Cardiovascular CPC Review JOHN SHIELDS, DNP, CRNA

Transcription

1 Cardivascular CPC Review JOHN SHIELDS, DNP, CRNA

2 Objectives Discuss physilgical differences acrss the lifespan Discuss functin and interactin f the cardivascular system t ensure the safe and effective administratin f anesthesia Recgnize physilgical and pathphysilgical cardivascular events and manage the anesthetic in accrdance with evidence-based practices

3 Natural Histry f Heart Failure Strke vlume is maintained at expense f Increased left atrial pressure Increased diastlic pressure Pulmnary venus cngestin Renin-angitensin-aldsterne system activated Catechlamine release/sympathetic utflw Vlume retentin Renin prductin

4 Hemdynamic Management Prevent mycardial depressin Maintain nrmal heart rate and prelad Avid high afterlad Maintain cntractility Manage decmpensated heart failure N particular advantage t any agent but lwer dses recmmended Mnitr with arterial line Avid large vlumes f fluid/diurese Use ephedrine, vaspressin and pssibly nrepinephrine fr hyptensin

5 Anesthesia fr Patients with Left Ventricular Assist Devices Any general anesthesia technique is acceptable (sme blcks) Typically anticagulated N spinal r epidural Dysrhythmias (PVC s) are cmmn, including VT MAP gal is mmhg Almst all VAD patients have ICD

6 Mnitring LVAD Patients Cntinuus flw device patients will lack a palpable pulse Dppler r manual cuff pressure may be necessary Arterial line may require ultrasund Auscultate the pump if it is humming then it is running

7 Preperative Assessment with Heart Valve Disease Determine hemdynamic significance f valve lesin (NYHA class, BNP, etc.) Assessment tls H&P/ECG Heart catheterizatin/ech Assess residual biventricular functin Identify secndary effects n ther rgan systems Pulmnary functin Hepatic functin Renal functin

8 Mitral Valve Stensis Prgressive calcificatin frm rheumatic fever Right ventricular cmprmise Left atrial enlargement/atrial fibrillatin/impaired diastle High pulmnary artery pressures and right ventricular afterlad Pulmnary edema, respiratry cmprmise Surgical interventin when <1.5 cm

9 Mitral Regurgitatin Causes include rheumatic heart disease, cngenital abnrmalities, mycardial ischemia and endcarditis 60% f LV strke vlume is ejected int the left atrium during systle LA size increases t cmpensate LV underges eccentric hypertrphy t cmpensate fr vlume verlad Surgical treatment nce symptmatic

10 Mitral Valve Prlapse Occurs in 1-2.5% f ppulatin Redundancy r degeneratin f leaflets causes prlapse Diagnsed by mid-systlic click Mst peple are asymptmatic but present with chest pain, palpitatins, emblic events but eventually MR Ventricular dysrhythmias are managed with beta blckers r lidcaine Hyptensin is treated with vlume

11 Artic Stensis Caused by chrnic degenerative calcificatin, cngenital bicuspid r rheumatic valves Artic valve area < 1 cm will manifest symptms (SOB, syncpe, angina) Cncentric LV hypertrphy Pressure-verladed, nncmpliant LV Fixed SV dependent n sinus rhythm

12 Artic Regurgitatin Caused by valve r artic rt abnrmalities Acute AI can ccur with infectius endcarditis, trauma, and artic dissectin AI leads t backflw frm arta int LV during diastle Chrnic AI leads t eccentric LVH and eventually heart failure

13 Gals with Significant Valve Disease Parameter Artic Stensis Artic Regurgitatin Mitral Stensis Mitral Regurgitatin LV Prelad Nrmal Nrmal Heart Rate r nrmal Nrmal Cntractility r nrmal r nrmal SVR Cncerns Ischemia, CPR ineffective, n reginal, phenylephrine r slw vlume use Watch fr CHF with bradycardia, HR , n reginal, vlume fr hyptensin Cardivert new AF, watch RV functin, maintain SVR, avid fluid shifts Hypventilatin bad, mnitr RV functin, avid verpressurizing vlatiles, mnitrs

14 A patient with AI is underging hip replacement. During surgery the heart drps frm 80 t 54. Atrpine shuld be administered prmptly. O True O False

15 Anesthesia Cnsideratins fr HOCM Hyperdynamic LV with MR frm SAM Maintain adequate intravascular vlume t avid MR Avid increases in cntractility and heart rate Deep anesthesia and mycardial depressin are advantageus (maintain beta blckers) Maintain nrmal-high SVR

16 Yur patient presenting fr gastric bypass has hypertrphic cardimypathy (HOCM). Which f the fllwing is a reasnable strategy t manage hemdynamics? A. Epinephrine mcg/minute B. Fursemide mg IV preperatively C. Maintain nrmal t high systemic vascular resistance (SVR) with phenylephrine mcg/minute D. Maintain less than 0.5 MAC vlatile agent t avid decreased SVR and mycardial cntractility E. Avid beta blckers

17 Cartid Stensis Hemdynamic challenges include CAD, hypertensin, diabetes Barreceptrs impaired by cartid disease, autnmic dysfunctin and antihypertensive medicatins Management includes crnary and cerebral perfusin, rapid emergence Mnitring includes arterial line and cerebral ximetry Reginal allws fr intraperative assessment but n utcme benefit

18 Principles f Cerebral Oximetry Cerebral saturatin changes crrelate with cerebral perfusin Critical values are nt cnsistent but trends and cmparisns are Values less than 40% r mre than 25% less than baseline are cause fr cncern Asymmetrical values are als bad Bilateral mnitring can help distinguish between cartid cclusin and systemic causes such as hyptensin and hypcarbia

19 Managing Intraperative Hypertensn LVH and BP > 180/110 assciated with increased periperative risk Mderate elevatins in diastlic BO (90-110) assciated with mycardial ischemia and arrhythmias JNC recmmends initiating treatment fr BP > 150/90 AANA recmmends cntrl BP with vlatile, administer piid as apprpriate Use parenteral anti-hypertensives as apprpriate

20 Which f the fllwing wuld nt be a cause f hypertensin in the surgical patient? A. Pain B. Hypxia C. Prlnged laryngscpy D. Deepening anesthesia

21 Intraperative Hyptensin Generally accepted t be SBP < 90 mmhg r 20% less than baseline Variety f causes, any factr affecting HR, prelad, afterlad and cntractility Mst cmmn causes include hemrrhage, hypvlemia, excessive anesthesia Treat emperically with fluid, vaspressrs and reduced anesthesia Rule uts include dysrhythmia, mycardial ischemia, anemia, anaphylaxis, sepsis Parameter Lw High Heart Rate Vlatile, piids, vagal Atrial fib/flutter Beta blckers, reversal Vtach (duh) Prelad Hypvlemia, bleeding, Overlad Afterlad Cntractility Vasdilatin, PE, MS, pneumthrax Lw SVR, sepsis, anemia, Neurgenic, SAM Cardimypathy, MI, Vascular dysfunctin, Vlatile AS, HOCM

22 During an explratry lapartmy in yur septic patient, bld pressure is 80/40, cardiac utput is 8.5 L/m (cardiac index 3.8 L/m 2 ), PPV 6 and heart rate is 85 bpm. Which initial interventin is least apprpriate? A. Calcium chlride 500 mg IVP B. Epinephrine 20 mcg IVP fllwed by infusin C. Phenylephrine 200 mcg IVP fllwed by infusin D. Vaspressin 0.5 units IVP E. Nrmal saline 1000 ml ver 15 minutes F. Methylene blue 2 mg/kg

23 Dysrhythmia Overview Rhythm Surce Management At least 29% f patients underging nn-cardiac surgery experience dysrhythmias Predispsing cardiac disease including cardimypathies, cnductin disrders and ischemia Physilgic respnses t surgery including surgical maneuvers and hypvlemia may be implicated SVT Re-entrant mechanism DCCV, beta blckers, CCB, adensine Atrial Fib Atrial activity DCCV (acute, TEE?), rate cntrl, anticagulatin Atrial flutter Re-entrant mechanism DCCV (acute, TEE?), rate cntrl, anticagulatin VTach Five H s, ischemia Ami, lid, prcainamide, DCCV VFib Five H s, ischemia ACLS, lid etc Trsades Plymrphic VT, electrlytes, drugs Magnesium, pacing

24 Yur patient fr lap chle has WPW and Crhn s disease. Useful pharmaclgic interventins fr rate cntrl in this patient include (mre than ne answer) A. Prcainamide 20 mg blus and 2 mg/minute infusin B. Diltiazem 2.5 mg blus and 10 mg/hur infusin C. Amidarne 150 mg blus and 1 mg/hur infusin D. Esmll 10 mg blus and 20 mg/hur infusin

25 Ptential Device Prblems Assciated with EMI Misinterpretatin f EMI as cardiac activity Pacing is inhibited r triggered inapprpriately Misinterpretatin f EMI as arrhythmia and inapprpriate shck Inapprpriate reprgramming f the device Current causes damage t the mycardium r the device

26 Cardiac Device Management Preperative Evaluatin Establish whether device is PM r ICD Establish whether EMI is an issue Crdinate care with CIED Team including interrgatin, reprgramming, disable therapies Determine whether pacer dependent Defib/pacing availability Effect f magnet n pacemaker Cnverts t asynchrnus Original settings resume after remval Effect f magnet n ICD Disables tachytherapies nly (nt pacing) Tachytherapies may remain disabled after remval

27 What kind f electrcautery practice r use is the mst dangerus fr patients wh have pacemakers? A. Use f biplar electrcautery B. Bvie pad placed as clse t the pacemaker as pssible C. Surgery belw the umbilicus D. Use f shrt (e.g., less than 10 secnds) bursts f electrcautery

28 Abdminal Artic Aneurysms Dilatin f the wall f the arta Causes: athersclersis, inflammatin, trauma, cnnective tissue disrders 50% likelihd f rupture f 6 cm AAA within ne year after diagnsis Indicatin fr surgery when 5 cm with endgraft r pen AAA

29 Majr Physilgic Changes Assciated with Infra-renal Artic Crss-Clamp Acute ventricular strain CO decreased Increased wall tensin/afterlad Increased MVO 2 Mycardial ischemia, CHF are cmmn Manage hypertensin with vlatile and vasdilatrs Ischemia f kidneys and spinal crd Accumulatin f acid metablites

30 When the abdminal arta is crss-clamped, what effect des it have n heart vlumes and pressures? A. Bth afterlad and peripheral vascular resistance increase B. Afterlad increases and peripheral vascular resistance decreases C. Peripheral vascular resistance increases and afterlad decreases D. There is n physilgic change unless the patient has artic insufficiency

31 After declamping, bld pressure is 70/40, heart rate is 90 bpm, PA pressures are 20/7, PPV is 14 and ETCO 2 is 18. Apprpriate interventins may include (mre than ne answer) A. Increasing cardiac filling vlume with albumin r crystallid B. Sdium bicarbnate 50 meq C. Discuss reclamping the descending arta with the surgen D. Nitrglycerin 100 mcg/minute t avid mycardial ischemia E. Trendelenberg

32 Mycardial Ischemia Imbalance f supply/demand Causes f increased demand include hypertensin, tachycardia severe AS Causes f decreased supply include hypxemia, anemia, hyptensin, crnary spasm and thrmbsis Athersclersis is the mst cmmn cause f ischemia Cmmn cause f mrbidity and mrtality, MACE Gals include xygenatin, crnary perfusin and avid hypertensin and tachycardia

33 Intraperative Management Cntinue beta blckers, perip initiatin is cntrversial Cntinue statins, aspirin Prevent ischemia by balancing supply/demand Avid hyptensin, fluid verlad, hypxia, anemia Keep HR, BP within 20% f baseline Avid prlnged DL t avid hypertensin/tachycardia Vlatile gd t decrease demand If lw EF use mre piids and less vlatile

34 Signs f Mycardial Ischemia ST segment abnrmality Dysrhythmias Cnductin abnrmality PA wavefrm abnrmality Decreased mycardial perfrmance (lw cardiac index r bld pressure) Wall mtin abnrmality (ech, visual)

35 70 y/ male with histry f hypertensin, diabetes and CAD and tw stents is underging partial clectmy. HR 144, BP 170/90. Esmll is a gd initial management strategy. O O True False

36 Crnary Stents Untreated surgical patients having surgery within 1 mnth f MI have anther MI 8-10% f surgical patients with stent within previus mnth have a majr cardivascular event r stent thrmbsis resulting in 40-60% mrtality Delay surgery 4-12 weeks with bare metal stents, 6-12 mnths with drug eluting stents Cntinue aspirin in all patients, dual antiplatelet therapy in at-risk

37 Which f the fllwing is NOT cnsistent with the periperative beta blcker guidelines? A. Beta blckers shuld be cntinued thrughut the periperative perid in patients with ischemic heart disease B. Beta blckers shuld be used intraperatively and titrated based n heart rate and bld pressure in patients with ischemic heart disease C. Beta blckers shuld always be avided in patients with symptmatic heart failure D. Beta blckers shuld rutinely be used in high dses (e.g., metprll 5-10 mg IVP) fr maximal anti-ischemic effect

38 Cardiac Tampnade Tampnade is an increase in pericardial pressure impairing diastlic filling Causes f pericardial effusin include infectin, malignancy, bleeding and uremia Presentatin includes hyptensin, tachycardia, tachypnea, JVD, muffled heart sunds, pericardial rub and pulsus paradxus Diagnsis ECG, CXR and echcardigraphy Treatment is pericardicentesis r pericardial windw

39 Anesthesia Management Management f symptmatic tampnade always requires remval f fluid thrugh pericardicentesis Subxiphid apprach Drain left in place? Reginal fr pericardicentesis, GA fr windw Maintain sympathetic tne and avid mycardial depressin Ketamine Small dses f epinephrine/nrepi Fluids

40 Causes f Shck Arterial bld flw is inadequate t meet tissue metablic requirements Tissue hypxia, ischemia and rgan failure eventually result Classified by mechanism including hypvlemic, cardigenic, bstructive and distributive Treat with ketamine, bld Hypvlemic Cardigenic Obstructive Distributive Bld lss Dysrhythmia Pneumthrax Sepsis GI lss (vmiting) Plasma lss (burns) Renal lss (plyuria) 3 rd space (ascites, SBO) Pump failure Acute valve dysfunctin Wall rupture Tampnade, cnstrictin Pulmnary Emblus Pulmnary hypertensin Obstructive valve disease Anaphylaxis Neurgenic Vasdilatrs Acute adrenal insufficiency

41 Shck and Cardivascular Cllapse Hypvlemic Shck Bld lss Trauma Distributive Shck Anaphylaxis/Sepsis Neurgenic Obstructive Shck PE Tampnade Cardigenic Shck LV/RV dysfunctin Valve dysfunctin CARDIAC CAUSES Cardiac arrest Heart failure Mycardial infarctin Cardiac arrhythmia Pulmnary emblism Cardiac tampnade PERIPHERAL VASCULAR CAUSES Hypvlemic shck (i.e., bld lss) Septic shck Anaphylactic shck Neurgenic shck Trauma

42 30 y/ female presents t OR after MVC. During surgery she becmes hyptensive and her urine utput declines. A. Obstructive B. Neurgenic C.Sepsis D. Cardigenic E. Hypvlemic F. Anaphylactic

43 60 y/ male with CAD underging a knee replacement exhibits irregular rhythm, HR 170. Despite effrts t cntrl rate, ST segment depressin is nted and SBP drps t 70. A. Obstructive B. Neurgenic C.Sepsis D. Cardigenic E. Hypvlemic F. Anaphylactic

44 45 y/ male presents t the OR fr multiple rthpedic injuries after falling frm a ladder. He presents with SOB, distant heart sunds and JVD. His BP drps precipitusly with inductin. A. Obstructive B. Neurgenic C.Sepsis D. Cardigenic E. Hypvlemic F. Anaphylactic

45 20 y/ male presents after MVC with C5 fracture. Just befre inductin BP drps t 70/40 and HR 40. A. Obstructive B. Neurgenic C.Sepsis D. Cardigenic E. Hypvlemic F. Anaphylactic

46 Yur patient presents fr lng bne fracture frm the trauma unit. The patient is hyptensive and yu suspect a pulmnary emblus based n (mre than ne answer) A. Increased CVP B. Hyptensin C. Oxygen desaturatin D. Decreased breath sunds n the left E. Right ventricular failure

47 Causes f Cardiac Arrest Anesthetic technique Iatrgenesis imperfecta Line placement Anaphylactic reactin Antibitics Muscle relaxants? Surgical technique Laparscpic misadventure Inadvertent bld lss Pre-existing medical cnditin

48 Summary Management f patient with ventricular dysfunctin is centered n less anesthesia and slwer administratin/titratin Valve stensis requires maintenance f adequate perfusin pressure and slw sinus rhythm Valve insufficiency requires maintenance f adequate filling, less diastle fr regurgitatin and afterlad/svr reductin Shck is classified by mechanism including hypvlemic, cardigenic, bstructive and distributive