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Cardiovascular > Postop care for CT patients > Flashcards

Postop care for CT patients Flashcards

1
Q

D3In postop CT patients are radial atrial lines often artificially low or high?

A

-low due to peripheral vasoconstriction
-if you don’t your radial aline place a femoral one as well

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2
Q

Why is dexmedetomidine preferred to propofol for postop CT pts?

A

less vasodilatory affect

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3
Q

How do CT patients total volumes compare to other vented patients’ tidal volumes?

A

-they tend to require higher tidal volumes
-due to a period of apnea during the bypass leading to postop atelectasis

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4
Q

What isotopes are typically used after cardiac surgery?

A

epinephrine, dopamine, milrinone, norepinephrine

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5
Q

What effects does epinephrine have on the CV system?

A

-stong inotropic
-moderate vasopressor
-so good for improving CO and BP

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6
Q

What are some adverse effects associated with epinephrine use?

A

-tachycardia
-increased myocardial oxygen demand
-increased risk of ectopy or arrhythmia
-persistent lactic acidosis after cardiac surgery

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7
Q

What is the typical inotropic dose of epinephrine after cardiac surgery?

A

0.01-0.05mcg/kg/min

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8
Q

What is the typical described effect of low dose dopamine?

A

vasodilation of the renal vascular bed

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9
Q

What is the typical described effect of moderate dose dopamine?

A

primarily inotropic

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10
Q

What is the typical described effect of high dose dopamine?

A

primarily vasoconstriction

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11
Q

What are adverse effects associated with dopamine use?

A

tachycardia and both atrial and ventricular arrhythmia

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12
Q

What is the MOA of milrinone?

A

phosphodiesterase inhibitor
-leads to increased production of cyclic AMP

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13
Q

What are the effects of milrinone?

A

-augments left and right ventricular function
-vasodilation
-potent pulmonary arterial vasodilator

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14
Q

Which patient populations is milrinone good for?

A

-undergoing mitral valve surgery
-significant right ventricular dysfunction
-have pulmonary hypertension

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15
Q

In which patient populations should milrinone be used with caution?

A

those with marginal systemic pressures
-if really need milrinone (patient with RV dysfunction and pulmonary hypertension) might need to add a vasopressor

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16
Q

What affect does epinephrine have?

A

potent vasopressor w/ some inotropoic affect
-so not really useful in augmenting cardiac output

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17
Q

What inotropic medication has a good, but transient, vasopressor effect with minimal adverse effects?

A

IV calcium
-give as 1-2gm calcium CHLORIDE
-give to all non-bleeding pts w/ new hypotension

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18
Q

What is the ionized calcium goal for post-cardiac patients?

A

> 5mg/dL

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19
Q

What is vasoplegia?

A

peripherial vasodilation seen after cardiac surgery
-often transient
-thought to be d/t pro-inflammatory effects of bypass
-resolves in first 12-24hrs after surgery

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20
Q

When should vasopressors not be started in post-cardiac patients?

A

when hypotension is seen with decreased CO
-give inotropes and resuscitate instead

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21
Q

What are the typical blood pressure goals in most post-op cardiac patients?

A

SBP 90-120, MAP 60-70

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22
Q

Which patient populations can tolerate higher than typical blood pressure goals post-cardiac surgery?

A

-elderly
-known peripheral vascular disease
-known carotid stenosis
-long-standing HTN

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23
Q

What vasopressor has some evidence of being particularly effective in counteracting perioperative ACE or ARB associated vasoplegia?

A

vasopressin

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24
Q

What medication can be used for refractory vasoplegia after cardiac surgery?

A

methylene blue 1.5-2mg/kg over min
-has minimal adverse effects

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25
Q

What alternate diagnoses should be considered if vasoplegia requiring vasopressors persists after the immediate postop period?

A

-pancreatitis (d/t cardiopulmonary bypass)
-mesenteric ischemia (d/t emboli or low flow state)
-adrenal insufficiency (rare but documented effect of etomidate)
-sepsis

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26
Q

Which agents are used to control immediate post-cardiac surgery hypertension?

A

-nitroglycerin
-sodium nitroprusside
-nicardipine

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27
Q

What makes nitroglycerin a favorable agent to use in hypertensive post-CABG patients?

A

-it can induce the vasodilation of both native coronary arteries and the LIMA
-rapid effect
-short half life (4 min)

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28
Q

What is the pathognomonic adverse effect of nitroglycerin at high doses or prolonged infusion?

A

cyanide toxicity

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29
Q

When should carvedilol be used over metoprolol for PO beta-blockaged in CABG patients?

A

-in patients with heart failure or reduced LV function
-nearly all CABG pts should be started on PO beta-blockers on POD1, usually 12.5-25mg BID of metoprolol

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30
Q

What is the fluid status on most post-cardiac surgery patients

A

fluid overloaded (markedly)
-most patients should be started on diuretic therapy on POD1
-in most patients with intact renal function this is IV lasix 20mg BID

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31
Q

In which patient populations should diuretics be started with caution?

A

-severe left ventricular hypertrophy (require higher intravascular volume to maintain LV filling due to reduced LV compliance)
-persistent vasopressor requirement
-evidence of end organ dysfunction (particularly renal)

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32
Q

Studies have shown that continuing statins perioperatively may reduce the incidence of what? Studies have shown that they may increase the risk of what?

A

-atrial fibrillation
-acute kidney injury

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33
Q

What do the 3 letters for temporary pacing wire settings stand for?

A

-first letter: chamber(s) paced (A-atrial, V-ventricle, D-dual)
-second letter: chamber(s) sensed (A-atrial, V-ventricle, D-dual)
-third letter: pacer’s response to sensing a native electrical signal (I- inhibited, D- response varies to optimize AV synchrony)

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34
Q

By how much will cardiac output be reduced if “atrial kick” is lost due ventricular pacing only?

A

-at least 20% but can be > 30% in those with underlying cardiac disease

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35
Q

What can a high pacing threshold indicate?

A

impending failure of the temporary epicardial wires

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36
Q

After which type of cardiac surgery is it more common to have AV node dysfunction?

A

seen in up to 20% of valvular surgery patients, rare in CABG patients

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37
Q

When may an increase in heart rate actually reduce a patient’s cardiac output?

A

-aortic stenosis
-severe, longstanding HTN
-these patients have decreased LV compliance and rely on longer diastolic periods for LV filling

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38
Q

What are the absolute contraindications for IABP?

A

-significant aortic valve insufficiency
-aortic dissection

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39
Q

What are the relative contraindications for IABP?

A

-AAA as it increases the risk for embolic complications
-advanced peripheral vascular disease due to increased risk of limb ischemia

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40
Q

What does 1:1 IABP support mean?

A

balloon inflates and deflates with every cardiac cycle
-increase to 1:3 for brief periods to assess ability to wean from IABP support

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41
Q

When does the IABP inflate and when does it deflate?

A

inflates during early diastolic and deflates

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42
Q

What are the different types of triggers for the IABP?

A

-rhythm/ECG (most common)
-arterial blood pressure
-pacemaker input

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43
Q

What is the concern about placing an IABP too proximal in the aorta? Too distal?

A

-proximal can occluded the L subclavian artery
-dsistal can affect renal perfusion
-optimal position is proximal descending aorta

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44
Q

On IABP what is the targeted augmented diastolic pressure and MAP (usually)?

A

-augmented diastolic in the 90’s
-MAP 60-70

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45
Q

What is the chief complication of IABP placement?

A

limb malperfusion/ischemia
-d/t embolism or compromised flow from the sheath
-most common in pts w/ PVD

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46
Q

What patient assessment is critical to do frequently while an IABP is in place?

A

pedal pulse checks to assess for limb malperfusion
-loss of pulses means immediate IABP removal (and contralateral replacement if patient is IABP dependent)

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47
Q

What should the concern be in a postop cardiac patient with decreased chest tube output and worsening hemodynamics?

A

tamponade

48
Q

What are the elements of non-operative care for bleeding post cardiac patients?

A

-plasma for INR > 1.3 & supplement w/ cryoprecipitate if fibrinogen < 100-150mg/dL
-platelets if < 80-100k/uL or evidence of dysfunction on TEG
-protamine if ACT > 120-140s or PTT > 40s
-PEEP to 8-10cmH2O can help control chest wall bleeding
-poikilothermia should be treated aggressively with warming measures
-PRBC at a higher Hgb/Hct than normal
-pressure (blood) is critical and should keep SBP 80-90
-prothrombinase concentrate or recombinate F7a should be considered for factory coagulopathy
-prolene (sutures) ie. re-exploration

49
Q

What is the incidence of cardiac tamponade in post-CABG patients?

A

< 0.5%

50
Q

How does post-cardiac surgery tamponade differ from medical causes of tamponade?

A

it is often from compression of a single chamber (MC right atrium)

51
Q

What variables should be assessed and addressed in the treatment of low cardiac output (in order)?

A

-rate
-rhythm
-preload
-afterload
-contractility

52
Q

What is the incidence of new post-cardiac surgery dialysis requirement?

A

1-3% and for most the dialysis requirement is permanent

53
Q

What is the strongest predictor of a new post-cardiac surgery dialysis requirement?

A

baseline renal dysfunction

54
Q

What is the workup for post-cardiac surgery oliguria?

A

-urine electrolytes
-microscopy studies
-renal US
-TTE/TEE (if not immediately postop can be a sign of tamponade)

55
Q

What are some etiologies of pre-existing RV dysfunction in cardiac patients?

A

-chronic left sided failure
-chronic valvular disease
-RV MI
-severe chronic lung disease (cor pulmonale)
-chromic pulmonary HTN
-congenital disease

56
Q

What are some etiologies of new postop RV dysfunction in cardiac patients?

A

-inadequate myocardial protection during ischemic arrest
-anastomic formation error in CABG
-coronary dissection at time of RCA grafting
-RCA ostium occlusion w/ aortic valve prosthetic
-massive PE (uncommon)

57
Q

What is the management of new RV dysfunction post-cardiac surgery?

A

-assess and treat any potentially correctable causes (surgical coronary obstruction, PE, compromise from sternal closure)
-optimize RV preload
-avoid secondary insult (avoid hypoxia, acidosis, hypercapnia, high airway pressures, arrhythmias, hypotension) as these will increase afterload and exacerbate RV dysfunction
-supportive therapy

58
Q

When would you consider surgical thrombectomy for a PE in a post-cardiac patient?

A

hemodynamic instability with new RV dysfunction

59
Q

How should atrial tachyarrhythmias be treated in patients with severe RV dysfunction post-cardiac surgery?

A

via direct current cardioversion

60
Q

What are some therapeutic options for RV dysfunction with concomitant pulmonary arterial hypertension?

A

-iNO (best option as it does not affect systemic pressures but pricey)
-inhaled prostacyclin (not as potent of a pulmonary vasodilator as iNO but less expensive)
-inotropic support (less ideal as they also reduce systemic pressures often requiring vasopressors to counteract), such as milrinone or dobutamine

61
Q

What are some therapeutic options for RV dysfunction in need of inotrope support without concomitant pulmonary arterial HTN?

A

-isoproterenol
-milrinone
-dopamine
-dobutamine
-epinephrine

62
Q

What is the treatment option for patients with refractory RV failure and refractory hypoxia?

A

ECMO

63
Q

What is often the limiting adverse effect when using isoproterenol to augment RV contractility?

A

tachycardia

64
Q

Which oral medication can be used to treat RV dysfunction in patients with concomitant pulmonary artery HTN?

A

PO sildenafil

65
Q

What is often the limiting adverse effect when using milrinone to augment RV contractility?

A

systemic vasodilation
-but does augment both RV contractility and LV contractility and improves RV diastolic function

66
Q

What are the effects of low to moderate doses of dobutamine?

A

-augment RV contractility
-increases cardiac output
-improves RV preload/filling

67
Q

What medications are the most appropriate in a patient with RV dysfunction and severe systemic hypotension?

A

-epinephrine
-dopamine

68
Q

Which patients are more susceptible to pulmonary arterial hypertension following cardiac surgery?

A

-those undergoing mitral or tricuspid valve disease
-those with advanced ischemic LV dysfunction

69
Q

Which inotrope is preferred in post-cardiac surgery patients with pulmonary arterial hypertension?

A

milrinone

70
Q

What percentage of cardiac surgery patients develop Afib/Aflutter in the postop period?

A

30%

71
Q

When is the peak incidence of Afib/Aflutter in a post-cardiac patient?

A

2nd - 3rd POD

72
Q

What are the strongest risk factors for the development of Afib/Aflutter post-cardiac surgery?

A

-prior atrial arrhythmias
-older age
-long standing HTN
-mitral valve surgery

73
Q

Which group of patients are most likely to decompensate due to Afib/Aflutter?

A

those with severe LV hypertrophy (aortic stenosis or long standing HTN)
-this population is more dependent on atrial function and require more time for diastolic filling

74
Q

What is the optimal pad orientation and energy setting for direct current cardioversion for hemodynamically unstable Afib/Aflutter?

A

-pacer pads should be anterior and poster
-for Afib the biphasic waveform energy at 120 - 200J is most effective
-for Aflutter the biphasic waveform energy at 50 - 100J is most effective

75
Q

What medications can be used for rate control in new onset Afib/Aflutter

A

-best option: metoprolol 2.5-5mg up to a dose of 10-15mg
-diltiazem
-digoxin

76
Q

What are post-operative risk factors for developing Afib/Aflutter?

A

-hypokalemia and hypomagnesemia (want K > 4.2 and Mg > 2.2)
-adrenergic stimulation due to post-op pain
-atrial stretch due to volume overload

77
Q

What is the first line treatment for rhythm control of Afib/Aflutter after cardiac surgery?

A

amiodarone
-IV load: 150mg over 10min followed by 1mg/min x6hr then 0.5mg/min x18hr
-PO maintenance therapy is then 100-200mg BID

78
Q

What daily monitoring is needed after the initiation of amiodarone for new Afib/Aflutter?

A

ECG for QT prolongation (this is a sign of amiodarone toxicity)

79
Q

What feature of amiodarone makes it likely to interact with other medications?

A

it is a cytochrome P-450 enzyme inhibitor

80
Q

What are alternatives to amiodarone for post-cardiac surgery Afib/Aflutter rhythm control?

A

-digoxin (IV or PO)
-sotalol

81
Q

What needs to be considered prior to DCCV if a patient has been in persistent Afib/Aflutter for 48hrs+?

A

TEE to assess for left atrial thrombus prior to converting

82
Q

What is the most common ventricular ectopy seen after cardiac surgery?

A

PVCs

83
Q

How do you differentiation Vtach from wide complex SVT on an EKG?

A

VT has wide complex QRS in all leads and a clearly regular rate, usually > 180bpm

84
Q

What is a common cause of intermittent, hemodynamically stable VT?

A

RV location of the PA catheter, as seen on CXR or if the catheter distance at the skin is < 40-45cm

85
Q

Why should epinephrine and vasopressin be avoided in a patient with VT and hypotension within 1 week after cardiac surgery?

A

resulting HTN can lead to disastrous bleeding consequences

86
Q

Which medications should be used to treat post cardiac surgery bradycardia if epicardial wires are not in place?

A

-IV isoproterenol (preferred)
-IV atropine (though transient affect)
-dopamine
-epinephrine

87
Q

What ECG changes are typical after a CABG?

A

T-wave and ST-segment morphology changes
-most of these have no clinical significance UNLESS associated w/ hemodynamic instability or ventricular arrhythmias

88
Q

What is seen on ECG for pericarditis?

A

diffuse ST-segment elevation with concave morphology and PR-segment depression

89
Q

Acidosis can do what in a post-cardiac surgery patient?

A

-increase susceptibility to arrhythmias
-contribute to altered enzyme function
-contribute to coagulation
-resuce vasoactive med efficacy

90
Q

What is the incidence of neurologic complications after cardiac surgery?

A

30%

91
Q

What are potential causes of neurological deficits after cardiac surgery?

A

-microemboli during procedure
-cerebral hypoperfusion due to low flow
-underlying CV disease
-intracranil hemorrhage due to anticoagulation
-air embolism
-macroscopic embolic events

92
Q

What is the incidence of stroke after cardiac surgery?

A

for CABG 1-2% and slightly higher for valve procedures

93
Q

When do post-cardiac surgery strokes tend to occur?

A

-30 to 40% are intraoperative
-majority of remainder occur in first 12-24hrs postop

94
Q

Why is a MRI brain preferred over CTH?

A

-CTH isn’t as sensitive in detecting early strokes as MRI
-but CTH is more readily available and faster to obtain

95
Q

What is the incidence of thrombocytopenia after cardiopulmonary bypass and what’s the etiology?

A

-seen in > 1/3 of patients
-due to platelet deformity and consumption, and hemodilution

96
Q

When does cardiopulmonary bypass related thrombocytopenia nadir?

A

2nd or 3rd day postop and normalizes over the following few weeks

97
Q

What is the incidence of HIT after cardiac surgery?

A

2%

98
Q

What is type 1 HIT?

A

-direct interaction between heparin and platelets
-appears early after surgery (1-3 days)
-self resolving within a few days

99
Q

What is type 2 HIT?

A

-IgG related
-antibodies form to heparin-platelet factor 4 complex
-occurs 5-10 days after surgery if no prior exposure
-occurs immediately after surgery if heparin exposure in last 3 months
-40-75% risk of thrombotic complications
-mortality of at least 25%

100
Q

When should HIT be considered?

A

-platelet count drop of >50% after surgery
-platelet drop by 30% or more to count of <100k
-any thrombotic event within a month of surgery

101
Q

Which diagnostic test for HIT is more specific?

A

functional test to measure platelet activity in presence of patient’s serum and heparin (serotonin release assay)

102
Q

What are the heparin alternatives to consider if HIT is suspected?

A

IV direct thrombin inhibitors
-argatroban (hepatic excretion)
-lepirudin (renal excretion)
-bivalirudin

103
Q

How does the post-op course differ for patients who received a radial graft for their CABG?

A

they should be placed on low-dose nitroglycerin or diltiazem IV for 24hrs then transitioned to oral
-radial grafts are more prone to vasospasm

104
Q

What should be the consideration in a post-mitral valve replacement patient with new hypotension and/or malperfusion?

A

SAM (systolic anterior motion, anterior leaflet obstructs LVOT)

105
Q

What is the treamemt for systolic anterior motion?

A

mostly medical
-resuscitation
-avoidance of tachycardia
-avoidance of inotropic meds
-increase systemic afterload

106
Q

How can aortic valve repair lead to coronary obstruction?

A

occlusion of one or both coronary ostia by the prosthetic
-requires immediate surgical correction

107
Q

How would right coronary artery obstruction manifest after a aortic valve repair?

A

new inferior lead ST-segment changes, especially. if associated with arrhythmias or hemodynamic instability

108
Q

Where is the SA node located?

A

membranous septum just below the aortic annulus

109
Q

Which procedure can injure the SA node?

A

aortic valve repair due to direct injury or post procedure edema

110
Q

What percent of patients require a permanent pacemaker after aortic valve repair?

A

7%

111
Q

Which procedure can damage the left circumflex coronary artery?

A

mitral valve repair but it’s rare

112
Q

What ECG changes are seen if the left circumflex coronary artery is damaged?

A

new lateral or inferolateral changes

113
Q

What are the two procedures used to address atrial arrhythmias?

A

-Cox maze
-pulmonary vein electrical isolation

114
Q

What percent of patients require permanent pacemaker after a maze procedure?

A

10-15%

115
Q

How long does it take for either procedure to treat atrial arrhythmia to be fully transmural?

A

several months, until then patients have high rate of atrial arrhythmias

Cardiovascular (7 decks)

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