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Nur 943 OB > Exam 3 CHD 4-5 > Flashcards

Exam 3 CHD 4-5 Flashcards

(97 cards)

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1
Q

Corrective procedure for Transposition of the Great Arteries (Vessels) (TGA)?

A

Arterial Switch

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2
Q

What are the 2 forms of TGA?

A

D-Transposition (Dextrotransposition)

L-Transposition (Levotransposition)

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3
Q

Which type of TGA is most common?

A

D-Transposition

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4
Q

Which type is where misdirected folding of embryonic heart tube- folding to the left side instead of right?

A

L-Transposition

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5
Q

Which type is where the Truncus Arteriosus fails to divide properly?

A

D-Transposition

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6
Q

What is the common origin of the aorta and pulmonary artery?

A

Truncus Arteriosus

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7
Q

Describe what happens with Dextrotransposition of the Great Arteries

A

The Truncus Arteriosus (common origin of the aorta and PA) fails to divide properly and creates 2 parallel circulations.

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8
Q

What 3 defects creates an exception to the parallel circulation that normally occurs with D-TGA?

A

PDA, ASD, VSD (Additional communications)

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9
Q

Trace the blood flow from the RA-Aorta with L-TGA

A

RA-MV-LV-PA-LA-TV-RV-Aorta

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10
Q

Which TGA is associated with switching the position of the RV and LV with NO AFFECT on the Great Vessels?

A

L-TGA

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11
Q

Describe what happens with Levotransposition of the Great Arteries

A

Misdirected folding of the embryonic heart tube occurs, it folds to the left side instead of the right. The RV and LV are switched and there is no affect on the great vessels.

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12
Q

TGA normally occurs with other anomalies, or in isolation?

A

Isolation

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13
Q

TGAs accounts for ____% of all CHDs.

A

6%

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14
Q

Sx of L-TGA at birth?

A

Asymptomatic at birth

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15
Q

Sx of R-TGA at birth w/o shunting lesions?

A

Profound Cyanosis

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16
Q

Sx of R-TGA at birth w/ shunting lesions?

A

Initially asymptomatic, progresses to tachypnea, tachycardia, heart failure, feeding problems, respiratory distress w/o cyanosis. LV volume overload and L to R shunting.

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17
Q

Auscultation, ECG and CXR associated with R-TGA

A

No murmur to Loud murmur (depends on shunt lesion)
RAD and RVH on ECG
Egg-shaped heart with narrow Stalk on CXR

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18
Q

Med/Surg Tx of D-TGA in neonate w/o sufficient shunting.

A

Prostaglandin Infusion- for patency of DA or stent placement
Balloon Septostomy- to create or increase ASD
O2
Tx of HF
Decrease PAP
Arterial Switch Operation- transecting PA and Aorta and reanastomosing to RV and LV

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19
Q

Anesthetic MGMT of TGA

Induction technique?

A

Inhalation or IV Induction
Ketamine 1-2mg/kg incrementally
Fentanyl 2-15mcg/kg incrementally
Rocuronium 1mg/kg

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20
Q

Anesthetic MGMT of TGA

Invasive lines?

A

Yes Arterial and CVP

Note- VSD closure needs bicaval cannulation, so use femoral venous line, not jugular

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21
Q

Anesthetic MGMT of TGA

Myocardial Ischemia concerns?

A

MI can occur after cross clamping is removed due to poor coronary anastomosis or air emboli in coronary artery- Increase CPP to flush out air. If no improvement, may need to go back on CPB to reassess anastomosis.

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22
Q

Anesthetic MGMT of TGA

____ to assess function of repair and presence of air

A

Echo

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23
Q

Anesthetic MGMT of TGA

Anticipate _______ HTN

A

Pulmonary HTN- can cause compression of Coronary Arteries and MI

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24
Q

Anesthetic MGMT of TGA

Inotropes?

A

More than likely

Use Dopamine, Epinephrine, and Milrinone

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25
Anesthetic MGMT of TGA | LV will be _________, so be careful with ______
LV will be NONCOMPLIANT, be careful with FLUIDS- give slowly and in small amounts
26
Anesthetic MGMT of TGA | Coagulation is possible?
Yeap- often need antifibrinolytics
27
Anesthetic MGMT of TGA | Postoperatively, have high risk of:
dysrhythmias and conduction defects
28
Anesthetic MGMT of TGA | Maintenance- Keep PVR ____
Keep PVR DOWN | Deep GA will blunt reactive Pulm. HTN
29
Anesthetic MGMT of TGA | Avoid ____HR and ___ CO with limited myocardial reserve.
Avoid Decreased HR and Decreased CO | Control BP
30
Single vessel from the heart gives rise to both aorta and pulmonary artery.
What is Truncus Arteriosus?
31
Truncus Arteriosus is associated with ______Syndrome
DiGeorge
32
List the Clinical Features and Concerns of DiGeorge Syndrome (Table 15-4)
Absent of small thymus T-Cell Abnormality w/ associated immunodeficiency Hypoparathyroidism w/ associated hypocalcemia Dysmorphic features, particularly a small mouth Increased surgical morbidity and mortality Irradiated blood products needed to prevent graft-vs-host disease
33
Mortality is high with Truncus Arteriosus, and surgery is performed _____
early in life
34
3 factors influencing mortality with TA.
Presence of: Truncal Valve Stenosis Coronary Abnormalities Low Birth Weight
35
Describe the surgery for TA repair
Closure of VSD, disconnect pulmonary arteries, place graft between RV and PA to provide pulmonary blood flow.
36
Type 1 TA
Main PA and Aorta arises from BASE of truncus
37
Type 2 TA
R and L pulmonary arteries arise SEPARATELY from truncus, close to each other
38
Type 3 TA
Pulmonary arteries arise on OPPOSITE sides of truncus
39
Type 4 TA
PA branches are ABSENT, pulmonary blood flow from aortopulmonary collaterals.
40
All forms of TA have mixing of _____ and ____ blood, with significant ____ to _____ shunting and ______overcirculation.
All forms of TA have mixing of oxygenated and deoxygenated blood, with significate L to R shunting and PULMONARY overcirculation
41
TA leads to (4 things)
Cyanosis Failure to Thrive CHF Pulmonary HTN
42
Induction concerns with TA Intubation may be _____ due to DiGeorge facial anomalies. Do not _____ or ________ if not intubated
Intubations may be DIFFICULT Do not PREOXYGENATE or HYPERVENTILATE if not intubated.
43
Anesthetic MGMT of TA | IV induction agents:
Ketamine 1-2mg/kg Fentanyl 2-4mcg/kg Roc 1mg/kg
44
Anesthetic MGMT of TA | Avoid _____ventilation and maintain O2 sat _____%
Avoid Hyperventilation | O2- 75-85%
45
Anesthetic MGMT of TA | Keep DBP > ____ to perfuse coronary arteries
20mmHg
46
Anesthetic MGMT of TA | Maintenance drugs
Fentanyl 20-50mcg/kg Roc Midazolam 0.1-0.2 mg/kg +/- Volatile agent
47
Anesthetic MGMT of TA | FiO2 -and avoid _________
Fio2 0.21 | Avoid Hyperventilation
48
Anesthetic MGMT of TA | Will probably require postop ____
ventilation
49
Why do we avoid hyperventilation with TA?
Hyperventilation causes decreased PVR, leading to Increased Shunt and CHF
50
What art the two types of Anomalous Pulmonary Venous Connections
Total and Partial
51
Describe the difference between TAPVC and PAPVC.
TAPVC- All pulmonary veins insert into anomalous site | PAPVC- One or more pulmonary veins drain into either venous or right side of heart instead of the LA.
52
What are the 3 types of TAPVC
Supracardiac Cardiac Infracardiac
53
Describe Supracardiac TAPVC
Supracardiac- Pulmonary veins connect to SVC through an ASCENDING VERTICAL VEIN
54
Describe Cardiac TAPVC
Cardiac- Pulmonary veins connect to RA through CORONARY SINUS
55
Describe Infracardiac TAPVC
Infracardiac- Pulmonary veins connect to IVC through COMMON VEIN.
56
S/Sx of TAPVC
CHF, Cyanosis, Respiratory Distress, and Tachypnea
57
TAPVC ECG CXR ECHO
TAPVC ECG- RA and RV Enlargement CXR- Cardiomegaly and Pulmonary Edema ECHO- Will Identify Shunting Lesion, Cardiac Size and Ventricular Function
58
Tx for TAPVC
Surgical Correction | Closing Shunting Lesions with a Patch
59
Anesthesia MGMT of TAPVC
Induction Roc 1mg/kg, Fent 1-3mcg/kg IV Volatile agents are rarely tolerated in obstructed TAPVC Maintenance- Fent 20-50mcg in divided doses. Reduction of PVR will worsen pulmonary edema Postop vent support. May need inotropes.
60
Anatomic Features (4) of Hypoplastic Left Heart Syndrome HLHS
Hypoplastic LV Mitral Stenosis or Atresia Aortic Stenosis or Atresia Hypoplastic Aortic Arch
61
At birth, neonates with HLHS will present with (3)
Heart Failure Shock Cardiovascular Collapse
62
ECG and CXR findings with HLHS
ECG- RAD, RVH | CXR- Cardiomegaly, prominent pulmonary vascular markings.
63
Surgical Tx of HLHS
Convert to single-ventricle circulation where RV becomes single systemic ventricle and pulmonary blood flow moves passively from SVC and IVC (aka Fontan Circulation)
64
Anesthetic management of HLHS
``` Balance PVR with SVR Infuse Prostaglandin Use normal to high PaCO2 and Low FIO2 High dose Opioid technique Venous Access through Femoral Vein Hypothermia may be needed Coagulation is possible, antifibrinolytics are used (TXA) ```
65
Ventilation for HLHS
Maintain O2 Sat 75-85% Avoid Hyperventilation- Increases pulmonary blood flow, Sat >85% leads to hypoperfusion
66
Maintenance drugs for HLHS
Fent 20-40mcg/kg Rock 1mg/kg Volatiles on CPB Midazolam 0.1-0.2mg/kg
67
HLHS Stage 2 correction occurs at _____ and Stage 3 correction at ______
6 months old | 2-6 years old
68
Long term outcome of HLHS
RV will fail and Pt will need transplant
69
Describe Tricuspid Atresia (TA)
Absence or permanent closure of tricuspid valve
70
Describe the different types of TA
I - Most common, normal relationship of great vessels to ventricles II - D transposition of the Great Vessels III- L transposition of the Great Vessels
71
3 features of TA
RV is hypoplastic ASD is present Pulmonary Blood Flow is restricted d/t pulmonary stenosis or atresia
72
TA- Will have ____to ____ shunting, with various degrees of cyanosis
R to L shunting
73
Initial palliative procedure for TA
Blalock-Taussig Systemic to PA shunt
74
Definitive procedure for TA
Bidirectional Glenn Shunt or Modified Fontan
75
Sx of TA | 50% of patients are symptomatic by _____ of life
24 hours
76
Sx of TA | If Pt has decreased pulmonary blood flow:
R-to-L shunting and Cyanosis Tachypnea Prominent A Waves Failure to Thrive
77
Sx of TA | If Pt has increased pulmonary blood flow:
minimal cyanosis but will still have tachypnea, tachycardia, hepatomegaly, prominent A waves, feeding difficulties and CHF
78
TA Auscultation ECG ECHO
TA Auscultation- Holosystolic murmur of a VSD or continuous murmur of PDA ECG- LAD, LVH, RA enlargment ECHO- absent of closed tricuspid valve, enlarged chambers (except RV), RVOT obstruction, PAP, flow moving across VSD.
79
Development of Severe Pulmonary HTN due to L-to-R shunt, where the increased PVR eventually causes shunt reversal to R-to-L shunt
What is Eisenmenger Syndrome
80
Sx of Eisenmenger Syndrome
Increased Hypoxia with Decreased Exercise Tolerance Enlarged RA and RV with Arrhythmias Hyperviscosity due to Hypoxia
81
Eisenmenger Syndrome ECG CXR
ECG - RVH | CXR- Prominent pulmonary vessels
82
Anesthetic MGMT of Eisenmenger Syndrome
Similar to management of other forms of pulm. HTN Avoid Insufflation- Worsens R-to-L shunt PVR is fixed and does not respond to SVR changes Keep SVR at preop levels
83
Overall CHD anesthetic implications | Is air bubbles good?
Nope
84
Overall CHD anesthetic implications | Qp:Qs > 1.5:1 limit _____ blood flow to prevent ___failure due to volume overload
pulmonary | RV
85
L to R Shunts | Little affect on onset of IV and inhalational agents as long as ________ is maintained
CO
86
L to R shunts | Pts with elevated pulmonary blood flow- Maintain or slightly increase ______
PAP
87
L to R shunts | Minimize agents that ___SVR or ____PVR
Increase SVR or Decrease PVR
88
R to L shunts These favor R-to-L shunting __PVR, ___RVOTO (infundibula spasm), ___SVR
Increased PVR Increased RVOTO Decreased SVR all favor R to L shunting
89
With RVOTO, changes in _____ does not alter Qp:Qs ratio, while changes in _____ does.
PVR does not alter | SVR does
90
``` Anaphylactic/neurogenic shock Anemia Cirrhosis Vasodilators Anesthetic Agents Histamine Alpha Blockers Ganglionic Blockers All Do What? ```
Decrease SVR
91
``` Increase or Decrease PVR Syndromes of low CO Hypovolemia Cardiogenic Shock Hypothermia Vasoconstrictors All Do What? ```
Increase SVR
92
``` Increase or Decrease PVR 100% O2 Hypocarbia Normothermia Low mean AW pressures or SV ```
Decrease
93
``` Increase or Decrease PVR Hypothermia A1 agonists Sympathetic Stimulation Increased SVR ```
Decrease
94
``` Increase or Decrease PVR Acidosis Hypoxemia Hypervarbia High mean AW pressure Catecholamine release ```
Increase
95
``` Increase or Decrease PVR Avoidance of catecholamine release Low mean AW pressures or SV Hypothermia Increased SVR Hypocarbia ```
Decrease
96
``` Meds like neo, ketamine, N2O Hypothermia B2 agonist All A1 agonists Deep GA NA Decreased SVR ```
Increase | and yes, this table lists hypothermia and A1 agonist as both increasing and decreasing PVR. What a fuck!
97
Who can go fuck right off?
You guessed it!!!

Nur 943 OB (11 decks)

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