High risk (>5% morbidity) surgeries for patients with preexisting CV disease: ___ surgery; major ___ surgery; ___ vascular surgery
Aortic surgery; major vascular surgery; peripheral vascular surgery
These surgeries have higher rates of morbidity just based on the procedure alone (not even considering additional patient factors)
___ risk surgeries: intraperitoneal; transplant; carotid; peripheral artery angioplasty; endovascular aneurysm repair (open AAA repair would be HIGH risk); head/neck surgery; major neurologic/orthopedic surgery—i.e.: multi-level fusion surgery, hip repair; intrathoracic—i.e.: lung surgery; major urologic—i.e.: prostatectomy, nephrectomy
Intermediate risk (1-5% morbidity)
___ risk surgeries: breast; dental; endoscopic; superficial; endocrine; cataract; gynecological; reconstructive; minor orthopedic; minor urologic
Low risk (< 1% morbidity)
METs = ___, how we measure a patient’s ___ capacity
Metabolic equivalents, how we measure a patient’s functional capacity
Gold standard of evaluating a patient’s functional capacity (main question we ask patients when doing our pre-op assessment?)
“Are you able to climb two flights of stairs without stopping, regardless of limiting symptoms?”
Inability of patients to climb two flights of stairs without stopping, regardless of limiting symptoms, leads to a ___% increase in risk for cardiopulmonary complications postoperatively
82% increase in risk
1 MET = ___ functional capacity
Poor
Examples = self-care, eating, dressing, using the toilet, walking indoors/around the house, walking 1-2 blocks on level ground at 2-3 mph
4 METs = ___ functional capacity
Good
Examples = light housework; climbing a flight of stairs without stopping, or walking up a hill longer than 1 to 2 blocks; walking on level ground at 4 mph; running a short distance; golf; dancing; throwing a baseball
Greater than 10 METs = ___ functional capacity
Excellent
Example = strenuous sports
8 clinical risk factors for CV surgery: poor ___ (right/left) ventricular function; ___ heart failure; ___ angina or MI within the past ___ months; age > ___; severe ___ity; reoperation (i.e.: redo CABG); ___ surgery; severe uncontrolled ___ illness (i.e.: COPD or diabetes + noncompliance)
Poor LV function; congestive heart failure; unstable angina or MI within the past 6 months; age > 65; severe obesity; reoperation (i.e.: redo CABG); emergency surgery; severe uncontrolled systemic illness (i.e.: COPD or diabetes + noncompliance)
___ = highest risk factor for perioperative MI
Unstable angina—chest pain that doesn’t go away with nitroglycerin or by stopping activity; unpredictable
Patient with history of MI—MI in the past > ___ months increase periop risk of infarction 6%
> 6 months
Patient with history of MI—MI in the past ___-___ months increase periop risk of infarction 15%
3-6 months
Patient with history of MI—MI in the past ___ months increase periop risk of infarction 30%
3 months
Patient with history of MI—highest at risk period for perioperative infarction is within ___ days after an acute MI
30 days
Patient with history of MI—AHA guidelines recommend waiting at least ___-___ weeks after an MI before undergoing elective surgery
4-6 weeks
Elective non-cardiac surgery should NOT be scheduled within ___ weeks after bare metal stent placement
6 weeks
Elective non-cardiac surgery should NOT be scheduled within ___ months after drug eluting stent placement
12 months
Which valvular disorder poses the greatest patient risk for non-cardiac surgery?
Severe aortic stenosis
Aortic stenosis is the greatest risk for non-cardiac surgery, especially when the cross sectional area of the valve is less than ___ cm ^ 2
< 1 cm ^ 2–indicates severe aortic stenosis
Electromagnetic interference risk is low as long as cautery is > ___ cm away from the pacemaker device (~ distance from pacemaker to ___)
> 15 cm away from the pacemaker device (~distance from pacemaker to belly button)
Typically do not need to disable the AICD in these cases because the chance of interference is so low
This class of medications enhances endothelial function; improves atherosclerotic plaque stability; and reduces vascular inflammation
Statins
Statin therapy should be continued perioperatively—T/F?
True
This medication class restores oxygen supply/demand mismatch; reduces perioperative ischemia; redistributes coronary blood flow to subendocardium; stabilizes plaques; increases V Fib threshold
Beta blockers
If patient is on beta blocker, it should be given within ___ hours of surgery
24 hours
ACE inhibitors have a ___ (shorter/longer) half-life than beta blockers
Longer half-life
Hold ACE inhibitors ___-___ days prior to surgery d/t extreme refractory ___tension that occurs when combined with volatile anesthetics
1-2 days prior to surgery d/t extreme refractory hypotension that occurs when combined with volatile anesthetics
Arterial catheter waveform—dicrotic notch = closure of the ___ valve
Aortic valve
Overdamped arterial line waveform = falsely ___estimates systolic BP and ___estimates diastolic BP
Falsely underestimates systolic BP and overestimates diastolic BP
Underdamped arterial line waveform = falsely ___estimates systolic BP and ___estimates diastolic BP
Falsely overestimates systolic BP and underestimates diastolic BP
___ test is performed to assess level of damping/accuracy of BP reading based on the amount of ___
Square wave test is performed to assess level of damping based on the amount of ringing (number of oscillations after the square wave)
Square wave test—optimally damped = ___-___ oscillations
1-2 oscillations
Square wave test—overdamped = ___ oscillations
< 1 oscillations
Square wave test—underdamped = ___ oscillations
> 2 oscillations
___damped waveform = bubbles in tubing; clots in tubing; vasospasm; long, narrow tubing (excessive tubing); compliant tubing—make sure pressure tubing is used if extension is required, NOT IV tubing; friction in fluid pathway
Overdamped waveform
___damped waveform = catheter whip or artifact; stiff, non-compliant tubing; hypothermia; tachycardia or dysrhythmia
Underdamped waveform
Distance to junction of vena cava and RA from different central line insertion sites—subclavian ___ cm; RIJ ___ cm; LIJ ___ cm; femoral ___ cm
Subclavian 10 cm; RIJ 15 cm; LIJ 20 cm; femoral 40 cm
CVP measures the ___ pressure; acts as a good predictor of patient ___ and ___ status
RA; acts as a good predictor of patient preload and volume status
Normal CVP range ___-___
1-10
CVP waveform—A wave = ___ of the right atrium
Contraction of the right atrium
CVP waveform—C wave = closure of ___ valve
Tricuspid valve
CVP waveform—V wave = ___ of right atrium; coincides with part of ___
Passive filling of right atrium; coincides with part of RV systole
___ (low/high) CVP readings—RV failure, pulmonary HTN, volume overload, pericarditis, cardiac tamponade, tricuspid stenosis or tricuspid regurgitation
High CVP readings
___ (low/high) CVP readings—hypovolemia, ARDS
Low CVP readings
PA catheter systolic range = ___-___ mm Hg
20-30 mm Hg
PA catheter diastolic range = ___-___ mm Hg
8-12 mm Hg
___ (low/high) PA catheter readings—LV failure; volume overload; pulmonary HTN; catheter “whip” (catheter may be coiled or advanced too far); ASD or VSD; L-R shunt; mitral stenosis or mitral regurgitation
High PA catheter readings
___ (low/high) PA catheter readings—hypovolemia, RV failure, tricuspid regurgitation or stenosis
Low PA catheter readings
Wedge/occlusion pressure is used to estimate ___
LVEDP
Normal wedge = ___-___ mm Hg
8-12 mm Hg (same as PA diastolic reading)
Wedge pressure is not a commonly monitored value d/t increased risk of vessel rupture when wedging is performed incorrectly/catheter is not in the ideal position—T/F?
True
___ (low/high) wedge pressures—LV failure; mitral stenosis or regurgitation; cardiac tamponade; constrictive pericarditis; ischemia; volume overload
High wedge pressures
___ (low/high) wedge pressures—hypovolemia, RV failure, tricuspid regurgitation/stenosis, PE
Low wedge pressures
Normal CO = ___-___ L/min
5-6 L/min
How can we measure CO?
Thermodilution method
Thermodilution method—area under the curve is ___ proportional to CO
Inversely
The greater the area under the curve, the lower the CO
The lesser the area under the curve, the greater the CO
Thermodilution method—overestimates of CO (less area under the curve) = ___ (low/high) injectate volume; injectate that’s too ___ (warm/cold); ___ on thermistor of PA catheter
Low injectate volume; injectate that’s too warm; thrombus on thermistor of PA catheter
Thermodilution method—underestimates of CO (more area under the curve) = ___ (low/high) injectate volume; injectate that’s too ___ (warm/cold)
High injectate volume; injectate that’s too cold
Chronic cardiac medications should be administered perioperatively with rare exceptions—T/F?
True
Keep patient on ___
Beta blocker
Hold ___ and ___ for at least 24 hours before surgery
ACE inhibitors (i.e.: lisinopril) and ARBs (i.e.: losartan) for at least 24 hours before surgery d/t refractory hypotension that can occur with these medications + volatile agents
Fentanyl induction dose—___-___mcg/kg
3-10 mcg/kg
Sufentanil is ___-___ times more potent than fentanyl
7-10 times more potent
Remifentanil induction dose ___-___mcg/kg; onset time ___ min and recovery time of ___-___ min
0.5-1 mcg/kg; onset time 1 min and recovery time of 9-20 min
Metabolism of remifentanil = ___ hydrolysis by nonspecific tissue and blood ___
Extrahepatic hydrolysis by nonspecific tissue and blood esterases (why it has such a short half-life)
Remifentanil may cause a rebound ___ when turned off; if you turn off remi without giving additional pain medication, patient will wake up in a/an ___ (increased/decreased) amount of pain
Rebound hyperalgesia when turned off; patient will wake up in an increased amount of pain
If you want patient to wake up without narcotic fog after turning off remifentanil, give ___ and ___
Ketamine and mag sulfate
Propofol induction dose—___-___mg/kg
1-2 mg/kg
Will give much smaller doses of prop to CV patients*
If patient’s BP is very high to start, you can give a large dose of prop for induction—T/F?
False—doesn’t mean you should give a large dose of prop for induction…likely they will bottom out faster
Prop ___ (increases/decreases) SVR, MAP, CI, and SV
Decreases
Always have phenylephrine ready!
If HD stable, you will use ___ for induction
Prop
If HD unstable, you will use ___ for induction
Etomidate
Prop ___ (increases/decreases) PONV
Decreases
Etomidate induction dose ___ mg/kg
0.2 mg/kg
Etomidate produces a small ___ (increase/decrease) in MAP and SVR; ___ (increase/decrease) in HR and CO
Small decrease in MAP and SVR; increase in HR and CO
Etomidate may initiate ___; ___ (increase/decrease) incidence of epileptiform activity in patients with known ___ disorders
Etomidate may initiate myoclonus; increase incidence of epileptiform activity in patients with known seizure disorders
Do NOT use etomidate in patients with ___ disorders
Seizure
Etomidate can induce ___ suppression—refractory ___tension, will need ___ to treat
Induce adrenal suppression—refractory hypotension, will need vasopressin to treat
Etomidate ___ (increases/decreases) PONV
Increases PONV
Ketamine induction dose ___mg/kg
2 mg/kg—this dose will make patient crazy for days
Ketamine dose given during case in combo with other drugs—___-___mg/kg
0.1-0.5 mg/kg
___ anesthesia is a common side effect of ketamine
Dissociative anesthesia—unique cataleptic trance
Ketamine causes unconsciousness in ___-___ seconds
20-60 seconds
Ketamine ___ (increases/decreases) HR, MAP, and plasma epinephrine levels (dependent on intact ___ reserve and robust ___)
Ketamine increases HR, MAP, and plasma epinephrine levels (dependent on intact sympathetic reserve and robust myocardium
Ketamine is advantageous for induction in ___volemia, major ___, or cardiac ___
Hypovolemia, major hemorrhage, or cardiac tamponade
Ketamine ___ (increases/decreases) ICP and coronary demand from ___
Increases ICP and coronary demand from sympathetic stimulation—why it is beneficial to give a smaller dose of ketamine with other agents
Ketamine works on the ___ receptor
NMDA receptor
Predominant effect of all inhalational agents is dose-dependent vaso___, reducing ___ and ___
Dose-dependent vasodilation, reducing BP and SVR
All inhalational agents cause dose-dependent ___cardia; will see this the most with ___, so never use this agent in cardiac cases
All inhalational agents cause dose-dependent tachycardia; will see this the most with desflurane, so never use this agent in cardiac cases
Usually will use ___ (what inhalation agent?) in heart cases
Isoflurane—cardiac steal and also doesn’t cause a lot of reflex tachycardia; patients wake up more clear-headed with iso than they do with sevo/des
PVD risk factors—___ing, ___tension, diabetes mellitus, family ___/___, ___ (males vs. females), elevated tri___, hyper___
Smoking, hypertension, diabetes mellitus, family history/genetics, males > females, elevated triglycerides, hyperlipidemia
PVD and blood pressure—patients with PVD may rely on ___ (increased/decreased) MAP to perfuse their vital organs
Increased MAP
PVD and blood pressure—even short periods of hypotension can lead to ___ in these patients; ___ BP monitoring is recommended for these cases
Even short periods of hypotension can lead to ischemia in these patients; invasive BP monitoring is recommended for these cases
PVD and blood pressure—rule of thumb—stay within ___% of the patient’s baseline BP
20%
Greatest risk factor for abdominal aortic aneurysm = ___
Smoking
Other major risk factors for AAA—___ age, gender—___ > ___
Old age, gender—males > females
Other risk factors for AAA—family ___, ___ disease, ___ cholesterol, ___, ___tension
Family history, coronary artery disease, high cholesterol, COPD, hypertension
AAA is ___-___ times more common in men than women
2-6 times
AAA is 2-3 times more common in white males vs. black males—T/F?
True
What is the imaging test of choice for AAA?
CTA
AAA surgical criteria—risk of rupture is low for AAA less than ___ cm in diameter
Less than 4 cm
Surgical intervention is recommended for: AAA ___ cm or greater; AAA 4-5 cm with greater than ___ cm enlargement in the last 6 months; ___ AAA; patients who are ___ with AAA
AAA 5.5 cm or greater; AAA 4-5 cm with greater than 0.5 cm enlargement in the last 6 months; ruptured AAA; patients who are symptomatic with AAA
AAA vessel dimensions correlate with the law of ___
LaPlace
Law of LaPlace—T = P x r
T = wall tension P = transmural pressure R = vessel radius
Law of LaPlace—wall tension is directly proportional to vessel ___ and ___; wall tension is inversely proportional to wall ___
Wall tension is directly proportional to vessel radius and pressure; wall tension is inversely proportional to wall thickness
Contraindications to elective AAA repair—intractable ___; recent ___; severe ___ dysfunction—recent ___, uncontrolled ___; chronic ___ insufficiency
Intractable angina; recent MI; severe pulmonary dysfunction—recent bronchitis, uncontrolled COPD; chronic renal insufficiency
Most frequent/preferred AAA site = ___
Infrarenal
Infrarenal AAA has decreased risk of renal ___ and renal ___ post-op
Renal ischemia and renal failure post-op
AAA repair—EKG monitoring—lead ___ to evaluate for arrhythmias; lead ___ for detection of ischemic ST changes
Lead II to evaluate for arrhythmias; lead V5 for detection of ischemic ST changes
PA catheters are routinely used intraoperatively during AAA repair—T/F?
False—NOT routinely used
Aortic cross clamping—hemodynamic changes—___ (increased/decreased) BP above clamp; ___ (increased/decreased) BP below clamp; ___ (increase/decrease) in afterload; ___ (increase/decrease) in MAP; ___ (increase/decrease) in SVR
Increased BP above clamp; decreased BP below clamp; increase in afterload; increase in MAP; increase in SVR
Aortic cross clamping—metabolic alterations—___ic and ___ic environment distal to the clamp
Hypoxic and ischemic environment distal to the clamp
Aortic cross clamping—traction on mesentery (tugging on the mesentery done for exposure to the aorta) may cause ___ (increase/decrease) in BP, SVR; ___cardia; ___ (increased/decreased) CO; and facial ___…aka ___ syndrome
May cause decrease in BP, SVR; tachycardia; increased CO; and facial flushing…aka mesenteric traction syndrome
Aortic cross clamp and AKI—___renal and ___renal cross clamp are associated with higher risk of kidney injury—reduce renal blood flow by as much as 80%
Suprarenal and juxtarenal cross clamp
___ is the preferred AAA because risk for kidney injury is decreased
Infrarenal—reduces renal blood flow by 40% (instead of 80%)
Suprarenal cross clamp times longer than ___ minutes increases the risk of postop renal failure
30 minutes
Aortic cross clamp and AKI management—most important—tight hemodynamic ___ and minimization of ___ times
Tight hemodynamic stabilization and minimization of aortic cross clamp times
Blood flow to the spinal cord—posterior—two posterior and two Posterolateral arteries = ___% of spinal cord blood flow; supply the ___ (sensory/motor) portion of the spinal cord
20% of spinal cord blood flow; supply the sensory (dorsal) portion of the spinal cord
Blood flow to the spinal cord—anterior—one anterior spinal artery—___% of spinal cord blood flow—supplies the ___ (sensory/motor) portion of spinal cord
80% of spinal cord blood flow—supplies the motor portion of the spinal cord
Blood flow to the spinal cord—any damage to the ___ spinal artery is detrimental because it provides 80% of the blood flow to the spinal cord; will see ___ (sensory/motor) damage if blood flow to this artery is compromised
Any damage to the anterior spinal artery is detrimental because it provides 80% of the blood flow to the spinal cord; will see motor damage if blood flow to this artery is compromised
Blood flow to the spinal cord—transverse blood flow to the spinal cord is provided via the ___ artery, AKA artery of ___
Greater radicular artery, AKA artery of adamkiewicz
This artery often gets injured during AAA repair; injury can cause post-op paraplegia
Greater radicular artery/artery of adamkiewicz
Risk is highest for ___ (sensory/motor) spinal dysfunction during AAA repair…why?
Motor spinal dysfunction because the anterior/motor cord receives 80% of spinal cord blood flow and it only goes through one artery—development of collateral flow is more difficult
Methods to decrease risk of spinal cord ischemia during AAA repair: CSF ___ (via ___ drain); mild ___thermia; maintenance of ___tension (SBP > ___) through the second postop day
CSF drainage (via lumbar drain); mild hypothermia; maintenance of normotension (SBP > 120) through the second postop day
Aortic cross clamp release—SVR ___ (increases/decreases), blood goes into previously dilated ___, leads to ___ (increased/decreased) venous return
SVR decreases, blood goes into previously dilated veins, leads to decreased venous return
Aortic cross clamp release causes transient vaso___—tissue ___, release of ___, leads to ___ (increased/decreased) preload and afterload
Transient vasodilation—tissue hypoxia, release of adenine, leads to decreased preload and afterload
Aortic cross clamp release—___ (increase/decrease) anesthetic depth (if you can); turn off vaso___; will need ___ and ___ at this point
Decrease anesthetic depth; turn off vasodilators; will need fluids and pressors at this point
Anesthetic management for open AAA repair—___ anesthesia is the most common approach; concern for dose-dependent myocardial ___ with anesthetic agents
General anesthesia is the most common approach; concern for dose-dependent myocardial depression with anesthetic agents
Fluid management is key for open AAA repair—third space losses of around ___ ml/kg/hr
10 ml/kg/hr
Open AAA repair—keep urine output at least ___ ml/kg/hr
1 ml/kg/hr
Ruptured aortic aneurysms—mortality rate ___-___%
80-90%
Triad of symptoms for ruptured AAA—severe ___/___ pain; altered level of ___ from ___tension; ___ abdominal mass
Several abdominal/back pain; altered level of consciousness from hypotension; pulsatile abdominal mass
Thoracic aortic aneurysm—___ (increased/decreased) incidence of rupture compared to abdominal aortic aneurysm
Increased incidence of rupture compared to abdominal aortic aneurysm
___ is the most common cause of thoracic aortic aneurysm
Atherosclerosis
S/S of thoracic aortic aneurysm—___, ___, ___
Pain, stridor, cough
Thoracic aortic aneurysm—aneurysm can impinge on ___ nerve—patient may have hoarseness; caution ___
Left recurrent laryngeal nerve—patient may have hoarseness; caution intubating!
Surgical repair of thoracic aneurysms—preferred site for arterial line is ___
Right radial (because left side of body will be lacking adequate perfusion d/t the aneurysm, will get poor readings)
Thoracic aneurysms have ___ (lower/higher) risk of spinal cord injury/ischemia during repair
Higher risk
For this reason, will likely place lumbar drain and monitor SSEPs/MEPs
Spinal cord perfusion pressure = ___
MAP - CSF pressure
Aortic cross clamp and spinal cord perfusion pressure—CSF pressure ___ (increases/decreases) distal to the clamp; arterial pressure ___ (increases/decreases) distal to the clamp; this causes spinal cord perfusion pressure to ___ (increase/decrease), which is why we use lumbar drain to drain CSF
CSF pressure increases distal to the clamp; arterial pressure decreases distal to the clamp; this causes spinal cord perfusion pressure to decrease, which we don’t want…which is why we use lumbar drain to drain CSF
Goal CSF pressure = ___ mm Hg
Less than 10 mm Hg
Spontaneous tear of the vessel wall results in passage of blood along a false lumen—what condition is this describing?
Aortic dissection
What is the most common factor that contributes to progression of aortic dissection?
HTN
___ aortic dissection has the highest incidence of rupture
DeBakey Type I/Stanford Type A
Classifications of acute aortic dissections—___ and ___ classifications
DeBakey and Stanford classifications
What type of aortic dissection is this?—originates in the ascending aorta and extends at least to the aortic arch and often to the descending aorta (and beyond); highest risk of rupture
DeBakey Type I
What type of aortic dissection is this?—originates in the ascending aorta; confined to this segment
DeBakey Type II
What type of aortic dissection is this?—originates in the descending aorta, usually just distal to the left subclavian artery, and extends distally
DeBakey Type III
What type of aortic dissection is this?—dissections that involve the ascending aorta (with or without extension into the descending aorta); highest risk of rupture
Stanford Type I
What type of aortic dissection is this?—dissections that do not involve the ascending aorta
Stanford Type II
Types of endoleak—attachment site leaks
Type I
Treatment = proximal or distal graft extension; secondary endograft; open repair
Types of endoleak—branch vessel leaks (i.e.: lumbar artery, renal artery, internal iliac artery, inferior mesenteric artery)
Type II
Treatment = monitor for enlargement; laparoscopic clip application; embolization
Types of endoleak—graft defect (i.e.: fabric tear, modular disconnection)
Type III
Treatment = secondary endograft, open repair
Types of endoleak—graft wall fabric hole or suture holes
Type IV
Treatment = observation, open repair
___ = systemic pressure in aneurysm sac despite no evidence of endoleak
Endotension
Treatment = secondary endograft; open repair
___ = the second most common vascular operation performed (2nd to coronary revascularization—i.e.: stents in cath lab, CABG)
Carotid endarterectomy (CEA)
___ (ischemic/hemorrhagic) strokes are responsible for 80% of first time strokes
Ischemic strokes
CEA is performed on patients with greater than ___% carotid artery stenosis
70%—no benefit to performing surgery on patients with < 70% stenosis; most patients develop adequate collateral
S/S of carotid artery stenosis = ___/___; carotid ___; ___ocular blindness
TIA/stroke; carotid bruit (or palpable carotid thrill); monocular blindness
Diagnosis of carotid artery stenosis = ___, carotid ___
CTA, carotid ultrasound
Cerebral perfusion pressure = ___ - ___
MAP - ICP
ICP is typically not elevated in carotid stenosis, so MAP plays the major role in determining cerebral perfusion pressure
When MAP is maintained between ___-___ mm Hg, cerebral autoregulation occurs (perfusion to the brain remains constant)
60-160 mm Hg
Chronic HTN shifts a patient’s cerebral autoregulation curve to the ___ (right/left)
Right—thus, a higher MAP is needed to maintain adequate cerebral perfusion
Anesthetic management for CEA—cerebral monitoring—nurse anesthetist will implement ___ monitoring
Cerebral oximetry monitoring
Anesthetic management for CEA—interventions for cerebral protection—avoid ___glycemia (usually goal < ___); hemodilution (blood ___); maintenance of ___carbia; tight control of ___
Avoid hyperglycemia (usually goal < 140); hemodilution (blood thinning); maintenance of normocarbia; tight control of BP
Cerebral oximetry during CEA—set ___ cerebral oximetry values prior to induction of anesthesia
Baseline—set so it automatically calculates changes in cerebral oximetry throughout the case
Cerebral oximetry during CEA—a decrease in cerebral oximetry values greater than ___% coincides with regional and global ischemia during CEA
20%
Anesthetic management for CEA—BP control—during carotid cross clamping, need MAP at ___% or ___ than the patient’s preoperative MAP; often goal is SBP ___ mm Hg or greater
At 20% or greater than the patient’s preoperative MAP; often goal is SBP 160 mm Hg or greater
Anesthetic management for CEA—BP control—watch for carotid sinus baroreceptor manipulation during carotid cross clamping—may see ___tension and ___cardia—if sustained, tell surgeon
May see hypotension and bradycardia
Carotid cross clamp is usually only on for ___-___ mins
30-45 mins
Goal BP following CEA and cross clamp removal—SBP ___ mm Hg or less
140 mm Hg or less
Regional anesthesia for CEA—deep/superficial ___ plexus block
Deep/superficial cervical plexus block
Advantages of regional anesthesia for CEA—awake patient for better ___ exam
Neuro
Anesthetic selections for CEA—no difference proven in better outcomes between regional vs. general; for this reason, general is usually used—T/F?
True
Do not use ___ (what inhalation agent?) during CEA
Nitrous oxide—risk for pneumocephalus
Postop complications of CEA—most common = ___—systolic BP greater than ___ mm Hg is associated with increased incidence of TIA, stroke, or MI
HTN—systolic BP greater than 180 mm Hg is associated with increased incidence of TIA, stroke, or MI
Postop complications of CEA—___ syndrome—caused by increased blood flow to the brain d/t loss of cerebral autoregulation; results in severe headache, visual disturbances, LOC, seizures
Cerebral hyperperfusion syndrome
Case selection—carotid stenting vs. CEA—stenting is worse for patients with ___ age; patients who can’t tolerate ___ agents; patients with ___ dysfunction; or patients with ___ related problems (i.e.: aortic occlusive disease that would make it difficult to do the procedure under fluoroscopy)
Advanced age; patients who can’t tolerate antiplatelet agents; patients with renal dysfunction; or patients with access related problems (i.e.: aortic occlusive disease that would make it difficult to do the procedure under fluoroscopy)
Case selection—carotid stenting vs. CEA—stenting is better in patients with ___ disease; CHD with an abnormal cardiac ___, ___ angina, or MI less than ___ month ago; ___ heart disease; CHF with EF < ___%; contralateral ___ nerve dysfunction; severe obesity; previous neck ___/___; trach___; ___ immobility; recurrent stenosis; high lesions (above C___); contralateral carotid ___
COPD; CHD with an abnormal cardiac stress test, unstable angina, or MI less than 1 month ago; valvular heart disease; CHF with EF < 30%; contralateral RLN dysfunction; severe obesity; previous neck radiation/surgery; tracheostomy; neck immobility; recurrent stenosis; high lesions (above C2); contralateral carotid occlusion
Complications of carotid stenting—most common = ___
Stroke caused by thromboembolism
Normal aortic valve area = ___-___ cm^2
2-4 cm^2
Aortic valve area with severe aortic stenosis = ___
< 1 cm ^2
Patho of aortic stenosis—chronic LV ___ (pressure/volume) overload; ___ (eccentric/concentric) LV hypertrophy to decrease wall stress
Chronic LV pressure overload; concentric LV hypertrophy to decrease wall stress
Patho of aortic stenosis—concentric left ventricular hypertrophy causes decreased ___ (systolic/diastolic) compliance; ___ (increased/decreased) coronary blood flow
Decreased diastolic compliance; decreased coronary blood flow
LV can’t relax because it is so stiff; supply and demand is mismatched
Patho of aortic stenosis—decreased diastolic compliance leads to ___ (increased/decreased) LVEDP/LVEDV
Increased LVEDP/LVEDV (because the blood can’t get out of the LV into the aorta)
Patho of aortic stenosis—myocardial ___ results from LV hypertrophy, ___ (increased/decreased) wall stress, ___ (increased/decreased) diastolic coronary perfusion, ___ (increased/decreased) coronary flow reserve
Myocardial ischemia results from LV hypertrophy, increased wall stress, decreased diastolic coronary perfusion, decreased coronary flow reserve
Hemodynamic goals—AS—maintain sinus ___; optimal HR ___-___; maintain ___ and avoid myocardial ___; treat ___tension promptly
Maintain sinus rhythm; optimal HR 60-80; maintain contractility and avoid myocardial depressants; treat hypotension promptly
___ and ___ anesthesia are contraindicated in patients with severe AS
Spinal and epidural anesthesia are contraindicated in patients with severe AS
Aortic regurgitation—most common etiology = aortic root dilatation from ___; can also result from deformed/thickened cusps—___ valve is most common
Aortic root dilatation from HTN; can also result from deformed/thickened cusps—bicuspid valve is most common
Patients with aortic regurgitation may be ___ for many years
Asymptomatic
Chronic AR—LV ___ and ___ overload occurs; LV maintains ___ (diastolic/systolic) function by dilation and increased compliance; LV decompensates at later stages with ___ (increased/decreased) LVEDP and LVEDV, leading to CHF, arrhythmias, sudden death
LV volume and pressure overload occurs; LV maintains systolic function by dilation and increased compliance; LV decompensates at later stages with increased LVEDP and LVEDV, leading to CHF, arrhythmias, sudden death
Aortic stenosis = ___ (volume/pressure) problem; ___ (eccentric/concentric) hypertrophy
Pressure problem; concentric hypertrophy
Aortic regurgitation = ___ (volume/pressure) problem; ___ (eccentric/concentric) hypertrophy
Volume problem; eccentric hypertrophy
Acute AR = LV ___ (pressure/volume) overload occurs; ___ (increased/decreased) LVEDP/LVEDV results in acute ___; emergency surgery often needed
LV volume overload occurs; increased LVEDP/LVEDV results in acute pulmonary edema; emergency surgery often needed
Hemodynamic goals—AR—optimal HR = ___; avoid ___cardia because it increases regurgitation; avoid ___ (increased/decreased) afterload
Optimal HR = 90; avoid bradycardia because it increases regurgitation; avoid increased afterload
SNP (sodium Nitroprusside) is preferred to keep afterload low
Acute AR—often need ___ + ___
Inotropes + vasodilator (epi + SNP/milrinone)
___ is contraindicated in AR because it increases diastolic filling of the LV
IABP
Increases diastolic filling of the LV, which increases regurgitant volume…so you are pushing more blood back into the LV which is what you don’t want
Mitral stenosis = ___ (volume/pressure) problem
Pressure problem—blood can’t get out of the LA into the LV
Patho of MS—pressure gradient between LA and LV prevents ___ filling; pulmonary ___ results from increased ___ pressure
Prevents LV filling; pulmonary hypertension results from increased LA pressure
Patho of MS—increased LAP leads to left atrial ___, atrial ___
Left atrial enlargement, atrial arrhythmias (AFib)
Patho of MS—pulmonary hypertension leads to ___ dysfunction, ___ enlargement, ___ regurgitation
Pulmonary hypertension leads to RV dysfunction, RV enlargement, tricuspid regurgitation (patient may need tricuspid valve repair)
Hemodynamic goals—MS—maintain ___ rhythm; avoid ___cardia, which ___ (increases/decreases) diastolic filling of LV and worsens MS; avoid factors which worsen pulmonary ___—___carbia, ___osis, ___thermia, ___ nervous system activation, ___ia
Maintain sinus rhythm; avoid tachycardia, which decreases diastolic filling of LV and worsens MS; avoid factors which worsen pulmonary HTN—hypercarbia, acidosis, hypothermia, sympathetic nervous system activation, hypoxia
Hypercarbia causes vaso___ in the pulmonary vasculature, ___ (increases/decreases) pulmonary blood flow
Vasoconstriction in the pulmonary vasculature, decreases pulmonary blood flow
Hypercarbia causes vaso___ in the neurovasculature (i.e.: carotid arteries); this would ___ (increase/decrease) your cerebral blood flow
Vasodilation in the neurovasculature; this would increase cerebral blood flow
Anesthetic management MS—control of ___ is essential
Heart rate—can use beta blockers, digoxin, calcium channel blockers, amiodarone
Intraoperative management—MS—___ is the single most useful drug with severe MS, even if patient has CHF/pulmonary edema
Esmolol
Fast on, fast off
10-20 mg bolus; 50-100 mcg/kg/min
Intraoperative management—MS—avoid ___ (what inhalation agent?) because of effects on pulmonary HTN
Nitrous oxide—increases pulmonary vasoconstriction and would thus worsen pulmonary HTN
Intraoperative management—MS—___ should be avoided because it can cause reflex tachycardia
Pancuronium
After MV replacement, hemodynamics usually improve because obstruction to LV filling is resolved; if patient had pulmonary HTN/RV dysfunction perioperatively, may need ___ or ___
Milrinone or nitric oxide
Patho of MR—___ (pressure/volume) overload of LV, leading to LV and LA ___
Volume overload of LV, leading to LV and LA enlargement
Patho of MR—LA can massively ___; ___ arrhythmias with LA enlargement; dilated LV decompensates at later stages with ___ (increased/decreased) LVEDV
LA can massively dilate; atrial arrhythmias with LA enlargement; dilated LV decompensates at later stages with INCREASED LVEDV (because regurgitation is occurring during systole, so less blood will be pumped out of LV during systole and more volume will be leftover in the LV at the end of systole)
Hemodynamic goals—MR—vaso___ to ___ (increase/decrease) afterload/regurgitant fraction and ___ (increase/decrease) forward flow; goal is to maintain ___ (low/high) normal HR to increase time of ventricular ___ (systole/diastole); maintain ___
Vasodilators to decrease afterload/regurgitant fraction and increase forward flow; goal is to maintain high normal HR to increase time of ventricular systole; maintain contractility
Hemodynamic goals for regurgitant valves (AR/MR)—want to keep the heart ___, ___ and ___ so that blood doesn’t flow backwards
Fast, forward, and full
MV repair—___ unmasked after surgery
LV dysfunction unmasked after surgery
LV function may be normal preop; after MV repair, it will be worse…because before surgery, LV had two outlets—could go out the LV outflow tract or back into the LA…after surgery, all blood has to go out of LV
___ regurgitation is not very common
Tricuspid
TR patho—RV + RA become ___ and ___; RA is very compliant, so RAP only rises with ___ stage disease; pulmonary HTN d/t MV disease ___ (increases/decreases) RV afterload and worsens TR; leads to ___ heart failure
RV + RA become overloaded and dilated; RA is very compliant, so RAP only rises with end stage disease; pulmonary HTN d/t MV disease increases RV afterload and worsens TR; leads to right heart failure—hepatomegaly, ascites
Hemodynamic goals—TR—if secondary to MV disease, treat ___ heart lesion; avoid pulmonary ___ and ___ (low/high) PVR; maintain normal to high ___ for RV stroke volume; ___tension treated with inotropes + volume because vasoconstrictors may worsen ___
If secondary to MV disease, treat left heart lesion; avoid pulmonary HTN and high PVR; maintain normal to high preload for RV stroke volume; hypotension treated with inotropes + volume because vasoconstrictors may worsen pulmonary HTN
EKG morphology—___ is the end of the QRS and beginning of ST segment
J point
We utilize the ___ along with the ___ to identify myocardial ischemia
J point along with the ST segment
Threshold values for ST segment depression—males and females of all ages in leads V2-V3 = -___ mm
-0.5 mm (-0.05 mV)
Threshold values for ST segment depression—males and females of all ages in ALL other leads = -___ mm
-1.0 mm (-0.1 mV)
What lead is typically used to monitor for ST segment changes?
Lead V5
What lead is used to assess narrow QRS complex rhythms?
Lead II
What EKG rhythm is this?—no P waves; PR interval not discernible; “controlled” if ventricular rate is < 100 BPM; only concern is when rate is > 100 bpm/there is a decrease in EF
Atrial fibrillation
What EKG rhythm is this?—saw toothed flutter waves; cannot measure PR interval; QRS is usually normal, but ST segment and T waves are not identifiable, so you can’t monitor ST segment for signs of iscehmia; a “regular” irregularity
A-flutter
What EKG rhythm is this?—prolonged PR interval > 0.2 sec and constant with each EKG cycle; usually clinically insignificant
First degree AV block
What EKG rhythm is this?—atrial rhythm is regular, but ventricular rhythm is irregular; longer, longer, longer, drop, then you’ve got a ___
Wenckebach (Second degree AV block—Mobitz I)…mobitz I because you wink (wenckebach) with one eye
What EKG rhythm is this?—P waves are normal, but some are not followed by a QRS; PR intervals are constant, the dropped QRS occurs without warning; “if some P’s don’t get through, then you’ve got a ___”
Second degree AV block—Mobitz II
EKG looks normal, and then you will have a P wave that is not followed by a QRS
What EKG rhythm is this?—rate < 45 bpm; no relationship between P wave and QRS complex; “when Q’s and P’s don’t agree, then you’ve got a ___”; ___ needs to be placed!
Third degree AV block; pacemaker needs to be placed
What EKG rhythm is this?—rate 150-250 bpm; P wave buried in QRS; QRS complex usually wide and with physic variation twisting around a central axis; seen with hypokalemia, hypocalcemia, hypomagnesemia
Torsades de Pointes
Torsades may be worsened by ___ administration
Lidocaine administration
Treat torsades with ___
Magnesium sulfate
Treatment for V-Fib = ___
CPR, epi, defibrillation
What EKG rhythm is this?—absent PR interval; wide, bizarre QRS complex; can be pulseless or with a pulse
V-Tach
Treatment for V-Tach with a pulse = ___
Synchronized cardioversion
Treatment for pulseless V-Tach = ___
CPR
What is the most common hospital source of pacemaker electromagnetic interference (EMI)?
Electrocautery
As long as cautery is used below the ___, you shouldn’t have issues with EMI
Waist
___ pads can interfere with pacemakers
Defibrillation pads
___ is generally contraindicated in patients with pacemakers
MRI
What surgical procedure may have a negative effect on pacemaker systems?
ESWL—electrocorporeal shock wave lithotripsy
How does ESWL affect pacemakers? The shock waves from the lithotripsy can cause ___ phenomenon
R on T phenomenon
Specifically—the shock wave can produce ventricular extrasystoles, so it is synchronized to the R wave (causing R on T phenomenon)…this will send the patient into crazy EKG rhythms and puts them at risk for V-Tach
NBG code for pacemakers—the first letter refers to the chamber(s) being ___
Paced
V = ventricle A = atrium D = dual O = none S = single (A or V)
NBG code for pacemakers—the second letter refers to the chamber(s) being ___
Sensed
V = ventricle A = atrium D = dual O = none S = single (A or V)
NBG code for pacemakers—the third letter refers to the pacemaker’s response to a ___
Sensed event
T = triggered I = inhibited D = dual (triggered + inhibited) O = no response
In a single chamber mode, “triggered” means that when an intrinsic event is sensed, a pace is triggered immediately thereafter. In a dual chamber mode, “triggered” means that a sensed atrial event will initiate (trigger) an A-V pace.
Things affecting pacemakers—external defibrillation—paddles should be placed ___ and ___ if possible; if bilateral anterior placement is necessary, try to maintain __ inches from the device
Anterior and posterior if possible; if bilateral anterior placement is necessary, try to maintain 6 inches from the device
Things affecting pacemakers—electrosurgery—use ___ (mono/bipolar) cautery whenever possible; use ___ (minimal/maximal) bovie settings; keep emergency external pacing/defibrillating device within reach; monitor mode of the device; ___ device post-op; keep a ___ handy
Use bipolar cautery whenever possible; use minimal bovie settings; keep emergency external pacing/defibrillating device within reach; monitor mode of the device; interrogate device post-op; keep a magnet handy
Things affecting pacemakers—magnets—placing magnet over permanent pacemaker will set the pacemaker into ___ mode, ___ rate—pacemaker will automatically pace the patient at the ___ rate
Backup mode, asynchronous rate—pacemaker will automatically pace the patient at the backup rate
Things affecting pacemakers—magnets—placing magnet over AICD will suspend ___ detection so the AICD will not shock the patient
EMI
Pacemakers in the ambulatory setting—have a ___ available in your room; make sure patient had a pre-op ___ and a recent pacemaker interrogation done within the last ___-___ months; know what the pacemaker ___ is set at and what the ___ rate is
Have a magnet available in your room; make sure patient had a pre-op EKG and a recent pacemaker interrogation done within the last 1-2 months; know what the pacemaker rate is set at and what the backup rate is
There is usually an EP person available to come interrogate a pacemaker at an ambulatory surgery center—T/F?
False—there is no EP person at an ambulatory surgery center
Procedures done at ambulatory surgery center usually have no cautery, so risk of EMI with pacemakers is very low—T/F?
True
Cardiac clearance is required for patients with a pacemaker/AICD planning to undergo surgery at an ambulatory surgery center—T/F?
True
Off-pump CABG can be performed minimally invasively through a thoracotomy approach, but typically a full sternotomy approach is still used—T/F?
True
Mid-lateral thoracotomy approach for off-pump CABG allows better healing for the patient because it’s a smaller wound; the procedure itself will take longer and there will be less visualization for the surgeon—T/F?
True
For off-pump CABG, a perfusionist and CPB machine are not necessary—T/F?
False—must still have a perfusionist available with a CPB machine ready in the room in the event that you have to go on-pump
Off-pump CABG is a ___ (shorter/longer) procedure than a traditional CPB CABG
Longer procedure—usually ~1.5 hours longer
Patient considerations for off-pump CABG—patient must have relatively good ___ function to be a candidate
LV function—the heart needs to have good enough squeeze as it is being manipulated by the surgeon—manipulation can cause swings in BP, restricts flow to the heart
___ management of the off-pump CABG patient is key
Fluid management
You will give ___ (more/less) crystalloid/colloid during an off-pump CABG vs. on pump; ___ has to be diligent in the management of fluids for off-pump CABG
More; CRNA has to be diligent in the management of fluids for off-pump
Perfusionist manages fluids on pump
___thermia is necessary during off-pump CABG; goal temperature of ___ C
Normothermia; goal temperature of 36 C
If patient does not maintain normothermia during off-pump CABG, you can still extubate them in the OR at the end of the case—T/F?
False—cannot extubate if patient is not normothermic
This is a key difference for off-pump and on-pump CABGs…on pump CABGs will always remain intubated and will be extubated in the ICU; off-pump CABGs can be extubated at the end of the case in the OR and taken to the ICU extubated if and only if they are normothermic
Anticoagulation for off-pump CABG—aminocaproic acid ___ (is/is not) administered
Is not administered for off-pump CABG
Aminocaproic acid (amicar) is an antifibrinolytic; normally give amicar when patient is on pump—start after central line is put in; give bolus and then infusion that runs for 4-5 hours; MOA = inhibition of plasminogen binding to fibrin, thus inhibits conversion of fibrin to plasmin
Anticoagulation for off-pump CABG—patient is still ___, but typically at a lesser dose vs. on pump CABG
Heparinized
Anticoagulation for off-pump CABG—partial heparinization ___-___ units/kg; goal ACT > ___
100-200 units/kg; goal ACT > 300
Some surgeons will still elect to fully heparinize for off-pump CABG at 300-400 units/kg
___ reversal will still be given for off-pump CABG, regardless of whether you do partial or full heparinization
Protamine reversal
Protamine should be pushed fast—T/F?
False—need to push your protamine SLOW!!! Over 5 minutes!
Procedural considerations for off-pump CABG—will see ___tension when the heart is initially lifted with footplate stabilizers/retractors
Hypotension
___ (more/less) manipulation is needed to bypass the LAD/diagonal arteries
Less manipulation
Usually do these grafts first; surgeon doesn’t need to turn/lift the heart as much to visualize these vessels, so you won’t see a lot of swings in BP
___ (more/less) manipulation is needed to bypass the PDA/circumflex arteries; keep MAP ___ (low/elevated) during this time
More; keep MAP elevated during this time—volume load with albumin
Usually do these grafts after LAD/diagonal; heart will be turned/manipulated a lot
Can see extreme hemodynamic compromise and myocardial ischemia during ___/___ grafting; may need to start ___ and/or ___
PDA/circumflex grafting; may need to start inotropes and/or vasopressors
At the point of proximal graft aortic anastomosis, MAP is lowered to ___ mm Hg because there is a higher concern for ___ when you’re working directly on the aorta
Lowered to 60 mm Hg because there is a higher concern for bleeding when you’re working directly on the aorta
May have to pause drips at this time!
Advantages to off-pump CABG—___ (more/less) surgical bleeding; ___ (more/less) heparin/concern for residual anticoagulation; if ___thermia maintained throughout, can potentially ___ patient while still in the OR; avoidance of aortic ___
Less surgical bleeding; less heparin/concern for residual anticoagulation (because you may do partial heparinization); if normothermia maintained throughout, can potentially extubate patient while still in the OR; avoidance of aortic cross-clamp
Advantages of off-pump CABG—avoidance of aortic cross clamp = ___ (more/less) risk of ischemia, debris embolization
Less risk of ischemia, debris (anything accumulating on the clamp) embolization
Mechanical circulatory assist devices—intraaortic balloon pump (IABP)—uses synchronized counterpulsation to enhance myocardial ___; ___ (increases/decreases) afterload during systole; ___ (increases/decreases) coronary blood flow to the heart during diastole
Uses synchronized counterpulsation to enhance myocardial perfusion; decreases afterload during systole; increases coronary blood flow to the heart during diastole
IABP therapy can be used to stabilize preop CABG patients following an acute ___; placed on patients who have difficulty separating from ___; used as a supplement during ___ (off/on pump) CABG
Can be used to stabilize preop CABG patients following an acute MI; placed on patients who have difficulty separating from CPB; used as a supplement during off pump CABG
Contraindications to placement of IABP—___sis; ___ (ascending/descending) aortic disease; severe ___; severe aortic ___
Sepsis; descending aortic disease; severe PVD; severe aortic regurgitation
Placement of IABP—typically placed through the ___ artery; tip of the balloon sits at the junction of the aortic ___ and the ___ aorta; should be 2 cm distal to the origin of the ___ (right/left) subclavian artery
Typically placed through the femoral artery; tip of the balloon sits at the junction of the aortic arch and the descending aorta; should be 2 cm distal to the origin of the left subclavian artery
Inflation of IABP—timed with the ___ on the arterial waveform; the balloon inflates once the AV ___ (opens/closes) and ___ (systole/diastole) begins; inflated balloon acts as a seal to ___ (increase/decrease) pressure and send the blood towards the ___ arteries
Timed with the dicrotic notch on the arterial waveform; the balloon inflates once the AV closes and diastole begins; inflated balloon acts as a seal to increase pressure and send the blood towards the coronary arteries
Deflation of IABP—the ballon deflates immediately before the onset of ___ (systole/diastole), at the beginning of the ___ wave on EKG
Deflates immediately before the onset of systole, at the beginning of the R wave on EKG
Deflation of IABP—deflation causes a vacuum effect—___ (increases/decreases) aortic pressure, ___ (increases/decreases) afterload; facilitates ventricular ___ (ejection/relaxation); ___ (increases/decreases) myocardial oxygen demand
Decreases aortic pressure, decreases afterload; facilitates ventricular ejection; decreases myocardial oxygen demand
Timing of IABP—usually a ___:___ or ___:___ ratio
1:1 or 1:2 ratio
Timing of IABP—1:1 ratio—the balloon inflates with ___
Every systole/diastole
Timing of IABP—1:2 ratio—the balloon inflates with ___
Every other systole/diastole
Timing of IABP—to wean patient off of IABP, trial a ___:___ ratio
1:4 ratio
If the patient starts on 1:1 ratio, try 1:2 for a little while, then 1:4
You can immediately remove the IABP if the patient is on a 1:1 ratio—T/F?
False—have to wean the balloon pump before removing it!
Complications of IABP—___—patient will be on anti___ for long term IABP management; ___ injuries; ___ at insertion site; ___cytopenia
Thrombus—patient will be on anticoagulation for long term IABP management; vascular injuries (vessel ischemia); infection at insertion site; thrombocytopenia
Most common complication of IABP is ___
Vascular injuries
ECMO = ___
Extracorporeal membrane oxygenation
ECMO provides both ___ and ___ arterial perfusion support
Pulmonary and systemic arterial perfusion support
ECMO is a closed circuit device that allows the ___/___ to recover from injury or trauma while maintaining ___ and ___
Allows the heart/lungs to recover from injury or trauma while maintaining oxygenation and perfusion
Indications for use of ECMO—___ shock; failure to wean from ___; ___ (left/right) heart failure; heart failure that cannot be treated with ___ device; resuscitation of patients requiring ___; patients with severe ___ failure/___
Cardiogenic shock; failure to wean from CPB; right heart failure; heart failure that cannot be treated with ventricular assist device; resuscitation of patients requiring CPR; patients with severe respiratory failure/ARDS
Two types of ECMO—___ and ___
Venovenous and venoarterial
___ ECMO is the preferred method for respiratory failure in patients whose cardiac function is intact
Venovenous ECMO
Venovenous ECMO—___ and ___ veins are the common cannulation sites; blood is drained from the ___ and ___ through cannula in vein; blood is oxygenated by ___ and returned to the ___
Femoral and IJ veins are the common cannulation sites; blood is drained from the SVC and IVC through cannula in femoral or IJ vein; blood is oxygenated by ECMO circuit and returned to the RA
Venovenous ECMO—can either utilize separate drainage/return cannulae or can use a single double lumen cannula—T/F?
True
Venoarterial ECMO is chosen for patients who require ___ ventricular support in addition to ___ support; it is used for patients who have poor ___ function
Patients who require left ventricular support in addition to pulmonary support; it is used for patients who have poor cardiac function
Venoarterial ECMO bypasses ___ circulation altogether; this causes a ___ (lower/higher) arterial oxygenation
Bypasses pulmonary circulation altogether; this causes a higher arterial oxygenation
Venoarterial ECMO—cannulas are usually placed ___ (centrally/peripherally); blood is drained from ___ and returned via cannula in the ___; process is similar to CPB; blood drains to a roller pump that circulates blood at ___-___L/min through a membrane oxygenator—___ is removed, ___ is added; blood is re___ before it is returned
Cannulas are usually placed centrally; blood is drained from RA and returned via cannula in the ascending aorta; process is similar to CPB; blood drains to a roller pump that circulates blood at 3-6 L/min through a membrane oxygenator—CO2 is removed, O2 is added; blood is rewarmed before it is returned
Venoarterial ECMO—central vs. peripheral cannulation
Central cannulation—typically used on patients who can’t wean from CPB, crashing patients; cannula drains blood from RA and is returned via cannula in the ascending aorta
Peripheral cannulation—blood is drained from RIJ or femoral vein and returned via femoral artery
Complications of ECMO—___ (anticoagulation is required); ___; ___; limb ___; multiorgan ___
Bleeding; stroke; infection; limb ischemia; multiorgan dysfunction
Ventricular assist devices (VADs)—indications—___ shock from acute MI; ___ cardiomyopathies; post-___
Cardiogenic shock from acute MI; viral cardiomyopathies; post-CPB
Contraindications for VADs—active ___; irreversible ___ or ___ dysfunction; severe ___ HTN; ___ cancer; major ___ disorders
Active infection; irreversible renal or hepatic dysfunction; severe pulmonary HTN; metastatic cancer; major coagulation disorders (i.e.: von Willebrand’s disease)
LVAD—mechanical circulatory assist device attached to the heart through a cannula; collects ___ (deoxygenated/oxygenated) blood that is returned to the ___ from an inflow cannula (that is usually placed at the apex of the ___); ejects blood out through an outflow cannula that is attached to the ___
Collects oxygenated blood that is returned to the LA from an inflow cannula (that is usually placed at the apex of the LV); ejects blood out through an outflow cannula that is attached to the aorta
RVAD—similar construction to LVAD but it receives ___ (oxygenated/deoxygenated) blood from the ___ and pumps blood into the ___ (pulmonary/systemic) circulation through an outflow cannula in the ___
It receives deoxygenated blood from the RA and pumps blood into the pulmonary circulation through an outflow cannula in the pulmonary artery
VAD categories—type of flow—___ or ___; ___ of time for use; location of device—___-, ___-, or ___-corporeal; source of driving power—___ or ___
Type of flow—continuous or pulsatile; length of time for use; location of device—intra-, extra-, or para-corporeal; source of driving power—pneumatic or electric
___ is a small, percutaneously inserted VAD
Impella
Impella is placed through ___ artery access via retrograde approach to access the ___ valve
Femoral artery access to access the aortic valve
Impella pumps blood from the ___ into the ___
Left ventricle into the ascending aorta
Impella pump rate ___L/min
2.5 L/min
Impella pumps ___
On its own
IABP is timed and requires the patient’s arterial pressure to pump; impella pumps regardless of what the patient’s body is doing—2.5L/min
Anesthetic management of patients with LVADs—patients may have ___ congestion from ___ (left/right) heart failure; patients may be on preop anti___, so there is concern for major ___ during procedures
Patients may have hepatic congestion from right heart failure; patients may be on preop anticoagulation, so there is concern for major bleeding during procedures
Anesthetic management of patients with LVADs—how these patients do is extremely dependent on ___; important to prevent ___cardia and maintain ___ tone during induction and maintenance of anesthesia; use ___ for induction, higher ___ dose; keep patient ___ throughout the case so you can maintain a ___ (lighter/deeper) anesthetic level without the patient moving
How these patients do is extremely dependent on heart rate; important to prevent bradycardia and maintain sympathetic tone during induction and maintenance of anesthesia; use etomidate for induction, higher narcotic dose (little to no propofol); keep patient paralyzed throughout the case so you can maintain a lighter anesthetic level without the patient moving
LVAD patients CANNOT tolerate ___cardia and ___tension
Bradycardia and hypotension
Anesthetic management of patients with LVADs—strict ___ technique must be maintained with invasive line placement due to ___ risk
Strict sterile technique must be maintained with invasive line placement due to infection risk
SEPSIS IS THE LEADING CAUSE OF MORTALITY IN LVAD PATIENTS
What is the leading cause of mortality in LVAD patients?
Sepsis
Anesthetic management of patients with LVADs—30% of LVAD recipients develop ___ ventricular dysfunction; use ___ to monitor and avoid overfilling of the ___
Right ventricular dysfunction; use TEE to monitor and avoid overfilling of the RV
Anesthetic management of patients with LVADs—treatment of RV dysfunction—___ to decrease RV afterload; ___ to dilate the pulmonary vasculature
Inotropes to decrease RV afterload (i.e.: epi, milrinone); inhaled nitric oxide to dilate pulmonary vasculature
Anesthetic management of patients with LVADs—LVAD flow is highly dependent on ___—use ___ and ___ products
Volume!!! Use blood and blood products
Don’t want these patients to become hypovolemic
Use blood to resuscitate—don’t slam in bags of crystalloid; if you don’t have blood right then and there, use albumin first
Anesthesia for non-cardiac thoracic procedures—pulmonary function criteria—suggests high risk if…FVC < ___%; FEV1 < ___L; FEV1/FVC < ___%; diffusing capacity < ___% predicted; PaCO2 > ___ mm Hg
FVC < 50%; FEV1 < 2 L; FEV1/FVC < 50%; diffusing capacity < 50% predicted; PaCO2 > 45 mm Hg
Drug therapy for non-cardiac thoracic procedures—sympathomimetics = beta ___ (agonists/antagonists) that ___ (increase/decrease) formation of cyclic-AMP, resulting in broncho___
Beta agonists that increase formation of cyclic-AMP, resulting in bronchodilation
Examples = metaproterenol, albuterol, terbutaline
Drug therapy for non-cardiac thoracic procedures—parasympatholytics = ___ (increase/decrease) levels of cyclic-GMP, which modulate broncho___
Decrease levels of cyclic-GMP, which modulates bronchoconstriction (so preventing bronchoconstriction by decreasing cyclic-GMP)
Examples = atropine, ipratropium bromide
Drug therapy for non-cardiac thoracic procedures—phosphodiesterase inhibitors—___ (inhibits/enhances) enzymatic breakdown of cyclic-AMP, which ___ (increases/decreases) cellular levels
Inhibits enzymatic breakdown of cyclic-AMP, which increases cellular levels
Example = aminophylline; therapeutic blood levels 5-20 micrograms/ml; loading dose 5-7mg/kg infused over 20 min; continuous infusion 0.5-0.7 mg/kg/hr
Drug therapy for non-cardiac thoracic procedures—steroids—reduce mucosal ___ and suppress ___
Reduce mucosal edema and suppress inflammation
Example = beclomethasone
Drug therapy for non-cardiac thoracic procedures—cromolyn sodium = mast cell stabilizer preventing degranulation and release of ___
Histamine
Drug therapy for non-cardiac thoracic procedures—digitalis—useful with ___ (left/right) sided heart failure or supraventricular dysrhythmias with rapid ___ response
Useful with left sided heart failure or supraventricular dysrhythmias with rapid ventricular response
Positioning for non-cardiac thoracic procedures—___ position is used anytime there is a desire to prevent flooding to the tracheobronchial tree during procedures
Prone
Positioning for non-cardiac thoracic procedures—___ is standard thoracotomy position
Lateral decubitus
Physiologic considerations of lateral decubitus—in upright position, apices of lungs are better ___, bases of lungs are better ___
Apices of lungs are better ventilated, bases of lungs are better perfused
Physiologic considerations of lateral decubitus—in lateral position, dependent (downward) lung gets more ___, upper lung gets more ___
Dependent (downward) lung gets more blood flow (perfusion), upper lung gets more air (ventilation…because air rises)
Physiologic considerations of lateral decubitus—if you clamp a lung (whether it’s the up or down lung), that becomes the “___” lung
That becomes the “down” lung or the lung that is not being ventilated
Lateral decubitus—in the awake patient who is breathing spontaneously…blood flow to the ___ (independent/dependent) lung > blood flow to the ___ (independent/dependent) lung; ventilation is greater in the ___ (independent/dependent) lung
Blood flow to the dependent lung > blood flow to the independent lung; ventilation is greater in the dependent lung
Lateral decubitus—in the anesthetized patient who is spontaneously breathing, chest closed—___ (independent/dependent) lung is better perfused; FRC is ___ (increased/decreased) in both lungs; ___ (independent/dependent) lung becomes less compliant, ___ (independent/dependent) lung becomes more compliant; ___ (increase/decrease) in shunt and dead space ventilation
Dependent lung is better perfused; FRC is decreased in both lungs; dependent lung becomes less compliant, independent (upper) lung becomes more compliant; increase in shunt and dead space ventilation
Lateral decubitus—in the anesthetized, paralyzed, mechanically ventilated patient, chest closed—___ (independent/dependent) lung is better perfused; ventilation to ___ (independent/dependent) lung is even greater
Dependent lung is better perfused; ventilation to independent lung is even greater
Lateral decubitus—in the anesthetized patient who is spontaneously breathing, chest open—___ shift; ___ respiration
Mediastinal shift; paradoxical respiration (instead of chest/abdominal wall moving out when taking a breath, it moves inward…this is what is causing the mediastinal shift)
Lateral decubitus—in the anesthetized patient, ventilation controlled, chest open—open chest ___ (increases/decreases) compliance of both lungs; airway pressure ___ (increased/decreased) in both lungs; cardiac index ___ (increases/decreases); MAP is ___ (changed/unchanged); CO2 elimination is greater from ___ (independent/dependent) lung; ___ (increased/decreased) amount of zone 1 and dead space ventilation
Open chest increases compliance of both lungs; airway pressure decreased in both lungs; cardiac index increases; MAP is unchanged; CO2 elimination is greater from independent lung; decreased amount of zone 1 and dead space ventilation
Disadvantages of lateral decubitus position—opposite hemithorax ___ (is/is not) accessible; V/Q ___; contamination of ___ (independent/dependent) lung; ___ (increased/decreased) FRC, airway closure and atelectasis in ___ (independent/dependent) lung; ___ from positioning
Opposite hemithorax is not accessible; V/Q mismatch; contamination of dependent lung; decreased FRC, airway closure and atelectasis in dependent lung; injury from positioning
In order to separate the lungs during intrathoracic operations, we use ___ lumen endotracheal tube; allows us to selectively ___/___ a lung during procedure
Double lumen endotracheal tube; allows us to selectively ventilate/collapse a lung during procedure
General anesthesia and one lung anesthesia—do not use ___ (what inhalation agent?); avoid ___emia; ___ infusion may be a choice; maintain good muscle ___
Do not use nitrous oxide; avoid hypoxemia; ketamine infusion may be a choice; maintain good muscle relaxation
Hypoxia that occurs during one lung ventilation may require—get an ___; may need to ___ the collapsed lung; give ___ to independent (up, deflated) lung; give ___ to dependent (down, inflated) lung
Get an ABG; may need to reinflate the collapsed lung; give CPAP to independent (up, deflated) lung; give PEEP to dependent (down, inflated) lung
Hypoxia that occurs during one lung ventilation—give CPAP to ___ (independent/dependent) lung; give PEEP to ___ (independent/dependent) lung
Give CPAP to independent (up, deflated) lung; give PEEP to dependent (down, inflated) lung
At the conclusion of lung resection, the deflated lung should be re-inflated carefully; positive pressure is held at ___-___ cm H2O to allow the surgeon to view suture lines and check for air leaks
35-40 cm H2O
What to do if sat drops from 100% to 93% during one lung anesthesia (patient becomes hypoxic)…switch to ___% FiO2; switch from ___ ventilation to ___ ventilation and check compliance; confirm DLT ___; send an ___; suction out the lung that is ___ (inflated/deflated); give ___ (CPAP/PEEP) to the deflated/up lung; if sat still does not come up, give ___ (CPAP/PEEP) to the inflated/down lung
Switch to 100% FiO2; switch from continuous ventilation to manual ventilation and check compliance; confirm DLT placement; send an ABG; suction out the lung that is deflated (up/independent lung); give CPAP to the deflated/up lung; if sat still does not come up, give PEEP to the inflated/down lung
If desaturation persists even after all of these interventions, you can unclamp the double lumen ETT, reinflate the deflated lung, and do two lung ventilation until the sats come back up
Why do we give CPAP to the deflated/up lung if hypoxia occurs during one lung anesthesia?
The deflated/up lung is NOT being ventilated, but it is being perfused (to an extent less than the inflated/dependent lung)…so blood is flowing to the lung but is not being oxygenated…desaturation can occur d/t the ongoing V/Q mismatch occurring in the deflated/up lung while it is not being ventilated
Give CPAP to lessen the V/Q mismatch—give some oxygen to the blood that is flowing there so you get a little ventilation with your perfusion
Why do we give PEEP to the inflated/down lung if hypoxia occurs during one lung anesthesia?
You should only do this if your sat still doesn’t come up after giving CPAP to the deflated/up lung
You can give PEEP to the inflated/down lung because this lung is being ventilated, so PEEP will allow some of those small alveoli to open up more so more oxygen can be delivered to the blood that is flowing there
HOWEVER…PEEP increases your intrathoracic pressure. So in theory, it would cause blood (perfusion) to shift from the inflated/down lung to the deflated/up lung (the lung that is NOT being ventilated). This would increase your V/Q mismatch even more. This is why PEEP is not first line when hypoxia occurs.
Contraindications to DLT—___ along the tube’s pathway; difficulty obtaining direct ___ during intubation; critically ill patients who don’t tolerate ___; ___ stomach/risk for ___
Lesion along the tube’s pathway; difficulty obtaining direct visualization during intubation; critically ill patients who don’t tolerate apnea; full stomach/risk for aspiration
Regional/GA for non-cardiac thoracic procedures—may use combination of general anesthesia with ___ epidural (level determined by surgery); utilizes ___ (more/less) narcotics, ___ (lower/higher) gas concentrations; enables ___ (slower/faster) emergence/recovery with benefits of good analgesia
May use combination of general anesthesia with thoracic epidural (level determined by surgery); utilizes less narcotics, lower gas concentrations; enables faster emergence/recovery with benefits of good analgesia
Rigid bronchoscopy is performed for—removal of ___ bodies; massive ___; dilate trachobronchial ___; ___ placement; biopsy and staging of ___ processes; establishment of an ___ airway
Removal of foreign bodies; massive hemoptysis; dilate tracheobronchial strictures; stent placement; biopsy and staging of malignant processes; establishment of an emergent airway
What do we worry about with rigid bronchoscopy?
Sharing the airway with the surgeon—requires extremely high vigilance and excellent ongoing communication
Also worry about arrhythmias, hypertension, hypoxemia
Patient position for rigid bronchoscopy—___ or ___
Sitting or supine
Give ___ early for rigid bronchoscopy
Glycopyrrolate—antisialogogue to dry up patient’s mouth
Rigid bronchoscopy—usually give patient ___ + ___ anesthetic; use ___ (short/long) acting drugs; postop hypoxemia will usually correct with supplemental ___; keep the sedation ___ (light/deep) to avoid ___ventilation
Usually give patient sedation + topical anesthetic; use short-acting drugs (remifentanil drip); postop hypoxemia will usually correct with supplemental O2; keep the sedation light to avoid hypoventilation
Fiberoptic bronchoscopy allows evaluation of the tracheobronchial tree ___ than rigid bronch
Deeper
Fiberoptic bronchoscopy is used for ___ disease diagnosis; staging ___; lavage/aspiration of thick secretions in acute ___; transbronchial ___ and ___
Pulmonary disease diagnosis; staging carcinomas; lavage/aspiration of thick secretions in acute atelectasis; transbronchial biopsy and brushings
Absolute contraindications for fiberoptic bronchoscopy = unstable ___ system; current life threatening cardiac ___; and severe ___emia
Unstable CV system; current life threatening cardiac arrhythmias; and severe hypoxemia
Problems during fiberoptic bronchoscopy—___ing; ___tension; ___cardia; may require lung separation if ___ develops
Coughing; hypertension; tachycardia (usually indicates inadequate anesthesia/topical anesthetic); may require lung separation if bleeding develops
EBL during fiberoptic bronchoscopy is usually ___
Negligible
Need to know from surgeon for fiberoptic bronchoscopy—if proceeding through ETT, will need ETT size ___-___; if proceeding next to ETT, will need ETT size ___-___
If proceeding through ETT, will need ETT size 7.5-8.0
If proceeding next to ETT, will need ETT size 5.0-6.0
Indications for pneumonectomy—___ lung cancer; drug resistant ___, ___bacterium, ___ infections, necrosis; ___ (done as a last resort)
Non-small cell lung cancer; drug resistant TB, mycobacterium, fungal infections, necrosis; trauma (done as a last resort)
Preop pneumonectomy—___ation, anti___, broncho___, place ___ epidural; monitors—A-line, CVP, PA on ___ (same/opposite) side; ___ lumen ETT
Hydration, antibiotics, bronchodilators, place thoracic epidural; monitors—A-line, CVP, PA on opposite side; double lumen ETT
Fluid management during pneumonectomy—want to run patient ___; EBL is usually ___
Want to run patient dry; EBL is usually < 500 cc
Post-op pneumonectomy—anticipate unrecognized ___ loss; postop pulmonary ___, ___asis; dys___; DVT and pulmonary embolism occur in ___% of patients; persistent ___ leak; excessive ___ shift, can be life threatening
Anticipate unrecognized blood loss; postop pulmonary edema, atelectasis; dysrhythmias; DVT and pulmonary embolism occur in 20% of patients; persistent air leak; excessive mediastinal shift, can be life threatening
Post-op pneumonectomy—ipsilateral (same side as the pneumonectomy) mediastinal shift—___tension; ___mias; cardiac ___; pulmonary ___
Hypotension; arrhythmias; cardiac herniation; pulmonary edema
Post-op pneumonectomy—contralateral (opposite side of the pneumonectomy) mediastinal shift—decreased ___ function; ___ (increased/decreased) venous return
Decreased lung function; decreased venous return
Chest tubes are kept ___ to prevent mediastinal shifts
Clamped—only brief unclamp for drainage of fluids
