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Physio III - Final Exam - Groups 7 & 8
Terms in this set (59)
true or false: when a surgeon prefers off-pump CABG the heart is not beating
false = it sure is beating
All of the following are benefits of off pump CABG except:
A. decreased risk of stroke and cognitive problems
B. shorter hospital stay and faster recovery
C. increased immune responses
D. less renal dysfunction
E. less coagulopathy
C = you would have decreased or fewer unwanted inflammatory/immune repsonses
How is reduced pulmonary function caused during on-pump CABG
atelectasis, increased shunting, and inflammation
true or false: on-pump CABG has a greatly reduced biomarker evidence of myocardial injury
false = OFF-pump CABG has this advantage
All of the following are true of disadvantages for off-pump CABG except:
A. increased blood in surgical field
B. repositioning of heart leads to severe hypertension and ischemia making ECG findings unreliable.
C. Bradycardia, atrial dysthymias, heart block, malignant ventricular dysrhythmias, and hemodynamic collapse can occur
D. TEE is unusable if heart is positioned with laparotomy pads or lifted out of chest
E. you can experience positional mitral regurgitation
B. = repositioning of heart would lead to severe HYPOtension
What types of blood tests would you want prior to a CABG procedure?
-Coagulation studies (ACT, PT/INR)
What types of monitors and invasive lines would you want for a CABG procedure?
CVC +/- PAC
venous bulb O2 (SjO2)
Would you want early or late emergence with OR extubation for a CABG?
EARLY emergence and early ambulation
What do you want to avoid during induction of a CABG and what are you trying to protect against?
protect against ischemia
what agent are you likely giving during the maintenance phase of a CABG and how much?
heparin = 100 u/kg
What are 3 anesthetic approaches for off-pump CABG?
1. GA (opioids with inhalational or TIVA)
2. GA (with thoracic epidural analgesia and controlled ventilation)
3. Awake Regional (with TEA and spontaneous ventilation)
What is your ACT goal for OP-CABG?
How can you avoid hypothermia for OP-CABG?
during ventilation of OP-CABG, what may be necessary to aid in visualization?
How much volatile anesthetic is considered most effective in protecting against myocardial ischemia (pharmacologic ischemic preconditioning)
All of the following are appropriate for maintenance of OP-CABG patient with pain management EXCEPT
A. thoracic epidurals
B. short acting opioids
D. long acting opioids
E. neuraxial narcotics
True or false: continuous infusion of vasopressors and fluid loading may be needed during sewing of the proximal anastomosis
false = this is needed for the DISTAL anastomosis
During the proximal anastomosis an infusion of what types of drugs may be needed to maintain systolic pressure between 90-100 during partial clamping of the aorta?
vasodilators of course
What steps are taken to evaluate the graft patency during postoperative evaluation of a CABG?
angiography or ultrasound doppler flow
What drug and what monitor are used during reperfusion and postoperative evaluation of CABG?
Drug = Protamine (1mg/100 U Heparin given slowwwlyyy)
Monitor = TEE (to check new and persistent regional wall motion abnormalities)
Prevention and treatment of arrhythmias during postoperative evaluation of CABG include all of the following except:
A. monitor electrolytes
B. treat sinus or SVT with beta blockers or diltiazem
C. shock for Vtach and fibrillation
D. pacemaker for any AV block
D. = pacemaker for COMPLETE AV block only
Which term is defined as extubation within 8 hours after surgery and early mobilization and discharge from hospital?
Which term is defined as immediate extubation in operating room, before transfer to ICU or intermediate care?
Early extubation for OP-CABG will do all of the following except:
A. prevent airway and lung trauma
B. reduce nurse dependency
C. increase nurse dependency
D. improve CO via spontaneous breathing
E. decrease patient stress
What is the preferred anesthetic option for early ambulation and postoperative analgesia for OP-CABG patient?
Where do donor hearts usually come from?
brain dead patients following head trauma or hemorrhage
Most cardiac transplant centers do not consider candidates older than ______ or with a life expectancy under ____ years
Donor-Recipient heart compatibility is based on what 3 things?
2. ABO blood type
3. cytomegalovirus serology
Which of the following is not an indication for cardiac transplant?
A. adult congenital or valvular heart disease
B. failing prior heart transplant
C. Irreversible pulmonary hypertension
D. Hypoplastic left heart syndrome (HLHA) in neonates
E. end stage heart failure due to ischemic or nonischemic cardiomyopathy
C. = this is actually a CONTRAINDICATION
Cardiac transplant is the treatment of choice reserved for otherwise healthy patients that are unlikely to survive the next _____ to _____ months without it
Which of the following is NOT a contraindication to cardiac transplant:
A. Solid organ or hematologic cancer within the last 10 years
B. active infection
C. recent pulmonary thromboembolism with pulmonary infarction
D. irreversible pulmonary hypertension
E. irreversible renal or hepatic dysfunction
A. = would be a contraindication if it was active or recent within the last 5 years.
true or false: cardiac transplant patients are considered full stomach
true! = they usually are not in a fasting state
what type of drugs are cardiac transplant patients usually coming in on?
What are 4 examples of mechanical circulatory support that a cardiac transplant may present with prior to surgery?
Coagulation disturbances in cardiac transplant patients is due to passive congestion of the _______ as a result of CHF.
What type of drug is usually started in the preoperative period for cardiac transplant patients? Give 3 examples
-Calcineurine inhibitor (cyclosporine or Tacrolimus)
Immunosuppressive drugs for cardiac transplant patients are at risk of what 2 things?
1. nephrotoxicity (will see increased creatinine concentration)
2. cyclosporine induced hypertension (treat with CCB or ACE-I)
What is important to maintain for cardiac transplant patients due to their preload dependency?
what is the risk of timing your induction sequence for cardiac transplant if it is delayed?
you jeopardize the donor heart by prolong the period of ischemia
What is the preferred anesthetic plan for induction of a cardiac transplant patient?
During induction of a cardiac transplant patient who have low EF, it can be helpful to infuse _____________ at a rate of _________ to avoid bradycardia and decreased CO
What vitals do you want to promptly treat and avoid during induction of a cardiac transplant patient?
avoid hypercarbia and hypoxia
promptly treat bradycardia and hypotension
what is placed IMMEDIATELY after induction of a cardiac transplant patient?
All of the following are possible induction plans for a cardiac transplant patient EXCEPT:
A. low dose ketamine and Versed followed by MR
B. Sufentanil 5 mcg/kg followed by succs 1.5 mg/kg for RSI
C. Fentanyl 15-20 mcg/kg +/- Propofol 1.5-2.5 mg/kg followed by MR
D. Fentanyl 5-10 mcg/kg +/- Etomidate .2-.3 mg/kg followed by MR
what is good choice for paralysis for cardiac transplant patient and why?
it avoids histamine release and is long acting
What is the most stimulating part of cardiac transplantation surgery?
The goal is to keep SBP < ______ , how?
How do you adjust your vent setting during this part?
120 (fentanyl & NTG)
turn the dang vent off so surgeon doesn't cut the lung
Heparin for cardiac transplant:
How much is given?
>400 seconds tested after 3 minutes heparin given
How does Amicar or TXA benefit for cardiac transplantation surgery?
antifibrinolytics that prevent plasmin binding to fibrin which helps to prevent post-op bleeding
**prevents break down of fibrin clot
During excision of the heart for cardiac transplant, explain the following steps.
1. Is the patient on CBP when the vena cava and aorta are first being cannulated?
2. What is then cross clamped?
3. What are used as tourniquets to avoid VAE?
4. What is then transected?
5. The atria is now incised but what remains?
6. What monitor is now withdrawn to the SVC?
4.PA and aorta
When a patient receives a new donor heart, all of the following steps must completed except:
A. The left IJ is used for biopsy access because the CVC/PAC access is via right IJ
B.Saline flush and remove air
C. anastomose to recipient atrial remnants
D. donor aorta and pulmonary artery connected end to end with recipient vessels
A. = flip the sentence around = the right IJ is used for biopsy access and CVC/PAC access is via the left IJ at this point.
true or false: when coming off bypass from cardiac transplantation, you do not refloat PAC in conjunction with TEE
false - you DO. it's actually a goal that needs to be met when coming off bypass
What may be seen when coming off bypass on the ECG due to the native sinus node if the original atrium is used for anastomosis for the grafted heart?
2 P waves
what is an important step when coming off bypass that is often forgotten???
turn the ventilator back ON!
true or false: transplanted heart lacks innervation and does not respond to autonomic influences when coming off bypass
what happens to HR when coming off bypass from cardiac transplantation?
Which of the following is FALSE regarding coming off bypass?
A. density of alpha and beta receptors are unchanged
B. Increased response to direct acting sympathomimetic drugs and circulating catecholamines
C. blunted response to ephedrine
D. Vagolytic drugs such as atropine do not increase HR and anticholinesterases do not slow HR
B. = there is a NORMAL response
All of the following are true regarding cardiac output when coming off bypass for cardiac transplantation except:
A. Hypovolemia poorly tolerated by these patients
B. Transplanted heart is able to increase HR in response to hypovolemia
C. Maintain cardiac output by increasing stroke volume
D. After several minutes the HR increase in response to circulating catecholamines
B. = it is UNABLE to increase HR in response to hypovolemia
what is a common complication with post-CPB that is caused by advanced heart failure prior to the heart transplant?
For patients who experience pulmonary hypertension coming off bypass, the new heart has to adapt to sudden increase in _________, and if not treated can cause _______ failure.
What is the treatment for this?
Tx = pulmonary vasodilators via prostaglandins E, NO, milrinone, isoproterenol
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