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Flashcards in Off Pump vs On Pump Management Deck (126)
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1

4 surgical techniques for Cardiac operations

1. On pump with an arrested heart
-sometimes arresting the heart is required and sometimes the surgeon will arrest the heart if its not required

2. On pump with a beating heart
-pump assisted beating heart surgery
-can be performed with total or partial bypass

3. Off pump
-patient is not put on the bypass machine
-heart stays beating

4. endovascular
-new technique available for valve repair/ replacement

2

Anesthetic Management for On PUMP cardiac surgery with an Arrested heart:

What are the first two steps prior to incision?

1. Cardiac Induction

2. BOBCAT

3

Cardiac Induction On pump:
Large doses of this drug is rarely used for induction?

What are 3 alternative techniques for achieving a cardiac induction?

-propofol

1. high doses of versed (5 mg) and fentanyl (250 mcg)

2. Etomidate
-produces less hypotension on induction
-causes adrenal suppression
-linked to worse postoperative outcomes

3. small propofol dose followed by inhalation induction with bag mask ventilation
-slower onset of hypotension after induction

4

What is an advantage of using etomidate on cardiac induction?

produces less hypotension on induction

5

what is a disadvantage of using etomidate on cardiac induction?

causes adrenal suppression and may be linked to worse postop outcomes

6

on Cardiac induction it is common to give the drugs (slow/fast) and use the _____ _____ pressure as a guide for when to intubate

slow

arterial line

7

on cardiac induction, intubation is indicated once the induction drugs have lowered the BP to an acceptable level so as not to produce ______ from intubation

hypertension

8

first B in BOBCAT

Baseline
-labs
-ACT

9

O in BOBCAT

OG
insertion and removal
-possibly reinsert the OG at the end of the case

10

where should you avoid placing the OG in cardiac patients? why?

in the nare
-patient is heparinzed

11

2nd B in BOBCAT

BIS monitor placement

12

C in BOBCAT

Central line placement

13

A in BOBCAT

Amicar Bolus

14

When is Amicar bolused?

after central line placement

15

What is the dose of the Amicar bolus?
What do you follow the bolus with?

5-10g
followed by 1g/hour infusion

16

T in BOBCAT

TEE monitoring

17

what is the most common anti-fibrinolytic drug used in cardiopulmonary bypass?

Amicar (epsilon-aminocaproic acid)

18

What drug may be used as an alternative to Amicar?

Tranexamic acid

19

Why are anti-fibrinolytic used in cardiac surgery?

They counteract the damaging effects of the bypass machine on the blood and reduce bleeding post-cardiopulmonary bypasss by inhibiting fibrinolysis

20

Why is a TEE placed during cardiac surgery?

Regional wall motion abnormalities on TEE have been shown to be the earliest and most sensitive sign to detect myocardial ischemia

21

What is the first step of cardiac surgery after induction and BOBCAT?

Leg incision to harvest the saphenous vein
-long step and can take up to an hour
-only applicable if doing a CABG

22

Which type of procedures do not require the harvesting of the saphenous vein?

valve repair/replacements

23

What is the next step after harvesting the saphenous vein (if needed)

Sternal incision and sternotomy

24

What patient consideration should you try to avoid during the sternal incision/sternotomy?

Hypertension
-intense stimulation during this period

25

What are 2 of the most popular drug options for preventing hypertension during a sternal incision/sternotomy?

fentanyl or nitroglycerin

26

What are the 2 steps the anesthetist MUST do during the sternal incision/ sternotomy?

1. turn off the ventilator
2. remove the breathing bag from the circuit
-do not want the lungs to inflate while the saw is in the chest

27

What step comes after the sternal incision?

Sternal retraction

28

After sternal retraction, what happens to intrathoracic pressure?

becomes the same as atmospheric pressure
-not negative anymore

29

What changes does the increase in intrathoracic pressure cause to the patient?
an (increase/decrease) in venous return
an (increase/decrease) in cardiac output

decrease in venous return
decrease in cardiac output

30

During sternal retraction, the retractors can cause compression of the ______ artery which may cause (right/left) radial artery arterial lines to show a falsely ____ number

subclavian
right
low