A small compilation of nurse anesthesia care plans

These anesthesia care plans are meant to inspire nurse anesthesia residents when they are making their care plans. Always make sure you fully understand and "own" your care plan. Your plan must be specific for your patient and should always be with the most up-to-date information.

Aortic Stenosis

AS 300Problem: In Systole (cannot eject)

Physiologic Considerations

LV preload

Increase or maintain, maintain stroke volume (SV), avoid venodilation – maintain SVR

HR - 70-90

Extremes are not tolerated well. A-fib causes loss of atrial kick. Bradycardia will decrease CO due to fixed SV. Tachycardia will cause decreased CPP and ischemia

Contractility

Maintain constant

SVR

Normal to high. Afterload is a stenotic valve. Increased SVR = Increased LVEDP and/or LVEDV = Increased MVO2

PVR

Maintain constant

Aortic Valve Anatomy

3 leaflets

2.5-3.5 cm2

Peak gradient <10 mmHg

Aortic Stenosis

  • Normal: 2.6-3.5 cm2
  • Mild: valve area > 1.5 cm2 = Asymptomatic
  • Moderate: valve area = 0.7-1.2 cm2
  • Severe: valve area <0.7 cm2, gradient >50 mmHg

Etiology

  • Congenital bicuspid (40-60 yr)
  • Degenerative calcification >70 yr

Symptoms

Angina - 5 yr survival

Syncope - hypoperfusion

Dyspnea/CHF - 2 yr survival

A-fib

Narrow pulse pressure <50

Surgery

NYHA class III and IV

Valve area < 0.9 cm2, LV hypertrophic

Aortic valve gradient > 50mmHg

Cardiac Remodeling

§  LV concentric hypertrophy

§  Increased LVEDP, LVEDV, LAP > 25-30 mmHg

§  Increased LA contribution to LV filling

§  Increased MVO2

§  Decreased O2 delivery = ischemia

§  Pulmonary HTN

§  RV failure

Preop Considerations

§  Angina, syncope, dyspnea

§  Systolic ejection click, holosystolic harsh murmur radiation to carotids. Diminished carotid pulses

§  EKG

§  LVH

§  AV- conduction blocks

§  ECHO to determine the size, severity, and pulmonary HTN

TEE

Measure gradient

Calculate valve area/valve morphology

Perioperative

Light premeds

Monitor hemodynamics

Prophylactic antibiotics (teeth/ infection)

GA- Regional (HOTN)

Phenylephrine gtt mixed

Surgical Technique

Myocardial protection difficult

Hypertrophied ventricle – cardioplegia ante grade / or retrograde via LV vent (via pulmonary veins as aorta open)

Cardiopulmonary bypass temperature 25-28 degrees C

Post Bypass

Maintain preload

SR - avoid tachycardia/bradycardia

Inotropic support (inadequate protection leads to poor revascularization)

Avoid increased afterload

Mechanical vs Tissue Valve

Mechanical

  • Longer life, requires anticoagulation

Tissue

  • Shorter life expectancy of 10-15 years, minimal to no anticoagulation (ASA)