Cardiac anesthesia 2

Question 1

Patient preparation prior to induction includes

Answer 1

oxygen via nasal cannula (NRB facemask if respiratory distress)
evaluate need for mild sedation
line placement
baseline ABG and baseline activated clotting time
cross matched blood
place external defibrillation pads prior to induction
make sure team is rolling back

Question 2

Evaluating the need for mild sedation includes

Answer 2

limiting or avoiding versed based on age & cognitive state preoperatively
fentanyl preferred

Question 3

Line placement prior to induction includes

Answer 3

2 PIVs & arterial line

typically cordis & SWAN placed after induction in stable patients

Question 4

Intraoperative preparation & positioning includes:

Answer 4

supine with legs padded
foam head support
arms tucked at sides and padded
check lines
prep area: from sternal notch to toes
Foley (hook up bladder temperature)
fluid & under-body forced air warmer
rapid infuser (Belmont or "Level-1")
drips spiked and ready to go

Question 5

The prep area includes

Answer 5

sternal notch to toes

Question 6

The best place to measure temperature is

Answer 6

bladder temp

Question 7

Describe the use of propofol as an induction agent.

Answer 7

use safely in patients with ischemic & valvular heart disease
biggest challenge is hypotension

Question 8

Describe the use of etomidate as an induction agent.

Answer 8

may be less likely to cause hypotension than propofol

Question 9

Describe the use of ketamine as an induction agent.

Answer 9

CV effects are advantageous

biggest challenge is CV stimulation

Question 10

Avoid ________ during induction and on CPB!!!

Answer 10

N2O

Question 11

Volatile anesthetics produce dose dependent

Answer 11

global cardiac depression

Question 12

The negative effects of volatile anesthetics are due to

Answer 12

alterations in intracellular Ca++

Question 13

Volatile anesthetics are responsible for sensitizing the myocardium to the effects of _____ in varying degrees

Answer 13

EPI

Question 14

Volatile anesthetics may prevent or facilitate _______ during myocardial ischemia or infarction

Answer 14

atrial or ventricular arrhytmias

Question 15

The perfusionist has a vaporizer on the bypass machine

Answer 15

and thus you should turn off your vaporizer

Question 16

Volatile anesthetics produce weak coronary

Answer 16

artery dilation and depresses baroreceptor reflex control of arterial pressure

Question 17

Pre-incision hypotension considerations include

Answer 17

lack of stimulation
systemic pressure support
risks involved with vasoconstrictors
recall rare at this point, unless severe hypotension occurs in the face of purely opioid technique

Question 18

For induction it is important to proceed

Answer 18

slowly and know your plan

it is not the drug but the way it is given that is important

Question 19

The induction technique may include

Answer 19

either high versus low dose narcotics work

use propofol or other induction agent with low dose narcotics

Question 20

If you anticipate a difficult airway, do not hesitate to

Answer 20

do an awake intubation

-a well planned, well topicalized patient provides the smoothest induction

Question 21

Post induction tasks include

Answer 21

central line (if not placed pre-op)
OG then TEE

Question 22

Veins that are harvested include

Answer 22

arterial and saphenous veins

Question 23

Incision time to bypass is intense

Answer 23

surgical stimuli

hypertension may develop- deepen anesthetic, vasoactive agents- NTG/NTP

Question 24

_______ can be significant with incision

Answer 24

bleeding

Question 25

Considerations for incision include

Answer 25

identifying and localizing ischemia | drop the lungs for sternotomy

Question 26

Prior to bypass, the patient should be

Answer 26

anticoagulated with heparin

Question 27

Heparin works by

Answer 27

binding to antithrombin III and potentiates its natural anticoagulant properties

Question 28

Heparin should be administered via

Answer 28

CVP or directly into RA

Question 29

The dosing of heparin is

Answer 29

weight based dosing at 300-400 units/kg- wait 3-5 minutes for ACT

Question 30

Normal ACT & CPB ACT:

Answer 30

Normal is 130 secs or less (80-120) | ACT of >400-450 for bypass

Question 31

With heparinization, _________ can decrease

Answer 31

SVR & BP can decrease by 10-20%

Question 32

Special circumstances in which heparin should not be used includes

Answer 32

ATIII deficiency- pt unresponsive to heparin; FFP can be given or thrombate III heparin-induced thrombocytopenia, antiplatelet, antibodies which lead to platelet aggregation and potentially life threatening thromboembolic events

Question 33

The ACT needs to be

Answer 33

>400 to go on CPB | -give heparin BEFORE any cannulas are placed

Question 34

Cannulation of the aorta (arterial) and RA (venous) considerations include

Answer 34

must drop the pts BP for aortic cannulation (systolic <90) BP might drop and/or arrhythmias can occur while placing venous cannula the perfusionist can give fluids via the arterial line

Question 35

Pre bypass and post heparinization medications include

Answer 35

medicate patient with midazolam and fentanyl

Question 36

If BP is too high during cannulation of the aorta,

Answer 36

aortic dissection can occur

Question 37

Cannulation of the coronary sinus for retrograde cardioplegia includes

Answer 37

similar effects to cannulation of the aorta & RA with a drop in BP

Question 38

Frequently encountered problems on bypass include

Answer 38

``` arrhythmias heart failure hypertension hypotension heart failure bleeding :sternotomy lacerates RV or aorta ```

Question 39

Hypertension during _______ is most concerning

Answer 39

aortic cannulation d/t risk of aortic dissection

Question 40

Hypotension prior to bypass may be treated with

Answer 40

volume through aortic line via pump

Question 41

Arrhythmias are usually related to

Answer 41

cardiac manipulation and cannulation | -may be the first sign of myocardial ischemia

Question 42

Transitioning to bypass involves the perfusionist opening

Answer 42

venous clamp and allowing blood to drain passively into venous reservoir which immediately begins to cool patient

Question 43

When the patients goes to bypass, the arterial line

Answer 43

tracing goes flat but ECG is still present

Question 44

Prior to going on bypass pull back

Answer 44

2-3 cm on PAC so it is no longer in pulmonary artery and won't cause obstruction

Question 45

When transitioning to bypass, look for

Answer 45

head for swelling- indicate proper placement of venous catheter check pupils & BIS--> thrombus

Question 46

Drugs to consider when transitioning to CPB include

Answer 46

give muscle relaxant to prevent shivering or if mixed venous gas is going down (70-80 is desired) give amnestic drug close down fluids

Question 47

CVP on bypass should be

Answer 47

0-5 possibly even negative

Question 48

______ will decrease on bypass but a marked decrease is concerning

Answer 48

Cerebral oximetry

Question 49

For adults, the CPB machine is primed with

Answer 49

1500-2500 mL of balanced electrolyte solution

Question 50

Albumin, heparin, mannitol, and NaHCO3- is often added to

Answer 50

increase osmolality, reduce edema, and promote diuresis

Question 51

The CPB machine causes significant

Answer 51

hemodilution and a decrease in oxygen carrying capacity occurs

Question 52

Typically a hematocrit of _____ is acceptable when patients are on bypass

Answer 52

20%

Question 53

Hemodilution is associated with

Answer 53

decreased viscosity, decreased SVR, and promotes blood flow to tissues

Question 54

Describe the path of cardiopulmonary bypass.

Answer 54

arterial inflow--> filter--> flow meter--> oxygenator--> heat exchanger--> pump--> bubble detector--> reservoir--> SVO2--> venous return line

Question 55

Cardioplegia is

Answer 55

cold- at 4 degrees C | contains K+- 26 mEq/L

Question 56

The potassium in cardioplegia causes

Answer 56

depolarization of the heart

Question 57

The cold for cardioplegia reduces

Answer 57

metabolism of the heart | vfib occurs at 25-30 degrees C

Question 58

Retrograde cardioplegia is infused via

Answer 58

the coronary sinus

Question 59

Issues related to CPB include

Answer 59

``` hypotension renal ischemia CVA air emobli introduced into CPB system thromboyctopenia increased inflammatory response altered post-op mental state "pump-head" ```

Question 60

Renal ischemia related to CPB occurs due to

Answer 60

hypo-perfusion and/or hemodilution

Question 61

A CVA while on CPB occurs from

Answer 61

thrombus in CPB system (clot or foreign object)

Question 62

Hypotension on CPB is related to

Answer 62

decreased SVR

Question 63

________ failure is mot common after bypass

Answer 63

kidney

Question 64

Cardiac surgery inflammatory response is a result of

Answer 64

surgical factors perfusion factors pharmacology & technological