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Cardiovascular physiology and anatomy core lecture
Wayne Pearceon 17 December 2015
Transcript of Cardiovascular physiology and anatomy core lecture
" . . . a mind free of thought, merged with itself, beholds the essence of the
While a mind filled with thought, identified with its own perceptions, beholds the boundaries and forms of this world."
"Phenomena are never either atomistically discrete or complete"
26 year old female, asymmetric hypertrophic cardiomyopathy, presents for cesarian section delivery of a term pregnancy. Medications: propranolol and imipramine.
Cardiovascular changes in pregnancy
Aortic stenosis and HOCM
Ions, pumps and exchangers
Choice of anesthetic technique
Heuristics for other valvular lesions
HOCM / IHSS and resuscitation
You decide to proceed with a GETA. Induction: grade IV view, despite preoxygenation patient rapidly desaturates and becomes tachycardic - first reaction?
cardiovascular response to hypoxia
Ischemia - heuristics?
HOCM and elevated sympathetic traffic
Airway - pregnancy - cardiovascular system
Difficult airway algorithm
Airway controlled with LMA - saturation restored. You decide to wake her up and proceed with a nasal fiberoptic intubation. On inserting the tube you precipitate brisk nasal hemorrhage - over her face, into her oropharynx. Now what?
Awake nasal fiberoptic intubation - airway preparation - pregnancy
Hemorrhage - hypovolemia - pregnancy -
Simple maneuvers for epistaxis
Anxiety, fear and HOCM
Neuraxial anesthesia in HOCM / difficult airway
Preload, afterload, wall tension, coronary perfusion pressure
Eventually patient intubated. A few minutes into surgery the patient develops a tachycardia of 140 and a blood pressure of 60 / 40.
Differential diagnosis of tachycardia.
Bowditch and Treppe phenomena
Calcium economy and flux in the myocardial cell
Appropriate temporizing response?
Pacemaker currents, diastolic depolarization, repolarization fragility
A good response to phenylephrine and fluid. The fetus is delivered. Oxytocin administered. Neonate's apgar low, heart rate - 60 / min.
Receptors and signal transduction.
Cardiac cycle: electrical and mechanical events
Determinants of cardiac output - Fick principle
Autosomal dominant, sarcomeric disease
There is no privileged level of causality in biology
Energy conservation, the fragility of repolarization, promiscuity, and nature's pact with the devil.
Perioperative renal protection
Do no harm
No magic bullet, no single EB measure
Mostly 'negative' recommendations
'Protocolized' hemodynamic optimization
Correct type and dose of resuscitation fluid
Optimize intra-abdominal perfusion pressure
Minimize secondary injury due to nephrotoxins and systemic factors
Causes of sudden cardiac death in the young
structural congenital heart disease - before and after surgery
congenital anomalies of the coronary circulation
hypertrophic and other cardiomyopathies
Channelopathies (ion channel disturbances)
. . . affect nearly every organ system.
Ion channel function highly protected by redundant mechanisms, and symptoms tend to be paroxysmal.
LQTS, SQTS, Drug-induced torsades de pointes
Brugada syndrome, Catecholaminergic Polymorphic Ventricular Tachycardia, Ankyrin-B syndrome