Cardiac anesthesia 3

Question 1

Preventing emboli for cerebral protection includes

Answer 1

hypothermia
blood gas management
adequate BP
cerebral oximetery

Question 2

After coronary anastomosis, you will start to

Answer 2

rewarm patient b/c it takes 30-40 minutes to gradually rewarm

Question 3

Rewarming begins

Answer 3

prior to aortic cross-clamp removal
with last distal anastomosis in angioplasty procedures or when all the valve sutures are in and knots are being tied down

Question 4

_______ may occur during rewarming so it is important to give

Answer 4

amnestic drug

Question 5

In preparation for coming off bypass, core temperature MUST be

Answer 5

above 35 degrees C (eventual target is 37 degrees C)

Question 6

Preparing to come off of bypass includes correction of

Answer 6

labs, ABG

-fix K+ first, then acid-base & hematocrit

Question 7

Describe the steps for coming off of bypass.

Answer 7

temperature
correct labs
inflate lungs
removal of cross clamp
defib
heart rate
rhythm 
venous return line clamped slowly
measure CO
monitor SVO2
shivering- give muscle relaxant
airway- turn the vent on!

Question 8

Blood sugar should be maintained

Answer 8

<200 because patients are pone to sternal wound infection

Question 9

Giving_________ results in less risk of afib afterwards

Answer 9

magnesium

Question 10

Removal of the cross clamp involves giving

Answer 10

hot shot (cardioplegia to start heart)

Question 11

Describe the heart rate when coming off of bypass

Answer 11

paced or SR at sufficient rate (80-90 bpm)

Question 12

Describe the rhythm when coming off of bypass.

Answer 12

AV paced or V paced

need adequate rate around 90 (will turn pacing rate down later in ICU)

Question 13

Measuring CO includes

Answer 13

watching TEE for LV failure, monitor PA and arterial line presures

Question 14

Measuring SVO2 is to watch for

Answer 14

increased demand or decreased delivery

Question 15

When the perfusionist begins to turn down flows and allow RA to fill, we should look for

Answer 15

PA and a-line pressures to increase

Question 16

Prolonged cross-clamp time significantly correlates with

Answer 16

major post-operative morbidity

Question 17

When the cross clamp is coming off, reperfusion, although essential to survival, may

Answer 17

paradoxically cause myocardial damage and limit the extent of recovery

Question 18

Complications of aortic cross clamp include

Answer 18

hemorrhage (at cannulate site), dislodgement of atheromas (clots) and aortic dissection

Question 19

ST elevation may indicate

Answer 19

air left in the heart

Question 20

When defibrillating a patient during cardiac surgery (open chest, direct contact defibrillation), defibrillation is typically at

Answer 20

10-30 joules

Question 21

When coming off bypass, give

Answer 21

protamine slowly at 1 mg/100 un of heparin given- wait until all the catheters are out to make sure you don’t crash back onto bypass

Question 22

When the chest is closed, cardiac tamponade may occur, the heart is

Answer 22

squished and team may have to open back up if not tolerated

Question 23

Coming off of bypass includes examining for

Answer 23

contractility
bleeding
systemic pressure in relation to PA pressure

Question 24

Describe contractility related to bypass.

Answer 24

the best monitor we have for coming off bypass is the eye
look at the heart to see how it is filling
heart needs adequate contractility to come off CPB
look at TEE: volume, wall motion, valve function

Question 25

Post CPB challenges include

Answer 25

``` recall and neurocognitive changes bleeding organ hypo-perfusion non-pulsatile blood flow, emboli, thrombi systemic inflammation response residual hypothermia ```

Question 26

Coming off of bypass may require the use of these drugs:

Answer 26

inotrope or afterload reducer

Question 27

Steps for coming off of bypass include:

Answer 27

``` rewarm correct labs deair closing hot shots cross clamp off heart fibrillates--> defibrillate ventilate pt ```

Question 28

Post CPB challenges related to bleeding may be due to

Answer 28

``` loss of clotting factors fibrinolysis thrombocytopenia surgical blood loss transfusion reaction vessel trauma metabolic by products ```

Question 29

Extended CPB and cross-clamp times makes it

Answer 29

HARDER to wean off CPB

Question 30

Reperfusion interventions include:

Answer 30

correct metabolic abnormalities spend time "paying back" by re-perfusing the empty heart at adequate perfusion pressure (typically 20-30 minutes) allows heart time to recover by washing out metabolic by products if exceptionally long clamp time, consider IABP

Question 31

Protamine may cause _________ which is why it is given slowly!!!

Answer 31

pulmonary hypertension and right heart failure

Question 32

protamine works by

Answer 32

neutralizing and reverse effects of heparin, heparin is unable to form a complex with ATIII

Question 33

The half-life of protamine is

Answer 33

shorter than heparin- on the order of 30 to 60 minutes which is the reason for "heparin rebound"

Question 34

Protamine may cause

Answer 34

type I (histamine release), type II (anaphylactoid), or type III (bad) allergic reactions

Question 35

Protamine may be administered via

Answer 35

peripheral vein

Question 36

Protamine has anti-coagulant effects that are not seen until levels of

Answer 36

2-3x the normal reversal dose are given (weak anticoagulant at normal levels)

Question 37

A final ACT should be drawn

Answer 37

15-30 minutes postop to ensure adequate reversal

Question 38

Transport post CPB includes

Answer 38

ambu bag & O2 tank monitor: ECG, arterial line emergency drugs keep surgical table sterile until out of room recheck breath sounds after moving to bed attach to vent in ICU & recheck breath sounds Transport assistance is needed in the form of a surgeon, anesthesiologist or another CRNA