Cardiac Surgery CSC Exam 2022 With Complete Solution With Rationales
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Course
Cardiac Surgery CSC
Institution
Cardiac Surgery CSC
You are caring for a patient with an intra-aortic balloon pump and note blood in the tubing. Your initial action should be:
A. Stop the balloon pump and notify the physician.
B. Administer 100% oxygen to help displace the helium and notify the physician
C. Leave the IABP running and notify the p...
Cardiac Surgery CSC Exam 2022 With Complete Solution
With Rationales
You are caring for a patient with an intra-aortic balloon pump and note blood in the
tubing. Your initial action should be:
A. Stop the balloon pump and notify the physician.
B. Administer 100% oxygen to help displace the helium and notify the physician
C. Leave the IABP running and notify the physician.
D. Purge the IABP manually to clear the blood from the tubing.
A. Blood in the IABP tubing indicates a balloon rupture which can cause gas embolus.
However, helium is thought to be easily absorbed in the presence of balloon rupture and
oxygen is not generally indicated. The appropriate action is to disconnect the balloon
from the console or turn it on standby so the movement of helium is stopped and notify
the physician. The nurse will need to prepare for IABP removal and replacement if
needed.
When caring for a patient immediately post CABG the nurse recognizes that the most
likely cause of hypotension in the immediate post-operative period is
A. Decreased circulating volume requiring no intervention unless persistent > 12 hours.
B. LV failure requiring an inotrope as first line treatment for any hypotension.
C. Decreased circulating volume representing the need for increased fluid
administration.
D. LV failure requiring an assist device.
C. Hypotension in the immediate postoperative period is usually caused by low
circulating volume and responds to treatment with fluids. Volume is the first line
treatment for hypotension. If there is no immediate response to volume administration,
500 mg of IV calcium chloride is often given. Existing vasopressors, such as
norepinephrine, can also be adjusted. It is important for hypotension to be promptly
treated. Persistent hypotension can result in hypoperfusion and end organ damage.
LV failure is not the most common cause of hypotension in the immediate post-
operative period and therefore inotropic agents are not first line agents used in the
treatment of hypotension. Hypotension that does not respond to fluid administration may
require an inotrope.
Preoperative clopidogrel should be held for how many days in the elective surgery
patient:
A.It does not need to be held.
B. 1-2 days.
C. 5-7 days.
D. 30 days.
C. Clopidogrel inhibits the P2Y12 receptor on the platelet for the lifetime of the platelet
(10 days). Inhibited platelets cannot participate in clotting, so the risk of bleeding
increases with antiplatelet drugs. Most clinical trials have identified an increased risk in
bleeding, transfusion, and re-exploration when clopidogrel is taken within 5 days of
surgery, and no increase in bleeding or transfusions when clopidogrel is stopped for > 5
,days prior to surgery. Therefore, clopidogrel should be stopped for 5 to 7 days prior to
elective surgery. Emergent surgery can be done regardless of when the last dose of
clopidogrel was taken, but will be associated with increased bleeding and need for
platelet transfusions.
The term OPCAB refers to:
A. combination open heart surgery and percutaneous procedure.
B. CABG surgery without the use of cardiopulmonary bypass (CPB).
C. the use of thoracotomy instead of sternotomy.
D. patients who are fast tracked to be discharged in less than 5 days.
B. OPCAB refers to off-pump coronary artery bypass. Surgery is done without CPB but
it still involves a median sternotomy.
MIDCAB (minimally invasive direct coronary artery bypass) is performed on a beating
heart without CPB and without the use of a median sternotomy. MIDCAB is commonly
done through an anterior thoracotomy incision and is used to bypass the mid to distal
LAD with a left internal mammary artery (LIMA) graft. A ministernotomy can also be
used to gain access during MIDCAB.
Which of the following patients is at highest risk for neurological complications after
CABG?
A. A 63-year- old patient with a BMI of 30 undergoing OPCAB
B. A 85-year-old patient with an atherosclerotic aorta undergoing CPB
C. A previously healthy 50-year-old woman undergoing CPB
D. A 67-year-old man having a MIDCAB to the LAD with no known history of
hypertension
B. Severe atherosclerosis of the aorta, advanced age, use of CPB, aortic cross-
clamping, diabetes, hypertension, female sex, and history of stroke place patients at
high risk for neurological complications following cardiac surgery. Other factors
contributing to neurological complications include alcohol abuse, heart failure,
arrhythmias, and hyperglycemia.
The nurse caring for the post operative cardiac surgery patient recognizes the following
as potential contributors to post-operative vasodilation that can cause hypotension:
A. Cooling that occurs while on cardiopulmonary bypass, and use of vasodilators post
op.
B. Use of norepinephrine or dopamine to support BP immediately post-op.
C. Inflammatory response due to CPB and use of norepinephrine to support BP
D. Rewarming that occurs after return to the ICU, and the inflammatory response to use
of cardiopulmonary bypass during surgery
D. Intraoperative cooling results in vasoconstriction; rewarming after surgery causes
vasodilation and can contribute to hypotension if volume administration is inadequate
for the increased size of the vascular space caused by vasodilation. The use of CPB
stimulates an inflammatory response that results in vasodilation that contributes to
hypotension.
Norepinephrine and dopamine cause peripheral vasoconstriction, not vasodilation.
A characteristic of a fast-track pathway after CABG would include:
A. anticipated discharge between post-op days 7 and 8.
B. a defined medication strategy to prevent postoperative atrial fibrillation.
,C. liberal use of opioid medications to increase patient comfort during the ventilator
weaning
process.
D. extubation by the third post-op day
C. Low-risk patients can be selected for fast tracking after CABG. These patients are
targeted for early extubation, early ambulation, and early discharge. Patients who are
fast tracked receive sedation and analgesia to allow for early extubation.
Pharmacological strategies to prevent atrial fibrillation and early phase I cardiac
rehabilitation are also key components of fast tracking.
You are caring for an early post-operative CABG patient who remains hypotensive
despite treatment with adequate fluid administration and an alpha constricting agent.
You know that one potential post-operative complication responsible for this persistent
hypotension could be:
A. Acute kidney injury.
B. Acute saphenous vein graft closure.
C. Acute respiratory distress syndrome (ARDS).
D. Vasoplegia.
D. Vasoplegia is a form of vasodilatory shock that can occur after separation from CPB.
It is characterized by significant hypotension despite adequate fluid resuscitation, low
SVR(due to vasodilation), and is resistant to vasopressors. When vasopressors
(norepinephrine, epinephrine, high dose dopamine, or vasopressin) are not able to
maintain blood pressure in the presence of adequate filling pressures, then vasoplegia
may be present. There are several theories behind the cause of vasoplegia, including
leukocyte activation and the release of pro-inflammatory mediators during
cardiopulmonary bypass, and vasoplegia has been associated with long-term use of
ACE inhibitors, calcium channel blockers, amiodarone, and heparin. Patients with EF
<35%, heart failure and diabetes are at higher risk. Vasoplegia can also be seen after
OPCAB.
Acute respiratory distress syndrome (ARDS) and acute kidney failure can both be
complications in the cardiac surgery patient, but do not typically occur early in the post-
operative course and are not necessarily associated with hypotension and failure to
respond to vasopressors.
An acute saphenous vein occlusion can occur as a result of persistent hypotension. The
most direct clinical signs of acute saphenous vein graft closure would be those of
ischemia.
Mediastinal drainage in the following amount meets criteria for re-exploration:
A. > 300 ml/hr for 2-3 hours.
B. > 200 ml/hr for 4 hours.
C. > 400 ml to 500 ml for 1 hour.
D. All of the above.
D. Chest tube drainage criteria for surgical re-exploration:
• > 400 to 500 ml for 1 hour
• > 300 ml/hr for 2 to 3 hours
• > 200 ml/hr for 4 hours
• Acute onset of bleeding >300 ml/hr after period of stable and minimal bleeding
, Patients with prolonged CPB times are likely to experience:
A. An increased likelihood of early extubation.
B. An increase in coagulopathies.
C. A decrease in total body fluid due to dehydration.
D. A decrease in chest tube drainage.
B. Coagulopathy is present to some degree with all CPB. During CPB, blood contacts
the non-physiological surfaces of the bypass circuit and an inflammatory response is
initiated. A coagulopathy can develop from activation of platelets and the fibrinolytic
system. Clotting factors, platelets, and RBCs are diluted during CPB. A longer pump
time is associated with increased coagulopathies.
Postoperatively, patients have an increased amount of total body fluid due to priming of
the CPB pump and administration of fluids during surgery. Extra volume is given to the
patient during cardiopulmonary bypass to assure adequate circulating volume through
the cardiopulmonary circuit.
Long pump times are associated with increased bleeding and therefore increased chest
tube drainage, and prolongs time to extubation.
Coagulopathy is present to some degree with all CPB. During CPB, blood contacts the
non-physiological surfaces of the bypass circuit and an inflammatory response is
initiated. A coagulopathy can develop from activation of platelets and the fibrinolytic
system. Clotting factors, platelets, and RBCs are diluted during CPB. A longer pump
time is associated with increased coagulopathies.
Postoperatively, patients have an increased amount of total body fluid due to priming of
the CPB pump and administration of fluids during surgery. Extra volume is given to the
patient during cardiopulmonary bypass to assure adequate circulating volume through
the cardiopulmonary circuit.
A. Long pump times are associated with increased bleeding and therefore increased
chest tube drainage, and prolongs time to extubation.
B. The patient is excessively dry from the hemoconcentration that occurs during
cardiopulmonary bypass.
C. The patient is still vasoconstricted from being cool during the prolonged
cardiopulmonary bypass time.
D. The patient has capillary leak and fluid is shifting into the interstitial space.
E. All of the above.
D. Failure of fluid challenges to raise preload may indicate the presence of capillary leak
and fluid shifting into the interstitial space. Patients with longer CPB times are at greater
risk for capillary leak. In patients with capillary leak, a large amount of fluid is required to
maintain adequate circulating volume. Administration of large amounts of volume also
increases the interstitial volume. Inotropes and vasopressors may also be needed for
hemodynamic support in the patient with capillary leak.
Vasoconstriction from hypothermia results in an increase in preload not a decrease.
Venous vasodilation will result in decreased preload.
Cardiopulmonary bypass results in hemodilution, not hemoconcentration. Extra volume
is given to the patient during cardiopulmonary bypass to assure adequate circulating
volume through the cardiopulmonary circuit.
The first line strategy to maintain an adequate cardiac index in the immediate
postoperative period includes:
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