Medical Pharmacology Chapter 43:  Adult Cardiac Procedures

 

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Cardiac Anatomy

  •  Ascending aorta: major branches (arising from the aortic arch)

    • Inominate

      • Divides into right subclavian and right carotid arteries

    • Left carotid

    • Left subclavian

  • Rationale for anesthesia providers in learning arterial circulation anatomy:

    • Target sites for direct arterial cannulations

    • Targets that must be avoided for venous cannulations

    • Helping to prevent surgical complications

  • Important arterial systems 

    Renal

    Coronary

    Carotid

    Cerebral

    Bronchial

    Spinal cord 

  • Coronary Vasculature

  • Many Factors may Affect ST, T and U ECG wave forms*

    •   Ventricular conduction abnormalities (idioventricular rhythms)

    •  Atrial repolarization (with tachycardia, atrial T waves "may pull down" the beginning of the ST segment)

    •  Metabolic factors (hyperventilation, hypoglycemia are examples)

    •  Electrolyte lobe of abnormalities:  (abnormal potassium, magnesium, calcium levels)

    •  Pharmacology: many drugs including tricyclic antidepressants, quinidine, digoxin (Lanoxin, Lanoxicaps)

    •  Myocardial disease-- such has ischemia, infarction, myopathy, myocarditis

    •  Neurological (neurogenic) considerations: trauma, tumor, stroke, hemorrhage are examples

*information courtesy of  Frank G.Yanowitz, M.D. &  The Alan E. Lindsey  ECG Learning Center, used with permission.

 

  • image courtesy of Marquette Electronics

     

    • "The "P wave presents atrial activation; the P-R interval is the time from onset of atrial activation to onset of ventricular activation. 

    • The QRS complex represents ventricular activation; the QRS duration is the duration of ventricular activation. 

    • The ST-T wave represents ventricular repolarization.  The QT interval is the duration of ventricular activation and recovery. 

    • The U wave probably represents 'afterdepolarizations' of the ventricles"

      • Courtesy of  Frank G.Yanowitz, M.D. &  The Alan E. Lindsey  ECG Learning Center, used with permission.

     

  • Ischemic Heart Disease: ECG manifestations: ST segmental changes

    • ST Segment Depression

      • Courtesy of  Frank G. Yanowitz, M.D. &  The Alan E. Lindsey  ECG Learning Center, used with permission.

      • Note that "upsloping" ST depression is not considered an ischemic abnormality.

 

    • Subendocardial ischemia:   Exercise induced or during anginal episode (courtesy of  Frank G.Yanowitz, M.D. &  The Alan E. Lindsey  ECG Learning Center, used with permission)

     

  • Differential diagnostic issues in evaluating ST segmental depression

    • Normal variant/artifacts include:

      1. ST-depression secondary to poor skin-electrode contact [pseudo-ST-depression]

      2. Hyperventilation-induced ST segmental depression

      3. Physiological J-junctional depression associated with sinus tachycardia

    •  Ischemic Heart disease

      • "Subendocardial ischemia" (shown above)

      • "Nnon-Q-wave a cardinal infarction"

      • "Reciprocal reciprocal changes in acute Q-wave myocardial infarction (e.g., ST depression in leads I & aVL

    •  ST-segmental changes not due to ischemic heart disease

      •  Digoxin (Lanoxin, Lanoxicaps)/digitoxin (Crystodigin) ECG effects

      •  Hypokalemia

      •  Some cases of mitral valve prolapse

      •  CNS disorders

      •  Secondary ST-changes with certain conduction abnormalities (e.g. right bundle branch blocks, left bundle branch blocks, Wolff-Parkinson-White disorder)

      •  Right ventricular hypertrophy (right precordial leads)

      •  Left ventricular hypertrophy (left precordial leads, I, aVL)

        • Courtesy of  Frank G.Yanowitz, M.D.&  The Alan E. Lindsey  ECG Learning Center, used with permission.

 

 

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  • Primary Reference: Lake, C.L. Cardiovascular Anatomy and Physiology, Third edition  (Barash, PG, Cullen, BF, Stoelting, R.K, eds), Lippincott-Raven Publishers, Philadelphia, pp. 805-835, 1997

  • Primary Reference:  Ross, AF, Gomez, MN. and Tinker, JH Anesthesia for Adult Cardiac Procedures in  Principles and Practice of Anesthesiology (Longnecker, D.E., Tinker, J.H. Morgan, Jr., G. E., eds)  Mosby, St. Louis, Mo., pp. 1659-1698, 1998.

  • Primary Reference: Shanewise, JS and Hug, Jr., CC, Anesthesia for Adult Cardiac Surgery, in Anesthesia, 5th edition,vol 2, (Miller, R.D, editor; consulting editors, Cucchiara, RF, Miller, Jr.,ED, Reves, JG, Roizen, MF and Savarese, JJ) Churchill Livingston, a Division of Harcourt Brace & Company, Philadelphia, pp. 1753-1799, 2000.

  • Primary Reference: Wray Roth, DL, Rothstein, P and Thomas, SJ Anesthesia for Cardiac Surgery, in Clinical Anesthesia, third edition  (Barash, PG, Cullen, BF, Stoelting, R.K, eds), Lippincott-Raven Publishers, Philadelphia, pp. 835-865, 1997

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