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Adv. Anesthesia > Week 2- CV Surg > Flashcards

Week 2- CV Surg Flashcards

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1
Q

CPP =

A

Aortic diastolic BP (AODBP) - left ventricular end diastolic pressure (LVEDP)

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2
Q

How is coronary vascular resistance autoregulated

A

MAP 60-140
HTN shifts curve to the right

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3
Q

How to increase supply and reduce demand (3)

A
  • Maintain adequate CPP & MAP
  • Increase time in diastole
  • Decrease myocardial oxygen demand
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4
Q

What factor is on both sides of myocardial oxygen supply and demand?

A

HR

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5
Q

Describe some goals of perioperative management to mitigate decreased supply

A
  • keep HR low (<70 BPM)
  • Maintain a high to normal MAP
  • Consider the use of nitro or diuretic
  • O2 sats greater than 95%
  • Maintain adequate HGL
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6
Q

What are factors that decrease supply

A

tachycardia
hypotension
LVEDP
reduced O2
Anemia

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7
Q

What are factors that increase demand

A

Increased SNS stimulation
Tachycardia
Increased preload
Increased contractility
Increased afterload

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8
Q

Describe some goals of perioperative management to mitigate increased demand

A
  • Maintain adequate depth on anesthesia, anticipate stimulating events
  • Keep HR relatively low (<70 BPM)
  • Use nitroglycerin or diuretic to decrease preload
  • Use BB, CCB to depress contractility
  • avoid HTN, consider the use of vasodilator
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9
Q

What is the most sensitive intraoperative monitor to detect myocardial ischemia

A

transesophageal echocardiography

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10
Q

What is cardiac stunning

A

reversible contractile dysfunction after brief periods of ischemia (< 20min)

Many patients require 12-24 h of inotropic support after CPB due to stunning.

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11
Q

What is ischemic preconditioning?

A

short periods of ischemia improves the heart’s ability to tolerate subsequently longer periods of ischemia

Inhalation agents (NOT N2O) has a preconditioning effect, potentially protects heart from ischemia & reperfusion injury.

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12
Q

What is cardiac hibernation?

A

self preservation mechanism whereby left ventricular contractile function is reduced to match O2 availability.

Chronic coronary plaques cause reduced coronary perfusion, steady state ischemia, which
results in a LV perfusion-contraction matching.

Pts with hibernating LVs have significantly ^ function following reperfusion w/
coronary stents/grafting.

May follow multiple episodes of cardiac stunning

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13
Q

Why does the heart undergo remodeling?

A

attempts to maintain cardiac output by altering perfusion, pressure, volume, heart changes sizes, shape, function

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14
Q

LV systolic dysfunction consists of eccentric/concentric dilation?

A

eccentric

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15
Q

LV systolic dysfunction etiology

A

myocardial ischemia; valve insufficiency; dilated cardiomyopathy

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16
Q

Describe the ranges of ejection fraction (mild, moderate, severe)

A

Mild: 41-51%
Mod: 30-40%
Severe: < 30%

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17
Q

How to manage systolic dysfunction perioperatively

A
  • preload- already elevated, may need diuretics
  • afterload- need to be reduced to reduce overall demand
  • contractility augmented w/ inotropes
  • HR may need to increase rate to preserve CO
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18
Q

What are some defining factors regarding LV diastolic dysfunction?

A

HF with preserved HF
concentric LVH (she THIC)

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19
Q

Etiology of LV diastolic dysfunction

A

myocardial ischemia
valve stenosis
HTN
hypertrophic cardiomyopathy
cor pulmonale
obesity

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20
Q

describe process of remodeling for LV diastolic dysfunction

A

increased pressure —> systolic wall stress –> thickening of the LV walls to overcome pressure –> fibrotic and noncompliant LV

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21
Q

How to manage diastolic dysfunction perioperatively

A
  • volume is required to stretch noncompliant LV
  • keep afterload elevated to perfuse the thick myocardium
  • contractility is usually normal
  • maintain slow to normal HR
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22
Q

Most common cause RV failure

A

left heart failure

Also pulm htn, right sided myocardial infarction

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23
Q

How to manage RHF perioperatively?

A
  • avoid any c/ of increased PVR- hypercarbia, hypoxemia, acidosis, nitrous oxide, desflurane, t burg
  • careful titration of fluid management
  • consider pressors like vasopressin, milirinone
  • inhaled nitric oxide can reduce PVR
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24
Q

What is cardioplegia?

A

Used to halt electrical activity of the heart and protect myocardial tissue

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25
What are some key side effects of CPB
inflammatory response & plt dysfunction
26
How does dilutional anemia happen with CPB
It is 1-2 L that is used to prime the circuit, will c/ reduction in patient's hematocrit Usually a positive and will offset the increased viscosity when blood cools in CPB
27
What are some actions the perfusionist can do if there is concern for decreased HGB prior to priming circuit?
Can consider retrograde autologous priming (RAP) Usually requires pressor support from us :)
28
Most common pump for CPB
centrifugal pump Flow can vary w/ changes in preload & afterload but it doesnt destroy blood elements
29
Describe concept of sweep
O2 and CO2 removal is controlled by changing liter gas flow rate through oxygenator Inhaled anesthetic gas added here @ OXYGENATOR to maintain depth of anesthesia
30
While on CPB patients are kept at ____-_____C.
34-36 C to decrease metabolic rate and oxygen consumption.
31
T/F: patients need to be actively rewarmed prior to separation from CPB.
TRUE!
32
What is the cardiotomy and basket suction in CPB?
○ Yankauer, “pump sucker”, and basket suctions are used to aspirate blood from surgical field (after heparinization). ○ Some blood may be diverted to cell saver
33
What is left ventricular vent in CPB?
○ Catheter placed in LV via right pulm vein ○ LV vent will help drain the blood that builds up in the LV (via bronchial arteries, thespian veins, AR)
34
What is the cardioplegia pump in CPB?
Perfusionist also has access to accessory roller pump to control cardioplegia infusion (antegrade and retrograde)
35
How does heparin work?
Binds to antithrombin III and increases its action 1000 fold
36
Heparin dose for CPB & ACT levels prior to CPB
400 u/kg normal ACT (80-120 sec), but you want it to be 400 sec or greater prior to CPB initiation
37
If your patient has HIT, what anticoagulation could you use?
bivalrudin
38
Describe dosage and administration of protamine.
reverse heparin- + charged protamine neutralizes the - charged heparin through electrostatic interaction 1 MG for every 100 U heparin Can c/ hypotension, HTN, RHF, anaphylaxis, give SLOW
39
How is cardioplegia given and what solution is commonly used?
SOLN: cold hyperkalemic crystalloid soln mixed w/ blood given q 15-20 min via monitoring of ECG activity or temp Admin: antegrade --> coronary arteries & retrograde --> coronary sinus & coronary veins
40
Physiologic effects of CPB
*Plts and clotting factors are diluted and denatured d/t mechanical trauma from the CPB circuit and suction devices * AKI * intestinal ischemia
41
Prior to aortic cannulation -- you must ensure SBP is what? and why?
90-100 MMHG or less to reduce risk of aortic dissection
42
Describe some drugs you want to have available coming off CPB
For sure CaCl 1-2 G IV
43
What medication can you use to counteract the hypotension you may see with protamine?
phenylephrine to increase SVR
44
Describe perfusion of the coronary arteries
Anterior interventricular septum- LAD Posterior interventricular septum- RCA Anterior lateral wall- LCX & LAD
45
Describe some HOCM goals
* high/normal preload * low/normal HR to maintain NSR * reduce contractility **** w/ esmolol * maintain SVR
46
As the CRNA, what are some things you can anticipate with acute aortic dissection
HIGH STRESS, emergent surgery! * assume full stomach * anxious patient * esmolol to control BP and HR * consider use of vasodilators to maintain MAP at 60-70 mmHG
47
What is an IABP
allows for intrinsic cardiac ejection assisted w/ synchronized counterpulsation
48
Describe how IABP works
inflation --> ONSET OF DIASTOLE (diacrotic notch) --> increased aortic diastolic pressure deflation --> onset of systole --> creates a vacuum that decreases afterload & MVO2 demand
49
Describe the positions of pacemaker (3)
Position 1- chamber paced Position 2- chamber sensed Position 3- response to sensing
50
Prior to cardiac surgery, PCM/ICD patients should be programmed to what?
PCM: should be interrogated and programmed to an asynchronous mode VOO/DOO at 80-90 ICD: should be programmed to disable antitachycardia therapy
51
When a magnet is placed on PCM & ICD-- what happens?
PCM: asynchronous pacing ICD: disables shock
52
anesthetic considerations with pacemaker
consider FIO2 less than 30% to minimize r/o fire during bovie use
53
What time of lead extraction is low risk versus high risk
Low risk: any lead < 1 yr High risk: PM lead > 10 yr, ICd >5 yr You want a CV surgeon available
54
During CV surgery, what should PCM be programmed to
asynchronous mode, VOO/DOO at 80-90
55
Indications for ICD
○ History of VT or VF ○ Postmyocadial infarction with LVEF < 35% ○ Cardiomyopathy with LVEF < 35% ○ Long QT Syndrome ○ Hypertrophic cardiomyopathy
56
What is VAD?
supports failing R or L ventricles by ensuring adequate ejection consists of an inflow cannula, a pump, and an outflow cannula
57
ECMo consists of what?-- and what does it need?
needs heparin coagulation similar to CPB w/ centrifugal pump, membrane oxygenator, heat exchanger, oxygen blender, control console
58
Role of IABP
allows for intrinsic cardiac ejection assisted w/ synchronized counterpulsation positioned 1-2 CM distal to the origin of the L SC artery
59
Anesthetic considerations of transcatheter mitral valve repair
GETA w/ arterial line and TEE placement
60
Anesthesia considerations for catheter ablation
GETA w/ a line adenosine & isoproteronol to ID areas of abnormal activity ACT 250-300 Monitor esophageal temp probe to reduce risk of thermal injury and/or atrioesophageal fistula caution w/ r. phrenic nerve injury
61
Deep hypothermic circulatory arrest considerations
* Want isoelectric EEG * 14.1-20 C * use antegrade cerebral perfusion if circ time is greater than 30 min * rewarming is done gradually/slow
62
What immunosupressants would you give and dosing for heart transplant?
Anti-thymocyte globulin Methylprednisolone 500 MG IV Diphenhydramine 50 MG IV
63
Considerations w/ heart transplant
* heart is denervated (high intrinsic rate & no response to glycopyrrolate) * Consider NO and inhaled vasodilators
64
Anesthesia goals with aortic stenosis
Similar to diastolic HF Maintain NSR Maintain baseline HR Maintain afterload Maintain preload
65
What TEE view allows you to confirm probes and wires?
midesophageal bicaval
66
Absolute contraindications of TEE
viscus perforation esophageal pathology- strictures, diverticula, recent suture lines
67
What is dilutional anemia?
○ Volume used is typically 1-2 L ○ Will result in a reduction in the pt’s HCT ○ Beneficial to offset the increased viscosity when the blood cools in CPB
68
Perioperative management of diastolic dysfunction
69
Perioperative management of systolic dysfunction
70
Etiology of LV systolic dysfunction
71
Etiology of LV diastolic dysfunction

Adv. Anesthesia (4 decks)

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