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a pt with CAd is having non-cardiac surgery PB 155/115, CO 3, PCWP 22.  what would be an appropriate antihypertnesive?
appears ot be due to increased SVR (preload is increased and CO is down)
what are the 2 most significant risk factors identified by the Goldman Cardiac risk Index for noncardiac surgery?
  • myocardial infarction
  • S3 gallop
what is the incidence of perioperative reinfarction for non-cardiac surgery at 0-3 months, 4-6 months, and after 6 months for a pt wiht a history of myocardial infarction?
  • 0-3:27-37%
  • 3-6:11-16%
  • >6: 5-6%
Elective surgery is best no performed until how mcuh time ahs elapsed after an MI?
6 months
which type of surgery cause the biggest risk of perioperative reinfaction
intrathoracic or intrabdominal surgery lasting longer than 3 hours
you pt had an MI 3 months ago and is now requireing surgery and needs GA.  which of the following will most increase the chance of reinfarction: labile hemodynamics. modest increase in HR, stable angina
labile hemodynamics
identify appropriate maintenance agents for a pt with CAD.  what agent would you avoid?
volatiles (if pt has good ventricular function)
low EF: opioid-based without nitrous( cna produce cardiac depression)
Avoid nitrous
3 signs of poor righ ventricular function
  • systemic venous congestion
  • peripheral edema
  • congestive hepatomaegaly
  • pulsating neck veins indicate venous congestion decondary to right vent. failure
how is left ventricular compliance assessed?
doppler electrocardiography
in general what usually causes left ventricle diastolic dysfunction
a decrease in left ventricular compliance (myocardial ischmia, pericardial effusion, shock)
what PCWP is indicative of heart failure?
**list 4 compensatory responses in the pt with cardiac failure
  • increased left vent. preload
  • increased sympathetic tone
  • renin-angio-adosterone system
  • release of AVP (arginine vasopressin, ADH)
  • ventricular hypertrophy
what hormonal system is activated as a compensatory mechanism in pt with CHF
renin-angio-aldosterone system and sympathetic nerveous system
what is the hallmark of decreased cardiac reserve (poor ventricular function)?  what is the best indicator of a pt's cardiac reserve?
fatigue at rest with minimal cardiac reserve
cardiac reserve can be estimated by questioning the pt aobut their exertional tolerance
what is the prinicple hemodynamic alteration wiht cardiac tamponade?  What is Beck's triad?
Decreased CO due to decreased SV from decreased ventricular filling (preload)
Beck's triad: constellation of hypotension, jugular venous distenstion, and distant, muffled heart sounds
what are the first signs of cardiac tamponade?
decreased BP and reflex tachycardia
what is pulsus paradoxus?
a large decrease (>10 mmHg) in BP during inspiration seen iwht cardiac tamponade.
normally SBP will decrease by about 6 mmHg during inspiration
if pt with cardiac tamponade needs to be induced, what agent should be selected?
ketamine 0.5 mg/kg and 100% O2 after decompression of pericardial space
3 temporary measures that can be take to maintain SV in th ept with cardiac tamponade are:
  • IV fluids
  • postitive inotrope for increased contractility (beta1 agonist)
  • correct metabolic acidosis
anesthetic considerations for pt with cardiac tamponade
  • large bore Ivs
  • maintain high sympathetic tone until tamponade is releived (ketamine and pancuronium plus succs for intubation)
  • generous IV fluid to maintain vnous return and filling pressures
aortic insufficiency: 3 important goals when caring for this pt
  • Fast
  • full: increase preload
  • forward: decrease afterload
what are the goals for the pt with cardiac tamponade
avoid vasodilation or cardiac depression
what drugs shoudl be avoided during anestheisa for the pt with cardiac tamponade
  • avoid things that decrease venous return, HR, or contractility
most common circulatory disorder
what class of drugs may be given preoperatively ot the untreated, unsymptomatic mildly hypertensive pt to attenuate tachycardia with tracheal intubation and tachycardig on emergence?
PO dose of beta antagonist: labetalol (normodyne, trandate), atenolol (tenormin), or oxprenolol (trasicor)
what is the goal during maintenance of anesthesia for the pt who has chronic hypertension?  what anesthetic technique may be useful for achieving this goal?
avoid wide fluctuations in BP
volatiles allow rapid adjustments in anesthetic depth in response to changes in BP
the Bp of a chronically hypertensive pt increases substantially during the case?  what should you do?
most often this is due to inadequate anesthesia, so deepen the anesthetic
if still hypertensive, give phentolamine or nitroprusside (1-2 mcg/kg/min) continuous infusion
Takayasu's arteritis: what is it?
pulseless diseae: absence of palpable peripheral pulses due to chronic inflammation of the arota and its branches; causes decreased perfustion to organs from occlusive inflammatory and thrombotic processes
most often occurs in asian females
5 CNS s/s of Takayasu's arteritis (due to involvement o fthe carotid arteries)
Visual disturbances
cerebral ischemia or infarct
what affects does Takayasu's arteritis have on pulmonary system
pulmonary hypertension
V/Q mismatch
what musculoskeletal system problems can be found in the pt with Takayasu's arteritis?
ankylosing spondylitis
Primary treatment for Takayasu's arteritis
6 anesthetic concnerns when caring ofr pt with Takayasu's arteritis
  • may need supplemental steroids due to chronic steroid therapy
  • pt may be anticoagulated (regional may not be OK)
  • musculoskeletal changes can be it difficult to do spinal or epidural
  • Noninvasive BP may be difficult to obtain
  • EEG monitoring is needed if carotid flow is compromised
  • hyperextension of neck for intubation can block flow through the carotids
2 actions that can help maintain cerebral perfusio in pt with takayasu's arteritis
  • avoid hyperventiliation
  • use volatile agent (they increase cerebral blood lfow)
does concnetric hypertrophy decrease wall tension?
Law of LaPlace: tension in the wall will decrease with wall thickness
what are the characteristics of sick sinus syndrome
  • bradycardia punctuated with episodes of supraventricular tachycardia; most often seen in elderly pts
is it necessary to treat any of the following before surgery: first degree hert block, second degree hrt blcok typoe I or type II
mobitz type II second degree hrt block has a serious prognosis and should be treated prior to surgery (pacemaker)
How does CVP compare with PCWP if pulmonary hypertension is present?
CVP will be higher than PCWP
what happens to the ventricular wall iwht a chronically elevated afterload?  what happens to chamber size?
concnentric hypertrophy: thickened wall to develop more tension and eject blood more effectively againts an increased afterload.
chamber size does not change
is left ventricular hypertrophy associated iwth mitral stenosis?
no, the left atrial pressure is increased and reflects backward through the pulmonary circulation leading to right ventricular concnetric hypertrophy
what prmotes ecentric hypertrophy?
identify 3 factors that will promote this developing
volume overload
aortic regurgitation, mitral regurgitation, excessive intravascular volume
how is diastolic dysfunction of the left ventricle assessed?  what is the BEST indicator of left ventricular diastolic dysfunction?
by examining left ventricular compliance
a decrease in compliance is the best indicator of dysfunction
pt with mitral vale stenoiss presents with HR 100 Bp 80/50, CVP12.  how is this treated
phenylephrine to increase BP and SVR and decrease HR will increase CO
Dopamine also for inotropic support
what muscle relaxants shoudl be given to a pt with mitral vavle prolapse?
Avoid agents that have cardiovascular affects (pancuronium, d-tubocuraine - rel. histamine)
Vecuronium or cisatracurium would be OK
cause of IHSS? Former name
cause is unknown
used to be called hypertrophic obstructive cardiomyopathy
what is the first line treatemnt for hypotension in pt with IHSS?  second line treatment?
what things can increase the outflow obstruciton in IHSS?
  • increased contractility
  • increased HR
  • decreased preload or afterload
what drugs are avoided in the pt with IHSS
vasodilators (nitroglycerin, nitroprusside)
positive inotropes (digitalis, calcium)
beta agonists
which of the following agents would most likely not be used in the pt woth IHSS: fentanyl, propanolol, halothane, phenylephrine
Fentanyl does not offer the beneficial effects (depressed myocardial contractility or increased SVR) that the others do
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