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Test deck name 1 Flashcards

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1
Q

______ blood is drained from the ____ side of the heart via a cannula in the ____ atrium and vena cava and carried by tubing to a reservoir > the main pump (centrifugal or roller) propels the blood to the oxygenator and a heat exchanger > oxygenated blood passes through an ____ filter before returning to the arterial circulation via a cannula in the ______ aorta to perfuse the rest of the body

A

Venous (deoxygenated blood) is drained from the right side of the heart via a cannula in the right atrium and vena cava and carried by tubing to a reservoir  the main pump (centrifugal or roller) propels the blood to the oxygenator and a heat exchanger  oxygenated blood passes through an arterial filter before returning to the arterial circulation via a cannula in the ascending aorta to perfuse the rest of the body

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2
Q

Which is better the Roller Pump or Centrifugal Pump?

A

Centrifugal because it is less traumatic to the formed elements of blood## Footnote♥ Maintains systemic circulation♥ All pump types are hemolytic to some degree Hemolysis increases logarithmically over time.centrifugal pump is nonocclusive - it uses gravity and spins the blood through a cone.* This is less traumatic to blood cells.* Since a centrifugal pump can’t produce excessive negative pressure, it tends not to entrain air, thus reducing the risk of air embolism.* Additionally, this type of pump is unable to produce excessively high positive pressure, so pump flow decreases when it is confronted by excessive afterload. This reduces the risk of line rupture if the arterial inflow line is clamped.* For all of these reasons, a centrifugal pump is preferred over a roller pump.* One disadvantage of the centrifugal configuration is the lack of an occlusion point. If there is an excessively high afterload, blood backs up towards the venous circulation, which reduces the patient’s circulating blood volume.

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3
Q

CPB – Venous Reservoir

A

CBP is initiated when the perfusionist removes the clamp that occludes the venous line tubingBlood drains from the patient to the reservoir by gravityRate of venous drainage is determined by size and placement of the drainVacuum-Assisted Venous Drainage (VAVD) can be added to reservoir -40 mmHg causes less hemolysis than -80 mmHg

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4
Q

What is the Centrifuge Pump?

A

Magnetically controlled impeller that rotates rapidly, creating a pressure drop that causes blood to be sucked into the housing and ejectedFlow varies with preload and afterloadLess traumatic to blood cellsDisadvantage: lack of occlusion point, if there is excessively high afterload, blood backs up towards venous circulation > reduces patients circulating blood volume

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5
Q

What is the danger of a Roller Pump?

A

Compresses blood tubing, which creates an occlusion point as it mechanically propels blood forwardConstant non-pulsatile blood is producedPump flow remains constant regardless of patient’s afterload or arterial resistance in the circuitTraumatic to blood cells

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6
Q

What is the function of the Oxygenator?

A

Historically bubble oxygenators were usedUsed oil:gas interface (no membrane)Carried risk of cerebral air embolismMembrane oxygenators used todayTightly wound fibers create a large surface area for blood to flow throughO2 level in blood can be controlled by changing FiO2CO2 level controlled by changing the liter gas flow rate (sweep) of gas through oxygenatorVolatile anesthetics added to the fresh gas inlet## FootnoteThe oxygenator is the component of the CPB machine where gas exchange occurs (it replaces the lungs).* A membrane oxygenator uses a blood-membrane-gas interface. It’s more expensive, but it’s safer.* A bubble oxygenator uses a blood-gas interface (no membrane). This architecture carries a risk of cerebral air embolism, which explains why a membrane oxygenator is preferred.

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7
Q

What is the function of the Heater Cooler?

A

Blood flows around tubes that are heated or cooled to achieve desired patient temperature levelPts can be actively cooled to reduced metabolic rate or temperature can naturally drift while surgery is performedActive rewarming takes place in preparation or the termination of CPB

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8
Q

What does the Cell Saver wash the RBC’s to a Hematocrit of?

A

HCT 50 - 75% (60-75%)♥ Even though RBC’s are saved and returned toincrease patient’s Hct,all other formedelements of the patient’s blood are “washed” off especially clottingfactors. End result is potential bleeding problems with massive blood loss

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9
Q

What does priming the circuit with anything other than blood products cause?

A

↓ hematocrit ↓ oxygen-carrying capacity* ↓ blood viscosity (good if hypothermia is used)* ↓ plasma concentration of drugs and plasma proteins* ↑ microvascular flow (due to reduced viscosity)

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10
Q

Know this

A
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11
Q

What is the preferred type of oxygenator?

A

Membrane oxygenator. It’s safer than a bubble oxygenator.

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12
Q

What can happen if air enters the venous line of the CPB circuit?

A

Airlock

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13
Q

What issues can arise during aortic cannulation? What should the BP be?

A
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14
Q

What is antegrade Cardioplegia?

A

Anterograde CardioplegiaDelivered down coronary arteriesCatheter inserted into the aortic root, just proximal to aortic clampFlows anterograde down the coronary arteriesHypothermia diastolic cardiac arrest usually follows in 1-2 minutes depending on how well the heart is perfusedIncompetent AV allows solution to leak into the LV

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15
Q

What is Retreograde Cardioplegia?

A

Delivered via coronary sinus and cardiac veinsCatheter blindly inserted into the right atrium and advances to the coronary sinusSurgeon may lift the heart to help locate the sinus  watch for dysrhythmias and hypotension

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16
Q

How does Potassium arrest the heart?

A
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17
Q

What are some key points?

A
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18
Q

How do you reverse Heparin after bypass?

A
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19
Q

What are two antifibrinolytics commonly used during cardiac surgery?

A

TXAAminocaproic AcidAntifibrinolytics Reduced surgical bleeding and decreases the incidence of blood transfusionAminocaproic acid (Amicar) and Tranexamic acid (TXA)Both form a reversible complex with plasmin that then inhibit fibrinolysisAmicar50mg/kg bolus over 20-30 min followed by infusion of 25mg/kg At Hamot – 5 gram bolus over 60 min followed by 5 gram over 5 hoursTXA10mg/kg over 20 min followed by 1-2 mg/kg maintenance throughout procedure

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20
Q

When is the most common time of patient awareness during cardiac surgery? Why?Should you deepen anesthetic and add additional paralytic?

A

SternotomyLungs deflated during sternotomy to decrease risk of cardiac or pulmonary laceration. Therefore, someone is not receiving volatile gas at that time.YesIncision to bypass periodIncision, sternotomy, & sternal spread > deepen anesthetic and administer additional paralytic if neededHighest rate of recall during cardiac surgery is during sternotomy

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21
Q

What should the ACT Be above before initiating CPB?

A

400 Seconds

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22
Q

THe SBP should be below what value before aortic cannulation?

A

90 - 100 mmHg## FootnoteBefore aortic cannulation, SBP is decreased to 90-100 mmHg or MAP <70 mmHg to decrease risk of aortic dissectionDeepen anesthetic level or use vasodilators

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23
Q

What is a contraindication to antegrade cardioplegia?

A

Incompetenet Aortic Valve

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24
Q

Blood flow during total cardiopulmonary bypass is:a. virtually non-pulsatileb. half the normal blood flowc. not adjustabled. a pulsatile flow

A

a. virtually non-pulsatile

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25
Protamine is given at the end of the case to reverse heparin. How is protamine administered?a. Fast IVPb. Slow IVPc. We don't give protamine to reverse heparind. It doesn't matter how it's administered
b. Slow IVP
26
Where is the antegrade cardioplegia line placed?a. Left atriumb. Aortic rootc. Cardiac veinsd. Coronary sinus
b. Aortic root
27
How is the heart arrested during cardiopulmonary bypass surgery?a.By infusing warm cardioplegia solution containing sodiumb. By infusing cold cardioplegia solution containing potassiumc. By infusing warm cardioplegia solution containing potassiumd. By infusing cold cardioplegia solution containing sodium
b. By infusing cold cardioplegia solution containing potassium
28
What is the hematocrit of the blood returned to the patient from a cell saver?a. 20-30%b. 50-75%c. >80%d. 30-45%
b. 50-75%
29
What phase is the Arterial Filter?
Final phase of CPBBlood passes through arterial filter before returning to the arterial cannula and the rest of the bodyPore size of 21-40 mcm and acts as an air bubble trap and particulate filter Preventing thrombi, fat globules, calcium and tissue debris from entering circulationMost often placed in ascending aorta
30
What is a Cardiotomy?
portion of the venous reservoir that has a separate filter and defoams blood and removes air and debris picked up by suction tip (“pump sucker”)Pump sucker is used in the surgical field or vents to drain the heart
31
What is the LV Vent?
LV Vent – Catheter placed in the LV through the right superior pulmonary veinSmall amounts of blood may enter the LV from bronchial arteries or the Thesbian vesselsAortic Insufficiency - If the patient has AI, blood and cardioplegia can backflow and fill the LV  the excess volume can cause the LV to distend, raise LVEDP, and compromise preservation by opposing the cardioplegia flow
32
What is a Cardiotomy?
portion of the venous reservoir that has a separate filter and defoams blood and removes air and debris picked up by suction tip (“pump sucker”)Pump sucker is used in the surgical field or vents to drain the heartA “basket” type suction device can be placed in an open cariac cavity to help drain the blood. This catiotomy portion of the blood can then be returned to the patient in one of 2 ways. First, the blood can be returned to a portion of the venous reservoir known as the cardiotomy. - Has a filter than can defoam the blood and remove air/debris from pump sucker. Blood returned via cardiotomy may contain fat, bone, and other debris. This is why many surgeons prefer cell-saver.Cell-savaged blood is later centrifuged, washed and returned to the patient.Research shows that systemic inflammatory markers decrease when shed blood is not returned to the patient undergoing CABG on CPB
33
Where do the Bronchial Arteries arise from?
Bronchial arteries arise directly from aorta or intercoastal arteries
34
What are the Thesbian veins and where do they drain?
Thesbian vessels – coronary veins that drain directly into the heart
35
What is the preferred anticoag for cardiac surgery?
Heparin preferred anticoagulant for cardiac surgery
36
What is the MOA of Heparin?
Heparin potentiates circulating antithrombin (AT III) by binding to AT III and thrombinIncreases the speed of the reaction between multiple clotting factors
37
What is the standard Cardiac Dose of Heparin?
300 - 400 units/kg
38
What increments are ACTs ran?
Baseline ACT obtained prior to heparin, 3-5 minutes after administration, and every 20-30 min during bypass
39
What does your ACT need to be to start CPB?
ACT level of more than 400 to initiate CPBRevered with protamine
40
What is a normal ACT?
80 - 120 seconds
41
People who have been recently exposed to Heparin may be resistant and require a higher dose. What is the definition of "Heparin Resistant"?
Defined as ACT <480 seconds despite admin of 400-500 units/kg IV heparin
42
What deficiency should be expected if the patient does not become anticoagulated with additional Heparin?
Antithrombin III deficiency should be expected if patient does not become anticoagulated after additional heparin admin
43
How do you treat Heparin Resistance?
Treated with 2 units FFP, AT III concentrate, or recombinant AT III
44
Can you put an icy slush around the heart?
Yep
45
Cardioplegia – hyperkalemia crystalloid solution mixed with bloodTypically cold (2-5°C)Induction dose contains 20-30 mEq/L potassiumMaintenance doses 12-16 mEq/L potassiumReadministered every 15-20 minutes while aorta is clampedGoal is to achieve hypothermic diastolic circulatory arrest to decrease the metabolic rate, O2 consumption, and excitatory neurotransmitter release and to preserve high energy phosphates substratesBrain  cerebral metabolic rate decreases 6-7% for every degree Celsius decrease in brain temperature
46
Do you arrest the heart in systole or diastole?
Diastole - the heart relaxes after contractionDuring diastole, with low LVEDP, myocardial oxygen consumption and energy substrate utilization are minimized. Rapid attainment of diastolic cardiac arrest at the onset of ischemic period is important and protection is further enhanced if the myocardium is simultaneously cooled.
47
Cardioplegia Contains high doses of which lyte?What is the normal temperature?What is the maintenance dose of Potassium? How often is it readministered?What are the goals? (4)How much does the Cerebral Metabolic rate decrease for every degree Celsius the brain temperature drops?
Cardioplegia – hyperkalemia crystalloid solution mixed with bloodTypically cold (2-5°C)Induction dose contains 20-30 mEq/L potassiumMaintenance doses 12-16 mEq/L potassiumReadministered every 15-20 minutes while aorta is clampedGoal is to achieve hypothermic diastolic circulatory arrest to decrease the metabolic rate, O2 consumption, and excitatory neurotransmitter release and to preserve high energy phosphates substratesBrain  cerebral metabolic rate decreases 6-7% for every degree Celsius decrease in brain temperature
48
Is the first dose of Cardioplegia solution given Anterograde or Retreograde?
First dose of cardioplegia usually given anterograde just after placement of the aortic clamp
49
What rammifications does an incompetent AV Valve have towards myocardial preservation?
Incompetent AV valve and myocardial preservation is inadequate, there may be difficulty achieving diastolic arrest and electrical activity may reappear on the ECG between doses of cardioplegia.
50
What happens with fluid leaks back in the LV?
Additionally, fluid that leaks back into the LV when the patient has AR can cause the ventricle to distend > opposing the anterograde flow of cardioplegia > increasing risk of ischemia. > purpose of the LV vent is to suction out this fluid and prevent distention.
51
What percentage of the nation's blood supply is used in cardiac surgery?How do blood transfusions impact short and long term survival rates?
10-15% of the nations blood supply is used in cardiac surgeryBlood transfusions during cardiac surgery are associated with worse short-term and long-term survival
52
What is Blood Salvage?
Blood SalvageSuctioned from surgical field or residual blood that remains in the CPB circuit at the end of bypassBlood is “washed,” a process that removes the serum, coagulation factors, and plateletsBlood is then placed and in bag and infused into the patientCell-savaged blood has a hematocrit of approx. 55-70%Infusing large quantities of salvaged blood can contribute to dilutional coagulopathy because this blood is devoid of coagulation factors and platelets
53
What is Retrograde Autologus Priming (RAP)?
Traditionally, adding pump prime to the patient blood volume at the beginning of CPB resulted in significant hemodilutionRAP is a technique in with CPB prime is displaced by passive exsanguination (back-bleeding) through the arterial and venous lines back into an empty bag that is out of the main circuit, prior to the start of CPBRAP significantly reduces allogenic blood transfusions for adult cardiac surgery patients requiring CPB
54
Why does CPB cause a systemic inflammatory response?
SIRS is thought to be activated as a result of CPB when the blood is exposed to the foreign surfaces of the CPB machineCPB causes a systemic inflammatory response syndrome that potentially can impact every organ systemHeart, brain, lungs, gastrointestinal, and coagulation are all at risk for negative impactIschemia reperfusion injury or embolization may occur and cause the release of endotoxins. Endothelial damage occurs, cellular immune response is activated, as well as compliment and coagulation cascade. When CPB is initiated, the body experiences a marked stress response: cortisol, catecholamines, arginine vasopressin, and angiotensin levels are elevated. Large amounts of O2 free radicals are produced.
55
What should the ECG Monitor be set up to?
ECG monitoring should include lead II and V4 or V5 with automated ST analysis for detection of ischemia. Classically, V5 has been identified as the most sensitive single lead for detecting periop ischemia but newer evidence is suggesting V4 has greater sensitivity. Usefulness of 5 lead ECG during cardiac surgery is limited because much of the anterior/posterior wall ischemia can not be detected. TEE more sensitive for detection of ischemia than ECG.
56
Is an Arterial Line put in before or after induction?
Typically, A-line prior to induction using sedation and local anesthetic. Pre-induction A-line is crucial when patient has life-threatening cardiac pathology (severe AS, left main CAD, severe pulmonary HTH, moderately to severe left or right ventricular dysfunction). Radial artery (most often from non-dominant hand) is harvest as a conduit for the CABG  A-line must be placed in on opposite arm or in the ipsilateral brachial artery proximal to the AC.
57
What is the perferred cannulation site for a central line?
Central venous access, right IJ preferred cannulation site because it is relatively easy to access and provides a straight course to the RA. If left IJ is used, careful to avoid the thoracic duct and left brachiocephalic vein.
58
What ist he most sensitive clinical monitor for detecting wall motion abnormalities?
TEE – Most sensitive clinical monitor for detecting wall motion abnormalities caused by myocardial ischemia. Absolute contraindications to TEE include pathologic conditions of the esophagus, including strictures, diverticula, tumors, traumatic interruption, or recent suture line.
59
Should you use Desflurane?
Desflurane should not be used > sudden increase in inspired concentration can lead to tachycardia and hypertension (detrimental to patient with severe CAD, hypertrophic cardiomyopathy, or stenotic lesions)
60
Des and N20 Raise what three things?
Des and N2O raise PVR, PA pressure, and wedge pressure
61
Why is nitrous avoided before, during and after CPB?
Avoid nitrous just before, during and after CPB because of the potential for expansion of air introduced into the circuit
62
What is Anesthetic Preconditioning?
Anesthetic pre-conditioning refers to the phenomenon whereby exposure of the heart to a volatile anesthetic before myocardial ischemia results in protection against the deleterious effects of myocardial ischemia and reperfusion
63
Are Volatile Anesthetics or TIVA preferred for CABG?
Volatile anesthetics can potentially cause myocardial depression, vasodilation and hypotension. However, meta-analysis demonstrated that including halogenated agents is associated with a better outcome after cardiac surgery than TIVA technique. Most cardiac surgical patients will benefit from the myocardial protection of volatile anesthetics, the exception may be those with severe LV dysfunction who can not tolerate further cardiac depression.
64
Opioids cause mycordial depression and unstable hemodynamics?T/F
FOpioids – do not cause myocardial depression and maintain stable hemodynamics
65
When should you use Etomidate over Propofol for induction?
Etomidate for a more stable hemodynamic profile
66
What is the ABX of choice?
Antibiotic Prophylaxis – B-lactam is abx of choice (class 1A) for cardiac surgical patients who are not at increased risk of MRSARe-dose q3-4 hours while incision is openGive within 1 hour of incisionBeta-lactam allergy  give vancomycin (as well as an aminoglycoside such as gentamycin if gram neg coverage is needed)Redosing not recommendedGive within 2 hours of incision
67
How often do you redose abx that are not Vanco?
Re-dose q3-4 hours while incision is open
68
How long before incision do you give ABX?
Give within 1 hour of incisionVANCO Give within two hours of incision
69
What is the danger of a REDO CABG?
Re-do sternotomy/previous CABG > Heart may be adherent to the sternum > arterial or venous bypass graft may be directly beneath sternumRare for cardiac structure or vessel to be damage, but if so, and bleeding becomes uncontrollable, IV heparin (300-400 units/kg) administered emergently, and patient will be emergently cannulated PRBCs should be readily available in all redo sternotomies
70
What vessel is harvested after sternotomy if it is a CABG?
Left internal mammary artery (LIMA)Often requires manipulation of the heart that results in hypotension and dysrhythmiasTrendelenburg position or small doses of phenylephrineSurgeon will ask for lungs to be deflated to improve surgical view LIMA to LAD LIMA runs from the left collar bone area down the chest wall. LAD (commonly responsible for windowmaker blockage). LIMA is taken down and attached beyond the blockageLIMA is gold standard for LAD, excellent long-term patency (90-95% at 15 years)
71
What are the complications of aortic cannulation?
arterial dissection, hemorrhage, plaque or air embolism, inadvertent placement of distal tip of the cannula in an aortic arch vessel
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