Seperation from CBP Flashcards by Kelsey Kronus

sequence of events coming off CBP

rewarming
removal of cross clamp and placement of partially occluding cross clamp
proximal anastomosis of SVG/radial artery grafts
establish rythm
wean from CPB

How well did you know this?

Not at all

Perfectly

getting ready for separation from bypass

temperature
cardiac rate and rhythm
adequate hematocrit
-blood products in the room
ventilation w 100% 02
anesthetics
pressors and inotropes

How well did you know this?

Not at all

Perfectly

ratio of blood prodcuts at VA and evidence

VA: 4uPRBS: 1 FFp & 6 pk plts

evidence 1:1:1 ratio or 1:1.15

How well did you know this?

Not at all

Perfectly

CVP mnemonic for C

cold
conduction
calcium
cardiac output
cells
coagulation

How well did you know this?

Not at all

Perfectly

CVP mnemonic for V

Ventilation
Vaprizer
Volume Expansion
Visulization (TEE)

How well did you know this?

Not at all

Perfectly

CVP mnemonic for P

Predictors
Protamine
Pressure
Pressors
Pacer
Potassium

How well did you know this?

Not at all

Perfectly

As a patient is rewarmed the surgeon will as for NTG and low dose dopamine what does this do

promotes vasodilation and rewarming, prevents vasopasm of coronary arteries, promotes flow in coronary arteries

inotropes help stunned myocardium recover

How well did you know this?

Not at all

Perfectly

predictors of difficulty separating from CPB

How well did you know this?

Not at all

Perfectly

weaning from cbp

-gradually allow the heart to fill and begin ejecting blood

How well did you know this?

Not at all

Perfectly

what is considered optimal preload in weaning

the lowest value that will provide adequate cardiac output

How well did you know this?

Not at all

Perfectly

What are the effect of high preload

increased wall tension
decreased CPP
decreased CO
precipitates pulmonary edema

How well did you know this?

Not at all

Perfectly

how can you prepare for vascular instability

manipulate vasoactive drugs and blood products/colloids, table position

may have pump blood to give back

How well did you know this?

Not at all

Perfectly

how can we monitor preload

monitor with PAP, TEE

How well did you know this?

Not at all

Perfectly

how can we control rate and rythm

higher rate is ok
pacer options
atrial kick

How well did you know this?

Not at all

Perfectly

how can we control contractility

inotropes

How well did you know this?

Not at all

Perfectly

how can we control afterload low vs high

typically a low SVR
-increase SVR with levophed, neo and PDE3 inhibitors
hight SVR
-inhalation anesthetics, narcs, vasodilators

How well did you know this?

Not at all

Perfectly

Post bypass CV collapse

profound hypotension, low CO that is unresponsive to inotropes and vasopressors
go back on pump
give full dose of heparin if protamine is already in
rest the heart IABP, LVAD,RVAD?

How well did you know this?

Not at all

Perfectly

Diagnosis of LV failure after bypass 3 causes of ischemia

graft failure
inadequate coronary blood flow
myocardial ischemia leading to damage

How well did you know this?

Not at all

Perfectly

causes of graft failure (ischemia r/t LV failure after bypass)

clot
distal suture causing constriction
kinking of graft
air in graft 
graft swen in backwards
poor IMA flow

How well did you know this?

Not at all

Perfectly

causes of inadequate coronary blood flow (ischemia r/t LV failure after bypass)

Study These Flashcards

incomplete revascularization
inadequate CPP
emboli in native coronary arteries
coronary vasospasm
tachycardia (less filling time)
increased myocardial 02 demand
surgical injury to native cornary artery

causes of myocardial ischemia leading to damage (ischemia r/t LV failure after bypass)

Study These Flashcards

poor myocardial preservation during CPB

evolving MI

LV failure after bypass due to valve failure with a prosthetic valve

Study These Flashcards

sewn in backwards
perivavlular leak
mechanical obstruction to outflow

LV failure after bypass due to valve failure with a native valve

Study These Flashcards

acute mitral regurg due to ischemia of papillary muscles

LV failure after bypass due to valve failure with a gas exchange problem

Study These Flashcards

Hypoxemia
-inadequate fi02
-atelectasis
-mechanical ventilator failure
-airway disconnect
-severe bronchospasm
-pulmonary edema
Hypoventialtion

Diagnosis of LV failure after bypass due to preload

inadeaquate preload -hypovolemia -no atrial kick excessive preload

differential dx of LV failure after bypass

ischemia, valve failure, preload, reperfusion injury, VSD, medications, acidemia, electrolyte imbalances, pre-existing LV failure

Interventions for LV collapse: Rate

High HR: evaluate pain, light anesthesia | Low HR: pacer

Interventions for LV collapse: rhythm

dx type and cause, treat, amiodarone

Interventions for LV collapse: preload

High preload: NTG, phlebotomy, Rev T-berg | Low Preload: volume

Interventions for LV collapse: contactility

High contractility: inhalation anesthetics, beta blocker, turn off inotropes low contractility: catecholamines, PDE3 inhibitors, IABP

Interventions for LV collapse: afterload

high afterload: vasodilators milrinone | low afterload: vasoconstrictors

zebras (haha) to LV collapse

``` pneumothorax hemothorax migration of ETT obs of tracheobroncial tree increase in dead space intracardiac shunt (PFO) protamine reactions anaphylaxis ```

risk factors for RV failure post bypass

``` pior pulmonary hypertension mitral vavle disease left to right shunt massive PE air emobli acute or chronic MR diastolic LV dysfunction ```

treatment for RV failure post bypass

``` treat ischemia increase preload intrope support hyperventialtion to decrease PVR nitric oxide 10-40 PPM PGE! infusion through RA line w NE via LA line sildenafil RVAD ```

what to avoid in RV failure post bypass

hypoxia acidemia hypothermia

inotrope support in RV failure

milrinone, dobutamine and isoproternial incrase RV contractility and decrease PVR

pulmonary vasodilators for RV failure in post bypass

NTG and Nipride

decannulation

after patient is stable keep SBP low start protamine at surgeons request blood products as needed

Protamine dosing

10mg protamine for every 1000 units of heparin

protamine side effects

hypotension, cv collapse, anayphlaxsis

risk factors for hypersensitivty to protamine

prior protamine exposure -give test dose pulmonary HTN -vasoconstriction, RV failure and death

what should you do if a protamine reaction occurs

``` stop the infusion ventilate with 100% 02 turn down inhalation agents volume and pressors antihistamines corticosteroids catecholamine infusion (epi) go back on pump (last resort) ```

residual heaprin effects

incomplete heparin neutralization (check ACT) heaprin rebound (occurs 4-6 hrs post-op when heparin dissociates from proten binding sites) give addition 25-50 of protamine

pharmacologic agents for blood conservation

amicar aprotinin ddavp

what does DDAVP cause? when is it useful?

causes release of von willebrand's factor and factor 8 | useful in patients with uremia, cirrhosis, recent ASA use

management of post-bypass bleeding

``` supportive therapy -normothermia -keep up with blood loss -treat hypertnetion promptly treat hemostatic disorder -neutralize heparin replace factors and platelets ```

causes of hemodynamic deterioration with chest closure

tamponade myocardial edema kinked graft protamine reaction -treat cause, leave chest open

fast track recovery

``` minimize narcotics and benzos rely more on inhalation agent propofol at end of case minimize muscle relaxant use at end of case goal: early extubation and activity ```

Seperation from CBP Flashcards

(48 cards)