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194 Cards in this Set
- Front
- Back
What is the normal CO?
What is the CO formula? |
5-6L/min
CO= SV * HR |
|
What is the normal CI?
|
2-5L/min
|
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How does coronary vascularture drain into the right atrium?
|
Coronary sinus
|
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What is normail coronary blood flow in cc/min; cc/gm/min?
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225-250cc/min
0.6-0.9cc/gm/min |
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How much of the CO does the coronary arteries receive?
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4-7%
|
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What is normal myocardial O2 consumption (MVO2)?
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8-10cc/gm/min
|
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What are the average heart sizes for females and males?
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Males: 280-340
Females: 230-280 |
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What MAP does coronary artery autoregulation occur?
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50-150mmHg
|
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When O2 demand exceeds supply, what develops??
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Ischemia
|
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How much O2 does the heart extract from received blood?
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65-70%
|
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What happens to the autoregulation curve in an HTN patient?
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Shifts to the right
|
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What are some manifestations of ischemia?
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EKG changes
Angina Impaired contractility Dysrhythmias- RCA stenosis |
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How do you treat coronary ischemia?
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Increase O2 supply (supplemental O2, bypass surgery, blood transfusion, vasodilator)
Decrease O2 demand (HR control, rest, MSO4) |
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What is the formula for coronary perfusion pressure?
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CPP= DBP-LVEDP
LVEDP is the pressure in the LV at the end of diastole DBP is the driving pressure in the aorta during diastole |
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What are the complications of bare metal cardiac stents?
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Scar tissue can lead to reocclusion
|
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What is the most common stent and what regimen must the pt be on?
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Drug eluting stent are the most common.
Pt must be anticoagulated, on plavix for a year. Drug eluting stents heal more slowly and do not form scar tissue. |
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What part of the heart does the LAD supply?
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Anterior 2/3 of vent septum
RBB LBB LV: apical wall, ant lateral wall Anterior papillary muscle of MV (cX artery) |
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What part of the heart does the RCA supply?
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RV
25-30% of LV SA node |
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What does it mean when someone is "right dominant"?
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PDA comes off of RCA. This occurs in 70-85% of population
|
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What part of the heart does the Cx supply?
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Posterolateral LV
Anterolateral Papillary muscle SA node (38% of pop) Left dominant: 45-50% LV |
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What part of the heart does the PDA supply?
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Inferior wall
Ventricular septum (posterior 2/3) Posteromedial papillary muscle (mitral valve) |
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What is the most common papillary muscle damage during ischemia and why?
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Posteromedial papillary muscle because only one coronary artery (PDA) perfuses this muscle.
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In coronary dominance, what does "right dominant" mean?
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RCA gives rise to PDA to supply the posterior inferiior aspect of the LV (70-85% of population)
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In coronary dominance, what does "left" dominant mean?
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The posterior inferior portion of the LV is supplied by either the Cx (left dominant) or both RCA and Cx (co-dominant (15-20%))
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The mitral valve has two muscles, what are the muscles and what CA perfuse them?
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1. Anterolateral papillary muscle; two blood supplies (LAD and LCx)
2. Posteromedial papillary muscle; supplied only by the PDA |
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Inferior wall MI; what EKG leads show changes; what are the S/S; and what rhythm changes will you see?
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Leads II, III, aVF
RCA blockage 1st degree heart block or 2nd degree type1 S/S: hypotension and JVD |
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What leads will show changes for anterior wall MI?
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V3 and V4
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What leads will show changes for septal wall MI?
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V1 and V2
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What leads will show changes for Lateral wall MI?
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I, aVL, V5 and V6
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Anterior wall MI will have blockage in what CA?
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LAD
|
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What arrhythmia will an anterior wall MI show?
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2nd degree type II or 3rd degree heart block.
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Septal wall MI will have blockage in what CA?
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LCA
|
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What arrhythmia will an septal wall MI show?
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2nd degree type II and Bundle branch blocks
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Lateral wall MI will have blockage in what CA?
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Cx and LCA
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What arrhythmia will an lateral wall MI show?
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2nd type II
3rd degree BBB |
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What leads will show changes for posterior wall MI?
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V1-3
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Posterior wall MI will have blockage in what CA?
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RCA
|
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What arrhythmias will show in a posterior wall MI?
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2nd degree type II
3rd degree PVCs VF VT LV failure with breathlessness |
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What is the max Hespan ml/kg to give?
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20ml/kg
|
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What doesn't plasmoid contain that LR does contain?
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Calcium
|
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What are some indications for CVP
|
Rapid fluid administration
Need for PA cath Transvenous pacing TPN Hemodialysis Operations at risk for VAE Cardioactive drugs |
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When do you inflate ballon on PA cath? At what cm?
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20cm
|
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SVO2 correlates with what other parameter as longs as O2 consumption is constant?
|
Cardiac index
|
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What factors affect sVO2
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Arterial content
CO O2 utilization |
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What caused decreases in SVO2?
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ARDS
MI, CHF, Hypovolemia Fever, exercise, agitation, shivering, thyrotoxicosis Bleeding, hemolysis, abnormal Hgb Hypoxia, vent changes |
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What causes increased SVo2
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Sepsis, burns, L to R shunt, AV fistula, hepatitis, pancreatitis, inotropes
Cyanide toxicity, carbon monoxide poisoning, methemaglobin, hypothermia |
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What is the most common cause of increased SVO2?
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Wedged catheter
|
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A-line waveform upstroke and downstroke show what?
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Upstroke- systole
Downstroke- diastole |
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What does the anacrotic upstroke of aline waveform show?
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contractility
|
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Aline waveform, what does the area under the curve show?
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Stroke volume
|
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What does the entire aline waveform limb show?
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SVR
|
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CVP monitoring: What do the a,c, and v waves show?
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A- atrial contraction
C- ventricular contraction V-filling of atrium |
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CVP: what do large A waves indicate?
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Tricupsid stenosis, RVH, or junctional rhythm
|
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CVP: What do lare C waves indicate?
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Tricupsid regurg
|
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What do C waves correlate with on the eKG? A waves?
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QRS correlates with C wave
P correlates with A wave |
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CVP monitoring: What does the x and y wave represent on a CVP waveform?
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X= atrial diastole
Y= Atrial emptying |
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PA cath: Large V waves indicate:
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Mitral Regurg
|
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What two CA supply the anterolateral papillary muscle?
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LAD and Cx
|
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If a pt has a LBBB and you float a PA cath, what rhythm are you at risk for putting the pt in?
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Complete HB because you can cause a RBBB if the cath irritates the right ventricle wall.
|
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Why is TEE used in MV case and not AV cases?
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Because MV are repaired (they want to see if the repair has stopped the regurg) and AV are replaced.
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RCA stenosis places the pt at greatest risk for _____.
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Arrhythmias
|
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If a patient has LMCA stenosis or proximal LAD, what must their MAP be maintained at?
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80-90.. increases perfusion pressure
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Pt with EF<25% most often requires what?
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IABP
|
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What is dyskinesis?
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Dyskinesis- when contracts moves muscle down. Working against normal contraction of the heart muscle
|
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What are the most stimulating points of cardiac anesthesia?
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laryngoscopy, incision, sternomy, retraction, opening of pericardium
|
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PA cath: Large V waves indicate:
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Mitral Regurg
|
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What two CA supply the anterolateral papillary muscle?
|
LAD and Cx
|
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If a pt has a LBBB and you float a PA cath, what rhythm are you at risk for putting the pt in?
|
Complete HB because you can cause a RBBB if the cath irritates the right ventricle wall.
|
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Why is TEE used in MV case and not AV cases?
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Because MV are repaired (they want to see if the repair has stopped the regurg) and AV are replaced.
|
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RCA stenosis places the pt at greatest risk for _____.
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Arrhythmias
|
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If a patient has LMCA stenosis or proximal LAD, what must their MAP be maintained at?
|
80-90.. increases perfusion pressure
|
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Pt with EF<25% most often requires what?
|
IABP
|
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What is dyskinesis?
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Dyskinesis- when contracts moves muscle down. Working against normal contraction of the heart muscle
|
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What are the most stimulating points of cardiac anesthesia?
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laryngoscopy, incision, sternomy, retraction, opening of pericardium
|
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PA cath: Large V waves indicate:
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Mitral Regurg
|
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What two CA supply the anterolateral papillary muscle?
|
LAD and Cx
|
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If a pt has a LBBB and you float a PA cath, what rhythm are you at risk for putting the pt in?
|
Complete HB because you can cause a RBBB if the cath irritates the right ventricle wall.
|
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Why is TEE used in MV case and not AV cases?
|
Because MV are repaired (they want to see if the repair has stopped the regurg) and AV are replaced.
|
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RCA stenosis places the pt at greatest risk for _____.
|
Arrhythmias
|
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If a patient has LMCA stenosis or proximal LAD, what must their MAP be maintained at?
|
80-90.. increases perfusion pressure
|
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Pt with EF<25% most often requires what?
|
IABP
|
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What is dyskinesis?
|
Dyskinesis- when contracts moves muscle down. Working against normal contraction of the heart muscle
|
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What are the most stimulating points of cardiac anesthesia?
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laryngoscopy, incision, sternomy, retraction, opening of pericardium
|
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What are some effects of N20?
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Second gas effect
Analgesic Stimulates SNS- ischemia Increases PVR Limits O2 concentration Increased Truncal Rigidity ELARGES INTRAVASCULAR AIR BUBBLES |
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what are some effects of isoflurane?
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Maintains CO
Lowers SVR Myocardial Steal Phenomenon Potentiates MR Reflex Tachycardia Inhibits Hypoxic pulmonary vasoconstiction |
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what are some effects of desflurance
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Similar to Isoflurane
Rapid increases in concentrations lead to tachycardia. Does not increase coronary artery blood flow ( steal phenomenon not an issue) |
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What are some of the effects of sevoflurane
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Nonpungent- great for inhalational induction.
SVR declines slightly less than ISO and DES Causes little rise in HR No evidence of Steal Phenomenon. Metabolite flouride may potentially cause nephrotoxicity. Long duration and low flow anesthesia potentiate Compound A accumulation |
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Name some of the effects of ketamine
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Dissociative anesthetic
Analgesia Increased MVO2 Increase secreations Increases BP, HR and CO Myocardial depression compensated by Sympathetic tone. |
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Name some of the effects of etomidate
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Sedative
Hypnotic Rapid Onset Hemodynamic stability Myoclonus Propylene Glycol- pain on injection Lacks analgesia properties Adreno-cortical suppression (long-term only) |
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Name anesthetic drugs from greatest to least myocardial depressant effects
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PROPOFOL is most depressant
MIDAZOLAM & PENTOTHAL are intermediate ETOMIDATE is least depressant |
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What are the effects of pancuronium
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Vagolytic
Symathomimetic Prevents brady from narcotics Aides in prevention of truncal rigidity when high dose narcotics are used |
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what are the effects of vecuronium
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Hemodynamic stable
No vagolytic effect – bradycardia may result. Significant hepatic metabolism – safe for renal dysfunction patients Requires more frequent dosing than pavulon |
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What are the effects of rocuronium?
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Faster onset than vecuronium of pancuronium.
Hemodynamic stability Prolonged duration in hepatic dysfunction- OK in renal patients. |
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What are some the effects of atracium?
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Does not relay on hepatic or renal elimination.
Hoffman elimination and ester hydrolysis makes safe for hepatic and renal patients. No vagolytic action Hypotension from histamine release |
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If opiates cause bradycardia, how do you treat it?
|
Vagolytics and IVF
|
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What should you do after post intubation while waiting for incision?
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Reduce inhaled agents
Small doses of vasoconstritor Adequate volume |
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When do 50% of ischemia events occur?
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Prior to CPB
|
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What are some signs of myocardial ischemia?
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ST segment abnormality
Dysrhythmias Conduction abnormality PA waveform abnormality Decreased myocardial performance (low cardiac index or blood pressure) Wall motion abnormality (echo, visual) |
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What may a bovie cause? When is the best time to bovie?
|
Ventricular fib. As electrical stimulation of the epicardium with the bovie may induce ventricular fibrillation, certain of the more skilled surgeons will only bovie during systole. Unfortunately, since the window of opportunity is rather narrow (0.04 seconds), the incidence of misadventure is somewhat high.
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What may heparin (30,000 units) cause?
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Hypotension
|
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When should lungs be deflated?
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Before sternotomy
|
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When is risk for intraoperative awareness the highest?
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Prior to sternotomy
|
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What are some treatments for sympathetic response to sternotomy?
|
Deepen anesthesia prior to these events.
Vasodilators may be necessary |
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What are some causes of intra-op hypotension during cardiac surgery?
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Surgical compression
Dysrhythmias Hypovolemia Decreased contractility |
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How would you treat intra op hypotension?
|
Lighten anesthesia
Vasopressors Volume Correct ischemia Ask surgeon to reposition heart Restoring HR and rhythm |
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If a patient has left main equivalent, what does this mean?
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LAD and cx are occluded
|
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What pts require a higher perfusion pressure?
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Acute/Ongoing MI
Renal/Cerebral insufficency Left main/left main equivalent Aortic stenosis Chronic hypertension |
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What are some cause of HTN during the intra-op period?
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Light anesthesia,
Sympathetic nerve stimulation while dissecting pericardium and aorta, Hypoxia/hypercarbia, Thyroid storm, Hypervolemia, MH, Withdrawl of B-Blockers |
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What is the treatment of HTN intra-op?
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Nitroglycerin ,
SNP, Esmolol, increased ventilation, narcotics, increased anesthetic level. |
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How much autologous blood removal is removed prior to CPB and how much is returned?
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500-1000
|
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How do you hypotension from CPB?
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Hypotension from decreased preload is treated with decreasing rate of withdrawal and give volume (crystalloid)
|
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What factors do antithrombin 3 work on?
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Antithrombin III works on 2 9 10 11 12
|
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How does heparin work ?
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It accelerates the action of AT-3
|
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When should a patient be heparinized?
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Prior to CPB
|
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What time of reaction does heparin and AT-3 create when they combine?
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Neutralization reaction
|
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A patient with AT-3 70-100% is considered what?
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Normal
|
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A patient with less than 40% AT-3 is considered to be what?
|
Heparin resistant
|
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How do you treat AT-3 deficiency?
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FFP restores levels of AT-3 and promotes anticoagulation effects of heparin.
|
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What is the dosage of heparin?
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300-400units/kg
|
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What is the duration of heparin?
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Dependent on body temp but approximately 100units/kg in 56 min.
|
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What is the normal ACT level?
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90-120 seconds
|
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What level must the ACT be before CPB is initiated?
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>400-450 seconds
|
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How often should an ACT be checked? How much heparin should be admin in boluses?
|
Every 15 min on CPB.
Given in 5,000-10,000. |
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Rapid administration of heparin may cause what?
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A decrease in MAP or PAP. Get an decrease in PVR due to relaxant effect on smooth muscle.
|
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When you bolus amicar what else should you bolus?
|
Heparin
|
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What class of drug is amicar and what is the dosage?
|
Anitfibrinolytic
150mg/kg bolus over 20-30 minutes. 10.5G for 70kg 4ml=1G Normal bolus 10.5g= 44ml Then 10mg/kg/hour for 5 hours |
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Before cannulation what should you do?
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Decrease BP it also help prevent blood loss
|
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Why is pericardial sling placed prior to cannulation?
|
It increase the work space. Sling may lift the heart decreasing venous return leading to hypotension.
|
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How does blood flow into oxygenator?
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By gravity
|
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How far should the PAC be pulled back when the aorta is cross clamped?
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Pull back PAC 2-3 cm
|
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Explain the process of arterial cannulation.
|
Arterial cannula is placed in ascending aorta (femoral can be used).
Aortic cannula is inserted first to allow for infusion of volume in case of hemorrhage during venous cannulation. SBP is decreased to 90-100 mmhg to reduce risk of aortic dissection. Emergent CPB can be innitiated using cardiotomy suckers. Air bubbles must removed prior to infusing volume |
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What are the complications of arterial cannulation?
|
Embolic from air or plaque
Blood loss – hypotension Aortic dissection- face/ head must be inspected to ensure proper placement Unilateral blanching of right side indicates inominate artery cannulation. |
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What are the complications from venous cannulation?
|
Hypotension
Bleeding Dysrhythmia Superior vena cava obstruction – face should be inspected for plethera and edema |
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After arterial cannulation, how can you tell if there is obstruction of the aorta?
|
Unilateral blanching of the face
|
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When on pump, what should the MAP be kept?
|
50-80mmHg
|
|
How much crystalloid is the pump primed with ?
|
2000ml crystalloids, colloid, mannitol, heparin, bicarb, and K+
|
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What should the PaO2 be maintained @?
|
200-400mmHg
|
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Why does blood accumulate in LV during CPB?
|
Incompetent aortic valve
Non-coronary blood flow Thesbian veins empty to left atrium. |
|
How is a LV vent placed?
|
Catheter in pulmonary vein, left atrium or apex of heart to prevent ventricular distention and myocardial injury
Decreasing wall tension reduces O2 consumption PAP is good reflection of LV filling pressure and LV distention ( >15 mmhg) |
|
When beginning bypass, low perfusion pressure is associated with? What should the perfusion pressure range be?
|
Low perfusion flow rate
profound vasodilation hemodilution 60-80 torr |
|
What is the normal perfusion flow rate while on CPB? What is the minimum allowable flow rate?
|
2.2 to 2.4L/min/M3
1.6L/min/M3 |
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What is the source of most blood trauma while on CPB?
|
Suction
|
|
When should ABGs be drawn?
|
5 min after starting bypass, then once every hour.
|
|
During CPB, what is acidosis a result of?
|
Acidosis (metabolic) is a result of inadequate perfusion.
Acidosis (respiratory) is a result of inadequate CO2 removed. |
|
What are the causes of low venous return?
|
Hypovolemia
Malposition of caval catheters Kinked venous return line Excessive pressure gradient |
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What does respiratory alkalosis do to cerebral blood flow?
|
Diminishes blood flow. pCO2 is the main factor controlling cerebral blood flow
|
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Why must the LV be vented?
|
The left heart must be vented to prevent pooling of this blood and distention of the heart
If not done, pulmonary edema and interstitial hemorrhage may occur |
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IF no urine output for 15 minutes after the intiation of CPB, what should you do?
|
Diuretic agents (Mannitol or Lasix) may be required after 15 minutes of no urine output in the presence of acceptable flow rates and pressures
|
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How can inferior venous cannula placement affect the liver?
|
The inferior venous cannula must be positioned properly to prevent hepatic congestion
|
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By what percentage does hypothermia reduce oxygen requirements? What are some other benefits of hypothermia?
|
Reduces oxygen requirements
…to 50% at 28° C …to 25% at 20° C Lower blood flows are required Heparin metabolism is reduced |
|
Explain the antegrade and retrograde cardioplegia administration.
|
Antegrade –via aortic root into coronary ostia. Flow is forward thru coronary arteries.
Retrograde – via coronary veins positioned in coronary sinus (right atrium). Flow is backward thru venous system to myocardium. Direct cardioplegia via conduit to distal anastomosis. |
|
What should HCT be maintained at during CPB?
|
20-30% due to hemodilution
|
|
How often should urine output be measured?
|
every 15 min
|
|
What should be increased due to the dilution effect?
|
IV anesthetics should be increased.
|
|
When should lung ventilation cease?
|
When CPB is full flow.
|
|
During rewarming, why does the patient lose the anesthetic effect?
|
Patient losses anesthetic effect of hypothermia due to warm cerebral blood flow
|
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How do you remove entrapped air after reexpansion of the lungs?
|
valsalva maneuver
|
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IF the HR is slow due to a AV block, what is the treatment?
|
Pacing DDD at 100
|
|
If inotropic support is needed, when does it need to be initated?
|
Start inotropic support when Aortic cross clamp comes off after we have started rewarming
|
|
What are some inotropes?
|
CaCl
Epinephrine Dobutamine Amrinone Milrinone |
|
What is amrinone? How does it work? What are some of the side effects?
|
Positive inotropic and vasodilator
Inhibits CamP (phosphodiasterase inhib) Reduces afterload and preload Increases CO S/E: thrombocytopenia hypotension |
|
What is milrinone and how does it work?
|
Inotropic /vasodilator
Phosphodiasterase inhib No thrombocytopenia S/E |
|
What side effect does amrinone have that milrinone doesn't have?
|
No thrombocytopenia
|
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When shouldn't CaCl be delivered?
|
Never give until cross clamp is off.
|
|
How is the aortic valve opened after coming off of bypass?
|
This is accomplished by placing a clamp on the venous line. This effectively redirects the blood flow to the right heart
|
|
At what systolic torr, should the patient be volume loaded?
|
100 torr
|
|
How do you treat hyperkalemia?
|
10u insulin and ½ d50, calcium, sodium bicarb
|
|
What should pt body temp be before separation from bypass?
|
>37 degrees
|
|
What is the formula for BP?
|
BP= CO*SVR
If BP and CO is known, then decision may be made as to whether fluid or vasopressors should be utilized |
|
What is the protamine dosage?
|
1mg/100units
|
|
What are some side effects of protamine ?
|
Pulmonary HTN or systemic HTN
|
|
What does FFP contain? What does Cryo contain?
|
FFP contains all factors and fibrinogen
Cryo contain factor VIII and fibrinogen |
|
What is the mechanism of action of amicar?
|
Impedes fibrinolysis by inhibiting plasminogen activator substrates. Antagonizing antiplasmin activity. Enhases hemostasis
|
|
What does DDAVP do? What patients is it indicated for?
|
Increases platelet aggregation in CRF pts, Von Willibrands disease
|
|
What factors does DDAVP increase?
|
Increases factor VIII
|
|
What is the limit of time on CPB?
|
About 2 hours
|
|
What dosages decrease during OP CABG?
|
Heparin and protamine doses
|
|
What isn't given during OP CABG that is given with on pump CABG?
|
Amicar and aprotinin
|
|
When are external defib pads place in OP CABG?
|
prior to incision
|
|
What body temp must be maintained for OP CABG?
|
normothermia
|
|
What type of fluid status is key to OP CABG?
|
Fluid loading
|
|
What ACT value do you want for OP CABG?
|
>300
|
|
Aortic stenosis cause the heart to become concentric or eccentric?
|
concentric
|
|
Regurg causes the heart to become eccentric or concentric?
|
Eccentric
|
|
What are some S/S of Aortic Stenosis?
|
Angina, syncope, chf
|
|
What are the hemodynamic goals for Aortic Stenosis?
|
Slow to NSR.
Increase preload Afterload increases to maintain CPP |
|
What are hemodynamic goals for MS?
|
HR-slow
Preload- increased SVR- maintain PVR- decrease |
|
What are the hemodynamic goals for AR?
|
HR- normal to increase
Preload- normal to increase SVR- decrease Contractility- increase |
|
What are some causes of MR?
|
Degenerative, coronary artery disease (ischemia, infarc), infection and cardiomyopathy
|
|
What is the normal orifice size for aortic orifice?
|
>2cm
|
|
What is the pressure gradient at the orifice of the aorta?
|
No gradient is normal.
<20mmhg mild; 20-40mmhg mod; >40mmhg severe; >70mmhg critical |
|
What are S/S of mitral valve disease?
|
Waking up short of breath or coughing
Becoming short of breath when you exert yourself, lie down or are emotionally stressed Excessive tiredness, with activity or as the day goes on Dizziness or lightheadedness Swollen ankles or feet A fast, pounding or irregular heartbeat A fluttering feeling in your chest |
|
Minimally invasive CABG uses what type of breathing tube?
|
Single lumen ETT with bronchial blocker under fiber optic visualization
Bronchial blocker removed before ICU Usually extubated soon after arrival to ICU Use low TVs when anastamosis, when req by surgeon |
|
Aortic stenosis will cause what type of PAC waveform?
|
Prominent A waves.
|