Term
| Patients with atherosclerotic coronary artery disease become symptomatic when lesions become ____% occluded |
|
Definition
|
|
Term
| Ischemic cardiac cells become more irritable,making the heart more vulnerable to what two things? |
|
Definition
1) V. Fib
2) Alteration in conduction pathways |
|
|
Term
|
Definition
| A condition which leads to congestive edema (both alveolar and interstitial) and hemorrhagic atelectasis. |
|
|
Term
| What is the theory behind pump lung? |
|
Definition
| That it is due to microemboli of protein aggregates, destroyed platelets, damaged fibrin and fat particles that imbed in the lung. |
|
|
Term
| Acute lung injury occurs due to activation of the compliment cascade and inflammatory system in response to what 3 factors? |
|
Definition
1) Hemodilution
2) Lung Hypoxia
3) Increased PA pressures |
|
|
Term
| Chest cooling causes injury to the _____ _____, and reduced _____ ______. |
|
Definition
| phrenic nerve, pulmonary function |
|
|
Term
| The primary post operative neuro complication after CPB is _____ |
|
Definition
|
|
Term
| ___% of patients demonstrate some neuro deficit after CPB |
|
Definition
|
|
Term
| The central nervous system is at risk when CPP decreases. Autoregulation occurs between what MAP? |
|
Definition
|
|
Term
| What is cerebral perfusion when autoregulation is intact? |
|
Definition
|
|
Term
| What occurs if CPP autoregulation is lost? |
|
Definition
|
|
Term
| Pump runs _____ are associated with an increase in cognitive dysfunction |
|
Definition
|
|
Term
| Explain how insulin resistance occurs as a result of CPB |
|
Definition
| Catecholamine levels rise significantly as time on CPB increases which may make the cells resistant even to exogenous insulin. |
|
|
Term
| T/F: Glucose containing solutions should be avoided in pts on CPB. |
|
Definition
| True, don't give glucose in IVF |
|
|
Term
| What organ is likely to become ischemic on CPB? |
|
Definition
| The bowel. Ischemic bowel leaks can occur. |
|
|
Term
| CPB times of _______ are associated with high incidence of post operative renal complications. |
|
Definition
|
|
Term
| List 6 factors that contribute to renal complications post CPB (See Mnemonic on other side) |
|
Definition
Mnemonic (V.I.P Cat)
1) Vasopressor use
2) IABP use
3) Procedure type
4) Cardiac Output (before and after)
5) Acute MI
6) Transfusion (massive transfusion) |
|
|
Term
| _____ levels are predictors of morbidity for renal complications |
|
Definition
|
|
Term
|
Definition
|
|
Term
| Abnormal creatinine is... |
|
Definition
|
|
Term
| Creatinine level that is considered renal failure |
|
Definition
|
|
Term
| Preoperative creatinine levels are _____ proportional to post operative mortality and renal failure and _______ related to cardiac index. |
|
Definition
|
|
Term
| Hypothermia ______ renal blood flow |
|
Definition
|
|
Term
| What 3 things are done with CPB to maintain adequate urine output while on pump? |
|
Definition
1) Hemodilution
2) mannitol in the priming solution
3) maintaining GFR |
|
|
Term
| Goal urine output while on CPB |
|
Definition
|
|
Term
| ______ while on CPB is detrimental to renal tubules |
|
Definition
|
|
Term
| In addition to catecholamines, what other substance is released by the body in response to CPB? |
|
Definition
|
|
Term
| What lab test should be checked after the patient is placed on pump and after they come off pump? |
|
Definition
|
|
Term
| What is the impact of CPB on potassium? |
|
Definition
| Cellular potassium uptake is increased, resulting in hypokalemia |
|
|
Term
| What is the impact of CPB on platelets? |
|
Definition
| Platelets become non-functional at 28 degrees celsius |
|
|
Term
| What is the impact of CPB on ACT, PT, and PTT? |
|
Definition
| They prolong with hypothermia |
|
|
Term
|
Definition
| is to provide a motionless heart on a bloodless field while the vital organs continue to be adequately oxygenated. |
|
|
Term
| CPB provides what 3 things |
|
Definition
1) respiration
2) circulation
3) temperature regulation |
|
|
Term
| CPB produces significant physiologic and physical changes in the blood (______, _____, _____, _____) and flow dynamics |
|
Definition
heparinization
platelet dysfunction
coagulopathy
fibrinolysis |
|
|
Term
| CPB changes the blood's _____ |
|
Definition
|
|
Term
| CPB produces an ____ ____ ______ response, causing symptoms similar to ____ or _____. |
|
Definition
| All body inflammatory, sepsis, trauma |
|
|
Term
| In CPB flow is changed from a _____ dynamic to a ___________ dynamic. |
|
Definition
|
|
Term
| Hemodilution causes the platelet count to drop by ___% (but usually remains> ______) |
|
Definition
|
|
Term
| Hemodilution causes a reduction in _____ _____ |
|
Definition
|
|
Term
| List the 7 components that comprise CPB |
|
Definition
1) oxygenator
2) venous reserve
3) arterial pump
4) cardioplegia circuit
5) ventilating circuit
6) monitoring and safety systems
7) various filters |
|
|
Term
| Since venous drainage in the CPB circuit to the venous reservoir depends on gravity, what 3 things can impact flow into the venous reservoir? |
|
Definition
1) The pt's intravascular volume
2) Position of the line & table height
3) Line resistance |
|
|
Term
| If the venous reservoir volume is low, then what can occur? |
|
Definition
| Air can be entrained into the arterial circulation |
|
|
Term
| At the time of aortic cannulation,how will BP be managed? |
|
Definition
| It will be reduced to improve visualization and prevent high pressure spray. |
|
|
Term
| There are 3 suction catheters that drain into the cardiotomy reservoir, where are they located? |
|
Definition
1) aortic root
2) LV
3) surgical field |
|
|
Term
| The most common solution used for cardioplegia |
|
Definition
| Blood mixed with hyperkalemic crystalloid (4:1; blood; crystalloid radio) |
|
|
Term
| The temperature of cardioplegic solution |
|
Definition
|
|
Term
| T/F: The cardioplegia solution is based on weight or BSA |
|
Definition
|
|
Term
| How often is cardioplegia solution administered during CPB |
|
Definition
|
|
Term
| What three ways can cardioplegic solution be delivered? |
|
Definition
1) antegrade (aortic root)
2) retrograde (coronary sinus)
3) directly into coronary ostia (ostial) |
|
|
Term
| ______ and ______ delivery of cardioplegic solution is often used simultaneously. |
|
Definition
|
|
Term
| _____ delivery of cardioplegic solution is used to perfuse areas beyond coronary blockages and during valve replacement |
|
Definition
|
|
Term
| What is the most often used method for priming the CPB |
|
Definition
|
|
Term
| Sanguineous priming is used in what 2 scenarios? |
|
Definition
1) the pt needs an exchange transfusion before CPB d/t sickle cell or heart transplant.
2) Pediatrics since the tubing used is the same for adults and they have less blood volume |
|
|
Term
| What is autologous priming? |
|
Definition
| Removing the patient's blood and adding it to the priming solution |
|
|
Term
| Asanguineous priming is used when HCT is ___ |
|
Definition
|
|
Term
| If HCT is less than 21% what will be added to the priming solution? |
|
Definition
|
|
Term
| How much solution is used to prime the CPB? |
|
Definition
|
|
Term
| Does hypothermia increase or decrease blood viscosity? |
|
Definition
|
|
Term
| The most common priming solution |
|
Definition
| A balanced solution (normosol, plasmalyte A, or Isolyte S) |
|
|
Term
| Hemodilution ______ viscosity, RBC trauma, and enhances tissue perfusion at a lower flow rate and ______ blood loss and the need for banked blood. |
|
Definition
|
|
Term
| Why is heparin added to the priming solution and when is it added? |
|
Definition
To prevent clot formation.
It is added prior to aortic cross clamping and may be added after the pt goes on CPB because it will drastically reduce heparin levels and increase the risk of clot formation. |
|
|
Term
| Why is bicarbonate added to the priming solution? |
|
Definition
| The circuit of the CPB contains acidic presrvatives. |
|
|
Term
| Why are antifibrinolytics added to the priming solution? |
|
Definition
| To reduce blood loss during surgery |
|
|
Term
| Why is mannitol added to the priming solution? |
|
Definition
|
|
Term
| Why are albumin or hetastarch added to the priming solution? |
|
Definition
| To maintain colloid osmotic pressure and to coat the artificial blood surfaces |
|
|
Term
| What steroid can be added to the priming solution? |
|
Definition
|
|
Term
| List 5 ways the CPB machine can fail |
|
Definition
Mnemonic: Pump FEAR
1) Pump Creep
2) Failure of the oxygenator
3) Electrical Failure
4) Air Embolism
5) Run away arterial pump head |
|
|
Term
| What is a potential problem with hand cranking the machine during an electrical failure? |
|
Definition
| It is easy to empty the venous reservoir and entrain air, so watch it! |
|
|
Term
| How would you manage a run away arterial pump head? |
|
Definition
-pull the electrical plug
-clamp venous/arterial lines
-move the tubing to a functional head |
|
|
Term
| What is pump creep and why is it a problem? |
|
Definition
| The roller keeps moving after it has been stoppend. It can entrain air. |
|
|
Term
| How do you manage oxygenator failure? |
|
Definition
Before cardiac arrest: wean of bypass and use the vent
After cardiac arrest: change the oxygenator during full arrest |
|
|
Term
| List 5 factors that increase risk with heart surgery |
|
Definition
1) age
2) functional status (METs)
3) multiple procedures in the same operative time
4)Time on Pump
5) Operative mortality is twice as high in women compared to men |
|
|
Term
| T/F: Cardiac drugs should be taken up to the day of surgery, and most clinicians advocate taking ACE inhibitors up to the day of surgery |
|
Definition
|
|
Term
| T/F: invasive lines should be placed prior to induction to observe for hemodynamic response to induction |
|
Definition
| Trick Question! Some people do lines before induction and some prefer to do it after induction. |
|
|
Term
| If a pt has UTI preop, what will happen? |
|
Definition
|
|
Term
| If a pt has a normal EF in your preop eval, is everything going to be awesome? |
|
Definition
| Not necessarily, check cath report, carotid dopplers, echo report, lab tests, coexisting disease, and vavular lesions |
|
|
Term
| How many IVs do you want in preop? |
|
Definition
|
|
Term
| Should the art line be femoral or radial? |
|
Definition
| femoral is better than radial in some cases, if they are taking a graft from that arm. |
|
|
Term
| What size central line do you use for a regular heart? |
|
Definition
|
|
Term
| What size central line do you use for a redo heart? |
|
Definition
|
|
Term
| What do you also need in addition to your Art line and central line for monitoring? |
|
Definition
|
|
Term
| Note _____ _____ and ___ ______ PRIOR to induction!! |
|
Definition
| filling pressures, ST segment |
|
|
Term
| List 6 things you need done before induction |
|
Definition
1) oxygen ASAP
2) sedation
3) all monitors on
4) ABGs sent
5) CO obtained
6) note filling pressures and ST segment |
|
|
Term
| Primary concern during induction |
|
Definition
| Prevention of myocardial ischemia |
|
|
Term
| List 7 factors for induction (for prevention of ischemia) |
|
Definition
1) Avoid tachycardia
2) Preoxygenate
3) Reduce Wall tension with nitro
4) Reduce heart workload
5) Maintain coronary perfusion with neosynephrine
6) Fluid replacement
7) Slow induction |
|
|
Term
| What are 5 considerations for drugs for a slow induction? |
|
Definition
1) midazolam is used
2) large doses of opioids
3) lower doses of volatiles
4) sedative hypnotic
5) muscle relaxant |
|
|
Term
| What should you always have on the table for induction for heart surgery? |
|
Definition
| ALL UPS AND DOWNS SHOULD BE ON THE TABLE!! |
|
|
Term
| What size ETT for women and men for heart surgery? |
|
Definition
| 8.0 for women, 9.0 for dudes |
|
|
Term
|
Definition
-draw baseline labs
-Cardiac Output
-gradually deepen the anesthetic
-OGT/NGT
-TEE probe
-Amicar (150mg/kg)
-Aprotinin |
|
|
Term
| Dose of Amicar post-induction |
|
Definition
|
|
Term
| Where should you keep the patients vitals |
|
Definition
| Keep them where they live, find their baseline |
|
|
Term
| Post-induction, what are some of your steps? |
|
Definition
-label all lines
-medication is accessible
-check a cardiac output
-draw baseline ABG |
|
|
Term
| The endoscopic vein harvest is a good indicator for what? |
|
Definition
| The depth of anesthesia, this begins prior to the sternotomy, so you can use it to tell how much narcotic will be needed for the sternotomy. |
|
|
Term
| ____ _____ and ______ are 2 very stimulating events |
|
Definition
| skin incision, sternotomy |
|
|
Term
| During sternotomy, the lungs must be ______ |
|
Definition
|
|
Term
| What is the most common time for recall? |
|
Definition
|
|
Term
| Considerations during sternotomy |
|
Definition
-stop ventilation and disconnect the circuit to deflate the lungs
-right atrium can be accidentally opened
-Muscle relaxant on board to prevent breathing and air entrainment
-Bradycardia d/t vagal outflow (be ready to treat) |
|
|
Term
| If RV or aorta is entered with sternotomy, you must do the following 4 steps (Mnemonic on other side)... |
|
Definition
Mnemonic: SHIT!!!!!!!!
1) Steep trendelenburg
2) Heparin- give heparin
3) Ice- possibly pack the head in ice
4) Thiopental (pentothal) 30 mg/kg |
|
|
Term
| LIMA dissection considerations |
|
Definition
-Left radial art-line can be dampened by the clamp
-little stimulation
-many sympathetic fibers on pericardium (so wide swings in HR and BP)
-Look at the heart b/c you can see if it is all jacked up, akinetic wall, dehydration
-RA and Aorta are prepared for cannulation at this time |
|
|
Term
| Heparin _________ IVP THROUGH A CENTRAL LINE is given BEFORE the aorta is cannulated!!! |
|
Definition
|
|
Term
|
Definition
3-5 minutes after heparin bolus
and 400 seconds before CPB initiation |
|
|
Term
| What problem do you expect after a large dose of heparin? |
|
Definition
|
|
Term
| You want the BP below what number before cannulation? |
|
Definition
|
|
Term
| Aortic cannulation is associated with a ______ ____ d/t stimulation of _____ _____ in the ______ _____ |
|
Definition
| hypertensive response, sympathetic nerves, aortic arch |
|
|
Term
| How should BP be managed before aortic cannulation? |
|
Definition
| It should be reduced with nitro, narcotci, volatile, propofol, or esmolol. |
|
|
Term
| The aortic is cannulated _____, and then it is tested for pressure and allows for monitoring. |
|
Definition
|
|
Term
| Venous cannulation in the right atrium to drain the SVC and IVC can result in? |
|
Definition
-decreased BP
-decreased CO
-arrhythmias |
|
|
Term
| Once the aortic and venous cannulation is performed, then ____ ____ can begin. Cooling can begin. The target temp for most cases on pump is _____. |
|
Definition
| partial CPB, 28 degrees celsius |
|
|
Term
|
Definition
-LV distension occurs from AO regurg, or blood flow through bronchial/thebesian veins
-this increase myocardial wall tension, increases O2 consumption, and results in ischemia
-Tension leads to poor cardioplegia to the deep vessels |
|
|
Term
| Cardioplegia occurs retrograde through the _____ _____ and antegrade through the ____ ___ or _____` |
|
Definition
| coronary sinus, aortic root, ostia |
|
|
Term
| During cardioplegia cannulation, severe ______ can occur and require _____ from you or the perfusionist. |
|
Definition
|
|
Term
| Cardioplegia is given every ____-____ minutes to avoid ischemia |
|
Definition
|
|
Term
| What event can occur after the cardioplegia catheters are in place? |
|
Definition
| Aortic cross clamping, document the time this happens! |
|
|
Term
| Which coronary artery graft is placed first? which is placed last? |
|
Definition
| The most severe is first, the LIMA is placed last. |
|
|
Term
| List 6 things to check before initiating CPB |
|
Definition
1) Arterial inflow of oxygenated blood is adequate
2) Venous return to the reservoir is adequate
3) ACT at least 400 seconds
4) Core temp monitor
5) Pupil size/symmetry baseline assessment
6) Depth of anesthesia is adequate |
|
|
Term
| What is your goal MAP and CI after AO cross clamp and CBP initiation |
|
Definition
MAP 50-70 mmHg
CI 2 L/min/m2 |
|
|
Term
| After AO cross clamp/CPB initiation ___ will ____ as a reflexive response to nonpulsatile flow and hemodilution |
|
Definition
|
|
Term
| Due to dilution and larger volume distribution you may need more of what after CPB initiation |
|
Definition
|
|
Term
| After CPB starts what do you do with the lungs? |
|
Definition
|
|
Term
| Core temp is often monitored via ______ |
|
Definition
|
|
Term
| ACTs are checked every _____ _____ after CPB initiation |
|
Definition
|
|
Term
| After CPB initiation, the heart is cooled with an ___ ____ ____ |
|
Definition
|
|
Term
| During rewarming there is a high risk for ____ |
|
Definition
|
|
Term
| During rewarming how do you position the patient? |
|
Definition
|
|
Term
| What infusion might you start during rewarming after the heart starts beating? |
|
Definition
|
|
Term
| What will be weird about the ECG after the heart beat is intitiated? |
|
Definition
| The QRS will be wide due to air and washout of cardioplegia. "it will usually fix itself gradually". |
|
|
Term
| List the checklist of 8 things for DC of CPB (Mnemonic on other side) |
|
Definition
Mnemonic: Rohlfs Likes CHEAP Vanilla
1) Rewarm systemically to 35-36 deg.
2) Labs- ABGs, HCT, Lytes, Plt count
3) Calibrate pressure transducers
4) Heart rate adequate, may need pacer
5) ECG- check for arrythmias/ST segment
6) Air- removal of intracardiac are by surgeon
7) Protamine
8) Ventilation- resume ventilation |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| Closure, what change do you see in CO? |
|
Definition
preload decreases and afterload increase (per Nagelhout)
CO will decrease because CO= SV x HR and SV decreases with decreased preload and elevated afterload decreases SV (wikipedia) |
|
|
Term
| What should you bring with you to transfer the patient to ICU? |
|
Definition
-monitors
-airway stuff
-drugs: ups/downs
-pacemaker
-and assess breathsounds |
|
|
