Cardiovascular Anesthesia

475 Pages·1985·18.63 MB·English

by  Carol L. Lake M.D. (auth.)

Cardiovascular Anesthesia
Carol L. Lake
Cardiovascular Anesthesia
With 165 Illustrations
Springer-Verlag
New York Berlin Heidelberg Tokyo
Carol L. Lake, M.D.
Associate Professor of Anesthesiology
University of Virginia Medical Center
Charlottesville, Virginia 22908
USA
Library of Congress Cataloging in Publication Data
Lake, Carol L.
Cardiovascular anesthesia.
Includes bibliographies and index.
1. Anesthesia-Complications and sequelae. 2. Heart
Surgery-Complications and sequelae. 3. Surgery
Complications and sequelae. 4. Cardiacs. I. Title.
[DNLM: 1. Anesthesia. 2. Cardiovascular Diseases
complications. 3. Cardiovascular System-drug effects.
4. Heart Surgery-complications. 5. Intraoperative
Complications-prevention & control. 6. Postoperative
Complications-prevention & control. WG 460 L192cl
RD87.3.C37L34 1984 617'.96 84-5549
© 1985 by Springer-Verlag New York Inc.
Softcover reprint of the hardcover 1s t edition 1985
All rights reserved. No part of this book may be translated or reproduced in any form without written
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While the advice and information in this book are believed to be true and accurate at the date of going to
press, neither the author nor the publisher can accept any legal responsibility for any errors or omissions
that may be made. The publisher makes no warranty, express or implied, with respect to the material
contained herein. The author and publisher have made every effort to ensure that the dosages and
techniques recommended in this book are those in accord with current practices and recommendations.
However, the clinician is urged to consult the package insert or manufacturer's brochure for changes in
indications, dosages, warnings or precautions, or alterations in techniques. In some cases, new or
investigational drugs have been described in this book for which ongoing research, governmental
regulations, and other sources of information will result in changes in indications and dosages.
Typeset by University Graphics, Atlantic Highlands, New Jersey.
9 876 5 4 3 2 1
ISBN-l3: 978-1-4612-9540-2 e-ISBN-13: 978-1-4612-5048-7
DOl: 10.1007/978-1-4612-5048-7
Preface
This book is intended to be a manual of an Progressing to the intraoperative phase,
esthesia for treatment of cardiac patients Chapter 3, on intraoperative monitoring, in
undergoing either cardiac or noncardiac sur cludes techniques of insertion for arterial, cen
gery. It was written for residents and fellows in tral venous, and pulmonary artery catheters,
anesthesiology, attending anesthesiologists with and use of cardiac output and other quantifia
specific interests in anesthesia for cardiac sur ble hemodynamic values. The electrocardio
gery, anesthesiologists caring for cardiac pa gram, including precordial, atrial, and esopha
tients undergoing noncardiac surgery, cardiolo geal leads are discussed. The cardiovascular
gists whose patients have cardiac or noncardiac effects of all of the commonly used anesthetic
surgery, and specialists in intensive care who drugs and the pharmacology of cardiac drugs
deal with cardiac patients after surgery. It cov (antiarrhythmic drugs, digitalis, vasopressors,
ers all aspects of a cardiac surgical patient's ex vasodilators, diuretics, and others) are de
periences, pre-, intra-, and postoperative, and scribed. The specific details of anesthetic and
also includes sections on cardiopulmonary hemodynamic management for coronary and
bypass, techniques of cardiac surgery, and valvular disease are covered in Chapters 5 and
myocardial preservation during surgery. The 6. Cardiac problems specific to children are dis
evaluation, intraoperative management, and cussed in the chapter on congenital heart de
postoperative care are applicable to patients fects and techniques of pediatric cardiac anes
undergoing either cardiac or noncardiac sur thesia. The effects of surgical correction or
gery. residual disease in later adult life are also
In the introductory chapter, the manual de described.
scribes basic cardiovascular anatomy and phys Postoperative conditions are described in
iology. Preoperative evaluation of cardiac sur Chapter 8. Chapter 11, on cardiopulmonary re
gical patients for all types of procedures, suscitation, reviews basic concepts and the
including the interpretation of expected find physiologic background of new approaches.
ings on history and physical examination, chest Specific disease states and other conditions,
roentgenogram, electrocardiogram, two-dimen such as pericardial disease, thoracic aneurysms,
sional echocardiogram, cardiac catheterization pacemakers, cardioversion, carotid disease, and
data, graded exercise testing, myocardial scin renal disease, seen frequently in patients with
tigraphy, and other invasive and noninvasive cardiac disease, are described.
procedures are described Chapter 2.
Contents
Preface v
Acknowledgments xi
Chapter 1 Cardivascular Anatomy and Physiology 1
Anatomy 1
Physiology 3
Summary 11
Chapter 2 Preoperative Evaluation and Preparation of
Cardiac Surgical Patients 15
History and Physical Examination 15
Evaluation of Left Ventricular Function 21
Electrocardiography 22
Cardiac Radiology 25
Echocardiography 29
Phonocardiography 32
Systolic Time Intervals 33
Cardiac Catheterization 34
Preoperative Assessment 40
Preoperative Preparation 41
Chapter 3 Intraoperative Monitoring of Cardiac Patients 50
Hemodynamic Monitoring 50
Electrocardiography 75
Temperature 76
Electroencephalography 77
Miscellaneous 78
Chapter 4 Cardiovascular Eft' ects of Anesthetics, Drugs, and
Adjuncts 89
Inhalation Agents 89
Intravenous Agents 96
Other Narcotics 103
Narcotic Antagonists 107
Barbiturates 108
Etomidate 108
Tranquilizers 108
Ketamine 109
Neuromuscular Blocking Agents 110
Chapter 5 Anesthesia for Patients with Coronary Artery
Disease 127
Coronary Artery Disease 127
Myocardial Oxygen Supply-Demand Balance 131
Vlll Contents
Monitoring Requirements 133
Intraoperative Myocardial Ischemia 134
Anesthesia 136
Specific Associated Disease States 139
Summary 139
Chapter 6 Anesthesia for Patients with Valvular Heart
Disease 147
Mitral Valve Disease 147
Aortic Valve Disease 152
Pulmonic Valve Disease 156
Tricuspid Valve Disease 157
Patients with Prosthetic Heart Valves 158
Cardiomyopathies 158
Intracardiac Tumors 161
Chapter 7 Anesthesia for Patients with Congenital Heart
Disease 166
Fetal and Neonatal Circulation 166
Acyanotic Lesions 168
Cyanotic Lesions 174
Specific Anesthetic Considerations in Pediatric Patients 183
Chapter 8 Postoperative Care of Cardiac Patients 195
Intensive Care Unit 195
Cardiac Care 197
Respiratory Care 200
Hepatic Care 210
Renal Care 210
Summary 211
Chapter 9 Cardiac Arrhythmias 218
Incidence 219
Evaluation by ECG 219
Recognition of Arrhythmia Type and Other ECG Abnormalities 221
Management of Atrial Arrhythmias 233
Cardioversion 234
Management of Ventricular Dysrhythmias 235
Chapter 10 Pharmacology of Cardiac Drugs 239
Antiarrhythmic Drugs 239
~-Adrenergic Stimulating Drugs 256
Vasopressor Drugs 259
Vasodilator Drugs· 261
Diuretics 268
Digitalis 269
Antihypertensive Drugs 271
Miscellaneous Drugs 273
Contents IX
Chapter 11 Cardiopulmonary Resuscitation 289
Review of Current Techniques 289
Physiology 293
New Techniques 293
Postresuscitation Care 294
Chapter 12 Cardiac Surgery: Operative Techniques 297
Coronary Artery Bypass Surgery 297
Left Ventricular Aneurysmectomy 301
Valve Replacement 302
Repair of Common Congenital Defects 305
Chapter 13 Cardiopulmonary Bypass 311
Anatomy 311
Physiology 320
Complications 324
Pharmacology 325
Special Techniques 326
Chapter 14 Intra-aortic Balloon Pumping and Other
Circulatory Assist Devices 336
Intra-aortic Balloon Pump 336
Pulsatile Assist Device 343
Left Ventricular Assist Devices 343
Chapter 15 Myocardial Preservation During Open Heart
Surgery 348
Myocardial Metabolism 349
Myocardial Ischemia 350
Cardioplegia Solutions 351
Reperfusion 358
Chapter 16 Blood: Coagulation, Anticoagulation, and
Conservation During Open Heart Surgery 366
Preexisting Coagulation and Hematologic Defects 3(37
Anticoagulants and Their Antagonism 369
Monitoring Coagulation Function 371
Coagulopathies 374
Blood Conservation 377
Chapter 17 The Complications of Cardiac Surgery 383
Cardiac Complications 383
Neurologic Complications 385
Respiratory Complications 388
Hepatic Complications 389
Renal Complications 389
Infectious Complications 391
Bleeding 392
Miscellaneous Complications 392
x Contents
Chapter 18 Anesthesia for Thoracic and Abdominal Aortic
Aneurysms 399
Pathophysiology, Diagnosis, and Treatment 399
Monitoring 400
Perfusion Techniques 401
Anesthetic Techniques 403
Complications 405
Chapter 19 Anesthesia and Cerebrovascular Disease 410
Pathophysiology, Diagnosis, and Therapy 410
Monitoring 411
Cerebral Blood Flow 413
Anesthetic Techniques 414
Complications 415
Combined Procedures 416
Chapter 20 Anesthesia and Renal Disease 420
Normal Renal Function 420
Renin-Angiotensin-Aldosterone System and Antagonists 420
Pathophysiology of Renovascular Hypertension 421
Monitoring Renal Function 421
Anesthetic Effects on Renal Function 421
Renal Failure in Cardiovascular Surgery 423
Cardiovascular Anesthesia and Surgery in Patients with Renal Failure 424
Chapter 21 Pacemakers 429
Indications 429
Types of Pacemakers 430
Electrode Systems 432
Technique for Placement 434
Pulse Generators 437
Anesthetic Management 438
Monitoring 440
Complications 440
Chapter 22 Pericardial Diseases 444
The Normal Pericardium 444
Etiology and Incidence 444
Cardiac Tamponade 445
Constrictive Pericarditis 449
Anesthetic Management 451
Index 457
Acknowledgments
The author wishes to thank the following indi numerous authors and publishers for permis
viduals who have contributed their time and ex sion to reprint figures from their work; manu
pertise to the completion of this book: Ms. facturers of medical products and equipment
Joanne Stanley for editorial and secretarial as for photographs of their products. Dr. Harold
sistance; Ms. Linda Hamme, Ms. Diane Butler, Carron, Dr. Cosmo A. DiFazio, and Dr. E. S.
and Ms. Cindy Hiter and others in the Division Siker all provided initial encouragement for the
of Biomedical Communications at the Univer writing of this book and offered numerous help
sity of Virginia for artwork, graphic design, pho ful suggestions and comments during its prep
tography, and printing of illustrations; Mr. Jef aration. Finally, I am especially grateful to Dr.
frey Engle for performance of biochemical and Robert M. Epstein and the faculty of the De
statistical data and checking of references; the partment of Anesthesiology for the opportunity
staff of Springer-Verlag for constructive edito and time to complete this manuscript in an in
rial assistance; Dr. Robert Mentzer and Dr. tellectually stimulating environment.
Lawrence Burwell for original photographs; the
1
CHAPTER
Cardiovascular Anatomy and Physiology
Modern cardiac anesthesia probably began with The tricuspid valve directs right atrial blood
the successful anesthetic procedure for mitral anteriorly, inferiorly, and to the left toward the
commissurotomy performed by Dr. Kenneth right ventricular outflow tract (17,24). Its leaf
Keown on June 10, 1948 (34). The first use of lets, originating from the anulus fibrosus, are
cardiopulmonary bypass occurred on May 6, thinner and more translucent than those of the
1953, paving the way for more complex surgery mitral valve (24). There are usually three leaf
and thus more complicated anesthetic manage lets, anterior, posterior, and medial. The largest
ment for cardiac patients. The need for a dis leaflet is the anterior leaflet. A medial leaflet at
tinct subspecialty of cardiac anesthesia was rec taches to both the membranous and muscular
ognized in the early 1970s, an event that has portions of the interventricular septum and
contributed immeasurably to successful cardiac may occlude a small ventricular septal defect
surgery. The modern cardiac anesthesiologist (24). Three papillary muscles control the leaf~
must be conversant with the anatomy, physiol lets (14). The largest one is the anterior papil
ogy, and pathology of the cardiovascular lary muscle, which originates from the modera
system. tor band and from the anterolateral ventricular
wall (84). It receives chordae tendiI).eae, strong
fibrous attachments, from the anterior and pos
Anatomy terior cusps of the valve (38). Small posterior
and septal papillary muscles receive chordae
The right atrium consists of two parts: (1) a pos from the posterior and medial cusps (64,84).
terior, smooth-walled part into which the su The right ventricle can be divided into the
perior vena cava (SVC) and inferior vena cava posteroinferior inflow portion containing the
(IVC) enter, and (2) a thin-walled, trabeculated tricuspid valve and anterosuperior outflow por
part, separated by a ridge of muscle, the crista tion from which the pulmonary trunk originates
terminalis or sulcus terminalis on the external (84). Prominent muscular bands-the parietal,
surface. This is the location of the sinoatrial septal, and moderator-and the crista supra
(SA) node (29). Opening into the atrium are the ventricularis define these two parts (84). The
inferior vena cava (whose ostium is guarded by wall of the inflow section is heavily trabecu
the Eustachian valve (50», the coronary sinus lated, particularly in the apex. The outflow por
(whose ostium mayor may not be protected by tion contains few trabeculae and is called the in
a coronary sinus or Thebesian valve (18», and fundibulum (84).
the superior vena cava. The medial right atrial Arising superiorly from the right ventricle,
wall contains a bulge, the torus aorticus, formed the pulmonary trunk passes backward and up
by the posterior and right coronary cusps of the ward beneath the aorta before bifurcating into
aortic valve (78). The posteromedial wall of the right and left pulmonary arteries. The ligamen
right atrium is formed by the interatrial septum tum arteriosum connects the upper aspect of
with its central ovoid portion, the fossa ovalis. the bifurcation to the inferior surface of the aor-