Size isn't everything, some like 'em small- PVD

Question 1

What

Answer 1

• After donor and recipient arteries are exposed, tunnel is created and graft is passed
• Graft may be saphenous vein or a prosthesis
  
  • usually prosthesis b/c if one vein is so bad they need a graft, the saphenous vein probably isnt much better
• Heparine IV given (note time)
• Anastomosis are constructed
• Arteriogram to confirm adequate flow
• heparin not likely to be reversed b/c it is probably a small dose

Question 2

Pt with PVD has _____ greater risk of MI, stroke, and death

Answer 2

3-5x

These pts probably also have CAD

Question 3

What are the preferred anesthesia techniques for peripheral revascularization surgeries?

Answer 3

• Regional Anesthesia:
  
  • increased graft blood flow
  • less increase in SVR with cross-clamping
  • postoperative pain relief
  • less activation of the coagulation system
• Regional Vs General
  
  • assess for coagulopathy
  • If regional, spinal may be best to avoid hematoma
  • No difference in cardiopulmonary complications btw RA and GA
  • Significantly fewer graft occlusion complications with RA

Question 4

What should you consider for the anesthesia management of a peripheral revascularization surgery?

Answer 4

• Consider co-morbidities
• Medication Hx and impact on anesthesia delivery
• end organ perfusion and oxygenation- may want foley
• blood gases to not electrolyte and pH changes
• Cross clamp- heparin administration
  
  • record time
  • reversal?

Question 5

How should you monitor a pt during peripheral revascularization surgery?

Answer 5

• Pts typically have CAD, DM, HTN
• Make sure pt takes BBs and other chronic meds
• Art line
• CVP or catheter- to monitor intravascular volume
• EBL
• estimated third space

Question 6

What are the goals when managing the anesthesia of a pt with mitral stenosis?

Answer 6

• Goals: slow, tight, full
• Avoid tachycardia or rapid ventricular response rate during afib (slow)
• avoid marked increases in central blood volume that could be caused by over transfusion or head-down position
• Avoid drug-induced decreases in SVR (tight)
• Avoid events such as arterial hypoxia and/or hypoventialtion that may exacerbate pulmonary HTN and evoke right ventricular failure

Question 7

How should you induce a pt with Mitral stenosis?

Answer 7

• With drugs that are unlikely to increase HR (avoid ketamine) or abruptly decrease SVR
• Ex. etomidate with balanced technique

Question 8

How should you try to manage the maintenance of anesthesia in a pt with Mitral stenosis?

Answer 8

• Use drugs that have minimal affect on HR,SVR, PVR, and myocardial contractility
  
  • may need BBs and CCBs, phenylephrine
• Monitoring:
  
  • need for invasive monitoring depends on the complexity of the procedure and magnitude of impairment caused by MS

Question 9

What are the goals when managing anesthesia for a patient with Aortic stenosis?

Answer 9

• Avoid any events that would further decrease CO
• Maintain NSR- properly times atrial contraction will produce an optimal LVEDV
• avoid bradycardia or tachycardia
• avoid hypotension- avoid decrease in SVR, very difficult to bring BP back up
• Optimize intravascular fluid volume to maintain venous return ad left ventricular filling
• **CPR is typically ineffective in pts with AS b/c it is impossible to get enough pressure to move blood through the small opening with compressions

Question 10

General anesthesia or Neuraxial anesthesia in pts with Aortic stenosis?

Answer 10

• General anesthesia preferred because of the sympathetic block that causes decrease in SVR

Question 11

How is mitral regurgitation noted on a pulmonary arterial occlusion pressure waveform (PAOP)?

Answer 11

• Regurgitant flow causes an exaggerated V wave
• Size of V wave correlates with magnitude of regurgitant flow
• Pic below shows normal wave (about 12), will go to 20 or 25 with regurgitation

Question 13

What are the goals for management of anesthesia in a pt with mitral regurgitation?

Answer 13

• Goals: fast, full, forward
• Avoid events that may further decrease cardiac output
• Avoid sudden decreases in HR
• avoid sudden increases in SVR
• monitor the size of the V wave as a reflection of regurgitant flow
• minimize drug-induced myocardial depression
• Ex. Etomidate or high dose opioid for induction

Question 14

What influences the how you will manage the maintenance phas of anesthesia for a pt with mitral regurg?

Monitoring?

Answer 14

• Maintenance anesthesia is influenced by the degree of LV dysfunction
• If not severe:
  
  • N₂O and volatile agent (Iso, des, or sevo b/c of minimal negative inotropic effects)
• If severe:
  
  • Use of high opioid technique minimizes drug induced myocardial depression- be aware that it might cause bradycardia
• Use of invasive monitoring depends on the complexity of procedure and magnitude of regurg

Question 15

What are the causes of aortic regurgitation?

Answer 15

• Diseased leaflets:
  
  • endocarditis*, rheumatic fever, BAV
• Problems with aortic root:
  
  • idiopathic aortic root dilation, aortic dissection*, marfan syndrome, ankylosing spondylitis
• *acute

Question 16

What are goals for anesthesia in a pt with Aortic regurgitation.

Answer 16

• Avoid sudden decreases in HR
• Avoid sudden increases in SVR
• minimize drug induced myocardial depression
• Induction- use drugs likely to maintain forward left ventricular SV
• Maintenance:
  
  • No LV dysfunction- N₂O plus VA (Iso)
  • LV compromise- consider opioid alone

Question 17

How should you manage the fluid for a pt with mitral regurgitation?

monitoring?

Answer 17

• Prompt replacement of blood loss is important to maintain forward LV SV
• Bradycardia may require prompt treatment with atropine
• monitoring:
  
  • based on complexity of surgery and severity of regurgitation