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Methods of Anesthesia II > Congenital Heart Disease > Flashcards

Congenital Heart Disease Flashcards

1
Q

atresia

A

opening in the body that has been narrowed or closed of valves

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2
Q

coarctation

A

narrowing

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3
Q

cor pulmonale

A

right ventricular hypertrophy (RVH)

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4
Q

infundibulum

A

muscle below the pulmonic valve

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5
Q

palliative surgery

A

operation intended to decrease severity of symptoms until pt can tolerate operation to fix condition

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6
Q

when is palliative surgery particularly common?

A

pediatric heart operations

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7
Q

BT shunt

A

blaylock-taussig shunt

artificial connection between aortic arch and pulmonary artery (artificial ductus arteriosus)

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8
Q

infective endocarditis

A

infection of the heart chambers or valves

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9
Q

why is the risk of infective endocarditis in patients with congenital heart disease important?

A

prophylactic antibiotics have been recommended for patients who need to undergo operations
(unrepaired, palliated or corrected they all need it)

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10
Q

compensating polycythemia

A

abnormally high Hct

-pts with congenital heart disease suffer from hypoxia and they make more red blood cells to compensate

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11
Q

what are pts with compensating polycythemia more at risk for?

A

thrombosis

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12
Q

paradoxical embolism

A

embolism that travels to the left side of the heart via ASD or VSD and is in arterial circulation (stroke!!)

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13
Q

where does a normal embolism travel

A

travel to the lungs and stay on the right side of the heart/pulm artery

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14
Q

what do anesthetists need to be very vigilant about when there is a risk for paradoxical embolism?

A

air bubbles in IV line

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15
Q

cardiac shunt

A

abnormal blood flow pathways from one side of the heart to another

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16
Q

what are the 4 possible cardiac shunts?

A

patent foramen ovale (PFO)
patent ductus arteriosus (PDA)
Atrial septal defect (ASD)
ventricular septal defect (VSD)

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17
Q

affect of increase SVR on cardiac shunt

A

more left to right shunt

increase pulmonary blood flow

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18
Q

affect of decrease in SVR on cardiac shunt

A

more right to left shunt

worsen hypoxemia

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19
Q

affect of increase PVR on cardiac shunt

A

more right to left shunt

worsen hypoxemia

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20
Q

affect of decrease PVR on cardiac shunt

A

more left to right shunt

increase pulmonary blood flow

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21
Q

are patients with right to left or left to right shunts more prone to have compensating polycythemia?

A

pts with right to left shunt because they have more hypoxia

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22
Q

what can the R-to-L shunt/hypoxemia be worsened by?

A

increases in PVR

decreases in SVR

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23
Q

what increases PVR?

A

hypoventilation

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24
Q

what can we do to decrease PVR?

A

higher FiO2

modest hyperventilation

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25
Q

what decreases SVR?

A

anesthetic agents (regional and general) titrate slowly

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26
Q

what induction agent can be used to maintain SVR?

A

ketamine

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27
Q

can you do single shot spinal anesthetic with right to left cardiac shunt?

A

no it is contraindicated

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28
Q

in a right to left cardiac shunt how will the inhalational induction speed change?

A

slower
blood from R will enter L without picking up agent
dilutes vapor in arterial blood

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29
Q

in a right to left cardiac shunt how will the intravenous induction speed change?

A

faster

drugs get to the L side of the heart faster

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30
Q

in a patient with right to left cadiac shunt what is the alteration to epidural catheter placement?

A

MUST use saline for loss of resistance

for risk of air in vein getting into systemic circulation

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31
Q

what does the left to right cardiac shunt do to pulmonary blood flow?

A

promotes excessive pulmonary blood flow

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32
Q

what can excessive pulmonary blood flow lead to?

A

increase PVR
right ventricular hypertrophy
right heart failure

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33
Q

what can the L-to-R shunt/pulm congestion be worsened by?

A

decreases in PVR

increases in SVR

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34
Q

How is the anesthetic inhalation induction effected in the L-to-R shunt?

A

minimally (if any)

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35
Q

how is the anesthetic intravascular induction affected in the L-to-R shunt?

A

slightly prolonged

it is slightly diluted

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36
Q

how should we change preload in a L-to-R shunt?

A

preload maintained to limit the amount of left to right shunting

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37
Q

eisenmengers syndrome

A

eventually the pressure in the right heart becomes large enough that the shunt converts to a right to left shunt.

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38
Q

is eisenmengers syndrome more likely with high or low PAP?

A

higher PAP

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39
Q

which do you need to be extremely vigilant in preventing intravenous air bubbles? R-to-L shunt or L-to-R shunt?

A

BOTH

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40
Q

when managing a congenital heart disease patient what should you ask?

A

does this pt have too much pulm blood flow OR not enough pulm blood flow?
what can I do to correct that?

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41
Q

if the patient has too much pulm blood flow how can we decrease left to right shunting?

A

increase PVR
hypoventilate
lower fiO2
decrease SVR

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42
Q

if the patient doesnt have enough pulm blood flow how can we improve left to right shunting?

A

increase SVR
decrease PVR
hyperventilate
increase Fio2

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43
Q

patent ductus arteriosus

A

ductus arteriosus never closed after birth

**some congenital heart disease having a PDA is necessary for survival

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44
Q

before birth how does the blood flow through the ductus arteriosus?

A

right to left shunt

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45
Q

after birth how does the blood flow through the ductus arteriosus?

A

left to right shunt

46
Q

if no other defects are present how should blood flow through the PDA?

A

left to right

increasing pulm blood flow

47
Q

what is different about a patient with a PDAs blood pressure?

A

low diastolic blood pressure

48
Q

anesthetic management of pt with PDA 3

A

1 measures to decrease left to right shunt and limit pulmonary congestion
2 up to 3 doses of indomethacin to close PDA
3 invasive monitoring is not essential in uncomplicated PDA

49
Q

what should the fiO2 and PaCO2 be for a patient with a PDA?

A

low FiO2

PaCO2 40-50mmHg

50
Q

surgical repair of PDA

A

ligation via left VATS

51
Q

preductal circulation

A

blood flow to areas of the body proximal to the ductus arteriosus

52
Q

postductal circulation

A

blood flow to areas of the body distal to the ductus arteriosus

53
Q

if the ductal connection is distal to the subclavian then the preductal circulation includes 3

A 
head (left common carotid)
right arm (brachiocephalic)
left arm (left subclavian)
54
Q

if the ductal connection is distal to the subclavian then the postductal circulation includes

A

lower extremities and abdomen

55
Q

if the ductal connection is proximal to the subclavian then the preductal circulation includes 2

A

head

right arm

56
Q

if the ductal connection is proximal to the subclavian then the postductal circulation includes

A

left arm

lower extremities and abdomen

57
Q

where should you take a preductal blood sample from?

A

RIGHT radial artery

58
Q

where should you take a postductal blood sample from?

A

artery in leg: femoral, dorsalis pedis, or posterior tibial artery

59
Q

if preductal oxygen saturation is significantly different from postductal oxygen saturation what does that suggest?

A

a heart defect with right to left shunting across a PDA

60
Q

Patient foramen ovale

A

foramen ovale never closed after birth

61
Q

how is blood expected to shunt in a PFO?

A

left to right

62
Q

anesthetic management for patient with PFO 2

A

1 decrease left to right shunting to limit pulmonary congestion
2 should not allow any air in IV

63
Q

surgical repair of PFO

A

intravascular right atrial disc deployed

64
Q

atrial septal defect

A

ASD is hole between right and left atria

LARGER PFO

65
Q

anesthetic management of pt with ASD

A

higher preload
elevated PVR
lower SVR

66
Q

ventricular septal defect

A

hole between left and right ventricles

67
Q

anesthetic management of pt with VSD

A

higher preload
elevated PVR
lower SVR

68
Q

surgical repair of VSD

A

open surgery with a patch placed

69
Q

Ebsteins Anomaly

A

malformation of tricuspid valve that results in tricuspid regurg= high right atrial pressure and right atrial enlargement

70
Q

what other defect is more likely to occur when the pt has ebsteins anomaly

A

ASD (perforated foramen ovale)

Right to left shunt

71
Q

how does blood shunt with ebsteins anomaly and ASD?

A

right to left

72
Q

anesthetic management of ebsteins anomaly

A 
decrease PVR
increase SVR
hyperventilate
supplementary oxygen 
avoid air bubbles in IV line at all costs
73
Q

what will the patients SpO2 be for ebsteins anomaly with ASD?

A

lower b/c it is mixed venous/arterial blood

74
Q

what would the hypoxemia in ebsteins anomaly cause?

A

compensating polycythemia

75
Q

eisenmengers syndrome

A

left to right shunt reverses into a right to left shunt

76
Q

clinical implication of eisenmengers syndrome

A

once it develops cyanosis ensures with varying degrees of heart failure
HIGH RISK for surgery

77
Q

anesthetic management for left to right shunts that have possible eisenmengers physiology 3

A

1 maintain SVR and PVR
2 fine balance managing oxygenation
3 single shot spinal is contraindicated

78
Q

coarctation of aorta

A

narrowing of the aorta distal to the left subclavian artery

79
Q

postductal coartation of the aorta %

A

more common 95% of cases

80
Q

what will a coarctation of the aorta do to cardiac output? what does this lead to?

A

severe decrease

poor peripheral perfusion, metabolic acidosis, high afterload, CHF, aortic regurg

81
Q

what will be the difference in blood pressures from the upper extremities and lower extremities in coarctation of the aorta

A

BP in upper extremities will be HIGHER than the lower extremities

82
Q

if the patient has a preductal coarctation of the aorta then what other defect is vital to increase CO?

A

PDA to boost CO via right to left shunt

83
Q

if the patient has a preductal coarctation of the aorta and PDA what is the affect on SpO2 for the upper and lower extremities?

A 
upper= normal sp02
lower= low sp02
84
Q

anesthetic management for coarctation of aorta

A

SVR maintained
preload maintained
bradycardia avoided
avoid abnormally high contractility or HR

85
Q

what will increase the risk of aortic dissection in a pt with coarctation of the aorta?

A

abnormally high contractility or HR

86
Q

2 options for surgical repair of coarctation of the aorta

A

balloon angioplasty

resection with end to end anastamosis

87
Q

interrupted aortic arch

A

aorta isnt fully developed and there is a gap between ascending and descending aorta

88
Q

in order for a pt with interrupted aortic arch to survive what two other defects must they have?

A

PDA

ASD or VSD

89
Q

where does the oxygenated blood from the left ventricle perfuse? interrupted aortic arch pt

A

right upper extremity and part of the head

90
Q

where does blood flow to the lower extremities come from in a pt with interrupted aortic arch?

A

right ventricle through PDA

mixed venous/arterial blood

91
Q

how do the blood pressure, pulse and spO2 differ from right arm to left arm

A

normally higher in the right because the interruption is usually proximal to the left subclavian

92
Q

anesthetic management for interrupted aortic arch

A 
keep ductus arteriosus patent
maintain preload
maintain SVR
maintain HR (avoid tachy and brady)
93
Q

surgical repair for interrupted aortic arch

A

aorta 1 attached to aorta 2

PDA and VSD closed

94
Q

what are the 4 defects of tetralogy of fallot?

A

1 pulmonic stenosis (right ventricular outflow tract obstruction RVOT)
2 right ventricular hypertrophy
3 VSD
4 overriding aorta

95
Q

in tetralogy of fallot how does the blood shunt?

A

right to left across the VSD

96
Q

what type of blood is perfusing the body through the overriding aorta in TOF patient

A

mixed venous/arterial blood and has a lower than expected sp02

97
Q

what are the 2 reasons that pulmonary blood flow is limited in a TOF pt?

A

1 pulm valve is stenotic

2 infundibulum is abnormal and causes stenosis below the valve as well

98
Q

what are the two ways for blood to get to the lungs in patients with TOF?

A

stenotic pulm valve

PDA (left to right shunt)

99
Q

is a PDA necessary for life sustaining pulm blood flow in a patient with TOF?

A

YES

100
Q

what are the two reasons that patients with TOF are hypoxic?

A

blood flow to lungs is limited

blood flowing through aorta is mixed venous/arterial blood

101
Q

what are the two primary ways to improve pulmonary blood flow and decrease hypoxia in patients with TOF?

A

1 keep PDA open
2 decrease amount of right to left shunt
(maintain/elevate SVR; keep PVR low)

102
Q

tet spell

A

sudden onset life threatening hypoxic spell in pts with TOF

103
Q

what are tet spells caused by

A

infundibular spasm

subsequent increase in right to left shunt

104
Q

pt that is experiencing a tet spell can do what at home to help?

A

squat or use valsalva maneuver

105
Q

causes of infundibular spasm 3

A

1 tachycardia and increases in contractility
2 hyperventilation (with spontaneous ventilation)
3 hypovolemia

106
Q

why does spontaneous hyperventilation cause an infundibular spasm?

A

decreases intrathoracic pressure with increases venous return and increases right to left shunt

107
Q

how does hypovolemia cause a infundibular spasm?

A

underfilled heart decreases diameter of RVOT

108
Q

treatment for tet spell 7

A

1- 100% O2
2- child in a knee chest position
3- fluid bolus to enhance preload
4- consider ketamine or phenylephrine increase SVR
5- consider moderate hyperventilation mechanically reduce PVR
6- consider beta blocker
7- avoid beta agonists when trying to raise blood pressure

109
Q

anesthetic managment for tetralogy of fallot 7

A

1- PDA kept open
2- promote pulm blood flow and minimize right to left shunt
3- hypotension avoided on induction
4- phenylephrine or ketamine when cyanotic
5- sympathetic stimulation minimized
6- avoid air bubble in IV line
7- preload maintained/elevated with volume

110
Q

surgical repair of TOF

A

initially BT shunt placed in palliative surgery

eventually surgery to repair VSD and repair/replace pulmonic valve

111
Q

TGA

A

transposition of the great arteries
RV pumps to aorta
LV pumps to pulm artery

Methods of Anesthesia II (13 decks)

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