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N934: Advanced Principles of Anesthesia > Exam 3 Cardiac > Flashcards

Exam 3 Cardiac Flashcards

(99 cards)

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1
Q

What needs to be evaluated pre-operatively in patients having cardiac surgery?

A

cardiac history
past surgical history
angina presentation
dysrhythmias
past medical history
co-morbid diseases
medications

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2
Q

When asking a patient about their cardiac history, what is prevalent?

A

severity of disease/ hemodynamic status
catheterization, ECHO, ECG reports
what is the baseline disease? (low EF, LVEDP, pulmonary HTN, valvular & congenital lesions, CHF)

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3
Q

What preoperative testing needs to be completed prior to cardiac surgery?

A

cardiac catheterization (locate blockages)
ECG: recent MI
ECHO report (EF, valve function, wall abnormalities, calcified aorta, atrial thrombus (no CVA)
Hematologic studies (Pt, ptt, baseline ACT)– clotting studies, platelet # and functionality (TEG)
CXR: calcifed aorta, cardiomegaly
renal function: decreased function increases post op mortality
liver function test: CPB my hypo-perfuse liver
T/C

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4
Q

What medications need to be continued?

A

antiarrhythmics
calcium channel blockers
beta blockers
nitrates

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5
Q

What are the goals of cardiac anesthesia? (4)

A

decrease cardiac oxygen utilization
maintain oxygen supply
anticoagulation
maintain BP in target range

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6
Q

How do you decrease cardiac oxygen utilization?

A

anesthesia, hypothermia, electrical silence, cardioplegia use, empty cardiac chambers, specifically in the LV (avoid distention)

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7
Q

How do you maintain oxygen supply?

A

maximize oxygen carrying capacity and flow
Hemodilution is acceptable perfusion pressure and flow

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8
Q

Describe myocardial protection strategies

A

cardioplegia induced systole
hypothermia
hemodilution

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9
Q

What is cardioplegic induced systole

A

electrical and mechanical activity ceases
potassium given continuously during cross clamping
must be able to cross clamp aorta (calcifications/clots present?)
blood vs. clear prime
hyperkalemia is issue with renal patients

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10
Q

How does hypothermia protect the myocardium?

A

alters platelet function and reduces fibrin enzyme function
inhibits initation of thrombin formation
reduces metabolic demands and increases tolerance to ischemia

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11
Q

Describe hemodilution’s role in myocardial protection?

A

increases flow due to decreased blood viscosity

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12
Q

List the order of events for a CAGB (15)

A

pre-operative preparation
monitors
lines
induction
wait
incision
drop lungs
sternotomy
surgical dissection
cannulation
on-bypass
off bypass
dry- up: give protamine
close chest
ICU

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13
Q

What monitors are needed for cardiac surgery? (7)

A

pulse ox
TEE
ECG (leads 2 and 5)
temperature
ABP (usually radial, sometimes femoral)
CVP (mandatory for infusion of drugs)
PA catheter

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14
Q

When do patients require a PA catheter?

A

severe LV dysfunction
profound pulmonary HTN

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15
Q

What does a transesophageal echo assess? (8)

A

evaluation of ventricular filling, estimation of cardiac output, assessment of ventricular systolic and diastolic function, valvular pathology, cardiac tamponade, calcified aorta, atrial thrombus

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16
Q

What interventions can a TEE help guide?

A

volume administration
start vasoactive drips
re-examine graft
assessment of surgical repair

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17
Q

What are contraindications for a TEE?

A

esophageal pathology (Alcoholic varices)
empty stomach prior to placing tube

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18
Q

When do you know the swan catheter has entered the pulmonary artery?

A

the waveform shows an increase diastolic pressure in the PA vs the RV

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19
Q

What are complications of the PAC/Swan? (11)

A

ventricular arrhythmias
heart block
pneumothorax
unintended arterial punction
valve damage
hematoma/ thromboembolism
vascular injury
perforation of thorax leading to hemothorax
PA rupture
cardiac tamponade
BSI

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20
Q

What patients have an increased risk of heart block with a Swan catheter?

A

LBBB

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21
Q

What is the most common acute injury of a PA catheter?

A

unintended arterial puncture

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22
Q

When is a pneumothorax from a PA catheter placement most common?

A

subclavian approach

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23
Q

What are the goal pre-bypass hemodynamics?

A

BP between 20% of patient’s baseline
HR between 40-80 are generally fine depending on situation prior to bypass

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24
Q

What are hemodynamic goals pre-bypass for aortic stenosis?

A

maintain preload
maintain SVR
HR 50-80
NSR

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25
What are the hemodynamic goals of pre-bypass for aortic regurgitation?
Forward, fast and full maintain preload Low SVR HR 50-80 NSR
26
What are the hemodynamic goals of pre-bypass for mitral stenosis?
Maintain preload maintain SVR HR 50-80 NSR
27
What are the hemodynamic goals of pre-bypass for mitral regurgiation?
maintain preload HR 50-80 NSR low SVR
28
What is needed for OR set up in cardiac cases? (6)
airway/ equipment pacemaker drips (NTG/NTP, E/NE, Phenylephrine/epedrine, dopamine/dobutamine, antiarrhythmics- esmolol, labelotol, magnesium, amiodarone) heparin and coagulation monitoring emergency drugs PRBCs magnesium insulin drip antifibrinolytics
29
Pre-induction patient preparation (7)
Nasal Cannula mild sedation PIVs x2, arterial line baseline ABG and baseline ACT cross matched blood placed external defibrillation pads prior to induction make sure team is aware rolling back
30
When can propofol be safely used for induction?
patients with ischemic and valvular heart disease
31
Describe the use of ketamine during induction
CV effects are advantangous Biggest challenge is CV stimulation
32
What needs to be avoided during induction and CPB?
N2O
33
Describe the effect of VAs during cardiac anesthesia (6)
produce dose dependent global cardiac depression negative effects of volatile anesthetics are due to alterations in intracellular Ca++ sensitized myocardium to the effects of EPI in varying degrees may prevent or faciliate atrial or ventricular arrhythmias during myocardial ischemia or infarction produce weak coronary artery dilation and depresses baroreceptor reflex control of arterial pressure
34
How can you treat hypertension from incision?
deepen anesthetic, vasoactive agents (NTG, NTP)
35
Discuss events from incision to bypass (7)
intense surgical stimulation hypertension handling of heart by surgeon bleeding can be significant identifying and localizing ischemia drop lungs for sternotomy arterial and saphenous veins are harvested
36
What is the MOA of heparin?
binds to antithrombin 3 and potentiaes its natural anticoagulant properties
37
What is the dose of heparin prior to initating bypass?
300-400u/kg wait 3-5 minutes for ACT
38
What is a normal ACT
<130seconds (80-120)
39
What is the goal ACT during CPB
400-450
40
How is the heparin administered for bypass?
CVP or RA
41
What can happen to the patient's hemodynamics after the administration of heparin?
decrease in SVR and BP by 10-20%
42
What are two special circumstances with the administration of heparin?
AT3 deficiency (FFP or thrombate 3) HIT (antiplatelet antibodies lead to platelet aggregation and potentially life threatening thromboemoblic events
43
Describe interventions need post heparinzation, but pre-bypass
drop BPs prior to aortic cannulation fluid administration via perfusionist in arterial line cannulation of coronary sinus for retrograde cardioplegia Make sure patient is adequately paralyzed
44
Where are the cannulas for bypass placed?
aorta (arterial), RA (venous)
45
What can happen while placing the venous cannula?
BP drop, arrhythmias
46
What are frequently encountered problems pre-bypass?
arrhythmias (d/t cardiac manipulation and cannulation) (first sign of myocardial ischemia) HTN Hypotension heart failure sternotomy lacerates RV or aorta causing bleeding
47
What occurs when transitioning to CPB?
perfusionist opens the venous clamp > blood drains passively into venous reservoir, immediately begins to cool patient
48
What does the CRNA needs to do after transitioning to CPB? (5)
arterial trace goes flat, ECG present pull back PAC 2-3 cm look at head for swelling check pupils andBIS stop ventilator once heart is empty
49
What occurs when the patient is placed on pump?
significant hemodilution and decrease in O2 carrying capacity Hct 20% acceptable
50
What is hemodilution associated with on pump?
decreased viscosity, decreased SVR and promotes blood flow to tissues
51
What is important to measure prior to coming off CPB?
urine
52
What are issues related to CPB
HTN related to SVR renal ischemia from hypoperfusion and/or hemodilution CVA from thrombus in CPB system (clot or foreign object) Air emboli introduced into CPB system thrombocytopenia increased inflammatory response altered post-op mental state (pump head)
53
What are two processes an inflammatory process is trigger in cardiac surgery?
surgical perfusion technology pharmacology
54
How does surgery trigger the inflammatory process?
aortic manipulations minimally invasive approach bank blood utilization duration of CPB
55
How does perfusion trigger the inflammatory process?
ultrafiltration shed-blood management circuit prime volume beating-heart technique
56
How does technology trigger the inflammatory process?
roller/centrifugal open/closed circuits surface coating selective filtration
57
How does pharmacology trigger the inflammatory process?
steroids statins others
58
What are signs of inflammation? (initators) (2)
systemic cytokine signaling and complement system activation expression of cell adhesion molecules
59
What are signs of inflammation? (effectors) (2)
margination of neutrophils, monocytes, and platelets release of granule proteases
60
What are the biggest culprits of emobli?
hypothermia blood gas management adequate BP cerebral oximetry
61
When will re-warming begin?
prior to aortic cross clamp removal OR last distal anastomosis in angioplasty procedure OR all the valve sutures are in and knots are being tied down
62
Describe what needs to be prepared for coming off bypass? (13)
core temperature above 35 correct labs, ABG (fix K first) inflate lungs removal of cross clamp defibrillation pace around 90 (av or v paced) venous return line clamped slowly, turn down flows and allow RA to fill measure CO, monitor PA and arterial line pressures monitor SvO2 (supply and demand balance) shivering (paralyze) airway (turn vent on)
63
Off bypass means
when pump comes off and venous cannula clamped
64
When coming off cross clamp, what can occur?
myocardial damage and limit extent of recovery
65
What are complications of an aortic cross clamp?
hemorrhage (at cannulation site), dislodgement of clots, aortic dissection
66
What is voltage is used to defibrillate a patient during cardiac surgery
10-30J
67
What is important to assess when coming off bypass?
CONTRACTILITY watch with eyes, look at TEE (volume, wall motion, valve function)
68
What interventions are made coming off bypass?
inspection for bleeding protamine adminstered slowly
69
What can type of scenerio can occur when the chest is closed?
cardiac tamponade
70
What is the dose of protamine needs to come off bypass?
1mg/100U of heparin
71
What are challenges to coming off CPB? (7)
recall and neurocognitive changes bleeding organ hypoperfusion non-pulsatile flow, emobli, thrombi systemic inflammatory response residual hypothermia
72
What makes it harder to come off CPB?
extend CPB and aortic cross clamp times may require IABP
73
Why does bleeding occur after CPB?
loss of clotting factors fibrinolysis thrombocytopenia surgical blood loss transfusion reaction vessel trauma metabolic byproducts
74
What are reperfusion interventions?
spend time paying back by re-perfusing the empty heart at adequate perfusion pressure (20-30 minutes) allows heart to recover by washing out metabolic by products correct metabolic abnormalities
75
What can protamine cause?
R heart failure pulmonary HTN administer slowly
76
What is the MOA of protamine
neutralize and reverse effects of heparin so heparin is unable to form a complex with ATIII
77
What type of allergic reactions cause histamine release?
1-3
78
WHat is the heparin rebound?
Half life of protamine is shorter then heparin therefore after 30-60 minutes may need to trend ACTs or correct
79
What do you need to transport a post CABG to the ICU?
ambu bag, o2 tank ECG, arterial line, emergency drugs
80
What is the typical recipient for a heart transplant?
NYHA functional class IV, life expectancy <12 months, EF<20%
81
What is the most common implication for heart transplant?
idiopathic cardiomyopathy
82
What are contraindications for a heart transplant?
>70Y, chronic renal disease, obesity
83
What is the anesthetic goal of heart transplantation?
go on CPB as fast as possible
84
What are anesthesia considerations for heart transplant?
timed so CPB is inititated when heart is available preop- VAD, IABP, ICD, inotropic drug infusion considered full stomach lines prior to induction smooth rapid control of airway slow adminstration of medications maintain HR and intravascular volume, avoid decrease in SVR adhere to immunosuppression
85
What medications should be available for heart transplnat?
E/isoproterenol, milrinone, nitric oxide, inhaled prostagladins vasopressin preserves SVR without effect on PVR
86
What are anesthestic considerations post-transplant?
loss of parasympathetic tone-> fast HR Direct acting myocardial adrenergic agents inotropes and vasoconstrictors available for HR BP And CO support volume dependent, frank starling mechanism still intact accelerated CAD w/o angina 2 p waves
87
What are the anesthetic considerations for off pump CABG?
immobilzation of the heart by compression and/or suction prevent hypotension and reduced coronary artery perfusion
88
How do you prevent hypotension and reduced CPP in off pump CABG?
volume load, head down, pressors
89
What is a MIDCAB? (minimally invasive direct coronary artery byass)
grafting of a single vessel LIMA to LAD
90
What is required in MIDCAB?
lung isolation with double lumen endbronchial tubes off pump case left anterior thoractomy incision
91
Anesthetic implications for minimally invasive aortic and mitral valve replacements
good preload, decrease HR arrhythmias CPB needs to be available decrease heparin dose needs to have defibrillation pads DLT for lung isolation femoral cannulation transvenous pacing (placed and tested) pads on central venous access
92
Anesthetic implications for total aortic valve repair/ total aortic valve implanation
approached through femoral artery or transapical (apex of left ventricle) IV sedation or GETA large bore IV, arterial line, central access TEE/TTE external defibrillator pads (R2 pads) vasopressors
93
What are blood conservation strategies in cardiac surgery?
anti-fibrinolytic drugs, minimizing hemodilution, cell saver, retrograde priming of pumo, normovolemic hemodilution, POC testing to support transfusion
94
What pathways are activated in cardiac surgery?
intrinsic and extrinsic
95
How is platelet function loss?
hemodilution, hypothermia, contact with CPB circuit
96
WHy does right ventricular dysfunction or failure occur after CPB?
inadequate myocardial protection or inadequate revascularization wiht resultant right ventricular ischemia
97
How do CNS insults occur?
micro-emboli, cerebral hypoperfusion and SIRS
98
What can increase the risk of post operative renal dysfunction?
renal insufficiency, Type 1Dm, vascular pathology and nephrotoxic agents
99
What does a midline sternotomy (or thoractomy) cause?
reduction in total lung capacity, vital capacity, and force expiratory volume

N934: Advanced Principles of Anesthesia (16 decks)

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