CV IV

Question 1

Pathophysiologic processes that affect arteries include what three things?

Answer 1

Pathophysiologic processes that affect arteries:***

• -Plaque formation
• -Thrombosis (acute tissue ischemia)
• -Aneurysm formation (weakening of arterial wall)

Question 2

Symptoms associated with peripheral occlusive disease

include what four things?

Answer 2

Symptoms associated with peripheral occlusive disease

Claudication, skin ulcerations, gangrene, and impotence

Question 3

Extent of disability is influenced with development of what blood flow?

Answer 3

Extent of disability is influenced with development of collateral blood flow*** (collateral circulation will sufficiently meet tissue oxygen demands)

Question 4

As the disease process progresses limb ischemia becomes what?

Answer 4

As the disease process progresses limb ischemia becomes symptomatic requiring therapeutic intervention

Question 5

Treatment for peripheral occlusive disease include?

Answer 5

Treatment for peripheral occlusive disease:
Pharmacolgic therapy
Surgical therapy:
Transluminal angioplasty
Endarterectomy
Thrombectomies
Multiple bypass procedures

Question 6

What is the anesthetic selection for a patient with peripheral vascular disease?

Answer 6

Anesthetic selection:

• -Anesthetic technique depends on type of surgical procedure and presence of coexisting disease
• -Local anesthetic and IV conscious sedation
• -Regional anesthesia (on lower extremities may decrease morbidity)
• -General anesthesia

Question 7

What are the postoperative consideration for a patient peripheral vascular disease?

Answer 7

Postoperative considerations:

• -Postoperative pain management an important issue
• –Administration of narcotics (contributes to cardiac stability)
• –Epidural opioids and local anesthetics

Question 8

ANESTHESIA FOR SURGERY ON THE AORTA
Surgery on the aorta presents unique challenges to anesthesia care providers
Procedure complicated by what two things?

Answer 8

ANESTHESIA FOR SURGERY ON THE AORTA
Surgery on the aorta presents unique challenges to anesthesia care providers
Procedure complicated by:
—Need to cross-clamp the aorta
—Potential for large intraoperative blood loss

Question 9

Aortic cross-clamping: ** w/o CBP will do what to LV and comprises what distally to the point of occlusion?

Answer 9

Aortic cross-clamping: ** w/o CBP will

• —Acutely increases LV afterload; Will cause severe HTN, myocardial ischemia, LV failure, or aortic valve regurgitation***
• –Comprises organ perfusion distal to the point of occlusion; interruption of blood flow to the spinal cord and kidneys can produce paraplegia and renal failure

Question 10

Most serious complication with an aortic dissection?

Answer 10

Most serious complication is aneurysm rupture*****

Question 11

Anesthesia for aneurysms of the ascending and transverse aorta requires what?

Answer 11

Anesthesia for aneurysms of the ascending and transverse aorta requires cardiopulmonary bypass**

Question 12

Treatment of dissecting aortic lesions:

Proximal dissections nearly always treated surgically and requires what?

Answer 12

Treatment of dissecting aortic lesions:

Proximal dissections nearly always treated surgically (require CPB)*****

Question 13

Aortic aneurysms mostly commonly involve what part of the aorta?

Answer 13

Most commonly involve the abdominal aorta**

Question 14

What are the etiologies for aortic aneurysms?

Answer 14

Etiologies; atherosclerosis*, medial cystic necrosis, rheumatoid arthritis, spondyloarthropathies, and trauma

Question 15

What is the greatest danger for aortic aneurysms, the formation of what?

Answer 15

Pseudoaneurysm formation*** (intima and media are ruptured)

Question 16

What is the normal aorta width in adults?

Answer 16

Normal aorta in adults: 2-3 cm in width***

Question 17

Atherosclerotic process usually generalized affecting other portions of what system?

Answer 17

Atherosclerotic process usually generalized affecting other portions of the arterial system

Question 18

Aortic trauma may result in what?

Answer 18

May result in massive hemorrhage and require immediate surgical intervention

Question 19

Aortic trauma injury can vary from a partial tear to what?

Answer 19

Injury can vary from a partial tear to a complete aortic transection

Question 20

Patients who undergo major vascular surgery are frequently what type of population and have varying degrees of concurrent disease

Answer 20

Patients who undergo major vascular surgery are frequently elderly and have varying degrees of concurrent disease

Question 21

Preoperative evaluation for patients going to have major vascular surgery should have Special attention should be directed toward what three functions in the body?

Answer 21

Special attention should be directed toward cardiac, renal, and neurologic function

Question 22

Preoperative renal dysfunction directly related to what postoperatively?

Answer 22

Preoperative renal dysfunction directly related to postoperative renal failure

Question 23

What is mandatory for intra-operative monitoring device?

Answer 23

Direct intra-arterial blood pressure monitoring

Question 24

What intra-operative monitoring device should you have that is not really mandatory for aortic trauma?

Answer 24

• -Pulmonary artery pressure monitoring
• -Transesophageal echocardiography (two-dimensional)
• -In-dwelling urinary catheter
• –Double-lumen ETT (if needed) inserted for one-lung ventilation to expose the descending thoracic aorta

Question 25

Which artery should you use for monitor arterial blood pressure for surgery on the ascending aorta?

Answer 25

Left radial artery used to monitor arterial blood pressure

Question 26

For surgery involving the aortic arch, additional considerations focus on achieving optimal cerebral protection are?

Answer 26

Additional considerations focus on achieving optimal cerebral protection: - -Systemic and topical hypothermia (15°C) - --Thiopental infusion (used to maintain a flat ECG) - -Methylprednisolone or dexamethasone - -Mannitol - -Phenytoin

Question 27

For surgery involving the aortic arch, long rewarming periods contribute to what?

Answer 27

Long rewarming periods contribute to intraoperative blood loss

Question 28

For surgery involving the aortic arch, rocedures usually performed through a median sternotomy and what else?

Answer 28

Procedures usually performed through a median sternotomy with deep hypothermic circulatory arrest (following CPB)

Question 29

Aorta must be cross-clamped above and below the lesion, what happens above and below it, in terms of bp?

Answer 29

Aorta must be cross-clamped above and below the lesion: Acute HTN develops above the clamp Hypotension below the clamp

Question 30

With surgery involving the descending thoracic aorta, what happens during cross-clamping with the LV?

Answer 30

Sudden increase in LV afterload during cross-clamping may precipitate acute LV failure and myocardial ischemia and exacerbate pre-existing aortic regurgitation******

Question 31

With surgery involving the descending thoracic aorta, what happens to CO and LVEDP?

Answer 31

CO falls and LVEDP and volume rise

Question 32

With surgery involving the descending thoracic aorta, Hemodynamic instability following release of the aortic cross-clamp (release hypotension) due to what?

Answer 32

Hemodynamic instability following release of the aortic cross-clamp (release hypotension) due to: - --Abrupt decrease in afterload - --Bleeding - --Release of vasodilating acid metabolites

Question 33

What is the major complication of clamping the thoracic aorta?

Answer 33

Major complication of clamping the thoracic aorta is spinal cord ischemia and paraplegia

Question 34

What is a contributing factor to paraplegia in clamping the thoracic aorta?

Answer 34

Use of nipride to control the hypertensive response to cross-clamping implicated as a contributing factor

Question 35

What are Other protective therapeutic measures to prevent paraplegia in surgeries that involving clamping of the thoracic aorta?

Answer 35

``` Other protective therapeutic measures:** Methylprednisolone Mild hypothermia Mannitol Drainage of CSF ```

Question 36

What monitor can you use and device can you use to help prevent paraplegia as a complication of clamping the thoracic aorta?

Answer 36

- Monitoring somatosensory evoked potentials | - Use of temporary heparin-coated shunt or partial CPB with hypothermia

Question 37

Increased incidence of renal failure following aortic surgery associated with what three things?

Answer 37

Increased incidence of renal failure following aortic surgery associated with: - Emergency procedures - Prolonged cross-clamp periods - Prolonged hypotension

Question 38

What three cardiac function should you maintain with patients going through aortic surgery to prevent renal failure?

Answer 38

Maintain adequate cardiac function: - Preload - Contractility - Systemic perfusion pressure

Question 39

What meds can you use for patients with going through aortic surgery to reduce renal failure?

Answer 39

- Infusion of mannitol (0.5 g/kg) prior to cross-clamping - Low (renal)-dose dopamine - Fenoldopam infusions (rapid acting vasodilators)

Question 40

What two approaches can you have with surgery on the abdominal aorta?

Answer 40

SURGERY ON THE ABDOMINAL AORTA | Anterior transperitoneal or anterolateral retroperitoneal approach

Question 41

Where can the crooss-clamp be applied to for an abdominal aorta? (three ways)

Answer 41

Cross-clamp can be applied to the supraceliac, suprarenal, or infrarenal aorta**

Question 42

What drug is necessary before occlusion before abdominal aorta?

Answer 42

Heparinization prior to occlusion is necessary

Question 43

What kinda of blood pressure monitoring do you need for surgery on the abdominal aorta?

Answer 43

Intra-arterial blood pressure monitoring

Question 44

Farther distally the clamp is applied the less effect on what part of the heart will you have?

Answer 44

Farther distally the clamp is applied, the less effect on LV afterload****

Question 45

What should the fluid replacement be guided by? and how much fluid should you be giving?

Answer 45

Fluid replacement guided by CVP or PA monitoring (10-12ml/kg)

Question 46

What drug should you use for renal prophylaxis with patients undergoing surgery on the abdominal aorta?

Answer 46

Renal prophylaxis with mannitol

Question 47

What type of anesthesia can you use in conjunction with general anesthesia with patients undergoing surgery on the abdominal aorta? (hint: its a block)

Answer 47

Epidural anesthesia (before heparin and stop heparin way after the coags are back to normal) (concerned with epidural hematoma) in conjunction with general anesthesia

Question 48

What is the initial emphasis in postoperative care that should be focused on with patients that went through abdominal aortic surgery? two things

Answer 48

Initial emphasis in postoperative care should be on maintaining hemodynamic stability and monitoring for postoperative bleeding

Question 49

With endovascular aortic aneurysm repair, what does the graft do in terms of blood flow?

Answer 49

Graft restricts blood flow to the portion of the aorta in which the aneurysm exists

Question 50

What is a less invasive approach to endovascular aortic aneurysm repair?

Answer 50

Deployment of an endovascular stent graft within the aortic lumen Performed for descending thoracic aortic aneurysms or abdominal aortic aneurysms

Question 51

What should your anesthesia appoarch be with a patient undergoing endovascular AAA repair?

Answer 51

Administration of anesthesia: Endovascular AAA repair: Neuraxial blockade or local anesthesia and sedation

Question 52

What should your anesthesia appoarch be for a patient undergoing endovascular thoracic aortic aneurysm repair?

Answer 52

Administration of anesthesia: Endovascular thoracic aortic aneurysm repair: General anesthesia

Question 53

For anesthesia with carotid artery surgery, what does ischemic strokes usually result from?

Answer 53

Ischemic strokes are usually the result of thrombosis or embolism in one of the blood vessels supplying the brain

Question 54

With patients under going carotid artery surgery what symptom should be stable and well controlled??

Answer 54

Angina should be stable and well controlled

Question 55

What two clinical status (disease process) should be optimized for someone undergoing carotid artery surgery?

Answer 55

Optimize clinical status in terms of co-existing diseases - --Uncontrolled preoperative HTN** (can cause more issues post op if uncontrolled) - --Uncontrolled hyperglycemia*** (want to control this, if not controlled, it will increase cerebral ischemic injury)

Question 56

Where should your MAP before for patients undergoing carotid artery surgery?

Answer 56

MAP maintained at or slightly above usual range***