Congenital P2

Front 1

What types of congenital heart diseases are acyanotic?

Back 1

atrial septal defect
ventricular septal defect
aortic stenosis
pulmonic stenosis
coarctation of the aorta
patent ductus arteriosus

Front 2

What types of congenital heart diseases are cyanotic?

Back 2

tetralogy of fallot
eisenmenger's syndrome
transposition of the great arteries

Front 3

What are the most and least common types of acyanotic defects?

Back 3

most- ventricular septal defects
least- atrioventricular septal defects

Front 4

What is the most common type of cyanotic defects?

Back 4

tetralogy of fallot

Front 5

What cardiac conditions are associated w the highest risk of adverse outcomes from endocarditis for which prophylaxis for dental procedures is reasonable?

Back 5

1. prosthetic heart valve or prosthetic material used for cardiac valve repair
2. previous infective endocarditis
3. congenital heart diseases

Front 6

What congenital heart diseases indicate prophylaxis for dental procedures?

Back 6

1. unrepaired congenital heart dz, including palliative shunts and conduits
2. completely repaired congenital heart defect w prosthetic material or device, whether placed by surgeon or cath intervention during first 6 mo. afterward
3. repaired congenital heart disease w residual defects at site or adjacent to site of prosthetic patch or prosthetic device (which inhibit endothelialization)
4. cardiac transplantation recipients who develop cardiac valvulopathy

Front 7

Why is abx prophylaxis within 6 mo of repaired congenital heart defects necessary prior to dental procedures?

Back 7

because endothelialization of prosthetic material occurs within 6 mo. of procedure

Front 8

What is preferred SBE prophylaxis in a pt not allergic to PCN?

Back 8

amoxicillin

Front 9

What is preferred SBE prophylaxis in a pt allergic to PCN/ampicillin?

Back 9

cephalexin, clindamycin, azithromycin, clarithromycin

Front 10

What is preferred SBE prophylaxis for a pt not allergic to PCN but unable to take oral meds?

Back 10

IV/IM ampicillin, cefazolin or ceftriaxone

Front 11

What is preferred SBE prophylaxis in pts allergic to PCN/ampicillin and unable to take PO meds?

Back 11

IM/IV cefazolin, ceftriaxone or clindamycin

Front 12

When is SBE prophylaxis given?

Back 12

single dose 30-60 min before procedure

Front 13

______ should not be used in an individual w history of anaphylaxis, angioedema, or urticaria w PCN/ampicillin.

Back 13

cephalosporins

Front 14

Left to right shunt, incr pulm blood flow, pulm HTN, RV hypertrophy, and CHF are all characteristics of...

Back 14

acyanotic congenital heart disease

Front 15

Atrial septal defects are 2-3x more prevalent in

Back 15

females than males

Front 16

This is the communication between L and R atria, and blood enters R atria from L atria, opposite of PFO.

Back 16

atrial septal defect

Front 17

What are the classification factors for small vs large Atrial septal defect?

Back 17

small: < 0.5 cm, small shunt, usually asymptomatic

large: >/= 2 cm, incr pulm blood flow, systolic ejection murmur in 2nd ICS, afib or svt, r axis deviation on EKG, dyspnea on exertion

Front 18

In atrial septal defect, SBE prophylaxis (is/isn't) recommended.

Back 18

is not unless a concommitant valvular abnormality (MVP/MV cleft) is present

Front 19

The anesthesia goals in atrial septal defect are?

Back 19

maintain systemic blood flow to ensure no alteration of IAs

Front 20

In atrial septal defect, IV agents may be..

Back 20

diluted, but this is unlikely

Front 21

What increases the magnitude of shunt in Atrial septal defect pts?

Back 21

drugs that produce prolonged SVR increases -- avoid!

Front 22

What does high Fi02 do in atrial septal defect pts?

Back 22

decr pulm blood flow and incr L to R shunt

volatile agents decr SVR whereas pos pressure ventilation incr PVR
(both beneficial)

Front 23

In atrial septal defect pts, it is crucial to avoid entrance of ____ into circulation.

Back 23

air!

Front 24

Anesthesia Mgmt Bottom line for atrial septal defect pts?

Back 24

1. maintain SVR in normal levels
2. use volatile agents and PosPresVent during surgery
3. avoid high Fio2 - ltd to 50%
4. regional can be considered as long as SVR maintained
5. SBE prophylaxis if in doubt

Front 25

This is the most common congenital cardiac defect?

Back 25

ventricular septal defect

Front 26

Approx 70% of ventricular septal defects are located in

Back 26

membranous portion of intraventricular septum

Front 27

At the lower left sternal border, this auscultation abnormality is heard during moderate to large ventricular septal defect

Back 27

holosystolic murmur

Front 28

ventricular septal defect pts are at risk for developing

Back 28

infective endocarditis

Front 29

Is SBE prophylaxis indicated in ventricular septal defect?

Back 29

yessiree

Front 30

Are inhaled and injected drug pharmacokinetics altered in ventricular septal defect?

Back 30

nope

Front 31

Acute or persistent incr in _____ or decr in ______ should be avoided in ventricular septal defect pts. These chnges can increase the magnitude of left to right shunting, like in ASD.

Back 31

SVR, PVR
these changes are likely w incr Fi02

Front 32

Are pos pressure ventilation and IAs tolerated in ventricular septal defect pts?

Back 32

yep

monitor induction effects on SVR (IAs especially)

Front 33

It is important to avoid (hypo/hyper)volemia in ventricular septal defect pts.

Back 33

hypovolemia

aggressively replace blood loss!

Front 34

____ pts have similar surgical mgmt as ventricular septal defect pts. SBE prophylaxis should _____ be provided.

Back 34

ASD, always

Front 35

This is present when the ductus arteriosus fails to close spontaneously after birth.

Back 35

patent ductus arteriosus

Front 36

Most patent ductus arteriosus pts are asymptomatic, but if the shunt is large, then pt will have...

Back 36

LV hypertrophy

Front 37

Neonates w patent ductus arteriosus are treated with _______ because....

Back 37

indomethacin regimen, can also use ibuprofen

want to inhibit cyclooxygenase - helps facilitate closure and surgery is indicated to repair if conservative tx fails

Front 38

Is SBE prophylaxis necessary in patent ductus arteriosus?

Back 38

yep

Front 39

What do decreases in SVR and positive pressure ventilation do to help in patent ductus arteriosus pts?

Back 39

improve systemic blood flow and increase PVR and decr L to R shunt

Front 40

In patent ductus arteriosus pts, it is crucial to avoid entrance of _____ into the pt.

Back 40

air into IV!

Front 41

Are IAs and PPV well tolerated in patent ductus arteriosus pts?

Back 41

yep

Front 42

Bicuspid aortic valves occur in ____% of the US population, and usually remains asymptomatic until ____.

Back 42

2-3%, adulthood

Front 43

Aortic stenosis is associated with a _____ heart sound audible over the 2nd ICS.

Back 43

systolic murmur

Front 44

What are the EKG and CXR findings in aortic stenosis?

Back 44

ST depression during exercise, LV hypertrophy

Front 45

Aortic stenosis leads to a _____ aortic valve and ____ wall of LV.

Back 45

narrowed, thickened/hypertrophic

Front 46

In aortic stenosis pts, it is crucial to maintain NSR because LV is dependent on...

Back 46

properly timed atrial contractions to ensure optimal LV filling and SV.

Front 47

In aortic stenosis, it is important to avoid prolonged or extreme alterations in what values?

Back 47

HR, SVR, IVFs

Front 48

In aortic stenosis pts, general anesthesia is preferred to regional in order to avoid

Back 48

sympathectomy

carefully titrate IAs to ensure no signifcant drop in BP; may use TIVA/N20/Opiate cocktail

Front 49

Is SBE prophylaxis indicated for aortic stenosis pts?

Back 49

yes!

Front 50

_____ produces obstruction to R ventricle outflow and is identified by a loud systolic ejection murmur at the L 2nd ICS.

Back 50

pulmonic stenosis

Front 51

Side effects of pulmonic stenosis:

Back 51

dyspnea on exertion, peripheral edema, ascites

Front 52

What happens when there is a patent foramen ovale in the presence of pulmonic stenosis?

Back 52

R to L shunting can occur -> cyanosis and clubbing due to bypass of pulm circulation

Front 53

The goal of managing pulmonic stenosis pts under anesthesia is to avoid....

Back 53

RV oxygen demand increase.

Front 54

How do you decrease RV oxygen demand increase for better anesthesia outcomes in pts w pulmonic stenosis?

Back 54

-avoid incr HR and contractility
-pos pressure vent well tolerated (impact of changes in PVR minimized by presence of fixed obstruction in pulm valve)
- aggressively treat decr BP w sympathomimetic drugs (phenylephrine-works quicker)
- aggressively treat dysrhythmias

Front 55

Which is better tolerated in pulmonic stenosis pts, general or regional anesthesia?

Back 55

general

Front 56

This heart defect arises from diaphragm-like ridge that extends into aortic lumen just distal to the left subclavian artery.

Back 56

coarctation of the aorta

Front 57

In pts w coarctation of the aorta, most adults are asymptomatic until the defect is detected during this part of physical exam?

Back 57

systemic HTN is detected in arms w diminished or absent femoral pulses

Front 58

coarctation of the aorta results in what heart sound on auscultation?

Back 58

harsh systolic murmur along L sternal border in back

Front 59

What does Ekg reveal in coarctation of the aorta pts?

Back 59

LV hypertrophy

Front 60

What are the complications of coarctation of the aorta?

Back 60

- HTN
- LV failure
- aortic dissection
- ischemic heart disease
- infective endocarditis
- CVA

Front 61

During surgical resection of coarctation of the aorta, what are important parts of monitoring strategy?

Back 61

-continuous BP monitoring on both upper and lower extrem
-monitor propensity of systemic HTN during cross-clamping of aorta (use nitroprusside infusion prn, assess renal and spinal cord perfusion)
-assess for neuro ischemic injury (SSEP)
-careful I/O, urine output

Front 62

Is SBE prophylaxis indicated in coarctation of the aorta?

Back 62

yes

Front 63

What are anesthesia post op concerns for coarctation of the aorta?

Back 63

watch for paradoxical HTN, use nipride to treat with or without esmolol

Front 64

Which is indicated as better technique for coarctation of the aorta, general or regional anesthesia?

Back 64

general - monitor for systemic hypo/hypertension
opioids for pain control
careful titration of vasodilators during

Front 65

What are the characteristics of cyanotic congenital heart disease?

Back 65

R to L intracardiac shunt,
decr pulm blood flow, arterial hypoxemia, erythrocytosis (HCT >70%, coag defects due to Vit K dependent clotting factors and defective platelet aggregation), brain abcess (due to hypoxic brain, mimics stroke)

Front 66

Most pts w tetralogy of fallot are _____ From birth.

Back 66

cyanotic

Front 67

What heart sounds accompany tetralogy of fallot?

Back 67

ejection murmur along L sternal border

Front 68

What does a SP02 reading demonstrate in tetralogy of fallot?

Back 68

low even when 100% Fi02 admin

Front 69

Is SBE prophylaxis indicated in tetralogy of fallot?

Back 69

YEP

Front 70

What are the characteristics of compensatory erythropoiesis in tetralogy of fallot pts?

Back 70

- hyperviscosity
- risk for CVA/cerebral abcess
- risk for infective endocarditis - SBE proph.

Front 71

____ is a common positioning feature in tetralogy of fallot.

Back 71

squatting!

Front 72

This is the sudden onset of arterial hypoxemia in tetralogy of fallot pts.

Back 72

hypercyanotic attacks

Front 73

What is treatment for hypercyanotic attacks in tetralogy of fallot pts?

Back 73

beta adrenergic antagonists to alleviate spasm to pulm outflow tract (esmolol, propranolol)

Front 74

What are the 4 features of tetralogy of fallot?

Back 74

1. VSD
2. pulm stenosis (many levels of obstruction from RV to lungs)
3. overriding aorta (lies directly over VSD and RV)
4. thickened RV muscle

Front 75

It is important to avoid increased R to L shunting in tetralogy of fallot pts because....

Back 75

increase in shunt results in decrease in pulm blood flow and PaO2.

Front 76

What actions increase R to L shunting magnitude in tetralogy of fallot pts?

Back 76

pulm blood flow is relatively fixed and inversely proportional to SVR (decr SVR, incr PVR, incr myocardial contractility)

Front 77

SVR can be decr in tetralogy of fallot pts by

Back 77

IAs, opioids, histamine release, ganglionic blockade, alpha adrenergic agents

Front 78

Pulm blood flow can be decr in tetralogy of fallot pts by

Back 78

pos pressure ventillation (but risk of hypoxemia outweighs risk of not using PPV), PEEP

Front 79

Preop considerations for tetralogy of fallot pts?

Back 79

- avoid dehydration (oral feedings)
- avoid crying (IM injections, IV starts)
- continue beta adrenergic antagonists until induction
- SBE prophylaxis

Front 80

Induction technique for pts w tetralogy of fallot?

Back 80

-ketamine 3-4 mg/kg IM or 1-2 mg/kg IV (incr SVR and pulm blood flow)
-for intubation, avoid histamine releasing NMB (Atracurium), use pancuronium if ketamine not used
- IA: sevo may lower SVR significantly, halothane preferred bc decr contractility and maintains SVR to greater degree

Front 81

What are maintenance strategies for pts w tetralogy of fallot?

Back 81

- N20 and ketamine to preserve SVR, (N20 may incr PVR but offset by positive effect on SVR)
-N20 disadvantage is reduction of Fi02 w/ its use
- pancuronium is preferred NMB
- controlled ventillation preferred

Front 82

This congenital heart defect occurs w L to R intracardiac shunt reversed through an ASD or VSD when the blood flow through the pulm bed equals or exceeds SVR.

Back 82

eisenmenger's syndrome

Front 83

This congenital heart defect manifests w cyanosis and decr exercise tolerance w/ palpitations. Also characterized by afib or flutter, visual disturbance, headache, dizzy, paresthesias.

Back 83

eisenmenger's syndrome

Front 84

This congenital heart defect is associated w an incr risk of CVA, brain abcess, pulm infarction, incr blood viscosity from erythrocytosis, and RV hypertrophy.

Back 84

eisenmenger's syndrome

Front 85

______ is characterized by a reversal of a L to R shunt into a R to L shunt caused by incr PVR to a level equal or exceeding SVR.

Back 85

eisenmenger's syndrome

Front 86

In eisenmenger's syndrome, it is important to maintain preop levels of ____ and recognize that sudden incr in R to L shunt will occur if a sudden drop in ____ occurs.

Back 86

SVR, SVR

Front 87

What gtt is commonly used to maintain SVR in eisenmenger's syndrome pts?

Back 87

phenylephrine gtt

Front 88

It is important to avoid hypovolemia and paradoxical embolization in eisenmenger's syndrome, and _________may be indicated if HCT > 65%.

Back 88

prophylactic phlebotomy

Front 89

Laparoscopic procedures are routinely contraindicated in eisenmenger's syndrome pts because

Back 89

insufflations of peritoneal cavity w CO2 may precipitate acidosis, hypotension and dysrhythmias.

Front 90

Which anesthesia technique is preferred in eisenmenger's syndrome?

Back 90

general preferred over regional, early tracheal intubation desirable

Front 91

If you have to give an eisenmenger's syndrome pt an epidural, it is best to use a local anesthetic solution that doesn't contain _______ because....

Back 91

epinephrine,

can exaggerate decr in SVR (catecholamine release)

Front 92

______ entails a failure of the truncus arteriosus to spiral, resulting in the aorta arising from the anterior portion of the RV and the pulm artery arising from the LV. There is complete separation of the _____ and ____ circulations.

Back 92

transposition of the great arteries,
pulmonary and systemic circ.

Front 93

Survival is only possible in transposition of the great arteries if...

Back 93

there i sa communication between the 2 circulations in the form of a VSD, ASD, or PDA.

Front 94

______ at birth are often present w transposition of the great arteries.

Back 94

cyanosis, tachypnea, CHF

Front 95

CHF in transposition of the great arteries pts results from

Back 95

LV failure due to volume overload created by L to R shunt created for survival.

Front 96

What is the required treatment for transposition of the great arteries?

Back 96

surgical correction

Front 97

During repair of transposition of the great arteries, infusion of _____ is necessary to maintain patency of ductus arteriosus.

Back 97

prostaglandin E

Front 98

Admin of O2 in transposition of the great arteries helps to decrease _____.

Back 98

PVR.

Front 99

____ and ____ are drugs of choice to treat the CHF associated with transposition of the great arteries.

Back 99

diuretics and digoxin

Front 100

It is crucial that the anesthetist take into account the separation of ______ in caring for pts w transposition of the great arteries.

Back 100

pulm and systemic circulations

Front 101

How are drug doses titrated for pts w transposition of the great arteries?

Back 101

decr doses because of minimal dilution to heart and brain

Front 102

How are IAs affected by transposition of the great arteries?

Back 102

may be delayed, only small amt of inhaled drug reaches circulation

Front 103

What are the induction and maintenance techniques in transposition of the great arteries?

Back 103

- ketamine 1-2 mg/kg IV w NMB for intubation
- maint w ketamine 0.25-0.5 mg/kg/hr w opioids and benzos
- avoid dehydration (careful I/O)
- limited use of N20 due to high need for Fi02 concentration