Previous exam 2002 Flashcards Preview

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Flashcards in Previous exam 2002 Deck (37):
1

Most common endocarditis organisms in native valve, renal valve IVDU, PVE

Native: Streptococci
Prosthetic:
Early Coagulase negative (Staph Epidermedis)
Late Strep
IVUD Staph Aeurus

Renal

2

What are advantages of IMA skeletonization

Increased conduit length
decreased infection
easier to identify an IMA injury
Less paraestheisa of chest wall
Less likely to twist
Convenient for complex arterial grafting (T-grafting and sequentials)

3

What are contraindications to using Bilateral internal thoracic arteries

Subclavian stenosis
Calcification of mammary
Severe obesity
AV fistula in same arm
Possible IDDM
Cardiogenic shock/Emergency surgery
Previous radiation to chest wall

4

Name 3 studies that show BITA is superior to LITA and what is survival difference

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5

What are operative indications for Prosthetic valve endocarditis

Unstable prosthesis (rocking)
Severe valvular insufficiency and CHF
Recurrent emboli
Heart block
Abscess or fistula formation
Fungal infection
Persistent positive blood culture despite appropriate antiobiotic therapy
Valve destruction?
Vegetation of any size

6

Why is it important to get ethics committee approval for studies

Ensure the 4 main ethical principles are followed
Beneficence
Non-malifiencen
Automony
justice

Other points include: patient safety, informed consent, liability, not replicating previous work, department approval, peer review, disruption of standard of patient care, adequancy of resources

7

What is most common congenital arch anomaly

Aberrant right subcavian artery off left descending aorta

8

What are is spinal cord anatomy and what are protection strategies

Where is artery of Adamkiewicz

3 proven methods
hypothermia
left heart bypass
CSF drainage
Others:
Pharmacological agnets (sterorid, mannitol, NMDA receptor anatognists
reimplntation of spinal (T9 to L2)
distal perfusion
Monitoring sensory e

9

What are is spinal cord anatomy and what are protection strategies

Where is artery of Adamkiewicz

3 proven methods
hypothermia
left heart bypass
CSF drainage
Others:
Pharmacological agnets (sterorid, mannitol, NMDA receptor anatognists
reimplntation of spinal (T9 to L2)
distal perfusion
Monitoring sensory e

10

What are common causes of aneursym post coarctation repair

Post patch repair true aneursym can develop opposite the actual patch
Psuedo-aneursym can develop with any repair but most common after interposition graft
Use of prosthetic patch---up to 40% develope medial degeneration opposite the patch
Females who get pregnant later may develop anesusym
Older age
Ratio of circumference of aoarta at site of repair to that of the aorta at the diaphram if greater the 1.5 then you have a risk

11

What is management of chylothorax

Chest tube insertion and drainage
NPO
TPN or medium chain trigylercides only

Problems with malnutrition, lymphocyte depletion (functionally immunosuppresed after 14 days)

Operative indications: continued drainage x 14 days; ? 1 liter/day

12

What is difference between constrictive and restrictive cardiomyopathy

Constrictive
CO is slightly lower
Volumes of both ventricles depressed or normal
EF is depressed or normal
pericardium is thickened
RVEDP (usually 1/3) of RVESP
PA systolic is < 50 mmHg
LAP is = to RAP and usually < 15
Restrictive
LAP > RAP by more then 5
Mean RAP below 25
RVEDP < 1/3 of RVESP
Lower CO
EF is usually very low

13

What is incidence of HIV, HBV, HCV from needle stick

HIV 0.5%
HCV 2%
HBV 20%

risk is higher with hollow needle and gross contamination

14

What are class I MHC cells

All nucleated cells

Class I MHC
HLA, A, B, B
On surface of all nucleated ells
No on RBC
Activates CD8 (cytotoxic)

15

What are class II MHC cells

Antigen presenting cells
dendritic cells, macrophages, B cells, endothelial cells

Class II MHC
activates CD4 cells (helper)
HLA DR, DQ, DP,
Expressed on antiigen presentin cells

16

What is mechanism of action of MMF (mycophenolate mofetil (cellcept) work

Purine analog (antimetabolite, it inhibits DNA and RNA synthesis by blocking purine biosynthesis) that is more potent and selective than azathioprine. It is is relatively selective for lymphocytem without significant effect on other proliferating tissues.

Both T and C cells are inhibited leading to a reduction in both humeral and cell mediated immunity

17

What is mechanism of action of Fragmin

Low molecular weight heparin with antithrombotic properties.

enhancing the inhibition of factor Xa and thrombin by potentiating the action of anti0thrombin. Only slightly affecting PTT

18

What are contraindications to pulmonary artery switch

Pulmonary stenosis
Aortic stensosis
Poor LV function or poorly developed LV

19

What is presentation of TGA--early vs late, what is early managment? What 2 surgical therapies exists at 3 months of age

Early patients present with cyanosis
Late patients present with heart failure with VSD and increased pulmonary blood flow and also right heart failure

Acute managment: PGEI, atrial septostomy--surger
TGA early operations
Mustard or senning atrial switch
Jatene arterial switch
Rastelli for TGA/VSD and PS
Damus-Kay-Stansel for TGA/VSD and sub-aortic stenosis

TGA late options
With non restrictive VSD--arterial switch
Atrial switch
Otherwise based on LV function
if leftward deviationof septum on echo high probably of failure post-op
May need PA banding to 80% of systemic pressure plus ormiuns systemic to arterial shunt---then when LV is conditioned the arterial switch can be performed.

20

List 4 complications of endovascular stenting

Endoleak
Graft thrombosis
Graft infection
aortic dissection
Graft kinking
colon necrosis
embolism

21

List classification of Endoleaks

Type I occur at prximal or distal attachment--failure to achieve hemostatic seal
Type II communication between a branch and excluded sac
Type III Mid graft section disruption of graft-graft overalps or leakage through the graft
Type IV (endo tension?) * not sure about this one

22

List factors for suitable stenting

No connective tissue disorder
Focal aortic lesion
Proximal + Distal landing zones
Diameter < 40 mm
Length > 2 cm
min angulation
Adequate vascular access

23

What is Abciximab mechanism of action and what is management if urgent surgery is needed

Abiciximab (ReoPro) is the Fab fragment of chermeric human0murine monoclonal antibody 7E3 which binds to the glycoprotein IIb/IIIa receptor of human platelets and inhibits platelet aggregation

prevents binding of fibrinogen, von Willebrand factor,

Try to wait 12 hours if urgent--1-2 days if elective

transfuse 2 adult doses of platelets as the patient is coming off bypass

24

What are fluid characteristics of chylothorax

Chylomicrons
Fluid analysis
odorless milky white
High triglyceride content 0.1 g/dl
Specific gravity is high > 1.012
Albumin 1-7 g/dl
White count usually 3000- 20 0000 cells

25

What are contraindications for TEE

Zenkers diverticulum
Esophageal varices
C-spine injury
Esophageal tumor/stricture
Severe C1 and C2 spine deneration (ie rheumatoid arthritis)

26

3 causes for elevation of hemidraphragm

Direct injury
Topic cold agents
stretch injury

27

What are the complications of SWAN cath placement

Vascular access
hematoma
air embolism
Pneomothorax
Catheter placement
arrhythmias
knotting
cardiac perforation/PA rupture/Endocarditis/air embolism

28

Risk factors for a bleed with a PA rupture

Advanced age
Hypothermia
Female
Leaving balloon inflated
Overfilling balloon
Prolonged period of overwedging

29

What is management of PA rupture

Hemodynamically stable
Supportive care, reverse anticoagulation, blood/volume replacement
Hemodynamically unstable
ventilate the "good" lung. Advance the ETT down left bronchus since most swans on the right.
Use a fogarty to block the right bronchus or use a double lumen ETT
inject contrast down distal port of swan to localize bleed (angio +/- embolisation_
May require wedge or lobectomy or pneumonectomy [OR if in ICU

Diagnosis: Blood in ETT, hemoptysis, and angio

Risk of death 50%

30

Non-occlusive ischemic gut--list 8 clinical manifestation and describe management

Abdominal distention
Nausea and vomiting
pain
leukocytosis
melena
speis
elevated lactate

management: NPO, NG, IV, Foley, CBC, PTT/INR, lactate, ABG, LFT, amylase, AXR

31

What is technique for Carotid Endarterctomy

Skin incision along anterior border of SCM--dissection deep to platysma

Superior edge of incision is close to great auricular nerve (C2, C3, parallel to ext Jugular); Marginal mandibular nerve, cervical branch of facial nerve

Expose carotid sheath: watch for hypoglossal nerve, ansa cervicalis, vagus nerve, glossopharyngeal nerve, superior laryngeal, recurrent laryngeal.

Expose bifurcation.

32

Two nerves at risk of injury for radial harvest

Superficial branch of radial nerve: anterior to protnator teres, posterior to brachioradialis, supplies sensation to middle finger to thumb

lateral antebrachial cutaneous nerve (proximal) and medial antebrachial cutaneous nervce (distal) supplies sensation to the lateral and medial aspects of the forearm

Median nerve: supplies sensation to palmar surface of hand and dorsal surface sensation to tips. Motor for pronation and wrist fixation

33

What are features of ischemic foot

Pain
Pallor
Parasthesia
Parralysis
poiklithermia
pulseless

34

What are the pathological features of mitral prolapse

elastic fiber and collagen fragmentation and disorganization
Acid muccupolyssacradide accumulation
thickening of leaflets

35

What medications are require post CABG

ASA--prevent graft thrombosis (mangano 2002)
Metoprolol--control HTN (survival benefit)
ACE inhibitor---ventricular remodeling
Statin--increases graft patency
Cardiac rehab
smoking sensation

36

Explain mechanism of thallium scan

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37

What is management of a pt with severe COPD and poor PFT prior to CABG
FEV < 65% and FEV1 < 1.5 DLCO < 40% and PCO2 > 45

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