Cardiovascular pathophysiology 3

Question 1

Identify the anesthetic considerations for constrictive pericarditis (Select 2).
a. Kussmaul’s sign is usually present
b. it is most commonly caused by a virus
c. afterload should be reduced
d. bradycardia should be avoided

Answer 1

a. Kussmaul’s sign is usually present
d. bradycardia should be avoided

Question 2

The _______ surrounds the heart.

Answer 2

Pericardium

Question 3

What three conditions affect the pericardium?

Answer 3

acute pericarditis
constrictive pericarditis
cardiac tamponade

Question 4

Acute pericarditis is usually the result of

Answer 4

inflammation

Question 5

Acute pericarditis does not _______________ unless inflammation leads to constrictive pericarditis or cardiac tamponade.

Answer 5

reduce diastolic filling

Question 6

Constrictive pericarditis is caused by

Answer 6

fibrosis or any condition where the pericardium becomes thicker

Question 7

Treatment for constrictive pericarditis is

Answer 7

pericardiotomy

Question 8

Anesthetic considerations for constrictive pericarditis include

Answer 8

avoiding bradycardia, preserving contractility, and maintaining afterload

Question 9

The pericardium is composed of

Answer 9

two layers: the visceral layer is attached to the myocardium
the parietal layer is anchored in the mediastinum

Question 10

The most common cause of acute pericarditis is

Answer 10

infection (viral)

Question 11

S/S of constrictive pericarditis includes

Answer 11

Kussmaul’s sign- JVD during inspiration
Pulsus paradoxus (decreased SBP > 10 mmHg during inspiration)
Increased venous pressure–> distended neck veins, hepatomegaly, ascites, peripheral edema
atrial dysrhythmias
pericardial knock

Question 12

The most common complication of pericardiotomy is

Answer 12

hemorrhage and dysrhythmias

Question 13

Treatment for acute pericarditis is

Answer 13

it usually resolves spontaneously
drugs are given to relieve pain

Question 14

Symptoms of acute pericarditis include

Answer 14

pericardial friction rub
ST elevation with normal enzymes
fever
acute chest pain with pleural component

Question 15

Identify the components of Beck’s triad (select 3).
a. increased pulmonary artery occlusion pressure
b. hypotension
c. tachycardia
d. jugular vein distension
e. muffled heart tones
f. mill wheel murmur

Answer 15

b. hypotension
d. jugular vein distension
e. muffled heart tones

Question 16

Pericardial effusion is the

Answer 16

accumulation of fluid inside the pericardial sac

Question 17

Pericardial effusion is not _______________ and seldom requires __________

Answer 17

an emergency; intervention

Question 18

_______ is the best method of diagnosis for pericardial effusion

Answer 18

TEE

Question 19

What is the difference between pericardial effusion and cardiac tamponade?

Answer 19

cardiac tamponade also results from fluid accumulation inside the pericardium, however the pericardial pressure is high enough to compress the myocardium

Question 20

Clinical presentation of cardiac tamponade includes

Answer 20

Beck’s triad
pulsus paradoxus
Kussmaul’s sign
reduced EKG voltage

Question 21

Describe Beck’s triad.

Answer 21

fluid accumulation in the pericardial sac–> muffled heart tones
decreased venous return to the right heart–> jugular venous distension
decreased stroke volume–> hypotension

Question 22

What is Kussmaul’s sign?

Answer 22

JVD on inspiration
increased CVP

Question 23

A patient with blunt chest trauma presents for pericardiocentesis. He exhibits jugular venous distension and Kussmaul’s sign. What is the best induction agent for this patient?
a. propofol
b. etomidate
c. ketamine
d. midazolam

Answer 23

C. Ketamine

Question 24

Surgical management of cardiac tamponade includes

Answer 24

pericardiocentesis (needle aspiration)
pericardiostomy

Question 25

What type of anesthetic is preferred for cardiac tamponade surgery?

Answer 25

local anesthesia over GA (d/t better hemodynamic stability)

Question 26

If GA is required for cardiac tamponade, what drugs should be used?

Answer 26

drugs that preserve myocardial function: ketamine nitrous oxide benzodiazepines opioids

Question 27

What should be done in regards to heart rhythm, preload, afterload, and contractility with cardiac tamponade?

Answer 27

maintain NSR preload afterload & contractility

Question 28

What kind of ventilation is preferred with cardiac tamponade surgery?

Answer 28

spontaneous ventilation over PPV

Question 29

What are the three approaches to pericardiostomy?

Answer 29

subxiphoid thoracoscopic thoracotomy

Question 30

Complications of pericardiostomy and pericardiocentesis include

Answer 30

pneumothorax re-accumulation of pericardial fluid puncture of the coronary vessels or myocardium

Question 31

A patient present to the preoperative clinic with a previous history of infective endocarditis. Which procedure puts this patient at the HIGHEST risk of an adverse outcome? a. cystoscopy b. colonoscopy c. dental implant d. coronary stent placement

Answer 31

c. dental implant

Question 32

Infective endocarditis is typically a

Answer 32

bacterial infection of the heart valves and endocardium

Question 33

Antibiotic prophylaxis against endocarditis is NOT required for

Answer 33

mitral valve prolapse CABG or coronary stent placement

Question 34

IV antibiotics for IE prophylaxis cinlude

Answer 34

ampicillin cefazolin ceftriaxone clindamycin

Question 35

The current ACC/AHA guidelines advocate for antibiotic prophylaxis only if the patient is

Answer 35

at higher risk of developing IE- risk is a function of patient and surgery related factors

Question 36

Patient-factors that increase risk for infective endocarditis include

Answer 36

history of IE, prosthetic heart valve, and certain congenital heart defects repaired congenital heart defect if the repair is <6 months old unrepaired cyanotic congenital heart disease heart transplant with valvuloplasty repaired CHD with residual defects that have impaired endothelization at the graft site

Question 37

Surgery-related factors that increase risk for infective endocarditis includ

Answer 37

"dirty" procedures such as dental procedures with gingival manipulation, certain respiratory procedures, and biopsies of infected lesions

Question 38

Which intervention is MOST likely to precipitate hemodynamic instability in the patient with obstructive hypertrophic cardiomyopathy? a. esmolol b. nitroglycerin c. phenylephrine d. 500 mL 0.9% NaCl bolus

Answer 38

b. nitroglycerin

Question 39

_______________ is the most common cause of sudden cardiac death in young athletes.

Answer 39

Hypertrophic cardiomyopathy

Question 40

Hypertrophic cardiomyopathy leads to _____________ during systole.

Answer 40

left ventricular outflow tract obstruction

Question 41

Causes of left ventricular outflow tract obstruction include

Answer 41

congenital hypertrophy of the interventricular septum systolic anterior motion of the anterior leaflet of the mitral valve

Question 42

Common conditions that worse LVOT include

Answer 42

decreased preload increased contractility decreased afterload

Question 43

Key treatments for worsening LVOT include

Answer 43

beta-blockers calcium channel blockers fluids phenylephrine

Question 44

What are all the names for hypertrophic cardiomyopathy?

Answer 44

obstructive hypertrophic cardiomyopathy hypertrophic obstructive cardiomyopathy asymmetric septal hypertrophy idiopathic hypertrophic subaortic stenosis

Question 45

What are the three determinants of blood flow through the LVOT?

Answer 45

systolic LV volume the force of LV contraction the transmural pressure gradient

Question 46

Conditions that distend the LVOT are _____________, while things that narrow the LVOT are

Answer 46

good; bad

Question 47

What will narrow the LVOT?

Answer 47

decreased systolic volume increased contractility decreased transmural pressure

Question 48

Surgical options for LVOT include

Answer 48

mitral valve replacement (can reduce SAM) septal myomectomy removes a portion of the septum and improves the transmural pressure gradient alcohol injection into the septal perforator arteries causes ischemic injury to the septum and improves the transmural pressure gradient