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114 Cards in this Set
- Front
- Back
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what are the 3 things in fetal circulation that go away when born
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1-ductus venosus
2-foramen ovale 3-ductus arteriosus |
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what is ductus venousus
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allow majority of oxygenated placental blood to bypass liver and enter IVC
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what is foramen ovale
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allows oxygenated blood from placenta to pass from RA to LA and into systemic circulation
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what is ductus arteriosus
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dexoygenated blood from SVC passes into RV & pumped into PA where much of it travels via DA into descending aorta to placenta to be oxygenated
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what are the things that occur in the transition from fetal to neonatal circulation
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*increased SVR
*decreased PVR *closure of foramen ovale *closure of ductus arteriosus *closure of ductus venosus |
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why is there an increased SVR with transition from fetal to neonatal circulation
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b/c of loss of low pressure placental circulation
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why is there a decreased PCR with transition from fetal to neonatal circulation
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b/c of
*expansion of lungs *vasodilation d/t aeration |
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why is there closure of foramen ovale with transition from fetal circulation to neonatal circulation
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due to flow reversal as SVR increases and PVR decreases
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why is there closure of ductus arteriosus with transition from fetal circulation to neonatal circulation
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flow reversal followed by constriction of the muscular wall
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why is there closure ductus venosus with transition from fetal circulation to neonatal circulation
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d/t muscular constriction of vessel wall
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what is the incidence of congenital heart dz
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7-10 / 1000 live births
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what is the most common form of congential dz
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congenital heart dz
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what accounts for 10% of the cause of congential heart dz
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chromosomal abnormalities
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majority of chromosomal abnormalities are associated with what
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trisomy 21
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what accounts for 90% of the cause of congenital heart dz
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multifactoral origin
(genetic +/- external factors) |
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what are some of the multifactoral origins of congenital heart dz
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*maternal dm
*rubella *ETOH abuse *lithium use |
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what is the MOST often occuring congential heart dz problem
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ventricular septal defect
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what are the ACYANOTIC lesions
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*ASD *VSD
*patent ductus arteriosus *aortic stenosis *pulmonic stenosis *coarctation of the aorta |
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what type of shunt does an ACYANOTIC lesion produce
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L to R
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an ACYANOTIC results in what
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*increased pulmonary blood flow
*pulmonary HTN *R vent hypertrophy *heart failure |
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when is repair best done on an ACYANOTIC lesion
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at an early age
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once PVR is what with an ACYANOTIC lesion sx may not produce significant benefit
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> 1/3 SVR
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atrial septal defect typically results from what
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spontaneous genetic mutations
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with atrial septal defects small lesions may do what
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remain ASYMPTOMATIC throughout life
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what is the threshold for closure with atrial septal defect
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when pulmonary blood flow is >1.5x systemic blood flow
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what are the symptoms of a large atrial septal defect
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*DOE
*supraventricular dysrhythmias *R heart failure *paradoxical air embolus *recurrent pulm infection |
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what are things that INCREASE L to R shunt
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*increased SVR
*decreased PVR |
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what are things that decrease L to R shunt
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*decreased SVR
*increased PVR |
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d/t increased pulm blood flow with atrial septal defect what might happen to IV drugs
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possible dilution
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d/t decreased systemic blood flow with atrial septal defect what might happen with inhalation induction
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possible delay
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what is the most common congenital HEART defect
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ventricular septal defect
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what heart defect often closes spontaneously in infancy
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ventricular septal defect
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what occurs with a large ventricular septal defect
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*initial L to R shunt
*over time RVH occurs *may become a R to L shunt |
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when should surgical correction occur with a ventricular septal defect
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prior to PVR/SVR ratio reaching 0.7
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with VSD L to R shunt what may IMPROVE the condition
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volatile anesthetics and and positive pressure ventilation
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with VSD late stage cyanotic R to L shunt what may WORSEN the shunt
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volatile anesthetics and positive pressure ventilation
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with VSD and late stage cyanotic R to L shunt what may IMPROVE the shunt
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increased FIO2 and sympathetic stimulation
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what causes patent ductus arteriosus
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failure of spontaneous closure
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what is the function of ductus arteriosus in the fetus
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allows PA blood to bypass lungs and travel to placenta via aorta
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when do symptoms develop with patent ductus arteriosus
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most children remain asymptomatic until adolescence
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what are the symptoms of patent ductus arteriosus
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*pulmonary HTN
*heart failure |
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what is the tx for patent ductus arteriosus
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medical tx
*non-selective inhibition of prostaglandin synthesis -indomethacin -ibuprofen |
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what do you WANT to do in the anesthetic management of patent ductus arteriosus
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MINIMIZE L to R shunt
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how would L to R shunt be MINIMIZED in the anesthetic management of patent ductus arteriosus
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*VA (decrease SVR)
*positive pressure vent (increase PVR) |
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what would need to be AVOIDED in the anesthetic management of patent ductus arteriosus
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*increased SVR
*decreased PVR |
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what medication would you AVOID in the anesthetic management of patent ductus arteriosus
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ketamine
(d/t increased SVR and worsening of shunt) |
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what amt of the population has a BICUSPID aortic valve
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2-3%
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AORTIC stenosis is often associated with what
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other CV abnormalities
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severe AORTIC stenois may present as what in infancy
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heart failure
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symptoms of AORTIC stenosis typically do not develop until when
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adulthood
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symptoms of AORTIC stenois include what
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*angina
*syncope *heart failure |
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what are the initial symptoms of PULMONIC stenois
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dyspnea on exertion
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with the development of R heart failure the symptoms of PULMONIC stenosis are what
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*peripheral edema
*ascites |
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if a foramen ovale is patent with PULMONIC stenosis what occurs
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cyanosis d/t R to L shunting
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what is the management of PULMONIC stenosis
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*AVOID decreases in systemic blood pressure
*maintain SR w/ a normal HR |
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where is preductal coarctation of the aorta
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just proximal to the L subclavian
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where is postductal coarctation of the aorta
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just distal to the L subclavian
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what is the MOST common preductal or postductal
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POSTDUCTAL
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what are the general s/s of coarctation of the aorta
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BP difference b/t upper and lower body
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what are the s/s of coarctation of the aorta proximal to the lesion
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*HA
*dizziness *epistaxis *palpitations |
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what are the s/s of coarctation of the aorta distal to the lesion
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claudication in LE
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what is the tx for coarctation of the aorta
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resection or balloon dilation when pressure gradient reaches 30 mmHg
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where should you measure BP with coarctation of the aorta
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above and below the lesion
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what are post-op concerns with coarctation of the aorta
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*paradoxical HTN
*effects of decreased spinal cird blood flow during cross clamp *abd pain |
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what are the CYANOTIC lesions
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*tetralogy of fallot
*transposition of the great arteries |
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what type of shunt do CYANOTIC lesions produce
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R to L
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R to L shunts result in what
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*decreased pulmonary blood flow
*arterial hypoxemia |
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what are the risks of a R to L shunt
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*thromoembolism secondary to erythrocytosis d/t hypoxemia
*brain abscess |
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what is the survival like with a R to L shunt
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*very limited in the absence of surgical correction
*takes communication of the systemic and pulmonary circulations |
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what is the most common cyanotic congential lesion
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tetralogy of fallot
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what are the components of tetralogy of fallot
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1-large-single VSD
2-overriding aorta 3-R vent outflow obstruction 4-R vent hypertrophy *********************************** |
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with tetralogy of fallot a large VSD results in what
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equilization of L and R vent pressures resulting in RVH
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with tetralogy of fallot R to L shunting occurs d/t what
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VSD, RVH and obstruction to the R vent outflow tract
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with tetralogy of fallot resulting decrease in pulmonary flow produces what
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arterial hypoxemia
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with tetralogy of fallot a decreased SVR does what
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increased R to L shunt worsening hypoxemia
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with tetralogy of fallot an increased SVR does what
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reduces R to L shunt
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what are the s/s of tetralogy of fallot
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*systolic ejection murmur
*cyanosis *squatting *increased Hgb & Hct *hypercyanotic attacks *CVA *cerebral abscess *infective endocarditis |
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with a R to L shunt what are things that REDUCE the shunt
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*INCREASED svr
*DECREASED pvr *INCREASED pulm blood flow |
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what are ways to increase SVR with a R to L shunt
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*ketamine (drug of choice)
*alpha agonism (phenyepherine) |
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what are ways to decrease PVR with a R to L shunt
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increased FIO2
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what are ways to increase pulmonary blood flow with a R to L shunt
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beta blockade if outflow obstruction d/t infundibular spasm
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with a R to L shunt what are things that WORSEN the shunt
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*DECREASED svr
*INCREASED pvr *INCREASED contractility *hypovolemia |
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what are ways to decrease SVR with a R to L shunt
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*VA
*histamine release *alpha-blockade |
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what are ways to increase PVR with a R to L shunt
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*positive pressure ventilation
*PEEP *opening of the chest |
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what are ways that contractility are increased in a R to L shunt
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increases in infundibular outflow obstruction
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what is the pre-op management of tetralogy of fallot
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*maintain hydration
*continue beta-blockers *avoid precip of hypercyanotic attack |
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what needs to be AVOIDED in the induction of a pt with tetralogy of fallot
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reduction in SVR
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what agent is the preferred choice for the IV induction of a pt with tetralogy of fallot
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KETAMINE
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what may occur with mask induction of a pt with tetralogy of fallot
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potential for decrease in SVR
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what maintanence tech with tetralogy of fallot maintains SVR
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ketamine + N2O
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during maintenance of anesthetic on tetralogy of fallot pts what needs to be AVOIDED
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VA
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what type of muscle relaxant needs to be AVOIDED in a tetralogy of fallot pt
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ones with histamine release
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what needs to be AVOIDED in the ventilation of tetralogy of fallot pts
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high inspiratory pressures and PEEP
**air embolism |
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what can be used in the HD management of tetralogy of fallot pts
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*beta-blockers
*phenylephrine |
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what is eisenmengers syndrome
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reversal of a L to R shunt d/t increases in pulmonary vascular resistance
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when does shunt reversal occur with eisenmesengers syndrome
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once the pulmonary vascular resistance exceeds systemic vascular resistance
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what is the treatment for eisenmengers syndrome
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*lung transplant with repair of VSD/ASD
*heart/lung transplant |
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what is transposition of the great arteries
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failure of the spiraling of the truncus arteriosus during development
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with transposition of the great arteries the aorta arises from where
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the RV
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with transposition of the great arteries the pulmonary artery arises from where
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LV
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transposition of the great arteries results in what
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complete seperation of systemic and pulmonary circulation
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what is required for survival with transpostion of the great arteries
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VSD, ASD, patent foramen ovale or PDA
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what is the mortality at 1yr without surgical tx with transposition of the great arteries
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100%
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what is the initial tx for transposition of the great arteries
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maintenance &/or expansion of communications b/t systemic & pulmonary circulations
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how is maintenance &/or expansion b/t systemic and pulmonary circulations kept with transposition of the great arteries
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*prostaglandin E infusion
(maintain patency of PDA) *balloon atrial septostomy (increase atrial mixing) *oxygen (decrease PVR) *diuretics and digoxin (if heart failure present) |
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what type of surgical tx are done on transposition of the great arteries
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*mustard or senning procedure (older adults)
*arterial switch (younger adults and children) |
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what is the mustard or senning procedure
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creates a baffle of pericardium or atrial tissue that directs caval blood into the L atrium
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what is the arterial switch procedure
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*transect and switch the aorta and pulmonary artery
*reimplant coronaries on aorta |
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what must be done with IV drugs with transposition of the great arteries
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must reduce dosages d/t lack of sig pulmonary circulation
(lack of pulm dilution) |
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what is a concern regarding inhaled drugs with transposition of the great arteries
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delayed onset d/t mininal transfer to the systemic circulation
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what are the goals in the anesthetic management of the pt with transposition of the great arteries
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*avoid myocardial depression
*maintain high FIO2 *maintain hydration |
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what is truncus arteriosus
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single arterial trunk overrides both ventricles
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what is the survival with truncus arteriosus
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very low
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what is the tx for truncus arteriosus
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*band pulm arteries if pulm blood is too high
*repair VSD so only LV ejects into arterial trunk *create an artificial pulm artery w/ valve to feed the R & L PAs |
