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N934 Adv Principles Fa 21 > Cardiac Anesthesia Part 1 continued and Part 2 > Flashcards

Cardiac Anesthesia Part 1 continued and Part 2 Flashcards

1
Q

what are the beneficial effects of mannitol as part of the pump prime solution

A

acts as an O2 free radical scavenger and a diuretic

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2
Q

what does hemodilution mean in relation to catecholamines

A

it also means a decrease in catecholamines

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3
Q

define the blood salvage strategy

A

mix the patients autologous blood with the prime solution

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4
Q

what does the LV vent do

A

drains thesbian veins

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5
Q

where does anterograde cardioplegia catheter go?

A

in the aortic root and sits proximal to cross clamp

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6
Q

where does retrograde cardioplegia catheter go?

A

coronary sinus

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7
Q

which comes first, cardiac arrest or cross clamp?

A

heart is arrested in diastole then cross clamp is applied. this is to ensure cardioplegia goes to the heart

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8
Q

what is long pump time associated with (neuro)

A

postoperative cognitive disorder

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9
Q

what are risks associated with postoperative renal dysfunction after bypass (6)

A

age, preexisting CKD, long pump time (>1h), DM1, nephrotoxic agents, vascular pathology

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10
Q

there is an activation of what and an increase in these two things on bypass

A

activation of extrinsic and intrinsic pathways

increase in angiotensin and free O2 radicals

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11
Q

when do you start re warming the patient

A

after seeing the last distal graft in. turn on warming blanket at this time

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12
Q

how long does it take to re warm a patient safely

A

30-40 minutes or about 1 degree celsius q3-5 minutes

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13
Q

where do you want to keep the BG to prevent infection

A

<200

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14
Q

how many joules for defibrillation after removal of cross clamp?

A

10-30 joules ( you may dial this in)

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15
Q

when do you start to turn on fluids and pressors while coming off of bypass

A

after lung reinflation (and de airing maneuvers), before cross clamp removal

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16
Q

what is an acceptable HCT while coming off pump

A

25-28

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17
Q

what do you give to decrease K

A

500mg CaCl

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18
Q

what do you give to prevent arrhythmias and decrease risk of afib

A

2-4g magnesium

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19
Q

special considerations if they did an internal mammary artery (/thoracic artery) to LAD while coming off bypass?

A

when inflating lungs, you can overstretch anastomosis easily. be aware

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20
Q

complications to aortic cross clamp (3)

A

hemorrhage (at cannulation site)
dislodgement of atheromas (clots)
aortic dissection

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21
Q

what do ST changes tell you as you are unclamping the aortic cross clamp?

A

tells the surgeon to look at the TEE for infarct versus air

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22
Q

when is the patient at the most risk for recall during CPB surgery

A

graft harvest, sternotomy, rewarming

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23
Q

dont give protamine until

A

all catheters are out. you want to make sure you do NOT have to go back on bypass

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24
Q

if the cardiac output is decreased but the blood pressure is ok, what would you consider

A

after load reduction or inotrope

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25
how slowly do you give protamine
over 20-30 minutes
26
which ACT number would alert you that they need protamine
>150
27
type 1 reaction from protamine
histamine release. slow the protamine, give volume, give neo/ephedrine PRN
28
type 2 reaction from protamine
IgE mediated, more like anaphylaxis but "not too problematic". bronchoconstriction can occur
29
type 3 reaction from protamine
heparin protamine complex that lodges in pulmonary circulation. bad. not good.
30
do you give protamine via CVC or PIV
always PIV, never CVC
31
if you see a drop in BP during chest closure, what should you consider administering
an inotrope
32
typical heart transplant recipient picture
``` NYHA functional class IV with a predicted life expectancy <12 months EF <20% ```
33
most common indication for a heart transplant
idiopathic cardiomyopathy
34
contraindications to receiving a heart transplant
>70 years old, chronic renal dysfunction, obesity
35
how is the anesthetic management timed for a transplant recipient
timed so CPB initiated when heart is available
36
what to look for pre op with heart transplant recipients
VAD, IABP, ICD, inotropic drug infusions
37
what type of induction, standard versus RSI for the transplant recipient?
RSI, considered full stomach since you "never know when youre receiving a heart". you want smooth rapid control of airway but do slow administration of medications
38
goal before heart arrives
get patient on CPB as fast as possible
39
when do you place lines on a heart recipient
before induction
40
maintain these three things to maintain CO for a heart recipient
HR and intravascular volume maintenance. | avoid a decrease in SVR
41
what do these patients take for an immunosuppressant protocol
high dose steroid and immunosuppressant drug
42
most common reason for inability to wean from CPB
right hear failure
43
medications you need to anticipate requiring for heart transplant
isoproterenol, epinephrine, phosphodiesterase inhibitors (milrinone), nitric oxide, inhaled prostaglandins
44
vasopressin in relation to SVR and PVR
preserves SVR without effect of PVR
45
post heart transplant HR
faster due to loss of parasympathetic tone
46
which receptors do you need to target for a post heart transplant patient to see an effect
need direct action on myocardial adrenergic receptors. basically make sure all of your drugs are direct acting
47
what are post heart transplant patients dependent on
volume (preload)
48
does the frank starling mechanism still apply post heart transplant to a denervated heart
yes
49
what are these heart transplant patients at risk for and how do they present
accelerated atherosclerotic disease. they dont have angina but will get arrhythmias
50
will you see bradycardia from fentanyl and anticholinergics in a denervated heart
no
51
are all reflexes post transplant gone?
no, some reflexes will be maintained
52
describe an off pump CABG (OPCAB)
immobilization of the heart by compression and/or suction of vessels theyre looking to treat
53
how to prevent hypotension and reduced coronary perfusion during an OPCAB
volume load head down pressors -theres alot of hemodynamic changes with this approach so youre doing alot of utilization of these three mechanisms during this approach
54
what to consider as a negative effect of suction during OPCAB
can compromise native coronary artery flow
55
monitors and equipment to have during OPCAB
still use TEE | have bypass on standby
56
do you do heparin during OPCAB
may use low dose heparin
57
do you still do a sternotomy for an OPCAB
yes
58
describe a minimally invasive direct coronary bypass (MIDCAB)
grafting of single vessel ex) LIMA to LAD
59
what is the surgical approach to a MIDCAB
you can do this alot of ways including left anterior thoracotomy incision requiring one lung ventilation or even a Da Vinci approach
60
ventilation strategy for a MIDCAB?
lung isolation with double lumen ETT
61
is a MIDCAB an on pump case?
no, off pump for this case
62
MIDCAB HR, preload, Vt considerations
decrease HR to decrease VO2 increase preload decrease Vt if not OLV
63
what medication should you have available for a MDICAB?
heparin
64
what should you have on the patient during a MIDCAB
defibrillation pads (and bypass on standby)
65
describe the surgical approach to a minimally invasive aortic and mitral valve replacement
can either do parasternal, thoracoscopy, partial hemisternotomy
66
where does the bypass insert on a patient receiving a minimally invasive aortic/ mitral valve replacement
femoral artery/femoral vein. there is apparently decreased bleeding related to this approach
67
access for a mini AVR and MVR procedure?
CVC
68
ventilation for a mini AVR and MVR procedure?
OLV/ DLT for lung isolation
69
two things to have on patient during mini AVR and MVR
transvenous pacers placed and tested | defibrillator pads
70
where else can a TAVR/TAVI be done
EP
71
approach to a TAVR/TAVI?
femoral artery or transapical (apex of LV)
72
anesthesia technique for TAVR/TAVI
can do IV sedation but usually GETA
73
access for a TAVR/TAVI?
large bore PIV, aline, CVC | may need fluoro to put in lines
74
TTE or TEE for TAVR/TAVI?
TEE if GETA, TTE if IV sedation
75
what should you have on the patient getting TAVR/TAVI
defibrillator pads
76
medications to have on standby during TAVR/TAVI
pressors
77
blood consideration strategies in cardiac surgery include (6)
``` antifibrinolytic drugs minimizing hemodilution cell saver retrograde priming of pump normovolemic hemodilution use of POC testing to support transfusion ```
78
platelet function is altered by these three things during cardiac bypass surgery
hemodilution hypothermia contact with CPB circuit
79
right ventricular dysfunction or failure may occur after CPB because of
inadequate myocardial protection or | inadequate revascularization with resultant RV ischemia
80
approaches to reduce inflammatory response during cardiac surgery
modification of surgical and perfusion techniques circuit components pharmacological strategies
81
even after uncomplicated cardiac surgery, a midline sternotomy (or thoracotomy) causes a significant reduction in these 3 pulmonary components
TLC, VC and FEV

N934 Adv Principles Fa 21 (23 decks)

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