1
Q
How many total lung segments are there and how are they divided?
A
42 total, 22 on the right, 20 on the left
2
Q
How are the lobes divided between the lungs
A
3 for the right, 2 for the left
3
Q
What is the difference between FEV1 and FEV1%?
A
FEV1 is the amount expired by a patient in 1 second, FEV1% compares the actual FEV1 to the average FEV1 of person of similar gender/height/age
4
Q
What is a normal FEV1% predicted?
A
80 to 120%
5
Q
T/F: FEV1 is strongly correlated with post-op outcomes?
A
True-ish, the FEV1% predicted is the actual sensitive value, though since FEV1 is just compared to FEV1% you can argue FEV1 is just as sensitive once you compare it to averaged values
6
Q
What is the formula to predict post-op FEV1 s/p removal of lung tissue?
A
Pre-op FEV1% x (1 - percentage lung tissue removed / 100)
7
Q
What PPO FEV1 has increased risk of pulmonary complications?
A
Less than 40%
8
Q
What PPO FEV1 has very high risk of post op complications?
A
Less than 30%
9
Q
What PaO2 and PCO2 are associated with poor surgical outcomes?
A
PaO2 less than 60
PCO2 greater than 45
10
Q
What PFT can be affected by chemotherapy?
A
DLCO - diffusing lung capacity for CO
11
Q
What is the minimum value for FEV1 that predicts a successful thoracic surgery? DLCO?
A
Both values that are less than 20% is the lowest they can be
12
Q
With a DLCO test, if the lungs are functioning well, and the perfusion is normal, what changes would you expect on expired CO?
A
Less CO would be detected
conversely, if the lungs/perfusion are impaired less CO will be absorbed and more would be expired/detected
13
Q
PA > Pa > Pv reflects what West zone?
A
Zone 1
14
Q
Pa > PA > Pv reflects what West zone?
A
Zone 2
15
Q
Pa > Pv > PA reflects what West zone?
A
Zone 3
16
Q
T/F: blood flow is gravity dependent
A
True
17
Q
T/F: Pa is always greater than Pv
A
True (look at west zone diagrams, the Pa is always greater than Pv)
18
Q
How does the absolute pressure of Pa and Pv compare in the dependent portion of the lung relative to the non-dependent?
A
The absolute pressure is greater in the dependent portion of the lung due to hydrostatic gradients
19
Q
How much of an increase in blood flow/pressure does the base of the lung receive relative to the apex?
A
~20 mmHg increase if the patient is upright
20
Q
What West zone experiences pulsatile flow?
A
Zone 2
21
Q
What West zone has the most compliant alveoli?
A
Zone 3 - combination of less distended alveoli and greater intrapleural pressure
22
Q
What is another term for V/Q mismatch in zone 1?
A
Dead space
23
Q
T/F: zone 1 occurs in healthy patients
A
False; only occurs during PPV or hemorrhage/shock/extreme hypovolemia
24
Q
Describe blood flow in West zone 2
A
Pulsatile; there is flow during systole, no flow during diastole (Because now PA is greater than Pa during diastole)
25
In what zone is a PCWP most accurate?
Zone 3 - because there is a continual column of blood
26
Describe how: FVC, FEV1, FEV1/FVC ratio and TLC change in an obstructive pathology
FVC - decreased or normal
FEV1 - decreased
FEV1 / FVC - decreased
TLC - increased or normal
27
Describe how: FVC, FEV1, FEV1/FVC ratio and TLC change in an restrictive pathology
FVC - decreased
FEV1 - normal or decreased
FEV1/FVC - increased
TLC - decreased
28
Cystic fibrosis is an example of what lung pathology?
Obstructive
29
Decreased area for gas exchange, air-trapping and hyperinflation of lungs are hallmarks of what?
COPD - Abnormal, permanent enlargement of the airspaces & destruction of alveoli
30
What are some examples of RLD?
Interstitial lung disease
Pulmonary fibrosis
Sarcoidosis
Obesity (hypoventilation syndrome)
R/t neuromuscular diseases
31
List some of the common characteristics of small cell lung cancer
Fast growing, aggressive, commonly caused by smoking, usually starts in bronchi and frequently metastasizes
32
List some common characteristics of non-small cell lung cancer
Less aggressive, affects both smokers and non-smokers, more common with a better prognosis
33
How is lung cancer commonly diagnosed?
Central/endo-bronchial lesions
Cytology analysis of sputum
Flexible fiberoptic bronchoscopy
Peripheral/pleural lesions
CT scan
Percutaneous fine needle aspirate
VATS
34
What type of lung cancer is radiosensitive?
Small cell lung cancer
35
Why is surgical resection controversial if the disease has spread to lymph nodes or other distal sites?
Because it has little effect on survival
36
What lung procedure is used to obliterate the pleural space to prevent recurrence of fluid, pus, or blood build up?
Pleurodesis
37
What approach is most common for thoracic surgery?
Anterolateral
38
How many cm above the heart is zone 2 found?
~ 3 cm
39
What are 3 indications for VATS?
Pleural surgery
Undiagnosed nodules
Interstitial disease
40
T/F: A lobectomy is generally not carried out via VATS
False
41
What are the advantages of VATS?
Reduced hospital stay
Less blood loss
Less pain……
Ribs are not separated and retracted!
Better postoperative pulmonary function
May be done robotically (more and more common)
42
What is the difference between lung isolation vs separation?
Separation = ADEQUATE deflation
Isolation = COMPLETE deflation
43
What orientation is most common for a DLT? Why?
Left DLT -> this is because the right takeoff branch from the right main bronchus occurs very quickly
44
What are some indications for a right DLT?
Right sided tube used for Left Pneumonectomy or left upper lobe/airway lesion
Distorted anatomy of left main bronchus:
Thoracic aortic aneurysm
Tumor compressing left main bronchus
45
What feature distinguishes a right DLT form a left?
Right sided tubes have an extra port to ventilate RUL
46
What size DLT is used for women?
Less than 1.5m = 32
1.5 - 1.6m = 35
Greater than 1.6m = 37
47
What size DLT is used for men?
Less than 1.6m = 37
1.6 - 1.7m = 39
Greater than 1.7 = 41
48
How many cc's of air go into each lumen of a DLT?
Tracheal = 5 - 7 ml
Bronchial = 2 - 3 ml
49
How far distal to the carina should the bronchial lumen of a DLT be?
5 - 10 mm
50
When are bronchial blockers preferentially used over a DLT?
Difficult airway
Nasal intubation + OLV required
Existing endotracheal tube or tracheostomy tube + OLV
A patient who requires OLV during surgery and is anticipated to require postoperative mechanical ventilation
51
What part do you clamp when using a DLT?
The adaptor not the tube
52
What ventilation strategy is used when ventilating only one lung?
Decrease Vt (4 - 6 ml/kg) and increase RR
53
Why is hyperoxemia generally avoided for OLV?
You can cause absorption atelectasis and coronary vasoconstriction
54
What kind of shunt generally occurs during OLV?
Right to left
55
Explain how dependent parts of a lung get more blood flow and ventilation
Due to gravity (blood flow), greater compliance (ventilation) and higher intrapleural pressure combined with smaller/more collapsed alveoli meaning they can expand more
56
What factors increase the risk for reduced ventilation of the dependent lung during lateral position + OLV?
Laying on a hard OR table
Mediastinal and abdominal pressure
57
What other phenomenon under anesthesia's direct control can shunt blood to the non-ventilated lung similarly to how atelectasis does?
Over-inflating the lung w/PP ventilation
58
At what MAC is the HPV response diminished/abolished from vasodilation?
Over 1 MAC
59
What conditions can decrease the HPV response?
Metabolic and respiratory alkalosis
Hypocapnia
Hypothermia
Hemodilution
Vasodilators
Sustained High FiO2
60
What is the primary CV concern with a recruitment manuever?
Transient hemodynamic derangements -> the massive increase in intrathoracic pressure temporarily reduces preload and BP can profoundly drop
61
What last ditch effort can be used to help treat persistent OLV induced hypoxemia?
Ligation of the pulmonary artery (now the blood has no choice but to keep going to the dependent lung)
62
What is the best predictor of a difficult DLT placement?
Pre-op CXR
63
What is the gold standard to evaluate cardiopulmonary function?
VO2-max
64
What is the average VO2 max for men/women?
Men = 30 - 40 ml/kg/min
Women = 27 - 32 ml/kg/min
65
What VO2 max is associated with increased risk? At what value is increased risk unlikely?
Increased risk = less than 15 ml/kg/min
Unlikely = greater than 20 ml/kg/min
66
How long after smoking cessation do complication rates decrease?
4 weeks
67
How long after smoking cessation does carboxy-Hgb concentrations decrease?
12 hours
68
How can small cell lung cancer cause Cushing's?
The cancer causes the body to release too much cortisol
69
What factors patient factors/co-morbidities can increase their risk during thoracic surgery?
Advanced age
Malnutrition/frail/poor general health
Chronic Obstructive Pulmonary Disease (COPD)
Pulmonary HTN
Obesity
Low FEV1
Low VO2Max/Low exercise tolerance
Dyspnea
Smoking (Risk increases with number of pack-years)
Concomitant medical conditions
70
How long should surgery be delayed with a bare metal stent?
4 - 6 weeks
71
How long should surgery be delayed with a drug eluting stent?
6 months
72
What effects does PP ventilation have on the right side of the heart?
It can increase the RV afterload, which in COPD patients can be catastrophic
73
Over time, what effects does increased PVR have on the heart?
Right heart strain or failure, especially in patients with pre-existing pulmonary hypertension or RV dysfunction
Increased oxygen demand as RV works harder
Sympathetic overdrive → worsens arrhythmia risk and myocardial workload
74
What arrhythmia is most common after thoracic surgery?
A. Fib - accounts for 60 - 70% of cases
75
What timeframe is an arrhythmia most likely to occur after thoracic surgery?
Within 7 days
76
What factors during thoracic surgery increase the risk of A. Fib occurring?
Surgical manipulation of the heart, pulmonary hilum, or vagus nerve
Inflammation and pericardial irritation
Sympathetic stimulation from pain, stress, or hypoxia
Fluid shifts and electrolyte disturbances
Hypoxemia and/or transient ischemia during one-lung ventilation (OLV)
77
For thoracic/lung cases, which side do you generally want to place the central line?
On the ipsilateral side
78
What 2 factors should be avoided in thoracic surgery to avoid ALI?
Fluid overload and hyperinflation/high ventilatory pressures
79
What blocks may help with post-op pain from thoracic surgery?
Paravertebral and/or intercostal blocks
80
What is the occurrence rate of respiratory failure s/p thoracic surgery?
15 - 20%
81
What effect does V/Q mismatch and resultant hypoxemia and hypercapnia during OLV have on the right side of the heart?
Increases RV pressure d/t increased afterload
82
What theoretical advantages does PCV have over VCV in thoracic cases?
PCV = less inflammatory
PCV = less barotrauma
PCV – lower peak pressures
*not necessarily fact, again, theoretical advantages*
83
What anesthesia method is generally preferred for a bronch?
TIVA - the circuit is frequently being opened/closed, so it can be difficult to maintain adequate depth of anesthesia w/volatiles
84
What procedure uses imaging and robotic algorithm to precisely target lung nodules for biopsy?
ION bronch or robotic bronchoscopy
85
What size ETT is generally needed for an ION bronch?
9.0
86
How does preoxygenation differ in an ION bronch case?
You use the lowest amount of oxygen possible, even preoxygenate on air rather than oxygen
87
Why do you use low FiO2 during an ION bronch?
To prevent absorption atelectasis
88
What ventilation strategy is generally used during an ION bronch?
High Vt and PEEP
89
What anesthesia strategy is generally preferred for ION bronchs?
TIVA w/paralysis
90
In LVRS surgery, what occurs after the endobronchial stents are placed?
They functionally collapse parts of the lung, creating a functional lobectomy to improve the V/Q mismatch
91
What complications can occur from a bronch?
Mechanical damage
Teeth
Lips
Tongue
Airways
Bronchospasm
May require albuterol
And/or breathing treatment post-op
Excess secretions/bleeding in airway
Suction ETT prior to extubation
It is normal for patient to cough a lot
92
What contents are generally visualized during a mediastinoscoy?
Heart/great vessels
Trachea
Esophagus
Thymus
Lymph nodes
93
What biopsies are an indication for a mediastinoscopy?
Para-tracheal lymph nodes
Para-carinal lymph nodes
94
What conditions can a mediastinoscopy diagnose?
Infection
Lymphomas
Sarcoidosis
95
What is an absolute contraindication to mediastinoscopy?
Prior mediastinoscopy -> scar tissue and distortion
96
What are relative contraindications to mediastinoscopy?
Limited cervical ROM
Thoracic aortic aneurysm (ascending or arch)
Severe tracheal displacement
History of radiation therapy to the chest
97
What are complications of mediastinoscopy?
Pneumothorax
Mediastinal hemorrhage
Venous air embolism
Recurrent laryngeal nerve damage
Compression of airway structures
(At any point in the anesthetic
Ventilation can be impossible even with positive pressure)
Obstruction of cardiac output
Compression of PA→ cardiac arrest
Superior vena cava syndrome
98
How can mediastinoscopy cause sudden/profound cardiac collapse?
Compression of the PA leading to cardiac arrest or SVC syndrome (mechanical obstruction of the SVC)
99
Where do you place an arterial line for a mediastinoscopy?
The right radial to monitor for brachiocephalic compression
100
What are common airway considerations for mediastinoscopy?
Mediastinal mass?:
Induce with patient in sitting position
Glidescope, step-stool, extra hands
Tracheobronchial compression?:
Awake intubation
Maintain spontaneous ventilation
Airway block?
SVC Syndrome?:
Be aware of potential for airway swelling/difficult airway
101
Where do you inject LA for a glossopharyngeal nerve block?
The anterior tonsillar pillar, you inject 2 mL of 2% lidocaine bilaterally
102
What sensory innervation does the glossopharyngeal nerve cover?
The posterior 1/3 tongue, vallecular, epiglottis, pharynx, gag
103
Where do you place LA for a superior laryngeal nerve block?
Needle is walked off the cornu of the hyoid and 2 ml of 2% lidocaine is injected bilaterally
104
What sensory innervation does the superior laryngeal nerve cover?
The pharynx, glottis, aryepiglottic folds
105
How do you perform trans-tracheal anesthesia?
You anesthetize the trachea/vocal cords, you locate cricothyroid membrane, aspirate for air then inject 4 mL of 2% lidocaine, ensuring you are injected slightly caudad
106
What airway blocks can be used for mediastinoscopy?
Glossopharyngeal nerve block, superior laryngeal nerve block and trans-tracheal anesthesia
107
What are 2 common indications for an esophagectomy?
Squamous cell carcinoma and adenocarcinoma
108
What are common causes of squamous cell carcinoma of the esophagus?
Smoking and excessive alcohol consumption
109
What condition can cause esophageal adenocarcinoma?
Barret's esophagus
110
Why does esophageal cancer have the ability to metastasize rapidly?
There are extensive lymph nodes surround the esophagus
111
What are the general concerns about radiation therapy in a pre-op evaluation for esophagectomy?
Lung, cardiac and airway injury are a possibility
112
What are general anesthesia considerations for an esophagectomy?
Arterial line
Pain control
Thoracic epidural
Consider CVP monitoring
Due to fluid shifts
Double lumen tube vs single?
Surgeon preference/approach
NGT
113
What are the common complications of esophagectomy?
PNA, ARDs and empyema
*Other complications include: anastomosis leak, dumping syndrome, stricture formation and an aspiration risk for life*
114
What series of events causes angina?
Partially or significantly occluded coronary artery
Release of adenosine, bradykinin, lactic acid etc.
Nociceptive receptors with afferent neurons to upper five thoracic sympathetic ganglia
Thalamic and cortical stimulation resulting in “chest pain”
115
What is the difference between stable and unstable angina?
Stable does not change in intensity/duration for a period greater than 2 months
Unstable occurs at rest or increases in severity/frequency
116
What 2 leads are most likely to detect ischemia?
II and V5
117
Why is nuclear stress imaging generally performed even if an EKG is negative for ischemia?
NSI is more sensitive than an EKG
118
What 2 ST segment patterns are more frequently associated with ischemic disease?
Downsloping and horizontal
119
What 2 EKG changes generally coincide with chest pain?
ST depression and transient T wave inversion
120
What 2 tracers are generally used in nuclear stress imaging?
Thallium and technetium
121
What tracer uptake correlates with normal circulation?
Significant uptake
*So decreased uptake indicates a perfusion abnormality*
122
What tracer uptake correlates with an old/prior MI?
Absent uptake
123
How do you produce tachycardia without exercise in nuclear imaging?
Use atropine, dobutamine and pacing to create cardiac stress
124
What 2 drugs are used in nuclear imaging w/o exercise to help measure the tracer?
Adenosine and Dipyridamole
*increased tracer = normal coronary vasodilation, decreased tracer means no dilation and arteries are likely atherosclerotic*
125
What type of plaque is most likely to rupture/occlude?
A large lipid core with a thin cover
126
Most MI's occur from rupture with what associated percentage of stenosis?
< 50%
127
What classes of drugs are used to help manage ischemic heart disease?
Anti-platelet drugs
Nitrates
B-blockers
Calcium Channel blockers
ACE inhibitors
128
T/F: ASA's MOA is irreversible for the life of a platelet
True
129
What are the 3 effects of ASA in managing ischemic heart disease?
Inhibits cyclooxygenase-1 (COX-1)
Inhibits thromboxane A2
Inhibits platelet aggregation
130
What drug is used if a patient cannot tolerate ASA?
Plavix
131
What is the MOA of Plavix?
Inhibits the P2Y12 receptor inhibiting platelet aggregation
*Like ASA, also irreversible for the life of a platelet, 80% recovery occurs at 7 days*
132
T/F: Plavix is not a prodrug
False - metabolized to active form in the liver
133
What drug class should be avoided if on Plavix?
PPIs - they inhibits the enzyme that metabolizes the prodrug into its active form
134
T/F: Prasugrel (Effient) is a prodrug
True
135
What enzyme is responsible for converting Prasugrel (Effient) and Plavix into their active forms?
CYP450
136
What are the primary advantages of Prasugrel (Effient)?
Pharmacokinetics more predictable
Rapidly absorbed
Faster onset of action
Less individual variability
*However, it is more potent….higher risk of bleeding*
137
In what conditions are nitrates contraindicated?
Hypertrophic cardiomyopathy and aortic stenosis
138
How do nitrates help improve ischemic heart disease s/sx?
They decrease PVR, decrease afterload and decrease myocardial O2 consumption
139
What 2 drug classes are nitrates synergistic with?
BBs and CCBs
140
What is the principal drug for stable angina?
BBs
141
What B-1 blockers are commonly used in ischemic heart disease?
Atenolol
Metoprolol
Bisoprolol
Acebutolol
142
What are the positive effects of BBs?
Decreases myocardial oxygen demand, increases length of diastole
143
What conditions are contraindications to BB use?
Severe bradycardia, SSS, severe reactive airways, 2nd/3rd degree heart block, uncontrolled CHF
144
What is a potential concern of BB use, particularly in diabetics?
BBs can mask hypoglycemia
145
T/F: BB use periop has the same benefit as initiating it prior to periop?
False; the main benefit is from starting it before surgery
146
What do CCBs bind to?
Binds to L-type calcium channels
147
What condition are CCBs most useful to treat?
Prinzmetal's angina
148
What are the positive effects of CCBs?
Decrease vascular smooth muscle tone, dilate coronary arteries, decrease contractility…improve supply/demand
149
What are potential negative effects of CCBs?
They can be potent vasodilators -> hypotension, peripheral edema and headaches are of concerns
150
When are ACE inhibitors indicated?
Patients with CAD that also have HTN, LV dysfunction and/or DM II
151
When are ACE inhibitors contraindicated?
Allergy, hyperkalemia and renal failure
152
Are STEMIs or NSTEMIs more common?
NSTEMI
153
What lab values peak early in an MI?
Myoglobin is the earliest, followed by total CK
154
What lab values peak later in an MI?
LDH peaks latest, troponin I and CK-MB peak earlier than LDH but later than myoglobin and total CK
155
What is the goal timeframe for thrombolytics?
Initiate within 30 - 60 minutes of hospital arrival and within 12 hours of symptom onset
156
What are contraindications to thrombolytic use?
Uncontrolled HTN, GI bleeding, recent hemorrhagic strokes, recent head trauma, suspected aortic dissection, known intracranial neoplasm
157
What is the occurrence rate of V-fib s/p MI?
3 - 4% in the first 4 hours
158
What ventricular and atrial dysrhythmias are most common s/p MI?
V-tach and A fib/flutter
159
What can precipitate A fib/flutter s/p MI?
Hypoxia, acidosis, heart failure and pericarditis
160
What factors are common to pericarditis?
Pain worse with lying down/inspiration
Pericardial friction rub
Diffuse ST-segment changes present
Treat symptoms…ASA
161
What is Dressler's syndrome?
Immune mediated pericarditis
Several weeks to months after acute MI
Treated with NSAIDS or corticosteroids
162
Injury to what s/p MI can cause mitral regurg?
Ischemic injury to the papillary muscle
163
What type of MI is more likely to cause mitral regurg?
An inferior wall MI
164
Treatment of mitral regurg s/p MI?
Decrease afterload (diuretics, nitrates) and improve coronary perfusion (IABP, valvuloplasty)
165
What type of MI is more likely to have conduction issues?
Anterior wall MI
166
Treatment of CHF/cardiogenic shock?
Reverse mechanical complications: papillary rupture, tamponade, severe MR
Improve BP: levophed, vasopressin, dopamine, dobutamine
Treat pulmonary edema: morphine, diuretics, mechanical ventilation
Restore coronary artery flow
IABP/LVAD
167
Where is an IABP most commonly inserted?
L femoral artery
168
Contraindications to IABP?
Severe aortic insufficiency
Aortic aneurysm
Severe peripheral vascular disease
Severe coagulopathy
169
What are potential complications to IABP use?
Limb ischemia
Aortic dissection
Hemorrhage from insertion site
Helium emboli
Infection
170
How is RV infarction diagnosed?
Hypotension, increased JVD with inspiration (Kussmaul sign), clear lung sounds with Inferior MI
Abnormal wall motion on echo
Afib 1/3, heart block 50%
171
What is the basic treatment for RV vs LV failure?
RV = Give fluids, avoid diuretics
LV = Give diuretics and decrease afterload
172
When does re-endothelialization
occur with: angioplasty, bare metal stents and drug eluding stents?
Angio = 2 - 3 weeks
Metal = 12 weeks
Drug = up to 1 year
173
What are the current DAPT recommendations for stents?
Angioplasty 2 weeks
Bare metal stents 6 weeks
Drug-eluding stents 3 months (preferably 1 year)
174
When is a CABG medically indicated?
Medical therapy fails
LM lesion of > 50%
EF <40% with significant disease
3 or more vessels with disease
175
When is an emergency CABG indicated?
Failed angioplasty
MI related septal rupture
MI related mitral regurgitation
Perforated coronary arteries during stenting
Cardiogenic shock
176
What are the 4 variables that can modulate a cerebral oximetry reading?
MAP, FiO2, HgB and ETCO2
177
What baseline do you need to obtain when using cerebral oximetry?
A room air baseline
178
What are 2 common induction combination strategies for a CABG?
High narcotic/Pavulon or Low narcotic/short acting NMBD/reversal
179
Why is an induction dose of ketamine discouraged in CABG patients?
Due to excessive catecholamine concerns
180
What is the BP goal for cannulation?
SBP of 90 - 100
181
What is the heparin dose for cannulation?
3 mg/kg or 300 units/kg of actual body weight
182
What is the goal ACT for an off-pump case? On pump?
Off pump = 300 to 350
On pump = greater than 400
183
What is likely the problem if you don't reach goal ACT despite giving a 2nd full dose of heparin for cannulation?
An AT III deficiency - consider giving FFP or an AT III concentrate
184
What is the temperature goal when the patient is cross clamped?
32 degrees C
*CMRO2 decreases by 7% per each degree in C drop*
185
When does pt rewarming start?
When the partial occluder clamp is on and the proximal grafts have started
186
When do you start IV sedation on a CABG case?
When re-warming starts
187
How many joules do you use for internal defibrillation paddle?
20 - 30
188
What is the goal BP for decannulation?
SBP of 90 to 100
*same goal for cannulation as well*
189
What components make up the CPB machine?
Cannula to drain blood from and return blood to body
Reservoirs for collection of blood
An oxygenator
Pumps
190
What is the normal HCT value when a pt is on pump?
17 - 25%
191
What drugs/fluids may be added to the CPB pump?
Albumin, PRBCs, e-lytes, mannitol or heparin
192
Where is antegrade cardioplegia administered? Retrograde?
Antegrade = aortic root
Retrograde = coronary sinus
193
What occurs in acute lung injury r/t CPB?
Diffuse congestion
Alveolar and interstitial edema
Hemorrhagic atelectasis
194
The renal complications of CPB are related to what?
Length of pump run-nonpulsatile flow
Excessive blood loss
Diabetes
Use of vasopressors
Advanced age
195
What is the goal UOP for cardiac surgery?
1 ml/kg/hr
196
What is the MOA of cyclokapron?
It inhibits the activation of plasminogen
197
What is the ideal timeframe to administer cyclokapron?
Less than 3 hours prior to surgery, if administered greater than 3 hours you can increase the bleeding risk
198
How does CO change in a cardiac transplant?
HR increases to 100 and CO is modulated by SV
199
What are the most commonly used echo views in cardiac surgery?
Transverse 4-chamber view
Transgastric short axis
200
What are contraindications to TEE?
Esophageal stricture
Esophageal masses
Recent bleeding from esophageal varices
Zenckers diverticulum
S/P radiation to neck
Recent gastric bypass surgery/gastric band
201
What are the basic differences between a bioprosthetic vs a mechanical valve?
Bioprosthetic
Composed of porcine or bovine
Last 10-15 years
Low thrombogenic potential
Mechanical
Metal or carbon alloy
Last 20-30 years
Highly thrombogenic
202
What are risk factors for mitral stenosis?
Female
Rheumatic fever: most common
Rheumatoid arthritis, SLE, stenosis s/p repair
203
What CV and pulmonary changes can occur d/t mitral stenosis?
CHF, pulmonary HTN and right heart failure
204
What is the critical MV area surface?
Less than 1.0 cm2, normal is 4 - 6 cm2
205
What occurs to LV diastolic filling in mitral stenosis?
LV diastolic filling is obstructed which increases LA volume and pressure
206
What EKG changes can suggest mitral stenosis?
Broad notched P waves: LAE on EKG; Atrial fib common
207
What is the treatment of mitral stenosis?
Maintain sinus rhythm
Diuretics
Decrease left atrial pressure
Heart rate control if atrial fib develops
BB, CCB, Dig or combo
Anticoagulation
Due to 7-15% risk/yr of embolic stroke
Balloon valvotomy vs. commissurotomy vs. replacement
208
What are the anesthesia goals for mitral stenosis?
Prevent/treat pulmonary edema
Atrial fib with RVR
Cardioversion; amiodarone, BB, CCB, Dig
Avoid increases in central volume
Excessive fluid administration
Trendelenburg position
Uterine contraction
Avoid decreases in SVR
Normal response (tachycardia) worsens CO
Phenylephrine, vasopressin
209
What drug class do you need to avoid in mitral stenosis?
Anti-cholinergics - you need to avoid tachycardia
210
What are the anesthesia goals for mitral stenosis during induction and maintenance?
Avoid tachycardia -> Ketamine, Pavulon, Histamine releasers
Have on hand short acting B-blockers
Avoid “light” anesthesia d/t tachycardia
Reverse gently
Care with excessive IVF
211
What are causes of mitral regurg?
Endocarditis
MVP
Left ventricular hypertrophy
Papillary muscle dysfunction
SLE
Rheumatoid arthritis
Ankylosing spondylitis
Carcinoid syndrome
212
What regurgitant fraction indicates severe mitral regurg?
Greater than 0.6
213
What is the regurgitant fraction dependent on?
Size of MV orifice
Heart rate
Pressure gradients (LV compliance and impedance to LV ejection)
214
What kind of heart murmur is associated with mitral regurg?
Holosystolic apical murmur that radiates to the axilla
215
What EKG changes indicate mitral regurg?
LAE and LVH
216
What is the treatment goals for mitral regurg?
Avoid bradycardia, increased afterload, and CHF
Diuretics
Vasodilators
ACE inhibitors
Biventricular pacing
Early replacement
EF <30%
RSV > 65 ml
217
Why is a repair preferred over replacement in the treatment of mitral regurg?
To maintain normal LV ejection anatomy
218
What is the pneumonic for basic goals for mitral regurg management?
Full, fast and forward
219
What are the basic anesthesia management goals for mitral regurg?
Prevent and treat decreased CO
Improve forward LV stroke volume -> Afterload reduction
Maintenance of normal to slightly high HR
220
What are the induction/maintenance goals for mitral regurg?
Avoid excessive narcotic-induced bradycardia
Etomidate: minimal myocardial depression/minimal SNS activity
Volatile anesthetics good choices to decrease SVR
Vasodilators: spinal/epidural
Keep it easy for the heart to eject blood
Maintain adequate volume
221
Obstruction to LV ejection d/t aortic stenosis causes what?
LV pressure and workload increase
Myocardial oxygen delivery decreases
222
What valve area indicates severe aortic stenosis?
Less than 1.0 cm2, normal is 2.5 - 3.5 cm2
223
What kind of murmur is associated with aortic stenosis?
Systolic murmur that radiates to the neck that mimics a carotid bruit
224
What treatment can help delay full blown aortic valve replacement?
Balloon valvotomy
225
What are the anesthesia goals for aortic stenosis?
Must maintain
Normal sinus rhythm
Need atrial contraction to maintain LV stroke volume
Need normal rate to maintain filling time and diastolic time
Normal volume and afterload
Maintain coronary perfusion
Prevent cardiogenic shock and cardiac arrest
226
What drugs are useful to use in anesthesia induction/maintenance for aortic stenosis?
Opioids, BZDs and etomidate as they have a minimal effect on SVR
227
What is the vasopressor of choice in aortic stenosis?
Phenylephrine
228
What are the treatments for brady and tachy dysrhythmias in aortic stenosis?
Brady: glyco, atropine and ephedrine
Tachy: esmolol, lidocaine, amio and defibrillation
229
What are causes of aortic regurg?
Endocarditis
Rheumatic fever
Bicuspid aortic valve
Aortic dissection
Marfan’s syndrome
Anorexigenic drugs
230
What is the regurgitant volume in aortic regurg dependent on?
HR and SVR
231
What kind of murmur is associated with aortic regurg?
A diastolic murmur on the right sternal murmur
232
What cardiac s/sx and diagnostic findings are associated with aortic regurg?
Widened pulse pressure
LV dysfunction…fatigue, dyspnea, coronary ischemia
LVH on EKG
Abnormal echo
233
What are the anesthesia goals for aortic regurg?
Maintain forward, LV stroke volume
HR 80ish
Prevent abrupt increases in SVR
Maintain contractility
234
What are the induction goals for aortic regurg?
Prevent extreme bradycardia
Volatile anesthetics awesome
+/- some opioid
NMBD’s with no effect on BP/HR (such as cisatracurium and vec. Roc is still commonly used, it can cause transient hypotension)
Maintain fluid volume to support preload
235
How long should coumadin/direct thrombin inhibitors be held prior to major surgery?
3 - 5 days prior
236
What type of MI is more likely to have issues with sinus brady?
Inferior wall MI
237
What is the treatment for Dressler's syndrome?
NSAIDs and corticosteroids
238
When does Dressler's syndrome occur?
Several weeks to months s/p acute MI
239
What are contraindications to nitrate use?
Hypertrophic cardiomyopathy and aortic stenosis
240
Why is low dose TXA preferable to high dose?
There is no difference in transfusion requirement between the high vs low dose, and high dose carries a seizure risk
241
T/F: indirect acting CV drugs are generally avoided in heart transplant patients
True
Semester 7 TxWes
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