Pap Vi- Test #2

Front 1

Initiation of bypass includes what steps? 3

Back 1

1. Venous then arterial cannulas released
2. Aorta cross clamped
3. Pump started

Front 2

Adequate flow to the _______ _________ should be monitored.

Back 2

venous reservoir

Front 3

How should the heart empty?

Back 3

gradually

Front 4

If the heart doesn't empty gradually, what are the 2 possible problems?

Back 4

either venous or aortic cannulas are malpositioned

Front 5

If the aortic cannula is the problem what must be done immediately?

Back 5

cross-clamp and give cardioplegia

Front 6

What should you document?

Back 6

time of bypass start

Front 7

Ventilation should be ________.

Back 7

stopped

Front 8

What is the typical pump flow?

Back 8

2-2.5L/min/m2

Front 9

Prior to bypass you should also empty?

Back 9

urine

Front 10

Once on bypass what are 3 reasons BP drops?

Back 10

1. Abrupt hemodilution
2. Decreased viscosity initially
3. Decreased SVR

Front 11

If the MAP is below 30 mmHg what are possible reasons? 4

Back 11

1. Aortic dissection
2. Poor venous return
3. Pump malfunction
4. Transducer error

Front 12

What is the goal for MAP while on bypass?

Back 12

50-80 mmHg

Front 13

MAP > ______ is hypertension.

Back 13

100 mmHg

Front 14

What can be done to reduce MAP?2

Back 14

1. Reduce pump flow
2. Isoflorane or nitroprusside

Front 15

Labs should be done at what 3 times?

Back 15

after induction for baseline, prior to bypass (ACT), after coming off pump

Front 16

During bypass what temperature does the body reduce to?

Back 16

20-28 degrees C

Front 17

What can occur when below 28 degrees C?

Back 17

vfib, must use cardioplegia!

Front 18

What is the anesthesia for the CPB patient?

Back 18

hypothermia

Front 19

When is awareness most common? 2

Back 19

initiation of bypass and during rewarming period

Front 20

What should you give to prevent recall?

Back 20

give MR, amnestics and anesthetic agents prior to rewarming

Front 21

What is another big concern during the bypass period?

Back 21

Cerebral events

Front 22

What could you give for cerebral protection?

Back 22

pentathol

Front 23

Neuro complications in open heart procedures are as high as _____ %.

Back 23

40 (usually transient if they occur)

Front 24

What are 3 reasons why a patient may be at an increased risk for neuro complications?

Back 24

1. Valves
2. Increased age
3. Cerebrovascular disease

Front 25

Neuro complications are probably ______ in origin.

Back 25

embolic

Front 26

Prior to termination of CPB, what temperature is needed?

Back 26

core - 37 degrees C

Front 27

What else is checked prior to termination of CPB?

Back 27

grafts and heart are free from air

Front 28

Slowly what is removed during termination of CPB?

Back 28

aortic cross clamp

Front 29

What is resumed prior to termination of CPB?

Back 29

ventilation

Front 30

What are general guidelines allowing termination of CPB? 4

Back 30

1. Stable rhythm
2. Adequate heart rate
3. Lab values obtained
4. Ventilation with 100%

Front 31

Hyperkalemia must be?

Back 31

treated

Front 32

During weaning, what will be occluded to allow the heart to fill?

Back 32

venous line, then arterial pump will be shutt off

Front 33

Suspect what if filling pressures increase rapidly with volume?

Back 33

ventricular impairment

Front 34

How do you know if you have pump failure?

Back 34

sluggish, poorly contracting heart with distension

Front 35

IF you have pump failure, what are the options? 4

Back 35

1. Restart bypass
2. Give inotrope to increase contractility
3. Reduce afterload
4. Consider IABP

Front 36

If you have HTN with high ventriuclar filling pressures and high CO what does this mean? what could you do?

Back 36

too full! give diuretics, venodilators, or wait

Front 37

If you have HTN with high ventricular filling pressures and low CO, what does this mean? what could you do?

Back 37

? decreased contractility or increased SVR*, give inotropes or vasodilators

Front 38

If you have a HTN patient wiht low ventricular filling pressures and high CO what does this mean? and what are treatment options?

Back 38

hyperdynamic! (pumping hard)
wait or give anesthetics (deepen)

Front 39

If you have a HTN patient with low ventricular filling pressures and low CO what does this mean? treatment?

Back 39

very high SVR with or without hypovolemia, give volume or vasodilation

Front 40

If you have a hypotensive patient with high ventricular filling pressures and high CO what does this mean? what do you do?

Back 40

too full, low SVR!
wait or use vasoconstrictor (to increase SVR)

Front 41

If you have a hypotensive patient with high ventricular filling pressures and low CO what does this mean? what are treatment options?

Back 41

BIG TROUBLE, very low contractility
1. Adjust preload if necessary
2. Inotropes
3. Vasodilators
4. Return to bypass
5. IABP or LVAD

Front 42

If you have a hypotensive patient with low ventricular filling pressures and high CO what does this mean? and treatment?

Back 42

very low SVR, give a vasoconstrictor

Front 43

If you have a hypotensive patient with low ventricular filling pressures and low CO what does this mean? treatment?

Back 43

hypovolemia, ? right ventricular failure
1. Transfuse
2. If right heart failure, return to CPB, inotrope, maintain perfusion pressure, if PA pressure is elevated use vasodilator, IABP or RVAD

Front 44

What do you want to control post-bypass period?

Back 44

bleeding

Front 45

What do you give post-bypass?

Back 45

protamine

Front 46

What is the dose of protamine?

Back 46

1-1.3 mg/100 U heparin

Front 47

What are 3 side effects of protamine?

Back 47

1. Hypotension
2. Pulmonary hypertension
3. Allergic reaction

Front 48

Overdose of protamine acts as an?

Back 48

anticoagulant

Front 49

What should you check after administration of protamine?

Back 49

act

Front 50

What is the desirable HCT?

Back 50

27-30%

Front 51

Persistent bleeding is associated with what 5 things?

Back 51

1. long bypass periods
2. Platelet dysfunction
3. DIC
4. Hypothermia
5. Inadequare heparin reversal

Front 52

What boosts von willebrands factor and factor VIII?

Back 52

DDAVP

Front 53

Post-op patient may be on ventilator due to?

Back 53

1. Reduced FRC
2. Diaphragmatic dysfunction

Front 54

Chest tube drainage greater than ______________ ml/hr is excessive in the first few hours.

Back 54

250-300

Front 55

After the first hour, _____ ml/hr is excessive.

Back 55

100

Front 56

Excessive bleeding may require?

Back 56

re-exploration

Front 57

"Off-pump" hearts, you should maintain?

Back 57

normophysiology- be proactive in treatment

Front 58

What should you do for off-pump heart to maintain hemodynamics?

Back 58

fluid load, have vasoactive and antiarrhythmic readily available

Front 59

Be prepared to increase or decrease ____ and ____ on demand.

Back 59

HR, BP

Front 60

What makes monitoring difficult?

Back 60

manipulation of the myocardium
- changing vectors

Front 61

ECG and TEE are relatively _______ indicators of ischemia.

Back 61

insensitive

Front 62

With an off-pump heart what has been proven to be a useful detector of cardiac problems?

Back 62

continuous cardiac output monitoring

Front 63

In an off-pump heart, you want to keep patient temp above what?

Back 63

36 degree C

Front 64

What 3 criteria usually have to be met to extubate an off-pump heart in the OR?

Back 64

1. Good LV function
2. Stable hemodynamics
3. No underlying pulmonary disease

Front 65

What are options for post-op pain control for off-pump hearts?

Back 65

Intercostal blocks, ketorolac, narcotics, epidural or intrathecal injections

Front 66

What is key in off-pump hearts?

Back 66

volume loading

Front 67

Elevation of the heart out of the chest cavity increases? due to?

Back 67

ischemic risk
-decreases preload
-impinges coronary vessels

Front 68

For off-pump hearts, you should use?

Back 68

short acting vasoactive agents

Front 69

For off-pump hearts, you should avoid?

Back 69

large narcotic doses

Front 70

What should the heparin dose be for off-pump hearts?

Back 70

1,000-15,000 U initially

Front 71

What do you want to keep ACT above?

Back 71

300 seconds

Front 72

How often should you check ACT?

Back 72

20-30 minutes*

Front 73

Its important to maintain what?

Back 73

acid/base balance

Front 74

What is the most severe complication from mediastinoscopy?

Back 74

hemorrage-- may require thoracotomy

Front 75

What artery could be compressed during a mediastinoscopy?

Back 75

inominate

Front 76

How do you monitor compression of inominate artery?

Back 76

pulse ox on right finger, art line right arm

Front 77

Also place what on the left arm?

Back 77

BP cuff to compare to R

Front 78

What is feared during induction of anesthesia for a patient with a anterior or superior mediastinal mass?

Back 78

airway obstruction