Describes coronary blood supply anatomy, myocardial oxygen demand and supply, and basic anesthesia consideration (history taking, special investigation, and optimization)
A patient with pacemaker presents a complex challenge to the attending anaesthesiologist. The mode of management will be according to the type of pacemaker implanted. This presentation discusses in brief the peri-operative consideration in a patient with pacemaker.
as the life expectancy has increased. more and more elderly patients are undergoing surgery. the burden of postoperative dysfunction has to be increased in future. There should be attempt to identify the risk factors and measures to prevent POCD.
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
Describes coronary blood supply anatomy, myocardial oxygen demand and supply, and basic anesthesia consideration (history taking, special investigation, and optimization)
A patient with pacemaker presents a complex challenge to the attending anaesthesiologist. The mode of management will be according to the type of pacemaker implanted. This presentation discusses in brief the peri-operative consideration in a patient with pacemaker.
as the life expectancy has increased. more and more elderly patients are undergoing surgery. the burden of postoperative dysfunction has to be increased in future. There should be attempt to identify the risk factors and measures to prevent POCD.
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
Cardiovascular emergencies are life-threatening disorders that must be recognized immediately to avoid delay in treatment and to minimize morbidity and mortality. Patients may present with severe hypertension, chest pain, arrhythmia, or cardiopulmonary arrest
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
1. CARDIAC
ANESTHESIA
By:
Dr. Othman Ismat Abdulmajeed
Consultant Cardiac Anesthetist
Hawler Medical College
othman.abdulmajeed@med.hmu.edu.iq
1
Dr.Othman Abdulmajeed
2. Dr.Othman Abdulmajeed
Pre-operative assessment
- Pre-operative tests ?
- Evaluation of LV function:
1- History.
2- Symptoms and clinical signs of left ventricular failure
3- Cardiac catheterization, CT angiography, and echocardiography
4- Ejection fraction (normally 65%)
5- LVEDP or PAOP: normal 6 to 15 mm Hg
6- Myocardial viability studies (contrast echocardiography or
positron emission tomography study)
2
Dr.Othman Abdulmajeed
3. - Major determinants of myocardial oxygen consumption..
The three major determinants of myocardial oxygen consumption are :-
1-myocardial wall tension.
2-contractility. 3- HR.
- Factors determining myocardial oxygen supply
Myocardial oxygen (O2) supply = coronary blood flow × arterial O2
content
The coronary blood flow depends on the following:
1- Diastolic aortic pressure (DAP).
2- LVEDP.
3- Patency of coronary arteries.
4- Coronary vascular tone.
3
Dr.Othman Abdulmajeed
4. Dr.Othman Abdulmajeed
Chronic Medications..
- Digoxin : In order to prevent digitalis intoxication after CPB,
digitalis preparations are usually discontinued one half-life (1.5 to 1.7
days for digoxin, 5 to 7 days for digitoxin) before surgery. Digitalis
intoxication is quite possible, especially after CPB when acid-base
and electrolytes are abnormal.
- Metoprolol : The β-blocker (metoprolol) should be continued not
only up until surgery but also throughout the perioperative period.
In patients with unstable angina, sudden withdrawal of β-blocker may
produce an exacerbation of symptoms and may precipitate acute MI.
4
Dr.Othman Abdulmajeed
5. Dr.Othman Abdulmajeed
• Potential benefits of β-adrenergic blockade in heart failure
include decreased HR and normalization of β-receptor
function.
• Slower HRs improve diastolic function by increasing the
diastolic filling time and myocardial perfusion and by
decreasing the myocardial oxygen consumption.
• If the patient who is on metoprolol develops hypotension
intraoperatively, then we first should think about the more
common causes of intraoperative hypotension, such as
hypovolemia, deep anesthesia, and surgical manipulation,
which should be corrected first.
• There are no specific antagonists for metoprolol. In rare
instances, it is necessary to administer atropine for
bradycardia or epinephrine, isoproterenol, glucagon, calcium,
or digitalis to counteract the negative inotropic state
associated with β-blockade.
5
6. Dr.Othman Abdulmajeed
Intra-operative monitoring
• ECG , Lead II and V5.
• Arterial line for IBP and ABG.
• PA and CVP catheters
• Temperature, Lower esophageal.
• Urine output.
• ET co2, Pulse oximetry.
• TEE.
• BIS
6
7. Dr.Othman Abdulmajeed
Monitoring..
• PA catheter and CVP catheter will be discussed in details
later on in CARDIAC MONITORING lecture. and ECHO will be
discussed in THE ECHO lecture in more details.
• ECG monitoring: Multiple-lead ECG monitoring provides the
best clinically available method of detecting perioperative
ischemia, therefore, leads II and V5 are the optimal leads for
intraoperative myocardial ischemia.
• If only one lead can be displayed, V5 should be used because
lead V5 has the greatest sensitivity: 75% intraoperatively and
89% during exercise treadmill testing.
7
8. Dr.Othman Abdulmajeed
Allen's test
• used to detect the presence of adequate collateral ulnar
arterial circulation,The Allen's test is:
• (Demo the procedure)
• Normal—if the flush appears in less than 7 seconds (presence
of adequate collateral connections between the superficial
[ulnar] and deep [radial] palmar arches)
• Borderline—7 to 15 seconds
• Abnormal—greater than 15 seconds
8
9. Dr.Othman Abdulmajeed
Induction of Anesthesia
• Midazolam 1 to 2 mg is given as soon as the standard monitors are
applied and prior to the arterial line is inserted (under local anesthesia)
• A smooth induction is essential to prevent hypotension, hypertension,
and tachycardia. Different techniques may be used to achieve a
smooth induction.
• For patients with good left ventricular function, anesthesia is induced
with fentanyl, 2 to 5 µg per kg, and propofol, 1 to 2 mg per kg.
• For patients with poor left ventricular function, potent inhalation agents
such as isoflurane, sevoflurane, and desflurane should be used
cautiously during induction of anesthesia because of their dose-
dependent reduction in myocardial contractility and systemic arterial
resistance.
• Alternatively, etomidate 0.2 mg per kg may be administered for
induction.
• However, it is more important to maintain stable hemodynamics than
the choice of induction anesthetic agents.
9
10. Dr.Othman Abdulmajeed
Maintenance of Anesthesia
•Again, smooth anesthesia is essential to achieve a balance
between myocardial oxygen demand and supply. Different
agents and techniques may be used to accomplish the same
goal.
•A combination of fentanyl (or another synthetic opioid) and
isoflurane, sevoflurane, or desflurane (or propofol) is a popular
choice.
•The depth of anesthesia must be titrated to meet the
requirements of the varying intensities of surgical stimulation.
Skin incision and sternal splitting are very painful. However, the
strongest stimulation is usually from sternal retraction with the
self-retaining retractor.
10
11. Dr.Othman Abdulmajeed
Inhalational Vs Intravenous ?
•Both inhalation, IV, and combined agents have been used
successfully.
•Both have advantages and disadvantages. Understanding the
cardiovascular effects of each anesthetic agent and careful
titration of each drug will improve the balance between
myocardial oxygen demand and supply.
•Early detection and appropriate control of the major
determinants of myocardial oxygen consumption (BP, HR,
PAOP) are mandatory if myocardial ischemia is to be avoided.
11
12. Dr.Othman Abdulmajeed
Understanding the CVS effects of ..
• Isoflurane, desflurane, and sevoflurane all produce a dose-related
depression in ventricular function and vascular tonus.
• Out of all the volatile anesthetics, isoflurane causes the most reduction in
vascular tone and coronary vasodilation, suggesting the possibility of steal
syndrome in patients with CAD.
• All of the potent drugs decrease arterial pressure in a dose-related manner.
The mechanism of BP decrease includes vasodilation, myocardial
depression and decreased cardiac output, and decreased sympathetic
nervous system tone.
• Narcotics such as morphine and fentanyl at their clinical dose have minimal
cardiovascular effects. Both may cause bradycardia. Neither sensitizes the
heart to catecholamines or depresses myocardial function.
• High doses of morphine, 1 mg per kg, produce a significant decrease in
arterial BP and systemic vascular resistance accompanied by an average
750% increase in plasma histamine. On the other hand, high doses of
fentanyl, 50 µg per kg, do not produce any significant changes in BP,
vascular resistance, and plasma histamine levels.
12
13. Dr.Othman Abdulmajeed
ST-segment depression,Rx..
• An ST-segment depression is indicating ischemia and should
be treated by:
• Increasing oxygen supply: correct hypotension (with IV
phenylephrine), hypoxemia, anemia.
Decrease oxygen demand: correct hypertension, tachycardia,
and increased PAOP or CVP by deepening anesthesia with a
volatile agent or by using vasodilators (nicardipine or
nitroglycerin) or β-blockers (metoprolol, esmolol, or labetalol).
• All the major determinants of decreased oxygen demand have
to be considered and corrected to their normal levels.
13
14. Dr.Othman Abdulmajeed
Prophylactic nitroglycerin..
• It has been reported that prophylactic administration of
nitroglycerin, 0.5 or 1.0 μg/kg/min, during fentanyl anesthesia in
patients undergoing CABG did not prevent myocardial ischemia
or reduce the incidence of perioperative MI.
14
15. Dr.Othman Abdulmajeed
Rx. of Hypertension..
Hypertension is usually due to inadequate depth of anesthesia and/
or activation of the sympathoadrenal pathways that occurs with
stress/surgery. Rarely, it is due to fluid overloading. The treatment of
hypertension includes the following:
• Deepening the anesthetic level. Inhalation agents such as
isoflurane and sevoflurane are more effective than narcotics
because of their vasodilator effect.
• Administering vasodilators, when inhalation agents are not used
• Nicardipine. Dose: 0.5 µg/kg/min, titrate to effect
• Labetalol. Dose: 5-mg increments, titrate to effect
• Nitroglycerin produces more venodilation than arteriolar dilation.
Dose: 20 to 200 µg per minute IV drip titration or bolus in 20-µg
increments. It is important to note that this agent affects BP mainly
via venodilation, which frequently will drop preload and may lower
the cardiac output such that greater fluid intake may be required.
15
16. Dr.Othman Abdulmajeed
Rx. of Hypotension..
Hypotension is usually caused by acute hypovolemia, deep
anesthesia, bradycardia, or ventricular failure. The treatment
options are as follows:
• Increase fluid infusion when CVP or PAOP is low.
• Lighten the level of anesthesia or use a vasoconstrictor:
phenylephrine, 0.1 mg IV increments, to correct vasodilation
produced by anesthesia.
• For bradycardia, epicardial pacing may be used to increase
the HR.
• Treat cardiac failure when PAOP is high and TEE shows
global hypokinesia: 1) Avoid deep level of anesthesia.
2) Restrict fluids. 3) Use Inotropes.
16
17. Dr.Othman Abdulmajeed
B-blocker during surgery..
• Indications :-
1. ST-segment depression associated with tachycardia; no response to
deepening the level of anesthesia
2. Supraventricular tachycardia
3. Recurrent ventricular arrhythmias
• Contraindications :-
Asthma, reactive chronic obstructive pulmonary disease
Esmolol is cardioselective and appears to have little effect on bronchial
or vascular tone at doses that decrease HR in humans. Esmolol is a
short-acting β-blocker with an elimination half-life of 9 minutes and a
pharmacologic half- life of 10 to 20 minutes. It has been used
successfully in low doses in patients with asthma. Esmolol is metabolized
rapidly in the blood by an esterase located in the erythrocyte cytoplasm.
17
19. Dr.Othman Abdulmajeed
Anti-coagulation
• Heparin has been used conventionally in doses of 300 (200 to
400) units per kg of body weight.
• After 2 hours of the initial dose, subsequent doses of 100 units
per kg are given for each additional hour of bypass. Because
there is marked individual variation, heparin doses are best
monitored by the ACT test.
• The normal control value of ACT is 105 to 167 seconds.
• A baseline value is determined before the administration of
heparin, and the test is repeated 3 to 5 minutes after heparin
is given and at intervals of 30 to 60 minutes thereafter.
19
20. Dr.Othman Abdulmajeed
Laboratory Monitoring during
CPB..
Should be done at least once hourly.
1. Arterial blood gases are kept at normal range.
2. Venous PO2 should be 40 to 45 mm Hg.
3. Hematocrit maintained between 20% and 30%
4. Electrolytes Na+, K+, ionized Ca2+
5. ACT measured each hour and maintained above 400 to 480
seconds.
6. Blood sugar probably should be kept below 250 mg per dL.
20
21. Dr.Othman Abdulmajeed
Hypothermia during CPB
• Hypothermia decreases oxygen consumption and helps to
preserve the function of tissues during a hypoxic or ischemic
insult.
• However, the balance between oxygen supply and demand
can be impaired by reductions in tissue oxygen delivery due to
increased blood viscosity, reduced microcirculatory flow, and a
leftward shift of the oxygen-hemoglobin dissociation curve.
21
23. Dr.Othman Abdulmajeed
Anesthesia during CPB
• Anesthesia is maintained with intermittent administration of IV
propofol, benzodiazepines, narcotic, and/or inhalation agents
through the pump oxygenator to achieve unconsciousness
and analgesia, to control BP, and to prevent shivering.
• Hypothermia itself produces anesthesia and prolongs the
action duration of IV agents by decreasing hepatic metabolism
and urinary excretion.
• Muscle relaxants are given to prevent diaphragmatic
movement that interferes with surgery and to prevent shivering
during hypothermia.
• Shivering may increase oxygen consumption to as high as
486% of normal.
23
24. Dr.Othman Abdulmajeed
Myocardial Protection
• The most popular and effective method of protecting the
myocardium is to reduce myocardial oxygen demand by
hypothermia and cardioplegia.
• Hypothermia is induced by a combination of systemic blood
cooling by heat exchangers in the oxygenator.
• Cardioplegia reduces myocardial oxygen consumption and
provides optimal conditions for surgery, It contains:-
Potassium and magnesium to relax the heart, Bicarbonate to
raise the PH level to 7.4-7.8 to increase intracellular shift of K+
and to prevent metabolic acidosis from ischemia. also contains
glucose and insulin. GTN is added to dilate the coronaries.
24
25. Dr.Othman Abdulmajeed
Pink Urine during CPB
• Pink urine is a sign of massive hemolysis. Hemolysis is mainly
associated with the frothing, violent turbulence, acceleration,
and shear forces of negative pressures generated by the
suction apparatus and is associated to a lesser degree with
the action of the pumps or with the gas-blood interface effects
in the oxygenator.
• The renal threshold for hemoglobin is 100 to 150 mg per 100
mL. It is advisable to maintain a high output of alkaline urine to
prevent possible tubular damage from acid hematin crystals,
which are converted from hemoglobin.
25
26. Dr.Othman Abdulmajeed
Ca++ at end of CPB
• With hemodilution, the ionized calcium frequently falls to
approximately 1.5 to 1.8 mEq per L (normal 2.2 to 2.6 mEq per
L, 1.1 to 1.3 mmol per L). Calcium chloride, 0.5 to 1.0 g,
frequently is given to increase myocardial contractility and
reverse potassium cardioplegia.
• Calcium increases the inotropic state of the myocardium and
induces an increase in systemic vascular resistance that
outlasts the inotropic effects.
• β-Blockers, increase intracellular calcium but also promote its
reuptake into the sarcoplasmic reticulum and may be more
appropriate in this setting.
• Calcium salts should probably not be given to patients with
good ventricular function in the absence of hypocalcemia or
hyperkalemia.
26
27. Dr.Othman Abdulmajeed
Blood Sugar during CPB
• Blood sugar levels are elevated during the perioperative
period with CPB, Hyperglycemia is most profound during
hypothermic CPB, with approximately 100% of patients
(diabetic and non-diabetic) achieving plasma glucose levels
greater than 200 mg per dL.
There are several reasons for this:
1. Starvation overnight.
2. Sympathoadrenal activation, in response to surgical stress.
3. Active cooling the body during bypass causes a profound
reduction in insulin production, induces peripheral insulin
resistance, and is associated with renal tubular impairment in
glucose regulation.
4. Dextrose containing cardioplegia.
27
28. Dr.Othman Abdulmajeed
CPB effects on Coagulation
• Platelet dysfunction and thrombocytopenia are found on and
after CPB. Platelet dysfunction is the most common cause of a
bleeding problem following CPB after heparin is reversed and
surgical bleeding is controlled.
• Generally, platelet function returns to near- normal status 2 to
4 hours following CPB.
28
29. Dr.Othman Abdulmajeed
Post CPB Inotropic support..
The need for inotropic support after CPB is usually assessed by
the following
• Preoperative ventricular function (ejection fraction).
• Effectiveness of intraoperative myocardial protection.
• Adequacy of surgical repair.
• Duration of aortic cross-clamping and CPB.
• Patient's age.
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30. Dr.Othman Abdulmajeed
Post CPB, Protamine..
•Protamine, 1 mg is given to reverse each 100 units or 1 mg of
heparin initially administered. Only the initial dose of heparin is
counted. The subsequently added dose of heparin, to keep the
ACT level above 480 seconds, is not considered because of its
metabolism and elimination.
•The ACT test is repeated 10 minutes after the administration of
protamine.
•Heparin is a strong organic acid (polyanion). Protamine is a
strong organic base (polycation). They combine ionically to form
a stable salt and lose their own anticoagulant activity. Protamine
contains two active sites, one that neutralizes heparin and
another that exerts a mild anticoagulant effect independent of
heparin.
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31. Dr.Othman Abdulmajeed
Post-0p. complications
Cardiovascular:
• CHF, arrhythmias, low output syndrome, myocardial ischemia or infarction due
to surgical manipulation, prolonged CPB and aortic cross-clamp (coronary
ischemia), use of cardioplegic solution, and occlusion or kinking of grafts
Pulmonary:
Acute lung injury or adult respiratory distress syndrome due to the following:
• Decreased blood flow to the lung during total CPB
• Collapsed alveoli during CPB, resulting in decreased surfactant and decreased
distensibility
• Fluid overloading
• Hyperoxia during CPB
• Left ventricular failure
• Microemboli
• Reperfusion injury
• Inflammatory response
• Infections
• Transfusion-related lung dysfunction
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32. Dr.Othman Abdulmajeed
Complications. cont..
Renal
• Polyuria from hemodilution and diuretics.
• Oliguria from hypoperfusion
• Acute kidney injury :-
A. Hypoperfusion
B. Ischemia
C. Inflammatory response
D. Nephrotoxins (preoperative contrast dyes, antibiotics)
• Acute tubular necrosis
• Acute or chronic renal insufficiency.
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33. Dr.Othman Abdulmajeed
Complications. cont..
Hemorrhage
• Too much or too little protamine to reverse heparin
• Thrombocytopenia and decreased coagulation factors
• Qualitative and quantitative platelet defect.
• Disseminated intravascular coagulopathy
• Fibrinolysis with low levels of fibrinogen
• Poor surgical hemostasis
Embolism: due to air, destroyed or aggregated formed blood
elements, fat, endogenous and exogenous debris
Neurologic: stroke and neurocognitive dysfunction
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34. Dr.Othman Abdulmajeed
Weaning..
• Ventilator management, weaning strategy, and extubation time
vary significantly among centers practicing cardiac surgery.
• Historically, patients were weaned from the respirator the
following morning after surgery.
• Recently, if the operative course is smooth and if the patient is
hemodynamically stable, weaning and extubation can be
performed early (usually 2 to 6 hours after surgery).
• Early tracheal extubation (fast-track) after CABG surgery may
have cost benefits and improvement in resource use when
compared with late tracheal extubation.
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