Week 2 Cardiac Surgery Flashcards
(105 cards)
1
Q
How do you calculate CPP?
Coronary Perfusion Pressure?
A
Ao. DBP - LVEDP
2
Q
What is Coronary vascular resistance autoregulated between?
A
60 - 140 mmHg
3
Q
How do you increase coronary supply, but also decrease demand?
3
A
- Maintain CPP & MAP (via a-agonists)
- Increase time in Diastole (by decreasing HR)
- Decrease Myocardial O2 demand
4
Q
What factors Decrease supply?
5
A
- Tachycardia
- HoTN
- Increase LVEDP
- Decrease O2
- Anemia
5
Q
How would you treat ea. factor that decreases supply?
A
- Tachycardia: Decrease HR (< 70 bpm w/ B-blocker)
- HoTN: increase MAP >70mmHg (NE or phenyl)
- LVEDP: Diuresis/Nitroglycerin
- Decrease O2: Increase SaO2 >95%
- Anemia: Maintain Hgb
6
Q
What factors Increase Demand?
5
A
- SNS stimulation
- Tachycardia
- Increase Preload
- Increase Contractility
- IncreaseAfterload
7
Q
How do you treat factors that Increase Demand?
A
- SNS stimulation: Maintain anesthesia depth
- Tachycardia: Decrease HR (> 70 bpm)
- Increase Preload: Nitro/Diueretics
- Increase Contractility: B-blockers/CCBs
- Increase Afterload: Avoid HTN via Clevidipine
8
Q
What is the most sensitive intraoperative monitor for detecting myocardial ischemia?
A
TEE
9
Q
Most sensitive EKG leads to monitor for ischemic changes?
A
V3 & V4
10
Q
Definition of Cardiac stunning?
A
Reversible contractile dysfunction after brief ischemia
(<20 min)
11
Q
Definition of Ischemic Preconditioning
A
Short periods of ischemia improve ♡’s ability to tolerate longer periods of ischemia
12
Q
Definition of Cardiac Hibernation
A
Self preservation via LV contractile function is Decrease to match O2 availability
13
Q
Sevoflurane & Isoflurane have what effect on the ♡?
A
Preconditioning effect: Protects ♡ from ischemia/reperfusion injury
14
Q
What is the term for ♡ Changes caused by alterations in SNS activation, perfusion, pressure, & volume?
A
Remodeling
15
Q
LV systolic dysfunction is also known as:
A
- Eccentric LVH or Dilation
- HFrEF
16
Q
What can cause Systolic dysfunction/Eccentric LVH?
3
A
- Myocardial Ischemia
- Valvular insufficiency
- Dilated CM
17
Q
Is EF preserved w/ Systolic dysfunction/Eccentric LVH?
A
No
18
Q
What is considered mild, moderate, & severe reduced EF?
A
- Mild: 41-51%
- Moderate: 30-40%
- Severe: < 30%
19
Q
red
With systolic dysfunction, what needs to be done to preload?
A
Already Increase, consider diuretics
20
Q
red
With systolic dysfunction, what needs to be done to Afterload?
A
Decrease to reduce myocardial demand w/ Cleviprex/Nicard
21
Q
red
With systolic dysfunction, what needs to be done to contractility?
A
Augment w/ inotropes (Epi/milrinone)
22
Q
red
With systolic dysfunction, what needs to be done to the ♡ rate?
A
W/ reduced EF, increased HR to preserve CO
23
Q
LV diastolic dysfunction is also known as:
A
- Concentric hypertrophy
- HFpEF
24
Q
What can cause LV diastolic dysfunction
6
A
- Myocardial ischemia
- Valvular stenosis
- HTN
- Hypertrophic cardiomyopathy
- Cor pulmonale
- Obesity
25
What are the physics based variables that are different between Systolic and Diastolic dysfunction?
* Systolic Dysfunction: too much Volume
* Diastolic Dysfunction: too much Pressure
26
With diastolic dysfunction, what needs to be done to the preload?
Increased volume to stretch noncompliant LV
27
With diastolic dysfunction, what needs to be done to the afterload?
Increase afterload to perfuse thick myocardium (Phenyl / NE
28
With diastolic dysfunction, what needs to be done to the contractility?
Keep normal (EF is preserved you dummie)
29
With diastolic dysfunction, what needs to be done to the ♡ rate?
Slow to normal (increased diastolic time)
30
What variables do you want to avoid in RVF?
| 7
**Increased PVR**
* Hypercarbia
* Hypoxemia
* Acidosis
* N2O
* Desflurane
* T-burg
31
Your pt has RVF and has HoTN, what medication might be preferred and why?
Vasopressin: vasopressor w/ decreased effect on PVR (acts peripherally)
32
Your pt has RVF and has a low CO, what medication might be preferred and why?
Milrinone: inotrope & vasodilator
33
Your pt has RVF and has a high PVR, what medication might be preferred and why?
iNO: decreased PVR
| nitric oxide
34
What is cardioplegia?
Used to halt electrical activity of the heart & protect myocardial tissue
35
Why isn't CPBP considered benign?
Causes:
* Inflammatory responses
* Platelet dysfunction
36
What are the five basic components of CPBP?
1. Venous reservoir
2. Main (arterial pump)
3. Oxygenator
4. Heat exchanger
5. Arterial filter
37
Priming the CPBP w/ an isotonic electrolyte solution may cause what effect in the patient?
Dilutional anemia
38
If concerned about decreasing Hgb, what might you consider for the CPBP?
Retrograde autologous priming
39
While the pt is on pump, where does the anesthetic gas get delivered?
Volatile gas is added to the oxygenator O2/Air mixture (Sweep + FiO2)
40
What temperature are pts kept at while on CPBP?
34-36° C
41
What temperature are pts kept at for Deep Hypothermic arrest?
20° C
42
Regarding temperature, what needs to occur before the pt comes off CPBP?
Actively rewarmed to 36 C
43
What are the (accessory) pumps located on the CPBP?
| 3
* Cardiotomy & Basket suction (Pump sucker)
* LV vent (drains LV)
* Cardioplegia pump
44
Mechanism of action of Heparin?
Binds ATIII and increased action by 1000 times
* Inhibits Thrombin & Fac. Xa
45
Dosage of Heparin bolus prior to cannulation?
400 units/kg
46
Required ACT prior to cannulation?
>400 seconds
47
When should ACT be checked throughout the case?
* Baseline
* 3-5 min after admin
* q20-30 min during
* 5 min after reversal
48
Your patient has a hx of HIT that occurred > 3 months ago, and you order a HIT antibody screening, what will a positive/negative result indicate?
* Positive: Heparin is CI
* Negative: Go ahead and give it, slugger
49
Your pt has a positive antibody HIT screen, what changes will you make to your anesthetic plan prior to CPBP?
Use Bivalrudin (1.5mg/kg bolus, 2.5mg/kg/hr infusion)
50
# e
What are the signs of a Protamine anaphylactoid reaction?
| 3
* Refractory HoTN
* P. HTN
* RHF
51
Dose of Protamine to reverse heparin?
1mg per 100 units of Heparin
52
How should Protamine be administered and why?
Administered slowly
* Mild HoTN 2/2 histamine release
53
What does cardioplegia consist of?
Cold hyperkalemic crystalloid solution mixed in blood
54
What antifibrinolytics are used in CV surgery and what do they do?
Aminocaproic acid & TXA
* Inhibit plasmin ability for fibrinolysis
55
TXA dose?
10mg/kg over 20 min
56
What is the definition of Ultrafiltration?
Perfusionist separates aqueous portion of blood from cellular elements
* Hemoconcentration
57
What is the definition of retrograde autologous priming?
CPBP is primed w/ passive exaginuation through arterial cannula
58
What is the definition of Acute Normovolemic hemodilution?
Removing 1-2 units of whole blood via central line prior to infusion
(only for pts w/ high Hcg: >38%)
59
What are some physiological effects on body systems from CPBP?
| 6
* SIRS
* Hemostasis Dysfunction
* CNS: cognitive decline
* Lungs: Atelectasis, ALI, ARDS
* Renal: **AKI**
* GI: **ischemia**
60
What specific effects occurs to the hematological system due to CPBP?
Platelet & Clotting Factor dilution/denatured
61
What are some CI to TEE?
| 4
* Esophageal stricture
* Viscous perforation
* Diverticula
* Recent Suture Lines
62
What are the most stimulating effects during CT surgery?
* Incision
* Sternotomy
* Sternal spread
63
What should be prepared beforehand w/ a re-do sternotomy?
* Have blood in room
* Emergent CPBP initiation
64
You gave you 100kg pt 40,000 units of Heparin and their ACT is 200 seconds after 3 & 5 minutes, what should you consider?
Consider they may have AT III deficiency and may require exogenous AT III
65
The surgeon is just about to cannulate for CPBP, what must you ensure occurs prior and why?
SBP 90-100 mmHg
* Reduce risk for Ao. disection
66
What is an indication a patient might need retrograde cardioplegia?
* Leaky Ao. valve
* CAD
67
Where is retrograde cardioplegia infused?
Coronary sinus
68
What needs to occur prior to pt coming off CPBP?
| 6
* Adequately warmed (>36°C)
* **Give 1-2gm CaCl**
* Vasopressors/dilators on hand
* Mechanically ventilate the pt
* Turn on your volatile anesthetic
* Pt has paced/perfusing rhythm
69
You are giving your pt Protamine reversal after decannulation, but now they have HoTN, what might you do?
**Give phenylephrine to increased SVR**
70
What view is used for insertion of CVL/Transceptal access on TEE?
Midesophageal Bicaval view
71
What coronary artery perfuses the Anterior interventricular septum?
Left anterior descending (LAD)
72
What coronary artery perfuses the Posterior interventricular septum?
Right coronary artery (RCA)
73
What coronary artery perfuses the anterior lateral wall?
Left circumflex (LCx) & LAD
74
What coronary artery perfuses yellow?
RCA
75
What coronary artery perfuses blue?
LCx
76
What coronary artery perfuses pink/red?
LAD
77
What are the hemodynamic goals in a pt w/ HOCM
Similar to AS
* Preload: Normal to increased
* HR: Normal to decreased
* **Contractility: decreased**
* SVR: Maintain
78
Which agent might be used to decrease contractility in a pt w/ HOCM
Esmolol
79
What medications are used to prevent rejection of a transplated heart?
| 3
* 50mg Diphenhydramine
* 500mg Methylprednisolone
* Anti-thymocyte globulin (ATGAM)
80
What considerations should you be wary of regarding heart rate in a Transplanted heart?
* Denervated heart (deleted PNS)
* Higher intrinsic rate
* No response to Glycopyrrolate/Atropine
81
Your patient is exhibiting JVD, edema, and SoB post heart transplant, what might you consider?
Initiating inhaled vasodilators like iNO
| They're experiencing RV failure
82
What is the purpose of Deep hypothermic circulatory arrest?
Prevent cerebral ischemia during circulatory arrest
83
What conditions are you anticipating to ensure Deep hypothermic circulatory arrest is successful?
| 3
* Isoelectric EEG
* Deep hypothermia 14-21° C
* < 30 min arrest period
84
If the circulatory arrest is anticipated to be greater than 30 minutes, what might you consider?
Antegrade Cerebral perfusion
via axillary, subclavian, or internal carotid
85
How and when does rewarming occur prior to separation from CPBP?
Rewarming slowly & gradually to 36.5°C
* Prior to separation
86
How will the surgical aspect of an Acute Aortic Dissection present?
Emergency, high stress surgery
87
How is anesthesia for a-fib catheter ablation usually performed?
GETA w/ an A-line
88
Which medications are used to stimulate abnormal electrical activity during a catheter ablation?
Adenosine & Isoproterenol
89
What should be monitored throughout a catheter ablation, and why?
Esophageal temperature probe
* Risk of Thermal injury/atrioesophageal fistula
90
What must occur prior to transseptal puncture during catheter ablation?
Heparinization to an ACT of 250-300 seconds
91
What must occur prior to ablation of the Right superior pulmonary vein?
Reversal of paralytic due to risk of right phrenic n. injury
92
Which cardiac procedures can be performed under MAC?
| 4
* Catheter ablation for VT/PVC/SVT
* LAAO
* TAVR
* PPM/AICD
93
Which cardiac procedure can be performed under minimal sedation
Leadless PPM
94
Indications for an AICD?
| 5
* Hx VT/VF
* Post-MI w/ EF < 35%
* Cardiomyopathy w/ EF < 35%
* Long QT syndrome
* HOCM
95
What occurs when you place a magnet on a PPM? AICD?
* PPM: asynchronous pacing
* AICD: Disables shock
96
How should an AICD be programmed prior to cardiac surgery?
Disable antitachycardia therapy
97
How should a PPM be programmed prior to cardiac surgery?
Asynchronous (VOO/DOO) @ 80-90 bpm
98
What is the Low, intermediate, and high risk for PPM lead extraction?
* Low: < 1year
* Intermediate: 1- 10 years
* High: > 10 years
99
What is the Low, intermediate, and high risk for AICD lead extraction?
* Low: < 1year
* Intermediate: 1-5 year
* High: > 5 years
100
What is required for a high risk lead extraction?
* Hybrid OR/Cardiac room
* Rapid transfusion equipment
* CV surgeon available
101
When does the IABP inflate?
Onset of diastole (dicrotic notch)
102
Where should the IABP tip be positioned?
1-2 cm distal to the origin L subclavian artery
103
What components does an ECMO device have?
| 5
* Centrifugal pump
* Membrane oxygenator
* Heat exchanger
* O2 blender
* Control console
104
ECMO, like its big brother CPBP, requires what pharmacologic intervention? Monitored by what laboratory/POC test?
* Heparin anticoagulation
* ACT: 180-250 seconds
105
What components does a VAD consist of?
* Inflow cannula
* Pump
* Outflow cannula
