Anesthesiology and the Heart

344 Pages·1990·22.832 MB·English

by  Dennis T. Mangano PH.D., M.D. (auth.), T. H. Stanley, R. J. Sperry (eds.)

ANESTHESIOLOGY AND THE HEART
DEVELOPMENTS IN CRITICAL CARE
MEDICINE AND ANESTHESIOLOGY
Volume 23
For a list of the volumes in this series see final page of the volume.
ANESTHESIOLOGY
AND THE HEART
edited by
T. H. STANLEY and R. J. SPERRY
Department ofA nesthesiology,
The University of Utah Medical School,
Salt Lake City, Utah, U.S.A.
KLUWER ACADEMIC PUBLISHERS
DORDRECHT I BOSTON I LONDON
ISBN-13: 978-94-010-7379-0 e-ISBN-13: 978-94-009-1966-2
DOl: 10.1007/978-94-009-1966-2
Published by Kluwer Academic Publishers,
P.O. Box 17,3300 AA Dordrecht, The Netherlands.
Kluwer Academic Publishers incorporates
the publishing programmes of
D. Reidel, Martinus Nijhoff, Dr W. Junk and MTP Press.
Sold and distributed in the U.S.A. and Canada
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Printed on acid-free paper
All Rights Reserved
© 1990 by Kluwer Academic Publishers
Softcover reprint of the hardcover 1s t edition 1990
No part of the material protected by this copyright notice may be reproduced or
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TABLE OF CONTENTS
Preface vii
List of Contributors ix
Assessment of the Patient with Ischemic Cardiac Disease
Dennis T. Mangano, Ph.D., M.D.
Evaluating the Right Ventricle 13
Pierre Foex, M.D.
Cardiovascular physiology of Congenital Heart Disease 25
Alan Jay Schwartz, M.D., M.S.Ed.
Myocardial Lymphatics and Cardiac Function 37
John P. Williams, M.D.
Pathophysiology of the Coronary Circulation 53
Pierre Foex, M.D.
The Aging Heart 65
Stanley Muravchick, M.D., Ph.D.
Hypertension: Is It Really Important? 69
Edward D. Miller, Jr., M.D.
Perioperative Myocardial Ischemia: Diagnosis and Treatment 79
Dennis T. Mangano, Ph.D., M.D.
Beta-Adrenergic Blocking Drugs 91
Robert G. Merin, M.D.
Aging, Autonomic Function and Cardiovascular Homeostasis 101
Stanley Muravchick, M.D.
The Cardiac Patient and Atrial Natriuretic Hormone 105.
Edward D. Miller, Jr., M.D.
Preoperative Hypokalemia and the Cardiac Patient 111
K. C. Wong, M.D., Ph.D.
Calcium Channel Blocking Drugs 119
Robert G. Merin, M.D.
Cardiovascular Pharmacology: What's New (And Useful)! 125
Paul G. Barash, M.D.
Anesthetic Management of the Child with Congenital Heart 133
Disease for Noncardiac Surgery
Alan Jay Schwartz, M.D., M.S.Ed.
vi
Anesthesia and the Renin-Angiotensin System 141
Edward D. Miller, Jr., M.D.
Controversies in Cardiac Monitoring 147
Paul G. Barash, M.D.
Nitrous Oxide and the Compromised Heart 163
Pierre Foex, M.D.
Inhalation Anesthetics in Patients with Cardiac Disease 177
John H. Tinker, M.D.
Opioids in Patients with Cardiac Disease 191
Theodore H. Stanley, M.D.
Is Isoflurane Contraindicated in Patients with Coronary 231
Artery Disease?
Robert G. Merin, M.D.
Cardiovascular Effects of Local Anesthetics 239
Benjamin G. Covino, Ph.D., M.D.
Pulmonary Edema: Is Your Fluid Management Breathtaking? 251
Paul G. Barash, M.D.
Should We All Have A Sympathectomy at Birth? Or At Least 263
Preoperatively?
Michael F. Roizen, M.D.
Cardiopulmonary Bypass 267
John H. Tinker, M.D.
Anesthesia for Carotid Artery Surgery 285
Jeffrey Katz, M.D.
Regional Anesthesia for Patients with Cardiac Disease 295
Benjamin G. Covino, Ph.D., M.D.
Anesthesia for Vascular Surgery 305
Michael F. Roizen, M.D.
PREFACE
Theodore H. Stanley, M.D.
Anesthesiology and the Heart contains the Refresher Course
manuscripts of the presentations of the 35th Annual Postgraduate
Course in Anesthesiology which took place at The Cliff Conference
Center in Snowbird, Utah, February 16-20, 1990. The chapters reflect
new data and concepts within the general framework of "evaluating
myocardial function," "pharmacology and the cardiac patient,"
"anesthesia for patients with cardiac disease," and "stress,
cardiopulmonary bypass, coagulation problems and related issues."
The purposes of the textbook are to 1) act as a reference for the
anesthesiologists attending the meeting, and 2) serve as a vehicle
to bring many of the latest concepts in anesthesiology to others
within a short time of the formal presentation. Each chapter is a
brief but sharply focused glimpse of the interests in anesthesia
expressed at the conference. This book and its chapters should not
be considered complete treatises on the subjects addressed but
rather attempts to summarize the most salient points. This textbook
is the eighth in a continuing series documenting the proceedings of
the Postgraduate Course in Salt Lake City. We hope that this and
the past and future volumes reflect the rapid and continuing
evolution of anesthesiology in the late twentieth century.
vii
LIST OF CoNTIUBUTDRS
Bailey, P.L.
Department of Anesthesiology, The University of Utah
School of Medicine, Salt Lake City, UT 84132, U.S.A.
Barash, P.
Department of Anesthesiology, Yale University
School of Medicine, New Haven, CT 06510, U.S.A.
Covino, B.G.
Department of Anesthesia, Brigham and Women's
Hospital, Boston, MA 02115, U.S.A.
Foex, P.
Nuffield Department of Anesthetics, The Radcliffe
Infirmary, Oxford OX2 6HE, United Kingdom
Katz, J.
Department of Anesthesiology, University of Texas
Health Science Center at Houston, Houston, TX 77030, U.S.A.
Mangano, D.T.
Department of Anesthesia, University of California,
San Francisco, CA 94102, U.S.A.
Merin, R.
Department of Anesthesiology, University of Texas
Health Science Center at Houston, Houston, TX 77019, U.S.A.
Miller, E.D.
Department of Anesthesiology, College of Physicians and
Surgeons, Columbia University, NY 10032, U.S.A.
Muravchick, S.
Department of Anesthesia, Hospital of the University of
Pennsylvania, Philadelphia, PA 19104, U.S.A.
Roizen, M.F.
Department of Anesthesiology and Critical Care, University
of Chicago Medical Center, Chicago IL 60612, U.S.A.
Schultz, J.R.
Department of Anesthesiology, The University of Utah School
of Medicine, Salt Lake City, UT 84132, U.S.A.
ix
x
Stanley, T. H.
Department of Anesthesiology, The University of Utah School
of Medioine, Salt Lake City, UT 84132, U.S.A.
Tinker, J.H.
Department of Anesthesia, University of Iowa College of
Medicine, Iowa City, IA 52242, U.S.A.
Williams, J.P.
Department of Anesthesiology, University of Texas at Houston,
Houston, TX 77030, U.S.A.
Wong, K.C.
Department of Anesthesiology, The University of Utah School of
Medicine, Salt Lake City, UT 84132, U.S.A.
ASSESSMENT OF THE PATIENT WlTII ISCHEMIC HEART DISEASE
DENNIS T. MANGANO, PH.D., M.D.
The patient with llID usually has one of the many symptom complexes
associated with varying degrees of ventricular dysfunction. Assessment of a
patient with llID presenting for surgery is usually conducted over a very brief
period of time and therefore requires a rather intense assessment of the patient's
cardiac status. Other factors add to the difficulties involved in this assessment: 1)
The age of the population presenting for surgery is increasing; 2) surgical
procedures are becoming more complex; and 3) cost containment procedures will
limit the number and type of preoperative tests used to assess risk in patients with
llID, and there will be increasing pressure on us to expedite such an assessment
(e.g., come-and-go, come-and-stay surgery). Thus, more than ever, we must
know what specific tests are available for assessment of these patients and what
information we can obtain from these tests to determine peri operative risk,
preoperative therapeutics, intraoperative monitoring, choice of anesthetic, and
postoperative care.
llID is a significant problem and will probably remain so well into the
1990s. This is substantiated by several statistics accumulated in the early 1980s
from the United States. It is estimated that 10 million patients have llID in the
United States today, 4 million of whom have had previous myocardial infarctions.
In anyone year, approximately 1.5 million patients develop a new myocardial
infarction and 700,000 deaths are attributed to IHD per year. Surgical procedures
performed each year on these patients include approximately 800,000 cardiac
catheterizations, with 285,000 coronary artery bypass grafts and an equal number
of coronary angioplasties. It is estimated that of the 20 million patients in the
United States that undergo surgery each year, approximately 1 to 2 million have
llID or are at high risk for it. Thus, the problem is significant to
anesthesiologists. It appears that the prognosis for patients with IHD is related to
the development and severity of dysrhythmias, myocardial infarction and
ventricular dysfunction. Before proceeding with a discussion of the tests used for
IHD, it is important to review the significance of dysrhythmias, infarction and
dysfunction in patients with IHD.
T. H. Stanley and R. J. Sperry (eds.),Anesthesioiogy and the Heart, I-Il.
© 1990 Kll4Wer Academic Publishers.