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Summer 2020 - Advanced Anesthesia - CV > Off Pump CABG & Mechanical Circulatory Devices - Quiz 7 > Flashcards

Off Pump CABG & Mechanical Circulatory Devices - Quiz 7 Flashcards

1
Q

What are the different approaches for doing a CABG?

A

Thoracotomy - minimally invasive

&

Full Sternotomy

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2
Q

Other than the Surgeon & Anesthetist, who else is also required to be in the room for a CABG?

A

Perfusionist w/ a CPB machine ready

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3
Q

An Off-Pump CABG usually takes _____ time than a traditional CPB CABG

A

An Off-Pump CABG usually takes MORE time than a traditional CPB CABG

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4
Q

What makes a pt. a good candidate for an Off-Pump CABG?

A

Good LV Function

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5
Q

How does Fluid Management differ from an On-Pump CABG vs an Off-Pump CABG?

A

Harder to give large amt of fluid Off-Pump unlike the CPB Machine that can give large amounts extremely quickly

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6
Q

Normothermia is absolutely necessary during a CABG. What are ways to maintain normothermia?

A

Monitor Core Temp

Water Thermoregulation Mattress

Heat Preserving Bouffant

↑Room Temp

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7
Q

What can happen if a pt does not maintain normothermia of 36o C during a CABG?

A

Will be unable to Extubate

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8
Q

Which Antifibrinolytic is normally given for an On-Pump CABG, but NOT given for an Off-Pump CABG?

A

Aminocaproic Acid (Amicar) - inhibits Plasminogen binding to Fibrin converting it to Plasmin

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9
Q

What is the dose of Heparin given for an Off-Pump CABG?

A

Less than it would be for On-Pump CABG

100-200 units/kg w/ a goal ACT > 300

(sometimes full heparin @ 300-400 units/kg)

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10
Q

What is the reversal for Heparin?

A

Protamine

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11
Q

How is the heart visualized during an Off-Pump CABG?

A

Surgeon uses Footplate Stabilizers & Retractors that Suction & Lift the Heart

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12
Q

How is the Blood Pressure managed during Verticalization of the Apex to visualize the PDA & Circumflex?

A

Keep MAP Elevated & Give Volume to counter Extreme Hemodynamic Compromise & Ischemia

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13
Q

At what point during an Off-Pump CABG does the MAP need to be lowered to 60 mmHg?

A

During the Proximal Graft Aortic Anastomosis

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14
Q

What are the Advantages of an Off-Pump CABG?

A

Less Bleeding

Less Heparin

Normothermia Maintained –> Potential Extubation

No Aortic Cross-Clamp

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15
Q

Why are Intra-Aortic Ballloon Pumps (IABP) used?

A

↑Cardiac Perfusion w/ Sync’d Counterpulsation

↑Coronary Blood Flow on Diastole

↓Afterload on Systole

Stabilizes PreOP CABG Pts post MI

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16
Q

What is used as a supplement for an Off-Pump CABG or for patients who have difficulty coming off the CPB machine?

A

Intra-Aortic Balloon Pump (IABP)

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17
Q

What are contraindications for placing a pt on a IABP?

A

Sepsis

Descending Aortic Disease

Severe PVD

Severe Aortic Regurg.

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18
Q

What site is the IABP inserted?

A

Via Femoral Artery

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19
Q

For an Intra-Aortic Balloon Pump, where does the Tip of the Balloon lie?

A

At the Junction of Aortic Arch & Descending Aorta

&

2 cm distal to the origin of Left Subclavian Artery

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20
Q

How does the Timing of an IABP work?

A

Timed w/ Dicrotic Notch & Inflates on Diastole when AV Closes to seal and increase pressure, sending blood to the coronary arteries

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21
Q

When does the IABP deflate?

A

Deflates right before Systole at the beginning of the R-Wave

22
Q

What does IABP Deflation do?

A

Vacuum Effect

↓Aortic Pressure & ↓Afterload

Facilitates Ventricular Ejection

↓O2 Demand

23
Q

What is happening here?

A

Premature Deflation during Diastole

Suboptimal Perfusion

Backflow

Angina

↑O2 Demand

24
Q

What is happening here?

A

Deflation in Late Diastole as AV Begins to Open

No Afterload Change or ↑Afterload

↑O2 Demand

Prolonged Isovolumetric Contraction

25
Q

What is happening here?

A

Inflation before AV Closure

↑LVEDV, ↑LVEDP, & ↑PCWP

↑LV Wall Stress

↑O2 Demand

Aortic Regurg.

26
Q

What is happening here?

A

Inflation way after AV Closure

Suboptimal Pefusion

27
Q

When would it be safe for a pt to be weaned off a IABP?

A

When pt does ok w/ a 1:4 Ratio on the IABP

28
Q

What are complications associated w/ an IABP?

A

Vascular Injury/Ischemia - most common

Thrombus

Infection

Thrombocytopenia

29
Q

What is Extracorporeal Membrane Oxygenation (ECMO)?

A

Closed circuit device that allows heart/lungs to recover while maintaing oxygenation & perfusion

30
Q

When is ECMO indicated?

A

Cardiogenic Shock

Failure to Wean off CPB

Rt. Heart Failure

Heart Failure unresponsive to VAD

Post CPR

ARDS

31
Q

What is the preferred ECMO method for pts. w/ Respiratory Failure & Intact Cardiac Function?

A

Venovenous ECMO

32
Q

What are the common cannulation sites for Venovenous ECMO?

A

Femoral & IJ Veins

33
Q

How does Venovenous ECMO work?

A

Blood is drained from SVC & IVC via IJ/Femoral Vein

then Oxygenated

then Returned to the Right Atrium

(can be separate drain & return cannulae or Single double lumen cannula)

34
Q

Which type of pt is Venoarterial ECMO used on?

A

Pts who need LV & Pulmonary Support

35
Q

How is Venoarterial ECMO different from Venovenous ECMO?

A

Venoarterial ECMO skips the Pulmonary Circulation for Higher Arterial Oxygenation

36
Q

How does Venoarterial ECMO work?

A

Centrally placed cannulas drain blood from Right Atrium & Returned to Ascending Aorta

37
Q

How would Venoarterial ECMO work if there is Peripheral Cannulation?

A

Blood is drained from Right IJ / Femoral & Returned to Femoral Artery

38
Q

For Venoarterial ECMO, what happens to the blood once it is drained and before it is returned?

A

Goes to a roller pump that circulates @ 3-6 L/min thru a Membrane Oxygenator, which removes CO2, Adds O2, then Rewarmed

39
Q

What are complications of ECMO?

A

Bleeding

Stroke

Infection

Limb Ischemia

Multiorgan Dysfunction

40
Q

What are indications for a Ventricular Assist Device?

A

Cardiogenic Shock post MI

Viral Cardiomyopathies

Post CPB

41
Q

What are contraindications to a Ventricular Assist Device?

A

Active Infection

Irreversible Renal/Hepatic Dysfunction

Severe Pulm. HTN

Metastatic Cancer

Major Coagulopathy

42
Q

How does an LVAD work?

A

Collects Oxygenated Blood from LA via Inflow Cannula & Pumps blood to the Aorta via the Outflow Cannula

43
Q

How do various Ventricular Assist Devices differ?

A

Continuous vs. Pulsatile

Short Term vs Longterm

Pneumatic vs Electric

Location: Intra-, Extra-, Para-Corporeal

44
Q

What is an Impella?

A

Small VAD placed percutaneously thru the Femoral Artery that pumps blood from LV to the Aorta @ 2.5 L/min

45
Q

Why do pts w/ an LVAD have a higher risk for bleeding?

A

These pts may have Hepatic Congestion from Right HF

46
Q

What are the Anesthetic Cardiovascular goals for pts w/ an LVAD?

A

Prevent Bradycardia

&

Maintain Sympathetic Tone

47
Q

What is the leading cause of death in LVAD patients?

A

Sepsis - maintain strict sterile technique

48
Q

Why is Intra-Op TEE used for pts w/ LVAD?

A

30% of these pts develop RV Dysfunction - use TEE to avoid RV Overfilling

49
Q

What meds can be given to treat RV Dysfunction?

A

Epinephrine & Milrinone - ↓RV Afterload

Nitric Oxide - Dilates Pulmonary Vessels

50
Q

LVAD Flow is highly dependent on Volume. What is the Volume of Choice?

A

Blood & Blood Products

Summer 2020 - Advanced Anesthesia - CV (9 decks)

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