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Anesthetic Management of Cardiovascular Disease
Terms in this set (89)
Cardiovascular complications account for ______ of mortality following noncardiac surgery?
Ischemic heart disease, CHF, CVA, high risk surgery, DM, creatinine >2
What increases perioperative cardiovascular risk?
What is the most common perioperative medical abnormality in surgical patients? What percent is this?
MI, CHF, stroke, renal fx, PVD, aortic disection
What are some complications of HTN?
A BP > ____mmHg systolic and > ____mmHg diastolic are associated with increased perioperative risk.
ARBs and ACE inhibitors
HTN pts are more prone to develop intraoperative HYPOtension, especially if taking these medications?
You should keep HTN pts BP within ___% of baseline?
130-139 / 80-89
What are the parameters for stage 1 HTN?
>140 / >90
What are the parameters for stage 2 HTN?
>180 / > 120
What are the parameters for hypertensive crisis?
Idiopathic, and makes up 85-95%
What are the most common type of HTN, its cause?
15%, attributed to disease process or medical condition
Secondary HTN makes up what % of cases?
ACEI and BB
All pts with a prior MI should be on what 2 medications, regardless if HTN is present?
>210/120, can lead to papilledema and encephalopathy
What is the parameters for Malignant HTN?
20, 15, doubles
Every ___mmHg increase in systolic and ___mmHg in diastolic BP, _______ the risk of cardiovascular disease.
BB & CCB - stopping could cause significant HTN. ARBs and ACEI are not usually held, but depends on facility
BB, CCB, ACEI, and ARBs, which should be continued day of surgery?
Holding - can cause increased risk of perioperative HTN
Continuing - can cause increased risk of intraop HYPOtension
What is the potential result of holding and continuing ACEI and ARBs prior to surgery?
CHF, but can be normal in children, young adults and athletes
An S3 usually indicates?
A resistance to LV filling, or LV hypertrophy
An S4 usually indicates?
Surgery should be Cx with a K+ >_____?
Treat the low K+ prior to surgery and continue as scheduled
A pt presenting for surgery with a low K+ (<3), what should occur?
Chronic HTN effects _____ and patients often need an elevated MAP and therefore BP should be maintained within 20% of baseline.
A mean PAP >25 at rest with PCWP <15 and an increased PVR
Define pulmonary HTN
Normal PVR value
weakness, fatigue, ascites, chest pain (d/t RV hypertrophy causing increased O2 demand with decreased coronary perfusion). Think right sided HF = RA & RV enlargement
Symptoms of pulmonary HTN
Pulmonic and tricuspid regurg
What valvular disorders could you have with pulm. HTN
A paralyzed left recurrent laryngeal nerve from compression via a dilated pulm. artery.
What is Ortner's syndrome?
Pain, hypoxemia, hypercapnia
What are some causes of intraoperative HTN
cerebral vasodilation causing increased ICP
What are the affects of hypercapnia?
Vasopressin or methyolene blue
What 2 drugs may be used to treat refractory hypotension to ACEI and ARBs?
O2 (decrease pulm vasoconstriction)
Diuretics (relieve R sided HF)
Phosphodiesterase inhibitors (end in afil and cause pulm vasodilation and improved CO)
Treatments for pulm HTN
Causes vasodilation - activates guanylate cyclase which causes an increase in cGMP which reduces intracellular Ca causing vasodilation
What is the MOA of nitric oxide on pulm smooth muscle?
SVR - maintain r/t fixed CO from R sided HF
Maintain NSR - rely on atrial kick to increase RV filling pressures to overcome PVR
Anesthetic management of pulm. HTN on SVR, rhythm, PVR
Milrinone, nitroglycerine, NO, prostacyclin
Name 4 potent pulm vosodilaters
Relieved with rest/NTG
Symptoms absent until 50-75% occlusion
-DM watch out for silent ischemia-
Describe stable angina
Last longer than 30min
Abrupt increase in severity, frequency or duration
Angina at rest
-will want to Cx surgery-
Describe unstable angina
Flow through a vessel is related to the 4th power of the radius. If vessel radius doubles then flow increases 16 times. Or if it quadruples then flow increases 256 times (4x4x4x4=256). If the radius decreases by half then pressure to maintain same flow must increase 16 times.
What is Poiseuille's law on blood flow through a vessel
At least 6 weeks
How long should a patient wait after having an MI before having an elective surgery?
EF < 50%
What EF, LVEDP and CI signify significant LV dysfunction?
Non-cardiac sx is not recommended for ___weeks after bare metal stents and ____months after a drug-eluting stent if withdrawing antiplatlet therapy for sx.
Aortic diastolic pressure - LVEDP
CPP is auto-regulated between
Inner 1/3 layer of subendocardium (increases to LVEDP lead to increased wall tension and decreased perfusion)
What area of the heart is most vulnerable to ischemia?
Atracurium - histamine release
What drugs to avoid intraoperativly in patients with ischemic heart disease
List the effect of volatile gases in order of greatest to least myocardial depression
Procainamide or amiodarone
What medications might be given for WPW syndrome or other accessory pathway leading to SVT?
Afib greater than 48hrs must be on anticoagulation for ____ weeks before and ___ weeks after cardioversion.
A normal EF with decreased CO, along with an increased LVEDP and decreased LVEDV, describes systolic or diastolic HF?
Atria. Causes vasodilation and diuresis
ANP is stored where and causes what when released?
Atria and Ventricles. Causes diuresis, vasodilation, and inhibits RAAS & SNS
BNP is stored where and causes what when released?
ANP and BNP
What is released within the heart to try an counteract remodeling?
Pulm. edema, dyspnea, orthopnea, nocturnal dyspnea are all signs of R or L HF?
JVD, ascites, edema, weight gain are all signs of R or L HF?
Ischemic heart disease, hyperthyroidism, excessive etoh, idiopathic, peripartum
Causes of dilated cardiomyopathy?
all decreased except an increased LVEDV
Effects of dilated cardiomyopathy on SV, contractility, EF, LVEDV?
Afterload reduction, avoid myocardial depression
Management of dilated cardiomyopathy?
decreased preload and afterload, increased contractility
Effects of hypertrophic cardiomyopathy on preload, afterload, contractility?
Decrease degree of LVOT obstruction by: maintain preload and afterload and reduce contractility. Avoid hypovolemia & inotropes
Management of hypertrophic cardiomyopathy?
they become dilated
What occurs with the atria in restrictive cardiomyopathy?
Stoke volume in restrictive cardiomyopathy?
Management of restrictive cardiomyopathy in preload, afterload, and contractility?
R sided heart failure. high pulm. pressures from chronic lung disease cause RV enlargement.
What is cor pulmonale?
viral infection or MI
What causes acute pericarditis?
severe pain that worsens with inspiration. Friction rub.
S/S of acute pericarditis?
ST elevation that changes to T wave inversions
What ECG changes might be seen with acute pericarditis?
JVD on inspiration
What is Kussmaul's sign?
decreased systolic pressure >10mmHg on inspiration
What is pulsus paradoxus?
Muffled heart sounds, JVD, hypotension
Volume expansion, increasing contractility, and correcting acidosis
Outside of a pericardiocentesis, what else may help manage cardiac tamponade?
Ketamine. Avoid general if possible, maybe a local for pericardiocentesis. N2O and fentanyl are good choices for maintenance of anesthesia, and want to avoid volatiles. Fluid helps maintain CO.
Anesthetic induction drug of choice for cardiac tamponade?
General causes direct vasodilation and myocardial depression, and PPV reduces venous return
Why should general anesthesia and PPV be avoided in cardiac tamponade?
What can mimic cardiac tamponade?
Kussmaul's sign more pronounced. Pulsus paradoxus is absent.
What sign is seen more prominently with constrictive pericarditis then tamponade, and what is absent?
Prominent "Y" on CVP tracing and represents rapid RV filling. Constrictive pericarditis
What is Fredrick's sign and when might you see it?
Minimize all changes
Management of restrictive pericarditis?
Carcinoid tumors can develop hypotension from their manipulation and may not respond to drug therapy. What drug is suggested to use in this case?
Histamine releasing agents - morphine, demerol, atricurium
What drugs should be avoided during removal of carcinoid tumors that cause hypotension?
100-120, because there is no vagal response
What is the resting HR of a transplanted heart and why?
autonomic influence. No SNS or PSNS innervation.
Transplanted hearts are lacking what?
It is completely denervated
Why is MI silent in transplanted hearts?
atherosclerosis, and receive periodic evaluations for its presence
What is very common in transplanted hearts?
Direct acting - neosynepherine. Epinepherine should also be available as atropine and glyco wont work
Which type of vasopressors would be more effective in a transplanted heart?
SA node of pt and that of the transplanted heart may both be detected
Why might you see a double "P" wave in a patient with a transplanted heart?
An autoimmune response to an MI causing pericarditis that occurs weeks to months after the MI.
What is Dressler syndrome and when does it occur?
Term for the absence of ventricular wall motion?
SNS, ADH, RASS
What are 3 endogenous vasopressor systems?
Pleural effusion involving lymph fluid?
Damage to this from placement of IJ CVC can result in Horner's syndrome (ptosis, miosis, and hemifacial anhidrosis)
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