Term
| How is the octupus or epicardial stabilization device helpful in off pump CABG? |
|
Definition
| It allows lifting of the heart for anastomosis versus compressing it which allows for better hemodynamic stability. |
|
|
Term
| What did they used to use to help slow the heart for off pump CABG? |
|
Definition
| Beta blockers, but not anymore with the use of the octopus |
|
|
Term
| T/F: For off pump CABG, full or half doses of anticoagulants are used. |
|
Definition
|
|
Term
| during off pump CABG, the ____ machine is ______ and ready to use. |
|
Definition
|
|
Term
| During anastomosis to the coronary artery, IVF is ______ and low dose infusino of a _______ may be used. |
|
Definition
|
|
Term
| During proximal anastamosis with the partial clamp, the BP is ______ to _____mmHg and a _______ may be used. |
|
Definition
| decreased, 90-100, vasodilator |
|
|
Term
| IV ______ is the most commonly used vasodilator because of its rapid onset and offset and its ability to _______ myocardial ischemia. |
|
Definition
|
|
Term
| Off pump was initially developed for ____ vessel disease, but is now used for _____ vessel disease, ____, and pts with _____ ___ function. |
|
Definition
| 1-2, multi, redo, poor LV |
|
|
Term
| For an off pump procdure, a ____ may be used for vessels with serious occlusion for distal flow. |
|
Definition
|
|
Term
| _____ _____ have shown to be cardioprotectant in an off pump procedure. |
|
Definition
|
|
Term
| How is aneshetic management different in an off pump procedure (compared to on pump)? |
|
Definition
| Long procedures with long term intubation are replaced with shorter acting drugs and the goal is early extubation. |
|
|
Term
| What monitors are needed for an off-pump procedure? |
|
Definition
| Arterial line and central line. PA catheter is not necessary. |
|
|
Term
| T/F: A PA catheter is necessary during an off pump procedure. |
|
Definition
| False, a PA catheter is not necessary. |
|
|
Term
| What are the two major concerns for anesthesia in an off-pump procedure? |
|
Definition
|
|
Term
| List 5 reasons why ischemia is difficult to detect during off-pump surgery? |
|
Definition
1) Standard monitors are not effective in detecting ischemia in this case.
2) ST segments changes are obscure/misleading
3) The retractor causes a low-amplitude ECG w/ axis deviation.
4) TEE may be unreliable due to a lap pad behind the heart or having the heart lifted slightly out of the chest.
5) CVP can be falsely elevated from changes in heart location, despite the patient actually being hypovolemic. |
|
|
Term
| The best way to avoid hemodynamic swings and subsequent ischemia is... |
|
Definition
| direct observation of the heart and surgeon communication. |
|
|
Term
| In off-pump surgery, the ______ _____ is occluded to isolate the ________ site. This means ______!! |
|
Definition
| coronary artery, anastamosis, ISHCEMIA |
|
|
Term
| Collateral circulation has frequently developed in _____ ____ lesions, which helps during coronary artery occlusion. |
|
Definition
|
|
Term
| Right coronary artery occlusion usually causes what 3 things? |
|
Definition
1) bradycardia
2) atrial arrhythmias
3) heart blocks |
|
|
Term
| What should be placed before the procedure if you are going to perform right coronary artery occlusion? |
|
Definition
|
|
Term
| Left side lesions will cause what two things? |
|
Definition
1) malignant ventricular arrhythmias
2) hemodynamic collapse |
|
|
Term
| In left sided lesions, what 3 interventions may be required by anesthesia? |
|
Definition
1) Inotropes
2) Vasoconstrictors
3) Volume |
|
|
Term
| What additional interventions may occur in off-pump surgery of a left side lesion? |
|
Definition
|
|
Term
| In off pump, the most critical lesion is performed _____ |
|
Definition
| Last (which is different than on pump) |
|
|
Term
| _____ _____ have proven to be "cardioprotectant" |
|
Definition
|
|
Term
| The normothermia and less invasive nature of off pump procedures allow for what 3 improvements over on-pump procedures? |
|
Definition
1) early extubation
2) improves coagulation profiles
3) improves patient satisfaction |
|
|
Term
| T/F: In off pump procedures, the use of anticoagulants and protamine is the same as on-pump. |
|
Definition
| False. There is variability in the use of anticoagulants and protamine. Some places use half or full doses of anticoagulants, some reverse with protamine, some use lower doses of protamine and others do not. |
|
|
Term
| List 4 ways to control post-op pain in off-pump surgery |
|
Definition
1) Narcotics
2) NSAIDS (if no renal involvement)
3) Epidurals (some concern with anticoagulation)
4) skin infiltration |
|
|
Term
| Deep hypothermic arrest is used for major surgical procedures because it provides a _______, ____ ____, ______ field. |
|
Definition
| motionless, cannula free, bloodless field. |
|
|
Term
| Deep hypothermic arrest is frequently used for what two procedures? |
|
Definition
1) giant cerebral aneurysms
2) ascending aortic aneurysms |
|
|
Term
| Cooling in deep hypothermic arrest is done to what temperature? |
|
Definition
|
|
Term
| Deep circulatory arrest can be tolerated for up to ___ _____ |
|
Definition
|
|
Term
| T/F: muscle relaxants should be given when using deep hypothermic arrest |
|
Definition
|
|
Term
| In cooling for deep hypothermic arrest, ____ is stopped, venous cannula is ____ ____, and blood _____ ______. |
|
Definition
| CPB, left open, passively exsanguinates |
|
|
Term
| T/F: Ambient room temp and sources do not need to be minimized in deep hypothermic arrest |
|
Definition
| False, you need to minimize ambient room temp and sources |
|
|
Term
| What can you do to the head to assist with cooling in deep hypothermic arrest? |
|
Definition
| Fucking pack that noggin with is packs. |
|
|
Term
| ____ should be monitored in deep hypothermic arrest |
|
Definition
|
|
Term
| Cooling for deep hypothermic arrest involves ______ and _______ cooling to the brain. |
|
Definition
|
|
Term
| Concentric vs Eccentric Hypertrophy (image) |
|
Definition
|
|
Term
|
Definition
| Occurs due to a pressure overload as with aortic stenosis or chronic hypertension, the ventricular wall becomes thicker and stiffer leading to reduced compliance, impaired cardiac filling and diastolic dysfunction. |
|
|
Term
|
Definition
| Occurs with a volume overload and the wall is thickened a little but the radius is also increased. The internet tells me this occurs with endurance athletes, aortic regurgitation causes eccentric and concentric hypertrophy, and mitral regurgitation causes eccentric hypertrophy. |
|
|
Term
| Cardiac remodeling eventually leads to _______ and _______ in _______ function |
|
Definition
| decompensation, deterioration, ventricular |
|
|
Term
| Both ______ and _______ functions require energy and can be compromised by ________ ischemia. |
|
Definition
| systolic, diastolic, ventricular |
|
|
Term
| What is the triad associated with aortic stenosis? |
|
Definition
Mnemoic SAC
1) Syncope
2) Angina
3) CHF |
|
|
Term
| In aortic stenosis, once angina develops, the life expectancy is ____ years. |
|
Definition
|
|
Term
| In aortic stenosis, once syncope develops, the life expectancy is ____ years. |
|
Definition
|
|
Term
| In aortic stenosis, once CHF develops, the life expectancy is ____ years. |
|
Definition
|
|
Term
|
Definition
|
|
Term
| When the aortic valve is <____cm2, symptoms are usually present. |
|
Definition
|
|
Term
| What waves are significant on the swan in aortic stenosis? |
|
Definition
|
|
Term
| The IABP ideally inflates just after the _____ ____ (the closure of the ______ ____ and beginning of _______). |
|
Definition
| dichrotic notch, aortic valve, diastole |
|
|
Term
| The balloon should ideally _____ just prior to ___ ______ to ______ afterload. |
|
Definition
| deflate, LV ejection, afterload |
|
|
Term
| Name 3 characteristics of people with an aortic dissection. |
|
Definition
1) 50-70
2) Hypertension
3) Connective tissue disorder (marphan's dz) |
|
|
Term
| 3 symptoms of people with aortic dissection |
|
Definition
1) Aortic murmur
2) severe pain (tearing, persisting, interscapular, precordial or neck)
3) Cardiac tamponade (rupture into the pericardium) |
|
|
Term
| which type of aortic dissection do you medically manage with control or pain and blood pressure? |
|
Definition
|
|
Term
| Which types of aortic dissections need surgical management? |
|
Definition
Type A (Types I and II)
Complicated Type III's (Type B) |
|
|
Term
| % of hospital deaths for ascending aorta dissection |
|
Definition
|
|
Term
| % of hospital deaths for arch aorta dissection |
|
Definition
| 10-25% (to 50%) due to the important branches coming off the arch |
|
|
Term
| % of hospital deaths for descending aorta dissection |
|
Definition
|
|
Term
| Heparin (with antithrombin III) predominantly targets |
|
Definition
Thrombin (factor 2a)
& Factor Xa |
|
|
Term
| Heparin is an ______ compound |
|
Definition
|
|
Term
| Does heparin inhibit factors V and III? |
|
Definition
| yes, it indirectly inhibits these facors because thrombin induces activation of factors V and VIII |
|
|
Term
| What is the most commonly used anticoagulant in the hospital? |
|
Definition
|
|
Term
| Heparin enhances the effect of antithrombin III by ______ times |
|
Definition
|
|
Term
| The therapeutic aPTT range is _____ times the control |
|
Definition
|
|
Term
| Is it ok to give heparin to pregnant women? |
|
Definition
| yeah, it does not cross the placenta |
|
|
Term
| Is heparin lipophobic or lipophillic |
|
Definition
|
|
Term
| Plasma 1/2 life of heparin |
|
Definition
1-2 hours
(for testing calculations it is 2 hours) |
|
|
Term
| Plasma 1/2 life of heparin increases with what 3 things? |
|
Definition
| 1) Liver and renal dysfunction 2) doses >100U/kg 3) temp < 37 C |
|
|
Term
| What is the heparin does for open heart? |
|
Definition
|
|
Term
| WHat is the target ACT for open hearts for heparin |
|
Definition
|
|
Term
| If the patient isn't repsonding to doses of heparin, what do you expect, and how the fuck are you going to fix it? |
|
Definition
| You suspect an antithrombin III deficiency, and you give FFP b/c it contains antithrombin III |
|
|
Term
| What can long term heparin and prednisone use cause? |
|
Definition
|
|
Term
| Heparin is used to treat fetal growth retardation at was dosage? |
|
Definition
|
|
Term
| What is a cause of antithrombin III deficiency? |
|
Definition
| estrogen-containing contraceptives |
|
|
Term
| What 3 things can produce resistance or reduce responsiveness to heparin? |
|
Definition
-continuous use of heparin preoperatively
-hemodilution of antithrombin III
-nitroglycerin infusions |
|
|
Term
| Large doses of heparin can cause transient hypotension, due to what mechanism? |
|
Definition
| Due to DIRECT action on the vascular smooth musculature. |
|
|
Term
| Is protamine an acid or base? |
|
Definition
|
|
Term
| What is protamine made from? |
|
Definition
|
|
Term
| _____ charged protamine binds to the _____ charged heparin forming a ______ ______ that has NO coagulant effecs. |
|
Definition
| Postively, negatively, stable complex |
|
|
Term
| The protamine-heparin complex is cleared via the _________ _____ within approximately ___ _______. |
|
Definition
| reticuloendothelial system, 20 minutes, |
|
|
Term
|
Definition
| 1 mg for every 100 units of predicted heparin |
|
|
Term
| 2/3rds of protamine is ______- a very alkaline amino acid. |
|
Definition
|
|
Term
|
Definition
| Heparin can still be lurking around after the protamine-heparin compound is cleared in 20 minutes. |
|
|
Term
| it's been 2 hours since the patient's last dose of heparin (4000 units). How much heparin is left and how much protamine do you need to reverse it? |
|
Definition
| 2000 units of heparin is left, you need 20 mg of protamine |
|
|
Term
| Side effects of rapid protamine injection include: |
|
Definition
-histamine release
-hypotension
-tachycardia
-facial flushing |
|
|
Term
| What are other side effects of protamine? |
|
Definition
-pulmonary hypertension
-allergic reactions |
|
|
Term
| What previous exposure increases your risk of allergic reaction to protamine? |
|
Definition
-NPH insulin
-protamine zinc insulin
-fish allergy
-vasectomy or infertile males |
|
|
Term
| Pulmonary HTN with protamine is caused by what and treated with what? |
|
Definition
-caused by thromboxane A2 and serotonin
-treat with a cyclooxygenase inhibitor |
|
|
Term
| if the pt has a protamine allergy what the hell can you do for reversal? |
|
Definition
-pretreat with Histamine blockers, steroids, and do a test dose of protamine
-Let the heparin metabolize on its own
-alternative reversal: hexadimethrine, platelet factor 4, heparinase I, methylene blue |
|
|
Term
|
Definition
-natural polypeptic
-bind heparin
-has been used in CPB |
|
|
Term
|
Definition
-Heparin degrading enzyme
-tested post CPB |
|
|
Term
| What are the alternate reversals for heparin? |
|
Definition
1) hexadimethrine
2) platelet factor 4
3) heparinase I
4) methylene blue |
|
|
Term
| What are the three alternatives to heparin? |
|
Definition
1) hirudin
2) hirulog
3) argatroban |
|
|
Term
| Hirudin and hirulog bind to what clotting factor |
|
Definition
|
|
Term
| Are hirudin, hirulog, and argatroban dependent on antithrombin III? |
|
Definition
| No, because they work directly on thrombin |
|
|
Term
| Alternatives to heparin are used to treat pts with _____ syndrome, and they are not reversed by ______ or _______ |
|
Definition
| HITT, protamine, platelet factor 4 |
|
|
Term
| Do alternatives to heparin impact aPTT and ACT? |
|
Definition
|
|
Term
| Argatroban elmination half-life |
|
Definition
|
|
Term
| _____ is approved for use in pts with a history of ____ and use in ____ circuitry. |
|
Definition
|
|
Term
| Low molecular weight heparins inhibit which factor mostly? |
|
Definition
|
|
Term
| Do LMWHs effect ACT an aPTT |
|
Definition
| No, and these are not monitored |
|
|
Term
| Surgery should be delayed ___ hours after the last dose of LMWH |
|
Definition
|
|
Term
| If an emergency: ________ neutralizes ____% of anti Xa of LMWH |
|
Definition
|
|
Term
| Does warfarin effect platelets? |
|
Definition
|
|
Term
| Warfarin causes a reduction in vitamin K which then inhbits the conversion of what clotting factors? |
|
Definition
|
|
Term
| The therapeutic effect of coumadin occurs after coag proteins are reduced by ___-___% |
|
Definition
|
|
Term
| Prothrombin Time (PT) is sensitive to what factors? |
|
Definition
|
|
Term
| Warfarin pKa and is it an acid or base? |
|
Definition
|
|
Term
|
Definition
|
|
Term
| Warfarin elimination half-life |
|
Definition
|
|
Term
| Warfarin duration of action |
|
Definition
|
|
Term
| Does Warfarin cross into breast milk? |
|
Definition
|
|
Term
| Does warfarin cross the placenta? |
|
Definition
| YES! it can cause serious fetal side effects!!!!!!! |
|
|
Term
| List 4 conditions that alter Warfarin levels |
|
Definition
1) foods with lots of vitamin K
2) alcohol
3) other anticaogulants (synergism)
4) other highly protein bound drugs (cimetadine, phenylbutazone, amiodarone) |
|
|
Term
| Treatment for mild bleeding from Warfarin |
|
Definition
-Vitamin K 1-5mg IV (1mg/min) or
10-20mg PO will reverse bleeding in 24 hours |
|
|
Term
| Treatment for severe bleeding from Warfarin |
|
Definition
| FFP, recombinant factor VIIa, prothrombin complex |
|
|
Term
| Antifibrinolytics reversibly bind with _________ preventing its conversion to _____ and the breakdown of fibrin |
|
Definition
|
|
Term
| Aprotinin is a reversible broad spectrum _____ _______ inhibitor, that inhibits formation of _____. |
|
Definition
|
|
Term
| By blocking plasmin, aprotinin increases ____ formation and increases _____ binding. |
|
Definition
|
|
Term
| Aprotinin blocks the _________ ______ of CPB and prevents blood loss by inhibiting ______ formation. |
|
Definition
| inflammatory response, plasmin |
|
|
Term
| Aprotonin it frequently used in what kind of heart surgery? |
|
Definition
|
|
Term
| Repeat dosing of aprotonin increases the incidence of allergic reaction __-__% |
|
Definition
|
|
Term
| Reaction to aprotonin increases if used within __ months of the initial dose |
|
Definition
|
|
Term
| 1ml of aprotinin contains how many KIUs? |
|
Definition
|
|
Term
| What is the test dose of aprotonin? |
|
Definition
| 1ml (10,000 KIUs) given 10 minutes before the loading dose |
|
|
Term
| What is full hammersmith dosing of aprotinin? |
|
Definition
| 2,000,000 KIUs IV over 20-30 minutes and 2,000,000 KIU in priming solution of pump, IV drip of 500,000 KIU for length of case until chest closed |
|
|
Term
| Aprotinin elimination half life and is eliminated by what primarily. |
|
Definition
| 1.5-2 hours, primarily renal elimination |
|
|
Term
| Aprotinin causes what in the supine position? |
|
Definition
|
|
Term
| Aprotinin has a ______ effect with heparin, increasing the ____> |
|
Definition
|
|
Term
| Aminocaproic Acid (Amicar) works by inhibiting ______ ______ |
|
Definition
|
|
Term
| Aminocaproic Acid (Amicar) dose |
|
Definition
| 4-5 Grams IV over 1 hour followed by 1 Gram/hour infusion |
|
|
Term
| Heart Room Aminocaproic Acid (Amicar) dose |
|
Definition
|
|
Term
| Aminocaproic Acid (Amicar) should not be used in DIC but can be used in any coagulopathy associated with primary fibrinolysis. How do you distinguish DIC vs primary fibrinolysis? |
|
Definition
| DIC has a consumption of platelets, and platelets are normal in primary fibrinolysis. |
|
|
