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67 Cards in this Set
- Front
- Back
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Name the 3 main coronary arteries and their configuration
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RCA; Left main branching into LAD and L CFX
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Sinus node is supplied by which artery?
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RCA in 60-50% and L CFX in 40-50%
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AV node is supplied by which artery?
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RCA in 85-90% and L CFX in 5-10%
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Incidence of periop myocardial re-infarction does not stabilize to ___% until __ months/years after the prior MI?
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5-6% until 6 months
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Giving B-blockers for ___ prior to surgery and continued for ___ reduces the risk of MI by ___?
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7-30 days; 30 days; 90%
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Risk factors for CAD?
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Elderly, HTN, DM, Significant Smoking Hx, HLD
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Who should recieve B-blockers?
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Patients with CAD, PVD, or 2 risk factors for CAD
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Who is contraindicated for b-blocker periop? What should they use instead?
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Asthmatics, NOT COPD. Use Clonidine instead (A2 agonist)
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Digitalis therapy can affect a ECG how?
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PR prolongation
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Right Coronary Artery. What ECG leads show ischemia? What area of myocardium is involved?
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II, III, aVF
Inferior Wall MI Right Atrium; SA node; AV node; Right Ventricle |
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Left anterior descending artery. What ECG leads show ischemia? What area of myocardium is involved?
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V3-V5
Anterior MI Anterolateral aspects of the left ventricle |
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Circumflex coronary artery. What ECG leads show ischemia? What area of myocardium is involved?
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I, aVL, V5, V6
Lateral MI, lateral aspects of the left ventricle |
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Patient has PVD, but has asthma (severe). What would you order pre-op for risk reduction?
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Clonidine 0.2mg PO night before along with 0.2mg/24hr patch.
Clonidine 0.2mg PO morning of surgery but hold for SBP < 120mmHg |
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What is an appropriate drug/dose for starting someone on a betablocker for peri-op?
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Atenolol 25mg PO
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Patient did not take any b-blockers but needs them? What do you give them IV?
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Metoprolol 5mg IV boluses. Standard dose is 10mg IV. Avoid in HR < 50 or SBP < 100. FYI Metoprolol 1mg IV = Metoprolol 2.5mg PO
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How long post-op should you continue a beta-blocker for periop?
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7-30 days (7 days for only risk factors, 30 days for actual disease)
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When should statin therapy start/stop periop?
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30 days prior and 30 days after surgery. Possibly indefinately.
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Beta-blockers are contraindicated in which disease?
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AV block (high degree) without pacemaker; reactive asthma; or an intolerance for b-blockers
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Is diabetes an indication for b-blockade (periop)?
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Yes
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True or False: Esmolol boluses decrease periop mortality?
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False; use metoprolol or something longer lasting
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What should you start a phenylephrine drip at for prophylactically for induction on a cardiac patient?
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0.2 to 0.4 ug/kg/min (100kg = 20-40mcg/min)
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Etomidate is good for patients with cardiac disease, why?
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Has limited inhibition of sympathetic nervous system and limited hemodynamic effects
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Can you use ketamine for induction in cardiac cases?
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It increases HR and BP which may increase myocardial oxygen requirements
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Which inhaled anesthetic agent should you be aware of for cardiac dz patients?
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Desflurane. Titrate up slowly because it can cause tachycardia, pulmonary HTN, myocardial ischemia, and bronchospasm.
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How can you use lidocaine (dose) of minimize effects of tracheal intubation? Two ways
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Tracheal lidocaine (2mg/kg) pre ET tube, or IV lidocaine 1.5mg/kg pre intubation
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Right atrial pressures do not reliably reflect left side filling pressures or pulmonary artery occlusion in what conditions?
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EF of less than 50%; It does when EF > 50% and no signs of LV dysfxn
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Mitral stenosis is usually caused by what?
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Fusion of leaflets, usually 20 yrs after rheumatic event (ie rheumatic fever)
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What can cause mitral stenosis that is not symptomatic to become symptomatic suddenly?
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Increase in cardiac output requirement, ie. sepsis or pregnancy
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Mitral stenosis is treated with which drug and what is the goal?
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Digitalis, goal is heart rates below 80 (adaquate dose)
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Why would a patient with mitral stenosis on warfarin?
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Mitral stenosis can cause increased left atrial distension leading to a.fib and stasis of blood leading to possible thrombi
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What IV induction drug should you avoid in mitral stenosis and why?
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Avoid ketamine for its propensity to increase HR.
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Can you use nitrous oxide in mitral stenosis?
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N2O causes pulmonary vasoconstriction but its not contraindicated except for people with co-existing SEVERE pulmonary hypertension.
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Rapid increases in desflurane can cause what cardiopulmonary issues?
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Tachycardia, bronchospasm, and pulmonary hypertension
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Which NMBD should you avoid in mitral stenosis and why?
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Pancuronium; It has ability to increase speed of transmission of cardiac impulses through AV node, possibly leading to increased HR. Especially problematic in people with A.fib as vent rate depends on AV node conduction
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Mitral stenosis: What concerns you about reversal of NMBD?
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Increased HR, sugammadex is a good solution or allowing it to be metabolized
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Fluid therapy and positioning considerations in mitral stenosis?
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Avoid fluid overload which can lead to LV failure and pulmonary edema; avoid head-down which can lead to increased pulmonary volume and pulmonary congestion/edema
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Why should you avoid hypotension on induction and what could you do?
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Quick bolus can cause hypotension, which can lead to increased HR. Prophylatic phenylephrine drip or slow induction
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You are measuring RA pressures and they go up, what could be some causes?
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Nitrous oxide, desflurane, acidosis, hypoxia, increased mitral regurg, light anesthesia
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Mitral stenosis: What are patient's at high risk of developing post-op?
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Pulmonary edema and right side heart failure. Mechanical support may be necessary after major thoracic/abdominal surgery.
Shift from PPV to Spontanous with weaning/extubation may lead to increased venous return and increased CVP with worsening heart failure |
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Mitral regurg shows up in which way on pulmonary cath?
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Pumonary occlusion pressure shows V waves
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Causes for mitral regurg?
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Rheumatic fever (usually has component of mitral stenosis)
Dilated cardiomyopathy (ischemia, multiple MIs, viral/parasitic infxns, or other) Isolated MR may be acute reflecting papillary muscle dysfxn after MI or ruputre of chordae tendineae secondary to infective endocarditis |
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Mitral regurg management?
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Avoid decreases in HR
Avoid very large decreases in HR but some afterload reduction (decrease in HR) helps with forward flow Avoid myocardial depressants Monitor V waves in PAC to as a reflection of mitral regurg flow |
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Mitral regurg: Any issues with general or regional anesthesia?
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Spinal can cause low BP and is rapid and uncontrolable. Continuous spinal is possibility. General is ok, just avoid des or N2o (avoid pulmonary vasoconstriction)
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Aortic stenosis: Significant criteria
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Gradient less than 50mmHg or AVA less than 1.2cm2
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Aortic stenosis: Critical criteria
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Gradient greater than 50mmHg or AVA less than 0.75cm2
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How can aortic stenosis cause angina due to ischemia in patients without CAD?
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AS causes LVH, increased myocardial oxygen requirement and higher LV pressures pushing down on coronaries
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Isolated nonrheumatic aortic stenosis usually results from ?
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progressive calcification and stenosis from a congential bicuspid valve
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AS from rheumatic disease is associate with what other heart condition?
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Mitral valve stenosis
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AS requires what with heart rate and why?
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NSR for properly timed filling and ejection and no increases in HR. Avoid
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What's special about IV meds in LVAD patients?
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These patients have low Vdist which increases plasma concentrations of IV meds
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Whats the most common cause of death in LVAD patients?
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Sepsis
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IE prophylaxis is for cardiac conditions with the highest risk, what are those?
What antibiotic should they get and for what cases? |
Prosthetic cardiac valves, previous IE hx, several types of congential heart disease (CHD), and cardiac transplant recipients who develop valvulopathy
For dental procedures and other procedures, NOT for GI and GU cases. Cephalexin 2g orally (or other 1/2nd gen oral cephalosporin) or clindamycin 600mg PO/IM/IV 30-60 mins before surgery |
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What does cooling on bypass due to hemostasis and platelets?
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Cooling reduces hemostasis and platlets are almost completely sequestered in the portal circulation at 20C but upon rewarming return with full function
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Whats the most sensitive marker of LV myocardial ischemia?
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Wall motion abnormalities on echo
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VO2 of one MET?
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One met is energy expended over 1 minute at rest
3.5ml/kg/min of O2 |
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Name some common right to left CHD shunts?
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Tetralogy of Fallot
Eisenmenger's syndrome Ebstein malformation of TV Pulmonary atresia with VSD Tricuspid Atresia PFO |
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In transposition of great vessels, what happens and how do you survive?
How does anesthesia work? IV and inhaled? |
RV to aorta
LV to pulm circulation Some mixing (ASD?) needs to be present but child will be profoundly hypoxemic Inhaled slow because minimal getting into circulation. IV undiluted direct to brain so use small doses/ rate of injection |
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Cooling to 28 to 30C decreases metabolic rate by about how much?
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50%
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What happens if you give protamine to patient without heparin?
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Anticoagulation due to binding of platlets and soluble coag factors
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Dose of protamine and caution in administration?
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1.3mg per 100units heparin.
Avoid rapid infusion due to hypotension secondary to histamine release from mast cells |
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Most to least important determinant of myocardial work?
Preload, Afterload, HR |
HR > Afterload > Preload
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What drugs can you throw down ET tube?
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ALONE
Atropine Lidocaine Oxygen Naloxone Epinephrine Vasopressin |
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Aminodarone: It's being infused intraop. What should you know about its effects and how to counter any side effects?
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It prolongs action potential without changing resting potential. It depresses SA and AV node thus used for SVT or VTs and WPW (increases refractory period of accessory pathway).
Atropine resistant bradycardia and hypotension can occur during general anesthesia 2/2 to significant anti-adrenergic effects. Tx with isoproterenol or temporary artifical cardiac pacemaker. |
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Whats normal cortisol production and max under stress cortisol production?
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15 to 20mg / day normal
Under stress 75-150mg /day |
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Myocardial oxygen consumption: Resting; cold fibrillating; quiet
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8-10 ml/100g/min
2 ml / 100g/min 0.3 ml / 100g/min |
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HOCM: Patient become hypotensive. What do you use and what do you avoid?
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Phenylephrine. Pure alpha agonist. Avoid drugs that can be ionotropes.
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What is protamine derived from?
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Salmon sperm
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