hyperkalemia)
Empty cardiac chambers Ø LV distension

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13
Q

Maintain O2 Supply

A

Maximize O2 carrying capacity & flow
Optimal Hgb/Hct 30%
Hemodilution (dilutes clotting factors) = less viscous ↓blood viscosity ↑flow
Acceptable perfusion pressures & flow

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14
Q

Hypotension

A

↓end-organ perfusion

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15
Q

Hypertension

A

Disrupt myocardial balance

↑MVO2 (demand)

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16
Q

Monitoring

A

Pox
NIBP + A-line
EKG (ensure correct placement especially leads II & V5)
Temp probe (Foley best site for core temp w/ less impact from cooling, but delayed reading)
Foley
CVP or PA cath
NIRS/BIS on before induction to provide baseline
TEE

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17
Q

Transesophageal Echo

A

Evaluate preload (ventricular filling)
Volume status
Estimate CO
Assess ventricular systolic/diastolic function
Valvular pathology
Aorta calcifications
Cardiac tamponade
Atrial thrombus
Assess air present in heart prior to closure → de-airing maneuvers
Anastomosis evaluation after patient off bypass

When to admin volume, start vasoactive gtts, re-examine graft, & assess surgical repair

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18
Q

TEE Contraindications

A 
Esophageal pathology (i.e. alcoholic varices)
Empty stomach before placing the probe
- After asleep place down OG to suction
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19
Q

Swan Ganz

A

Pulmonary artery catheter
Typically placed in the R IJ (most direct route)
Cordis placed after induction as introducer to float the PA through when needed
TEE > PA cath

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20
Q

PA Catheter Insertion

R Atrium

A

5mmHg

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21
Q

PA Catheter Insertion

R Ventricle

A

15-30 / 0-8

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22
Q

PA Catheter Insertion

Pulmonary Artery Normal Pressures

A

15-30 / 5-15 mmHg

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23
Q

PA Catheter Wedge Pressure (PAWP)

A

Reflects the L ventricle pressure
Dampened waveform
Balloon inflated & catheter wedged into pulmonary artery distal branch
= 10

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24
Q

Swan Ganz Complications

A

Ventricular arrhythmias
Heart block (especially in patient w/ pre-existing L bundle branch block)
Pneumothorax (most common w/ subclavian approach)
Unintended arterial puncture (most common acute injury)
Valve damage
Hematoma/thromboemoblism
Vascular injury (localized hematoma)
Thorax perforation → hemothorax
Pulmonary artery rupture → blood noted in ETT
Cardiac tamponade
Bloodstream infection

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25
Aortic or Mitral Stenosis Valve Repair
``` Maintain preload (volume) Maintain SVR (afterload) Lower HR < NSR 50-80bpm ```
26
Aortic or Mitral Regurgitation Valve Repair
Maintain preload (volume) ↓SVR ↑HR to promote forward flow & prevent regurgitation
27
Monitoring, Equipment, & Drugs (Infusions/Emergency)
Pacemaker Infusions: - Nitroglycerin or sodium nitroprusside - Epi or NE - Phenylephrine - Dopamine/Dobutamine - Antiarrhythmics (Esmolol, Lidocaine, Magnesium, Amiodarone) - Insulin Coagulation monitoring ACTs or TEG/ROTEM Emergency drugs - Atropine, Glycopyrrolate, Ephedrine, Succinylcholine Type & cross 4 units PRBCs available in OR
28
What neuromuscular blocking agent should be avoided in cardiac anesthesia? Why?
Pancuronium | Vagolytic ↑HR d/t reflex tachycardia
29
When to administer antibiotics?
Pre-incision & post bypass
30
What diagnoses fibrinolysis? When to start monitoring to be effective?
Thromboelastogram (TEG) | BEFORE going on CPB
31
Preop Anesthetic Considerations | How to prepare the patient for induction?
Oxygen via NC or non-rebreather Limit or avoid Midazolam Place lines before induction - PIV x2, A-line, CVP, PA catheter (after induction in stable patients) Discuss access when surgical team regarding A-line & vein or graft harvesting sites Obtain baseline ABG & ACT Place external defibrillation (R2) pads on prior to induction
32
Intraop Anesthetic Considerations: | Positioning, Incision, & Temperature
Positioning - supine w/ arms tucked Ensure lines infusing, A-line waveform present, & blood return + Preop area from sternal notch to toes (saphenous vein graft) Fluid warmer Under-body forced air warmer Rapid infuser available Infusions set-up, programed, connected to the patient, & ready to go
33
Volatile Anesthetics
Dose-dependent cardiac depression Negative effects d/t intracellular Ca2+ alterations Sensitizes the myocardium to Epi Prevent or facilitate atrial or ventricular arrhythmias during myocardial ischemia or infarction Produces weak coronary artery dilation & depresses baroreceptor reflex control (arterial pressure)
34
Induction
Narcotics CV stable - High dose - Low dose w/ induction agent Awake intubation when difficult airway anticipated Post-induction place central line, OG, & TEE (stable patients when not placed pre-induction)
35
What to anticipate pre-incision?
Lack stimulation → HoTN Systemic pressure support Recall rare
36
Incision → Bypass
Sternotomy - drop the lungs Discontinue or ↓pressors prior to sternotomy Intense surgical stimulation w/ incision HTN → deepen the anesthetic & consider vasodilator agents Anticipate significant bleeding (consider previous sternotomy effects & anticipate response) Identify & localize ischemia Arterial and/or saphenous veins harvested
37
Pre-Bypass
Administer Heparin *Drawn up BEFORE sternotomy → available in case need to crash onto bypass Check ACT
38
Heparin MOA
Binds to antithrombin III & potentiates natural anticoagulant properties
39
Heparin Dosage
300-400 units/kg
40
Heparin Administration
Via central line BEFORE cannulas placed | *Check ACT 3-5min after administration
41
Normal ACT
< 130 seconds | 80-120 seconds
42
ACT range required to start cardio-pulmonary bypass?
> 400-450
43
Response to Heparin
↓SVR/BP 10-20%
44
HIT
Heparin-induced thrombocytopenia Antiplatelet antibodies → lead to platelet aggregation & potentially life-threatening thromboembolic events Platelet count < 100,000 *Previous Heparin exposure Check antibodies to antiplatelet factor IV
45
Heparin Alternative
Bivalirudin | Direct thrombin inhibitor
46
Pre-Bypass (Post Heparinization)
↓BP before aortic cannulation to prevent aortic dissection TEE to assess Ca2+ deposits or plaques present in aorta Aorta cannulation (arterial) 1st - Perfusionist able to administer fluids through R atrium (venous) cannulation 2nd - HoTN and/or arrhythmias w/ venous placement Coronary artery sinus cannulation - retrograde cardioplegia ↓BP
47
Pre-Bypass Complications
Arrhythmias - cardiac manipulation & cannulation; potentially 1st sign myocardial ischemia HTN especially during aortic cannulation HoTN - admin volume via aortic line or pump; consider pressors Heart failure Bleeding - sternotomy lacerates R ventricle or aorta
48
Transitioning to Cardio-Pulmonary Bypass
Perfusionist opens venous clamp to passively drain blood into the venous reservoir Begins active patient cooling A-line flat Pull back pulmonary artery catheter 2-3cm into R ventricle Assess for swelling or blanching (indicates improper venous catheter placement Ø adequate drainage from the head) Pupils & BIS
49
When to stop the ventilator?
When transitioning to bypass once the heart volume emptied | Bypass at full flows discontinue IV fluids
50
Bypass Numbers
Pump flow 2.5-3L/min or 50-60mL/kg Goal MAP 65-70mmHg (valve repair 50-60) CVP 0-5 or (-) w/ vacuum assist to remove the blood Mixed venous saturation 70-80% Cerebral oximetry ↓normal when transition to bypass
51
Pump Prime
Ask perfusionist 1,500-2,500mL balanced electrolyte solution Crystalloid Albumin, Heparin, bicarbonate, & Mannitol (↑osmolality ↓edema → promote diuresis) Corticosteroids, antifibrinolytics, & blood products
52
Anticipated patient response to going on bypass
Dilutional effect ↓viscosity (cooling ↑viscosity) ↓SVR → promotes blood flow to tissues Catecholamine dilution → administer + inotropes Hemodilution ↓O2 carrying capacity
53
Cardio-Pulmonary Bypass Goal
Bloodless field Still heart (not beating) Quiet <3
54
Hct %
20% acceptable Goal 25-28% Optimal viscosity = 30% Admin PRBCs after patient off bypass
55
How often to check labs after bypass initiated?
Q30min | ABG & ACT
56
Cardioplegia Solution
``` 4°C Reduces cardiac metabolism Contains KCl 26mEq/L → depolarization Glucose 43.9g/L Mannitol 12.5g/L NaHCO3 2.67mEq/L Methylprednisolone Na+ 1g/L Normosol-R pH 7.6 Osmolality 480mOsm/Kg H2O ```
57
When does V-fib occur? | Hint: Temperature °C
25-30°C
58
When does the heart arrest?
DIASTOLE phase
59
Cardio-Pulmonary Bypass Complications
HoTN ↓SVR Renal ischemia d/t hypo-perfusion and/or hemodilution CVA d/t thrombus in bypass pump (clot or foreign object) Air emboli Thrombocytopenia → extrinsic & intrinsic coagulation pathways activated ↑inflammatory response Altered postop mental status "pump head"
60
What patients are at an ↑risk to experience postop renal compromise?
Pre-existing renal conditions Pump run time > 1hr Elderly
61
Cerebral Protection Mechanisms:
Hypothermia Blood gas management Adequate BP BIS & cerebral oximetry *Emboli 1° culprit → CNS complications
62
When does re-warming the patient begin?
During the last anastomosis Turn on warming blanket Indicates close to coming off bypass 30-40min to re-warm patient
63
Re-Warming
Begins PRIOR to aortic cross-clamp removal When last distal anastomosis in angioplasty procedure All valve sutures are in & knots are being tied down
64
↑temperature ___°C per ___-___ minutes
↑1°C per 3-5 minutes
65
What to anticipate w/ re-warming?
Recall risk - administer amnestic & neuromuscular blocker | Vasodilation ↓BP
66
Preparation to come OFF bypass:
``` Core temperature > 35°C (target 37°C) Check labs: ABG, ACT, electrolytes, CBC+ 1. Correct K+ 2. Acid base balance 3. Hct% Inflate the lungs w/ manual ventilation Perform de-airing maneuvers Remove aortic cross-clamp Ensure HR > 90bpm (pacing as required) Perfusionist slowly clamps the venous line & turns down flows to allow R atrium to fill - Monitor PA & A-line pressures (anticipate ↑) Pump off & venous cannula clamped = OFF bypass Monitor CO via TEE, PA (re-float Swan Ganz), A-line ↑SvO2 indicates ↑O2 demand or ↓delivery Shivering → administer muscle relaxant Turn ventilator on Perform recruitment maneuvers PRN ```
67
Hyperkalemia Treatment
CaCl 500mg
68
Magnesium
2-4 grams | ↓A fib risk
69
How to restart the heart?
Surgeon administers "hot shot" warm cardioplegia solution w/o K+ after removing the cross-clamp Unsuccessful? Attempt internal shock or pacing
70
Blood Glucose Goals
< 200 180-200 ↑risk sternal wound infections w/ uncontrolled blood glucose levels
71
Diabetic response to bypass:
↑glucose on bypass | Regular insulin gtt
72
When providing recruitment breaths & manual ventilation what does the anesthetist need to monitor for?
Pressures < 30cmH2O | Internal mammary/thoracic artery anastomosis → LAD
73
Aortic Cross-Clamp Time
Prolonged cross-clamp time α postop morbidity
74
Normal patient response to aortic cross-clamp removal:
Paradoxical myocardial damage & limit recovery extent d/t free radicals released from the site (anaerobic metabolism) Slow release As blood flow returns, metabolites will be washed out
75
Aortic Cross-Clamp | Complications
Hemorrhage at the cannulation site Atheromas (clots) dislodgement Aortic dissection
76
What does ST elevation indicate?
``` Myocardial supply & demand mismatch → ischemia Air trapped in the heart - Notify the surgeon - De-airing maneuvers - Needle insertion by surgeon ```
77
Open Chest Defibrillation
10-30 joules
78
Assessments when coming OFF bypass:
Contractility - heart filling & rhythm TEE - volume, wall motion, valve function Inspect for bleeding Systemic α pulmonary artery pressure
79
Protamine Dosage
1mg per 100 units Heparin
80
Protamine Administration
SLOWLY via peripheral line | Potential to cause pulmonary HTN & R heart failure
81
Post-Bypass Complications
``` Recall Neurocognitive changes Bleeding - ↓clotting factors, fibrinolysis, thrombocytopenia, surgical blood loss, transfusion reaction, vessel trauma, & anaerobic metabolites Organ hypo-perfusion Emboli or thrombi Systemic inflammatory response Residual hypothermia ```
82
Protamine
Multiple low-molecular weight proteins derived from salmon sperm Neutralizes & reverses Heparin effects → Heparin-Protamine complex
83
Protamine Half-Life
30-60 minutes | Potential to experience "Heparin rebound"
84
When to check ACT after Protamine administration?
15-30 minutes
85
Protamine Type I | Allergic Reaction
Histamine release → HoTN Prevent w/ slow administration over 20-30min Treat w/ volume or inotrope
86
Protamine Type II | Allergic Reaction
IgE antibody mediated | Bronchoconstriction presents as anaphylactic reaction
87
Protamine Type III | Allergic Reaction
Heparin-Protamine complex lodges in the pulmonary circulation → pulmonary HTN & R ventricle failure Prevent w/ administering slowly via peripheral vein
88
Closing the Chest
Cardiac tamponade type scenario where the heart squished & patient unable to tolerate → open back up ↓BP Monitor TEE & hemodynamics
89
Transport to ICU
``` Ambu-bag O2 tank Monitors Emergency drugs Keep surgical table sterile Transport assistance Re-check breath sounds Attach to ventilator 100% FiO2 ```

AS - N934 Advanced Principles II (18 decks)

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