Valvular Heart Disease And Anaesthesia: Quiz

Liver disease is not commonly associated with patients undergoing carotid endarterectomy (CEA). CEA is a surgical procedure performed to remove plaque buildup from the carotid arteries in order to prevent stroke. Commonly associated diseases with CEA include coronary artery disease (CAD), diabetes, and cerebrovascular accident (CVA) as these conditions often coexist with carotid artery stenosis. However, liver disease is not typically linked to carotid artery disease and therefore not commonly associated with patients undergoing CEA.

In an ASA 3 patient undergoing an Aorta-life bypass, a Bair Hugger for lower extremities is not necessary. A Bair Hugger is a device used to maintain the patient's body temperature during surgery. However, in an Aorta-life bypass procedure, the lower extremities are not directly involved or exposed, so there is no need for a Bair Hugger specifically for the lower extremities. Other measures such as serial H&H and ABG's, an A-Line for continuous blood pressure monitoring, and a fluid warmer may be necessary for the procedure.

Regional anesthesia is sometimes preferred when performing a CEA primarily because it allows for continuous neurological assessment. With regional anesthesia, the patient remains awake during the procedure, allowing the healthcare team to monitor their neurological status throughout. This is important in carotid endarterectomy (CEA) surgeries as it involves the removal of plaque from the carotid artery, which can potentially lead to neurological complications. By continuously assessing the patient's neurological function, any changes or signs of ischemia can be detected early and appropriate interventions can be taken.

The most common side effect associated with the administration of protamine is hypotension. Protamine is a medication used to reverse the effects of heparin, which is commonly used as an anticoagulant. Hypotension refers to low blood pressure, and it can occur as a result of protamine administration due to its vasodilatory effects. This can lead to a decrease in blood flow and oxygen delivery to tissues, potentially causing symptoms such as dizziness, lightheadedness, and fainting. Monitoring blood pressure and providing supportive care are important in managing this side effect.

Aortic regurgitation and mitral regurgitation are classified as volume overload disorders. In aortic regurgitation, the aortic valve does not close properly, leading to the backflow of blood from the aorta into the left ventricle during diastole. This increases the volume of blood in the left ventricle, causing volume overload. Similarly, in mitral regurgitation, the mitral valve fails to close properly, resulting in the backflow of blood from the left ventricle into the left atrium during systole. This also leads to volume overload in the left ventricle.

In rheumatic mitral valve disease, left atrial enlargement can lead to the development of atrial fibrillation. Atrial fibrillation is characterized by rapid and irregular electrical impulses in the atria, resulting in an irregular and often fast heart rate. This arrhythmia is commonly seen in patients with rheumatic mitral valve disease due to the structural changes and increased pressure in the left atrium. Atrial flutter, atrial tachycardia, and paroxysmal atrial tachycardia may also occur in these patients, but atrial fibrillation is the most common arrhythmia associated with left atrial enlargement in rheumatic mitral valve disease.

During Carotid vascular surgery, maintaining blood pressure slightly above pre-operative levels is important to ensure adequate blood flow to the brain. This is because carotid arteries supply blood to the brain, and any decrease in blood pressure during surgery can lead to a decrease in cerebral perfusion and potential brain damage. By keeping blood pressure slightly above pre-operative levels, the surgeon can help maintain sufficient blood flow to the brain and minimize the risk of complications.

Following the release of the aortic cross-clamp, a sudden increase in end-tidal carbon dioxide (ETCO2) levels would be expected. This is because the release of the cross-clamp allows for improved blood flow and oxygenation to the tissues, leading to increased carbon dioxide production and subsequent elimination. Therefore, the sudden increase in ETCO2 indicates improved tissue perfusion and ventilation.

During anesthetic management of a patient with hypertension, it is important to keep the intraoperative blood pressure within 20% of the baseline blood pressure. This means that the blood pressure should not deviate more than 20% from the patient's normal baseline reading. This allows for a controlled and safe management of the patient's hypertension during the procedure.

The hemodynamic goals for a carotid endarterectomy (CEA) are to maintain cerebral perfusion pressure (CPP) at a high-normal blood pressure (BP) range. This is because maintaining a high-normal BP helps ensure adequate blood flow to the brain during the surgery. Hypotension can lead to decreased blood flow and increased risk of ischemia, while hypertension and tachycardia can increase the risk of bleeding within the surgical field. Therefore, the goal is to keep the BP within a high-normal range to optimize cerebral perfusion while minimizing the risk of complications.

The correct answer is that all of the above interventions are acceptable. Atropine can be used to counteract any vagal response that may occur during the surgical traction on the carotid sinus. Infiltration with local anesthetic is important to minimize pain and discomfort during the procedure. Finally, the release of traction by the surgeon is necessary to ensure that the procedure is completed safely. Therefore, all of these interventions are appropriate in this context.

Aortic cross-clamping refers to the temporary occlusion of the aorta during certain surgical procedures. This procedure increases the afterload, which is the resistance against which the heart must pump blood. By clamping the aorta, the blood flow is restricted, causing an increase in pressure within the arterial system. This increased pressure increases the workload of the heart, leading to an increase in afterload. Therefore, the primary effect of aortic cross-clamping is an increase in afterload.

Aortic Stenosis and Mitral Stenosis are classified as Pressure Overload disorders because both conditions involve narrowing or obstruction of the valves, leading to increased pressure within the affected chambers of the heart. In Aortic Stenosis, the aortic valve becomes narrowed, causing the left ventricle to work harder to pump blood out of the heart. Similarly, in Mitral Stenosis, the mitral valve becomes narrowed, resulting in increased pressure in the left atrium. Both conditions lead to pressure overload on the affected valves and chambers, ultimately affecting the heart's ability to efficiently pump blood.

Lactic acid build-up distal to the aortic clamp will cause vasodilation. Lactic acid is produced when there is insufficient oxygen supply to tissues, such as during ischemia. This lactic acid can cause the blood vessels in the affected area to dilate, leading to increased blood flow. Vasodilation helps to deliver more oxygen and nutrients to the tissues, aiding in their recovery.

Left ventricle function is the best parameter to assist in deciding the best anesthetic technique for a cardiac patient. The function of the left ventricle is crucial in determining the efficiency of the heart's pumping action. By assessing the left ventricle function, the anesthesiologist can determine the patient's cardiac output and overall cardiovascular health. This information is essential in selecting the appropriate anesthetic technique that will not compromise the patient's heart function during surgery. The type of surgery, blood pressure, and heart rate are also important factors, but left ventricle function provides a more direct indication of the patient's cardiac status.

At stage 3 of hypertension, a patient would begin to experience renal dysfunction. This is because hypertension can lead to damage and narrowing of the blood vessels in the kidneys, reducing their ability to function properly. This can result in decreased urine output, increased protein in the urine, and other signs of kidney dysfunction. Stage 3 hypertension is characterized by a systolic blood pressure of 180 mmHg or higher or a diastolic blood pressure of 110 mmHg or higher.

In patients with mitral stenosis, the narrowing of the mitral valve obstructs blood flow from the left atrium to the left ventricle. This can lead to increased pressure in the left atrium and congestion in the lungs. Keeping the heart rate equal to or slightly below baseline helps to maintain adequate filling time for the left ventricle, allowing for optimal cardiac output and reducing the risk of pulmonary congestion. Elevating the heart rate above baseline can decrease the diastolic filling time and worsen symptoms. Aim for a heart rate above 80 bpm or aiming for heart rate are not recommended strategies for managing mitral stenosis.

Infrarenal refers to the portion of the abdominal aorta that is located below the renal arteries. AAA (abdominal aortic aneurysm) is a condition characterized by the enlargement or ballooning of the abdominal aorta. The majority of AAA cases, around 90-95%, occur in the infrarenal region of the abdominal aorta. This means that the aneurysm is located below the renal arteries, which are the arteries that supply blood to the kidneys.

A femoral central catheter is not a necessity to monitor a patient undergoing a right CEA. Monitoring a patient undergoing a right CEA typically involves the placement of an arterial line (A-line) in the left arm to monitor blood pressure, large bore IVs for fluid administration, and serial arterial blood gas (ABG) measurements to assess oxygen and carbon dioxide levels. The femoral central catheter is not directly related to the monitoring of a patient undergoing a right CEA procedure.

Rheumatic fever is the most common cause of Mitral Stenosis. Rheumatic fever is an inflammatory disease that can occur after an untreated streptococcal throat infection. It can cause damage to the heart valves, particularly the mitral valve, leading to stenosis. This occurs when the valve becomes stiff and narrowed, reducing the flow of blood from the left atrium to the left ventricle. Hypertension, aortic regurgitation, and left ventricular hypertrophy are not typically associated with the development of mitral stenosis.

Aortic stenosis is a condition where the aortic valve narrows, causing obstruction of blood flow from the heart to the rest of the body. This obstruction leads to an increased workload on the left ventricle of the heart. In response to this increased workload, the left ventricle undergoes hypertrophy, which is the thickening of the heart muscle. Concentric hypertrophy refers to the thickening of the heart muscle without any dilation of the ventricular chamber. Therefore, it is the most likely outcome for a patient with aortic stenosis as it is a compensatory mechanism to overcome the obstruction and maintain cardiac output.

Vasodilators are not appropriate interventions to counteract the effects of "unclamping" because they would further relax and dilate blood vessels, potentially exacerbating the problem. "Unclamping" typically refers to the release of a clamp on a blood vessel, which can lead to decreased blood flow and oxygen supply to tissues. To counteract this, interventions such as increasing minute ventilation, administering calcium chloride, or using sodium bicarbonate can be used to improve blood flow and restore normal physiological functions.

All of the options listed (Swan Ganz line, A-Line, Large Bore IV's) are required for symptomatic Aortic Stenosis patients. This means that none of the options are not required, hence the correct answer is "All the above are required".

In patients with Aortic Stenosis, sudden decreases in systemic vascular resistance (SVR) should be avoided because it can lead to a decrease in blood pressure and compromise cardiac output. There is an increase in myocardial oxygen demand in patients with Aortic Stenosis due to the narrowing of the aortic valve, which causes the heart to work harder to pump blood through the narrowed valve. Maintenance anesthesia is preferable with nitrous oxide (N2O) and high dose narcotic in patients with Aortic Stenosis because these agents help maintain hemodynamic stability. Atropine is not preferred over Robinul for reversal in patients with Aortic Stenosis because Robinul, a vagolytic agent, is more effective in increasing heart rate and improving cardiac output in these patients.

The correct answer is "On the right side because in case occlusion to left occurs." This is because if there is an occlusion on the left side during the procedure, the A-line on the right side will still provide continuous monitoring of the patient's blood pressure and allow for appropriate interventions to be taken. Placing the A-line on the left side may not provide accurate information about the perfusion of the operative side.

The statement that Pavulon is a good choice for facilitating intubation is not true regarding patients with Mitral Stenosis. Pavulon is a neuromuscular blocking agent that can cause muscle relaxation, but it does not provide any airway protection or sedation, which are important considerations during intubation in these patients. Therefore, other medications or techniques should be used for facilitating intubation in patients with Mitral Stenosis.

During a carotid endarterectomy (CEA), it is important to maintain the end-tidal carbon dioxide (ETCO2) waveform on the anesthesia monitor at a level of 36. This value indicates the amount of carbon dioxide present at the end of exhalation and is used as an indicator of effective ventilation and perfusion. Keeping the ETCO2 at 36 ensures proper gas exchange and adequate oxygenation during the procedure.

Surgery on the ascending aorta typically involves a median sternotomy, which is a surgical incision made along the sternum to access the heart and aorta. CPB, or cardiopulmonary bypass, is also used during this procedure. CPB involves diverting blood flow away from the heart and lungs, allowing the surgeon to operate on a still, bloodless field. This is done by connecting the patient to a heart-lung machine, which takes over the functions of the heart and lungs during the surgery.

Aortic stenosis is a condition characterized by the narrowing of the aortic valve, which obstructs blood flow from the left ventricle to the aorta. This obstruction leads to increased pressure in the left ventricle during systole, causing concentric hypertrophy, an adaptation where the ventricular walls thicken to generate more force. Additionally, the increased pressure in the left ventricle can cause an increase in left ventricular end-diastolic pressure (LVEDP). Aortic stenosis also leads to increased dependence on atrial contraction to maintain adequate cardiac output. However, it does not increase ventricular compliance, which refers to the ability of the ventricles to stretch and fill with blood during diastole.

In a patient with Mitral Regurge, a murmur would be heard on the fifth intercostal space, which is located at the left midclavicular line. This is because the mitral valve is located between the left atrium and the left ventricle, and when there is regurgitation of blood from the left ventricle back into the left atrium, a murmur can be heard in this area.

Postoperative mortality refers to death that occurs within a certain period after a surgical procedure. In the case of AAA repair (abdominal aortic aneurysm repair), the most common cause of postoperative mortality is myocardial infarction (MI), also known as a heart attack. This is because AAA repair is a major surgical procedure that can put stress on the cardiovascular system. The surgery itself and the manipulation of the aorta can potentially lead to complications such as blood clot formation, which can block the blood flow to the heart and cause a heart attack. Therefore, MI is the most likely cause of postoperative mortality in AAA repair patients.

After aortic clamping during elective AAA repair, the most likely drug to administer would be NTG (nitroglycerin). Aortic clamping can cause decreased blood flow to the heart, leading to myocardial ischemia. NTG is a vasodilator that helps to relax and dilate the blood vessels, improving blood flow to the heart and reducing the workload on the heart. This can help prevent or treat myocardial ischemia and maintain stable blood pressure during the procedure. Neosynephrine is a vasoconstrictor, apresoline is a vasodilator used for hypertension, and dobutamine is a beta-1 agonist used for cardiac support in heart failure.

A patient with severe aortic stenosis may be at risk for hemodynamic instability during induction of anesthesia. High dose fentanyl induction may be chosen because it provides analgesia and sedation without causing significant cardiovascular depression. This allows for a smoother induction process and minimizes the risk of hemodynamic compromise in the patient with aortic stenosis.

Rocuronium or Sux (succinylcholine) would be the drugs of choice for intubation of patients with Mitral Stenosis (MS) because these medications provide rapid onset and short duration of muscle relaxation, allowing for a smoother intubation process. Ketamine is not the drug of choice for induction in severe MS patients as it can cause an increase in heart rate and blood pressure. Narcotics and propofol infusions should be avoided due to their potential for myocardial suppression. Aggressive fluid therapy is not necessary in MS patients as they are typically in a chronic fluid-depleted state and at risk for hypotension.

Injury to the optic nerve due to hypoperfusion is not a post-operative complication related to carotid endarterectomy (CEA). CEA is a surgical procedure performed to remove plaque buildup in the carotid artery, which can improve blood flow to the brain and reduce the risk of stroke. Common post-operative complications include hemorrhage, hypertension due to denervation of carotid baroreceptors, and injury to the recurrent laryngeal nerve (RLN). However, injury to the optic nerve due to hypoperfusion is not directly associated with CEA.

The correct answer is cross clamping with thoracotomy using OLV. This is because surgery on the descending aorta typically requires accessing the aorta through a thoracotomy, which involves making an incision in the chest wall. Cross clamping refers to temporarily blocking the blood flow in the aorta to perform the necessary repairs. OLV (one-lung ventilation) is used during thoracotomy to collapse one lung and provide better exposure and access to the surgical site.

Performing endovascular grafting procedure is contraindicated in cases of AAA rupture. This is because AAA rupture is a life-threatening emergency that requires immediate surgical intervention, such as open repair or endovascular repair with a stent graft. Endovascular grafting is not suitable for ruptured AAA as it may not provide adequate sealing and may not be able to control bleeding effectively. Therefore, AAA rupture is not an indication for endovascular grafting procedure.

Mitral regurge refers to the backward flow of blood from the left ventricle into the left atrium during systole. This causes an increase in pressure in the left atrium, which is reflected in the waveform on the Swan line. A prominent V wave is seen in the waveform when there is regurgitation because the increased pressure in the left atrium leads to a larger V wave. Therefore, the correct answer is that Mitral regurge will result in a prominent V wave in the Wedge waveform on the Swan line.

During aortic cross-clamping, the aorta is temporarily blocked to allow for surgical procedures. This leads to an increase in systemic vascular resistance (SVR) and mean arterial pressure (MAP) due to the obstruction of blood flow. Additionally, the left ventricle compensates for the increased afterload by increasing its contractility, resulting in an increased cardiac output (CO). However, the ejection fraction (EF%) is a measure of the percentage of blood pumped out of the left ventricle with each contraction and is not directly affected by aortic cross-clamping. Therefore, the correct answer is increased CO, as it is an expected hemodynamic change during aortic cross-clamping in a patient with normal left ventricular function.

In mitral regurgitation, the backflow of blood from the left ventricle to the left atrium occurs during systole. This means that maintaining a normal sinus rhythm is not as crucial for achieving a better stroke volume because the regurgitated blood will still flow back into the left atrium regardless of the rhythm. In contrast, in conditions like mitral stenosis, aortic stenosis, and idiopathic hypertrophied subaortic stenosis, maintaining a normal sinus rhythm is important as it allows for proper filling and emptying of the ventricles, leading to a better stroke volume.

During cross-clamp, it is important to vasoconstrict to keep the blood pressure slightly elevated and restrict fluids. This is necessary to minimize the risk of bleeding and maintain hemodynamic stability during the procedure. Having a central line, A-line, and large bore IVs is also important to monitor and manage the patient's fluid status and administer medications as needed. Additionally, turning off heating blankets during cross-clamp helps prevent hypothermia, which can have negative effects on the patient's physiology. Therefore, all the statements provided are true except for the statement that says vasoconstriction and fluid restriction should not be done during cross-clamp.

Following carotid endarterectomy (CEA), the most common hemodynamic response is hypertension. This is because during CEA, the carotid artery is manipulated, leading to increased blood flow to the brain. This increased blood flow triggers a reflex response in the body, causing an increase in systemic blood pressure. Hypertension following CEA is a normal physiological response and is typically transient, resolving within a few hours after the surgery.

Administering a negative chronotropic agent would be the most appropriate course of action in this scenario. Atrial fibrillation with an uncontrolled ventricular rate can worsen symptoms in a patient with critical mitral stenosis, leading to pulmonary edema. A negative chronotropic agent, such as a beta-blocker, can slow down the heart rate and improve symptoms by reducing the workload on the heart. This can help alleviate the pulmonary edema and improve the patient's condition.

A systolic murmur auscultated at the 2nd intercostal space is typical for aortic stenosis. This is because aortic stenosis is characterized by narrowing or obstruction of the aortic valve, which leads to turbulent blood flow during systole. This turbulent flow produces a murmur that can be heard best at the 2nd intercostal space, which is the location where the aortic valve is most easily heard. Mitral stenosis, mitral prolapse, and aortic regurgitation would typically present with different types of murmurs and would not be expected to be heard at the 2nd intercostal space.

Sodium nitroprusside is a potent vasodilator that can decrease systemic vascular resistance and increase cardiac output. In aortic regurgitation, the aortic valve does not close properly, causing blood to flow back into the left ventricle during diastole. This leads to increased volume overload and decreased forward flow. By dilating the systemic vasculature, sodium nitroprusside can help to decrease the regurgitant volume and improve forward flow, thereby increasing cardiac output. Therefore, sodium nitroprusside would be most beneficial in aortic regurgitation to enhance cardiac output.

The correct answer is 38 mg. Protamine is a medication used to reverse the anticoagulant effects of heparin. The general guideline for protamine administration is to give 1 mg of protamine for every 100 units of heparin previously administered. In this case, 7,500 units of heparin were given, so the appropriate dose of protamine would be 75 mg (7,500 units divided by 100). However, since it has been one hour since heparin administration, some of the heparin may have already been metabolized. Therefore, a slightly lower dose of protamine, such as 38 mg, may be appropriate.

In patients with Mitral Regurgitation, decreases in systemic vascular resistance (SVR) should be avoided. This is because MR is characterized by the backflow of blood from the left ventricle into the left atrium during systole, leading to decreased forward flow and decreased cardiac output. To compensate for this, the body increases SVR to maintain adequate blood pressure and perfusion. Decreases in SVR can further decrease forward flow and worsen the symptoms of MR. Therefore, it is important to avoid interventions or medications that can cause a decrease in SVR in these patients.

Resistance to vasoactive medications, requiring higher doses does not typify the response expected when managing a patient with hypertension. In patients with hypertension, vasoactive medications are commonly used to lower blood pressure. However, resistance to these medications, requiring higher doses, is not a typical response. Instead, the expected response would include an exaggerated hypotensive response to induction, hypertension upon intubation of the patient, and chronic volume depletion requiring fluid boluses during surgery.

Hydration is the most effective method to preserve renal function during aortic cross-clamping. Aortic cross-clamping can lead to reduced blood flow to the kidneys, which can cause renal dysfunction. By maintaining adequate hydration, blood volume and perfusion to the kidneys can be optimized, reducing the risk of renal injury. Hydration helps to maintain renal blood flow and glomerular filtration rate, preventing ischemic damage to the kidneys. Mannitol, Lasix, and Fenoldopam are not specifically indicated for preserving renal function during aortic cross-clamping.

Acute mitral regurgitation is most commonly caused by a myocardial infarction. During a heart attack, the blood supply to a part of the heart muscle is blocked, leading to damage or death of that muscle tissue. This can weaken the heart muscle, including the muscles that support the mitral valve. As a result, the mitral valve may not close properly, causing blood to flow backward into the left atrium. This backward flow of blood is known as mitral regurgitation. Therefore, myocardial infarction is the most likely cause of acute mitral regurgitation.