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.

Mitral Stenosis

Problem

In diastole - decreased flow from LA

  • Decreased LV volumes, SV, and LVEDP

What to Optimize

LV Preload

Maintain forward flow

HR

65-80, maintain NSR, avoid tachycardia

Contractility

Maintain

SVR

Maintain

PVR

Avoid increase, avoid hypercarbia, hypoxemia, acidosis, hypothermia

Anatomy

2 leaflets

Attached to papillary muscles by chordae tendineae

Anterior leaflet (next to outflow tract - note systolic anterior motion SAM)

Posterior leaflet

Valve area 4-6 cm2

  • Mild MS: asymptomatic with compensation, valve area 1.5-2.5 cm2
  • Moderate MS: A-fib with decreased CO, valve area <1-1.5 cm2
  • Severe MS: terminal, valve area <1 cm2

Etiology

  • Secondary to rheumatic heart disease (RHD) with scarring and fibrosis
  • Women>men
  • Often MR and AR if RHD
  • Congenital or degenerative

Surgical indication

NYHA class III or IV symptoms (1.5-2.5 cm2)

Valve area <1 cm2 (critical) or emboli

Symptoms

Left atrial enlargement

Pulmonary edema

Dyspnea

PND

Fatigue

Palpitations - A-fib common

RHF with severe MS

Tricuspid regurgitation

LVF due to restructuring of chordae tendineae

Preop Considerations

  • Diastolic murmur
  • EKG - LAH, prominent a-waves, A-fib
  • ECHO - Evaluate valve area, detect thrombus

PAWP

Overestimate LVEDP (use TEE to estimate)

Large a-wave

Increased risk for PA perforation with pulmonary HTN

Surgical Therapy

Balloon Valvuloplasty

Mitral valve replacement

Open mitral commissurotomy

Mechanical/bioprosthetic

Surgical Technique

Median sternotomy or lateral thoracotomy

+/-Bicaval cannulation - venous if transseptal to MV

CPB with temp 28-32 C

Post bypass

  • PAP and PVR will usually decrease
  • Persistent Pulmonary HTN
  • Phosphodiesterase inhibitors
  • Avoid an increase in PVR
  • Severe Pulmonary HTN - Nitric Oxide
  • Maintain afterload
  • Treat SV arrhythmias
  • Maintain LV and RV Functions