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Anesthesia Basics > Ch. 25 Cardiovascular Disease > Flashcards

Ch. 25 Cardiovascular Disease Flashcards

1
Q

Most common symptom of cardiac disease in men is ______ and in women is ______.

A

men - SOB w/ exercise, women - fatigue

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2
Q

What does ventriculography determine?

A

ejection fraction

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3
Q

What does dipyridamole-thallium scintigraphy mimic?

A

coronary vasodilator response (but not heart rate response associated with exercise)

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4
Q

Name some cardiac tests that may be performed on some patients

A

ECG, exercise stress test, TTE, TEE, radionuclide ventriculography, dipyridamole-thallium scintigraphy, cardiac catheterization, angiography

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5
Q

What are the two most valuable tools for predicting adverse outcomes in cardiac patients?

A

H&P and EKG

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6
Q

What are the five most common coexisting noncardiac diseases associated w/ CAD?

A

HTN, PVD, COPD (from cigarette smoking), renal dysfxn from chronic HTN, DM

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7
Q

Patients may remain asymptomatic despite ____ to ____% stenosis of coronary arteries.

A

50-70%

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8
Q

What is the most striking evidence of decreased cardiac reserve?

A

limited exercise tolerance in the absence of pulmonary disease

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9
Q

What are some symptoms of significant cardiac disease?

A

inability to lie flat, awakening from sleep with angina or SOB, angina at rest or w/ minimal exertion

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10
Q

What does dyspnea following onset of angina indicate?

A

LV dysfunction due to myocardial ischemia

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11
Q

Does silent MI cause angina? What percentage MI’s are silent?

A

No; approxmately 15%.

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12
Q

What patient populations have a higher frequency of silent MI?

A

women and diabetics

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13
Q

What are the two main reasons that tachycardia leads to MI?

A

Increases myocardial O2 demand and decreases time of perfusion

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14
Q

Why are elective surgeries often delayed 2-6 months after an MI?

A

Incidence of myocardial reinfarction increases the closer it has been since an MI.

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15
Q

If a patient is taking beta blockers after a previous MI, should they be continued prior to surgery?

A

Yes. When followed for 7 days after, it decreases the risk of mortality 50%.

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16
Q

Does perioperative clonadine reduce mortality risk in patients who’ve had a previous MI?

A

Yes. It reduces 30-day and 2-year mortality risks.

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17
Q

Is it advisable to continue statins with fluvastatin prior to surgery for a patient whose had a previous MI?

A

Yes

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18
Q

Risk of myocardial reinfarction increases when the procedure is greater than __ hours?

A

3

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19
Q

What are the 5 risk factors for CAD?

A

age 60+, HTN, DM, smoking, hyperlipidemia

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20
Q

All patients with CAD, PVD, or two CAD risk factors should have what?

A

perioperative beta-blocker unless there is a specific contraindication

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21
Q

What is a good subsitute for beta-blockade in patients who are contraindicated?

A

clonidine (or dexmed?)

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22
Q

Which drugs should be continued in the perioperative period for patients who’ve had a previous MI?

  • beta-blockers
  • Ca++ channel blockers
  • nitrates
  • statins
A

All decrease risk of perioperative M&M

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23
Q

ST segment greater than ____ confirms the presence of myocardial ischemia.

A

1mm

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24
Q

What level of cholesterol is considered hyperlipidemia?

A

> 240mg/dL

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25
Q

If a patient has a contraindication to perioperative beta-blockade, what drug should be substituted and how should it be administered?

A

Clonidine

  • 0.2mg PO night before + TTS#2 (0.2mg/24hr) patch
  • 0.2mg PO morning of surgery
  • leave patch on for a week
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26
Q

What if a patient is identified as having CAD, PVD or two of the risk factors the morning of surgery?

A

administer IV atenolol or metoprolol in pre-op clinic unless systolic is under 100 or HR is less than 50

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27
Q

Name two scenarios in which a patient should be seen by cardiology

A

patients with aortic stenosis; patients with intracoronary stents on platelet inhibitors

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28
Q

Should platelet inhibitors be continued in patients with intracoronary stents?

A

Yes, it can be lethal otherwise, especially in recent stents

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29
Q

Patients with bare metal stints typically need to be on antiplatelet therapy for how long?

A

3+ mo

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30
Q

Patients with drug-eluting stints typically need to be on antiplatelet therapy for how long?

A

1yr+

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31
Q

Three cases in which beta-blockers are contraindicated?

A

AV block (hi-grade) w/o pacemaker, reactive asthma, intolerance to beta-blockade

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32
Q

Periop beta blockers should be continued for at least _____ postop?

A

7 days

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33
Q

Which of a patient’s medications should not be taken preoperatively?

A

oral hypoglycemic drugs

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34
Q

What induction drug should be avoided in cardiac patients?

A

Ketamine because of it’s increase in HR and BP

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35
Q

Why should you be careful with desflurane in cardiac patients?

A

Increasing the level quickly can cause sympathetic stimulation, leading to tachycardia, pulmonary HTN, MI and bronchospasm

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36
Q

Which volatile causes sympathetic stimulation when increased quickly?

A

desflurane

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37
Q

What drug would be a good choice to add when a difficult intubation on a cardiac patient is anticipated?

A

tracheal lidocaine to reduce sympathetic response to DL

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38
Q

What is coronary steal?

A

Regional myocardial ischemia associated with drug-induced vasodilation. Arteries in ischemic areas are already fully dilated, so vasodilation could divert blood to other areas.

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39
Q

What effect does pancuronium have that is noteworthy in cardiac patients?

A

Increases HR/BP (less than 15% above predrug values). May offset opioid decrease in BP/HR

40
Q

Why might glyco be a better choice than atropine for reversal?

A

glyco has more titratable chronotropic effects than atropine

41
Q

Which drug is a good choice for myocardial ischemia with normal BP?

A

nitroglycerin (rather than SNP)

42
Q

Should patients with DM receive periop beta-blockade?

A

Yes, DM is an indication

43
Q

Mitral stenosis is associated with what arrhythmia?

A

mitral stenosis –> distended atria –> afib

44
Q

Valvular diseases often develop from what condition? How long can they be asymptomatic

A

rheumatoid fever, can be asymptomatic for 20-30 years

45
Q

If a patient is taking digitalis for mitral stenosis, should it be continued perioperatively?

A

yes

46
Q

If a patient is taking warfarin for mitral stenosis, should it be continued perioperatively?

A

it should be switched to heparin

47
Q

Why should fluid volumes be carefully monitored in patients with mitral stenosis?

A

Pulmonary hypertension may already be present due to fluid backup. Adding more volume could increase the risk of pulmonary edema and LV failure.

48
Q

Are there any positioning considerations for people with mitral stenosis?

A

Trendelenburg may not be well tolerated due to increased pulmonary volume

49
Q

What are situations when a patient may have acute mitral regurgitation?

A

papillary muscle dysfunction or rupture of chordae tendonae after MI

50
Q

Hemodynamically significant aortic stenosis is associated with pressure gradients of?

A

less than 50mmHg across the aortic valve (or valve areas less than 1.2cm2

51
Q

Why is it important to maintain sinus rhythm with aortic stenosis patients?

A

too low (100bpm) decreases ejection time and decreases time for perfusion

52
Q

(hyper/hypo)tension should be avoided in patients with aortic stenosis?

A

hypotension

53
Q

A code can be extra deadly with a patient who has ____ because

A

aortic stenosis; chest compressions likely will not generate adequate stroke volume across the stenosed valve - use a defibrillator

54
Q

Which volatile is a concern with patients who have aortic stenosis? Why?

A

all of them, because they all depress sinus node automaticity, which can lead to junctional rhythm and improperly timed atrial contractions

55
Q

______ has a roughly equivalent affect on the LA as aortic regurgitation does on the LV

A

mitral valve prolapse

56
Q

With what valvular disease should you avoid events that increase cardiac emptying?

A

mitral valve prolapse

57
Q

What are three perioperative events that increase cardiac emptying?

A

sympathetic system innervation; decreased SVR; sitting or reverse-Trendelenburg position

58
Q

Preoperative evaluation of a patient with a pacemaker includes:

A

determine why they have pacemaker; assess its function, brand, model, magnet mode; check programmer availability and availability of person who can operate it

59
Q

What are some devices that are under the skin that are not pacemakers?

A

deep brain stimulators, AICD’s, IV pumps, spinal stimulators for chronic pain, bladder stimulators for neurogenic bladder, gastric stimulators for obesity, IV ports, vagal stimulators for sleep

60
Q

What devices need to be inactivated for surgery?

A

automated defibrillators

61
Q

What is essential HTN?

A

sustained increases in systemic BP (systolic >160 or diastolic >90) independent of a known cause

62
Q

With CHF patients, the goal is to minimize detrimental effects on ____?

A

cardiac output

63
Q

Which are preferable to maintain BP in a patient with CHF: inotropes or vasoconstrictors?

A

vasoconstrictors

64
Q

What is hypertrophic cardiomyopathy?

A

obstruction to LV outflow produced by asummetrical hypertrophy of the IV septal muscle

65
Q

What is the goal of treatment of patients with hypertrophic cardiomyopathy?

A

decrease pressure gradient across LV outflow obstruction

66
Q

What are CV differences between primary and high-potency opioids?

A

primary opioids don’t produce myocardial depression and can decrease SVR; high potency opioids stimulate the vagus nerve, lower HR, and can decrease sympathetic stimulation

67
Q

What is cor pulmonale? How does it occur?

A

RV hypertrophy; secondary to chronic pulmonary HTN

68
Q

What are some ways to decrease pulmonary HTN?

A

prostaglandins, endothelin receptor antagonists, inhaled NO, inhaled milrinone, type 5 PDE inhibitors, soluble guanylate cyclase activators

69
Q

Nitrous oxide has what effect on pulmonary vascular resistance?

A

increases it

70
Q

What are changes seen in cardiac tamponade?

A

decreases in diastolic filling P; decreases in SV; decreases in systemic BP

71
Q

What is cardiac tamponade?

A

accumulation of fluid in pericardial space

72
Q

Why might vasodilation be deadly in a patients who have cardiac tamponade?

A

Pressure in central veins needs to exceed pressure in RV or else there will be no cardiac output

73
Q

Why is GA with positive-pressure ventilation a concern in patients who have cardiac tamponade?

A

It can cause profound HoTN, decreased venous return and myocardial depression leading to death

74
Q

What is the primary objective in treating a patient who has cardiac tamponade?

A

draining the pericardium

75
Q

How fast should induction, intubation and drainage of the pericardium occur in a patient who has cardiac tamponade?

A

ideally under 60s

76
Q

Why might a patient with cardiac tamponade have cardiogenic shock?

A

stroke volume is decreased due to increased pericardial pressure

77
Q

Elective repair of an abdominal aneurysm is recommended when the estimated diameter of the aneurysm is more than _____ because __________.

A

5cm; the incidence of spontaneous rupture increases dramatically when the size exceeds this

78
Q

What is a benefit to gradual release of the aortic cross-clamp?

A

systemic decreases in BP are minimized

79
Q

The checklist prior to going on bypass follows what acronym?

A

HADDSUE “had to sue”

80
Q

What are the items on the checklist prior to going on bypass?

A

Heparin, ACT (450+), Drugs, Drips, Swan (pull back 5cm), Urine, Emboli (any visible in cannula?)

81
Q

What are common CPB temperatures at what stages?

A

18C prior to circulatory arrest, 28C prior to cross-clamping, maintained at 33C, rewarmed to 37C

82
Q

What is the hematocrit typically during surgery?

A

20-30%

83
Q

What is the usual initial dose of heparin prior to CPB?

A

300-400units/kg

84
Q

The ACT is typically maintained at above ____ during CPB.

A

450s

85
Q

A mixed venous PO2 less than ___ is associated with metabolic acidosis and inadequate tissue perfusion

A

30mmHg

86
Q

Why is bladder temperature superior to rectal temperature?

A

it better reflects core temperature

87
Q

What is cardioplegia? How is it accomplished?

A

cessation of the heart for CPB achieved with K+containing cardioplegia solution

88
Q

If hyperkalemia persists following CPB, how should it be treated?

A

with insulin (10-20units) and glucose (25-50units) IV (or Lasix)

89
Q

How is SVR calculated?

A

SVR = 80 x (MAP – CVP)/CO

90
Q

What is the most common hemodynamic abnormality following CPB?

A

low SVR

91
Q

How is acute mitral regurgitation treated?

A

reverse Trendelenburg

92
Q

People who take what medication may be at increased risk of protamine reaction? Why?

A

Diabetes who take NPH insulin because it contains protamine

93
Q

Ways to reduce protamine allergic reaction? (other than pressors, fluids)

A

histamine blocker (H1 benedryl), H2 blocker cimetidine, steroid (hydrocortisone)

94
Q

What is a good position for off-pump CABG?

A

steep Trendelenburg with right tilt

95
Q

Should patients undergoing off-pump CABG continue antiplatelet therapy preoperatively?

A

yes, with the exception of aspirin

Anesthesia Basics (13 decks)

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