Prince Caseous' special MI mini deck Flashcards
Where would the MI be if the RCA is occluded?
Where would the MI be if the LCA is occluded?
Where would the MI be if the LAD is occluded?
Where would the MI be if the LCX is occluded?
- RCA = posterior, inferior MI
- LCA = massive anterolateral MI
- LAD = Anteroseptal MI
- LCX = Lateral MI
Which lead do you want to be in for someone who has had ischemic disease?
2 and V5
Because you want to look at the inferior and anterior portion of the heart which is where the left ventricle sits because it is most likely to become ischemic (d/t higher O2 needs)
How is myocardial ischemic disease managed pharmacologically?
(5)
-
Beta blockers- reduce contractility and HR
- helps reduce demand and increase supply
- Calcium channel blockers- dilate the coronary arteries, reduce contractility, reduce afterload
- Ace inhibitors- may improve contractility by afterload reduction
- Nitrates- dilate coronary arteries and collateral blood vessels, decrease peripheral vascular resistance (afterload), venodilation (preload)
- Antiplatelet drugs- reduce potential for thrombosis
What are the elective surgery recommendations after having a procedure for myocardial ischemic disease?
(chart)
The risk of perioperative death due to cardiac causes is ____ in the general population.
When do most perioperative MIs occur?
<1%
24-48 hours after surgery
How do you determine what kind of work up required or if you can proceed with surgery in a patient who has been previously revascularized?
(chart)
How do you determine what kind of work up is required or if the surgery can proceed in a patient with myocardial ischemic disease who has NOT been previously revascularized?
(chart)
What causes decreased Oxygen supply?
- tachycardia
- hypotension
- vasoconstriction
- O2 carrying capacity
- Acid/base, anemia, hypoxia
- increased viscosity
- arterial patency
- coronary spasm
Monitoring for ischemia:
RCA: leads used, area of myocardium involved
Circumflex: leads used, area of myocardium involved
LAD: leads used, area of myocardium involved
(chart)
What causes increased O2 demand?
- Tachycardia
- increased contractility, preload, afterload
- shivering
- hyperglycemia
- hypertension
- **It is easier for us to control the demand than the supply
What are the intra-op considerations for a patient with myocardial ischemic disease?
(chart)
- Surgery will set off inflammatory response that will ultimately cause decreased oxygen delivery
- Surgery will set off neuroendocrine stress response that will ultimately increase oxygen demand
What are important considerations for the anesthesia of a patient with myocardial ischemic disease?
Regional
General
- Regional- good option if available
- pre-emptively treat hypotension with fluids and phenylephrine
- if bradycardic, use ephedrine
- General
- maintain balance between O2 supply and demand
- do not allow for long periods of hypotension as it causes decreased BF to coronaries
- important to maintain BP within 20% of patient’s baseline
Induction of a pt with myocardial ischemic disease:
goals
drugs to use
- Goal to have minimal hemodynamic effect during laryngoscopy
- try to minimize response- opioids, lidocaine
- If severe cardiac dysfunction, use Etomidate or High opioid technique
What should be your goals for maintenance of anesthesia for pts with myocardial ischemic disease?
- Avoid tachycardias
- maintain normal preload and afterload
- decrease contractility if LVF is normal (EF normal)
- ok to use high gas technique
- high opioid technique to maintain contractility if pt has LV dysfunction
- normal sinus rhythm
- Control demand- metabolic O2 need
