clinical cases in anesthesia

523 Pages·2005·5.69 MB·English

by  Allan Reed

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Clinical Cases in Anesthesia ISBN:0-443-06624-8
Third Edition
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Notice
Anesthesiology is an ever-changing field.Standard safety precautions must be followed,but as new research
and clinical experience broaden our knowledge,changes in treatment and drug therapy may become
necessary or appropriate.Readers are advised to check the most current product information provided by
the manufacturer ofeach drug to be administered to verify the recommended dose,the method and
duration ofadministration,and contraindications.It is the responsibility ofthe licensed prescriber,relying
on experience and knowledge ofthe patient,to determine dosages and the best treatment for each
individual patient.Neither the publisher nor the author assumes any liability for any injury and/or damage
to persons or property arising from this publication.
The Publisher
Previous editions copyrighted 1989,1995.
International Standard Book Number:0-443-06624-8
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Editorial Assistant: Rachel Poyatt
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Printed in the United States ofAmerica.
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To Michael and Becky, of whom I have always
been proud.
–Allan P. Reed
In loving memory of my mother, Lea, and to my father,
Herman, who were my strongest supporters and
inspired me to be the best I could be.
–Francine S.Yudkowitz
C
O N T R I B U T O R S
Mark Abel,MD Howard H.Bernstein,MD
Assistant Professor Associate Professor
Department ofAnesthesiology Departments ofAnesthesiology and Obstetrics,
Mount Sinai School ofMedicine Gynecology,and Reproductive Science
New York,New York Mount Sinai School ofMedicine
New York,New York
Sharon Abramovitz,MD
JoAnne Betta,MD
Instructor in Anesthesiology
Weill Medical College of Department ofAnesthesiology
Cornell University Englewood Hospital and
New York,New York Medical Center
Englewood,New Jersey
Barbara Alper,MD
Michael E.Bilenker,DO
Assistant Professor
Department ofAnesthesiology Department ofAnesthesiology
Mount Sinai School ofMedicine Mount Sinai School ofMedicine
New York,New York New York,New York
Arthur Atchabahian,MD Levon M.Capan,MD
Assistant Professor Professor
Department ofAnesthesiology Department ofAnesthesiology
Columbia University College ofPhysicians and Surgeons New York University School
New York,New York ofMedicine
New York,New York
Adel Bassily-Marcus,MD
Michael Chietero,MD
Clinical Instructor
Critical Care Associate Professor
Mount Sinai School ofMedicine Departments ofAnesthesiology and Pediatrics
New York,New York Mount Sinai School ofMedicine
New York,New York
Yaakov Beilin,MD
Isabelle deLeon,MD
Associate Professor
Departments ofAnesthesiology and Obstetrics, Assistant Professor
Gynecology,and Reproductive Science Department ofAnesthesiology
Mount Sinai School ofMedicine Mount Sinai School ofMedicine
New York,New York New York,New York
viii CONTRIBUTORS
James B.Eisenkraft,MD Ronald A.Kahn,MD
Professor Associate Professor
Department ofAnesthesiology Department ofAnesthesiology
Mount Sinai School ofMedicine Mount Sinai School ofMedicine
New York,New York New York,New York
Dennis E.Feierman,PhD,MD Dan A.Kaufman,MD
Associate Professor Assistant Professor
Department ofAnesthesiology Department ofAnesthesiology
Mount Sinai School ofMedicine Mount Sinai School ofMedicine
New York,New York New York,New York
Gordon Freedman,MD James N.Koppel,MD
Associate Professor Assistant Professor
Department ofAnesthesiology Department ofAnesthesiology
Mount Sinai School ofMedicine Rockville Center
New York,New York New York,New York
George V.Gabrielson,MD David C.Kramer,MD
Associate Professor Assistant Professor
Department ofAnesthesiology Department ofAnesthesiology
Mount Sinai School ofMedicine Mount Sinai School ofMedicine
New York,New York New York,New York
Mark Gettes,MD Joel M.Kreitzer,MD
Assistant Professor Associate Professor
Department ofAnesthesiology Department ofAnesthesiology
Mount Sinai School ofMedicine Mount Sinai School ofMedicine
New York,New York New York,New York
Cheryl K.Gooden,MD Merceditas M.Lagmay,MD
Assistant Professor Assistant Professor
Departments ofAnesthesiology and Pediatrics Department ofAnesthesiology
Mount Sinai School ofMedicine Mount Sinai School ofMedicine
New York,New York New York,New York
Laurence M.Hausman,MD Andrew B.Leibowitz,MD
Assistant Professor Associate Professor
Department ofAnesthesiology Department ofAnesthesiology
Mount Sinai School ofMedicine Mount Sinai School ofMedicine
New York,New York New York,New York
Andrew Herlich,MD Gregg Lobel,MD
Professor Department ofAnesthesiology
Department ofAnesthesiology Englewood Hospital and Medical Center
Temple University School ofMedicine Englewood,New Jersey
Philadelphia,Pennsylvania
Ilene K.Michaels,MD
Ingrid Hollinger,MD Assistant Professor
Professor Department ofAnesthesiology
Department ofAnesthesiology Mount Sinai School
Mount Sinai School ofMedicine ofMedicine
New York,New York New York,New York
CONTRIBUTORS ix
Sanford Miller,MD Arthur E.Schwartz,MD
Associate Professor Associate Professor
Department ofAnesthesiology Department ofAnesthesiology
New York University School ofMedicine Mount Sinai School ofMedicine
New York,New York New York,New York
Alexander Mittnacht,MD Aryeh Shander,MD
Assistant Professor Professor
Department ofAnesthesiology Department ofAnesthesiology
Mount Sinai School ofMedicine Mount Sinai School ofMedicine
New York,New York New York,New York
Neeta Moonka,MD Chairman
Department ofAnesthesiology
Department ofAnesthesiology
Englewood Hospital and Medical Center
Englewood Hospital and Medical Center
Englewood,New Jersey
Englewood,New Jersey
Linda J.Shore-Lesserson,MD
Steven M.Neustein,MD
Associate Professor
Associate Professor
Department ofAnesthesiology
Department ofAnesthesiology
Mount Sinai School ofMedicine
Mount Sinai School ofMedicine
New York,New York
New York,New York
Irene P.Osborn,MD Leon K.Specthrie,MD
Associate Professor Assistant Professor
Department ofAnesthesiology Department ofAnesthesiology
Mount Sinai School ofMedicine Mount Sinai School ofMedicine
New York,New York New York,New York
Michael Ostrovsky,MD Marc E.Stone,MD
Attending Anesthesiologist–Cardiac Anesthesiologist Assistant Professor
Seton Medical Center Department ofAnesthesiology
Daly City,California Mount Sinai School ofMedicine
New York,New York
Allan P.Reed,MD
Associate Professor Celeste Telfeyan,DO
Department ofAnesthesiology Assistant Professor
Mount Sinai School ofMedicine Department ofAnesthesiology
New York,New York Mount Sinai School ofMedicine
David L.Reich,MD New York,New York
Horace W.Goldsmith Carolyn F.Whitsett,MD
Professor and Chairman
Associate Professor
Department ofAnesthesiology
Departments ofMedicine,Hematology and
Mount Sinai School ofMedicine
Medical Oncology,and Pathology
New York,New York
Mount Sinai Hospital
Jodi L.W.Reiss,MD New York,New York
Assistant Professor
Francine S.Yudkowitz,MD,FAAP
Department ofAnesthesiology
Associate Professor
Mount Sinai School ofMedicine
Departments ofAnesthesiology and
New York,New York
Pediatrics
Navparkash S.Sandhu,MD
Mount Sinai School ofMedicine
Assistant Professor New York,New York
Department ofAnesthesiology
New York University Medical Center
New York,New York
P
R E F A C E
Preface to the Third Edition abdominal section readers will find valuable new cases on
endovascular surgery, morbid obesity, laparoscopy, carci-
Why a third edition? noid,and kidney transplantation.Various other important
topics such as hemophilia,infant anesthesia,lower extrem-
Following the success of the second edition, this new
ity anesthesia,and celiac plexus blocks also appear in this
edition expands and updates the previous text, and also
new edition. Postanesthesia care is expanded to include
includes more solutions to frequently occurring practical
pulmonary function testing, respiratory failure, delayed
problems.The new text adds numerous important topics.
emergence,coma and brain death,and anaphylaxis.
The cardiovascular section offers new cases relating to
Besides numerous new cases,the existing cases are thor-
cardiac tamponade, cardiomyopathy, noncardiac surgery
oughly revised to include the new treatments, treatment
after heart transplantation, coronary artery bypass graft-
guidelines, and the relevant pharmacology. Basic science
ing, and do-not-resuscitate.Also, cardiovascular pharma-
research that seems poised for clinical applications is also
cology and new practice guidelines will be incorporated
included.In all,it is hoped that the new edition will follow
into the appropriate cases.The respiratory section features
in the footsteps ofits predecessors as an important and use-
new cases on post-thoracotomy complications and thora-
ful clinical reference on all aspects ofanesthesia practice.
coscopy.The central nervous system part is enriched with
cases on monitoring in spinal injury, transsphenoidal Allan P.Reed,MD
hypophysectomy,and magnetic resonance imaging.In the Francine S.Yudkowitz,MD,FAAP
F06624-Ch01 2/14/05 3:06 PM Page 1
1
C CARDIOPULMONARY
A S E
RESUSCITATION
Alexander Mittnacht,MD
David L.Reich,MD
A
5. What is the optimal dose ofepinephrine?
6. What is the indication for vasopressin in CPR?
n 86-year-old woman with congestive heart failure,
7. What are the indications for sodium bicarbonate
coronary artery disease,and syncopal episodes presents for
(NaHCO ) administration?
3
elective permanent pacemaker insertion.A recent 24 hour
8. What are the indications for calcium salt adminis-
ambulatory electrocardiogram recording demonstrated
tration?
multiple episodes of severe sinus bradycardia associated
9. What is the antidysrhythmic therapy of choice in
with pre-syncopal symptoms.Monitored anesthesia care is
VF/pulseless VT?
requested in light ofthe patient’s advanced age and associ-
10. What are the management strategies in bradycardias?
ated medical conditions.The infiltration oflocal anesthesia
11. What is the treatment of supraventricular tachy-
and isolation of the cephalic vein in the left deltopectoral
dysrhythmias?
groove proceeds uneventfully. During placement of the
12. What are the indications for magnesium therapy?
ventricular pacing lead, ventricular ectopy occurs as the
13. What are the indications for a pacemaker?
lead encounters the right ventricular endocardium.
14. Why is it important to monitor serum glucose?
Subsequently,as the lead is repositioned,ventricular tachy-
15. What are the indications for open cardiac massage?
cardia is induced and rapidly deteriorates into ventricular
16. What is the management strategy for pulseless
fibrillation.
electrical activity (PEA)?
1. What is the initial response to a cardiac arrest?
QUESTIONS
The initial response to a witnessed cardiac arrest is to
1. What is the initial response to a witnessed cardiac confirm the diagnosis.Patients in arrest are unresponsive,
arrest? apneic, and pulseless. Assistance should be called for
2. How do chest compressions produce a cardiac output? immediately prior to any intervention.In the past,it was
3. What are the recommended rates of compression recommended to call for assistance after the initiation of
and ventilation? cardiopulmonary resuscitation (CPR), but since 80–90%
4. What are the complications ofCPR? of patients with sudden cardiac arrest have ventricular
1
F06624-Ch01 2/14/05 3:06 PM Page 2
2 CLINICAL CASES IN ANESTHESIA
fibrillation (VF),which is the most treatable dysrhythmia reports ofpatients who,during episodes ofmonitored VF,
but which requires urgent defibrillation, the rescuer is have developed systolic pressures capable of maintaining
advised to call first so that a defibrillator can be brought to consciousness by coughing. This demonstrates that chest
the scene.The only exception is in the case ofchildren less compressions per se are not necessary to maintain a cardiac
than 8 years of age, who usually arrest because of airway output. Furthermore, CPR is frequently ineffective in
problems. In that case, an attempt at securing the airway patients with a flail chest until chest stabilization is
should first be made. achieved.If direct compression were the etiology of blood
Monitored patients should be treated according to the circulation in CPR,then a flail chest would be an advantage
Advanced Cardiac Life Support (ACLS) protocol devised by increasing the efficiency of the “direct” compression.
for their dysrhythmia. This includes basic life support These observations have led to the proposal ofthe “thoracic
(BLS), usually in the form of CPR, as well as adjunctive pump”theory ofCPR.
equipment for airway control,dysrhythmia detection and The “thoracic pump” theory proposes that forward
treatment,and post-resuscitation care.Unmonitored,unre- blood flow is achieved because of phasic changes in
sponsive patients should have their airway assessed first intrathoracic pressure produced by chest compressions.
followed by two breaths and a pulse check. In a witnessed During the downward phase of the compression,positive
cardiac arrest, a precordial thump may be indicated but intrathoracic pressure propels blood out of the chest into
CPR must be started immediately if the patient remains the extrathoracic vessels that have a lower pressure.
pulseless.As soon as possible,paddles or electrocardiogram Competent valves in the venous system prevent blood from
(ECG) leads should be placed on the patient to determine flowing backwards.During the upward phase of the com-
the rhythm.Ifpulseless ventricular tachycardia (VT) or VF pression, blood flows from the periphery into the thorax
is the initial rhythm,the patient should receive up to three because of the negative intrathoracic pressure created by
uniphasic countershocks ofincreasing power:200 joules (J), release ofthe compression.With properly performed CPR,
200-300 J,and 360 J,respectively.Biphasic equivalents are systolic arterial blood pressures of 60–80 mmHg can be
approximately halfthat ofuniphasic doses.IfVF or pulse- achieved, but with much lower diastolic pressures. Mean
less VT is not the initial rhythm,or ifthe countershocks are pressures are usually less than 40 mmHg.This only provides
unsuccessful, then chest compressions and ventilation cerebral blood flows ofapproximately 30% and myocardial
should be continued and the patient treated accordingly blood flows ofabout 10% compared with pre-arrest values.
(Figure 1.1).
The essential element in treating cardiac arrest is rapid
3. What are the recommended rates of compression
identification and treatment.The goal ofCPR is to provide
and ventilation?
oxygenated blood to the heart and brain until ACLS proce-
dures are initiated. The best results (survival of approxi- Animal models of CPR have shown that the optimal
mately 40%) are achieved in patients receiving CPR within blood flows are achieved when chest compressions are
4 minutes and ACLS within 8 minutes of arrest, whereas performed at 80–100 times per minute and the chest is
survival is less than 6% when CPR and ACLS are started compressed 1.5 to 2 inches (3–5 cm).The new Guidelines
after 9 minutes. for Cardiopulmonary Resuscitation published by the
The groups of patients most likely to be resuscitated American Heart Association in 2000 recommend a chest
include patients outside the hospital with witnessed arrests compression rate of100 times per minute.The proportion
due to VF, hospitalized patients with VF secondary to oftime spent during the compression phase should be 50%
ischemic heart disease,arrests not associated with coexisting ofthe relaxation phase.
life-threatening conditions,and patients who are hypother- Artificial ventilation is preferentially given by endotra-
mic or intoxicated.Patients with severe multisystem disease, cheal tube (ETT) at a rate of 10–12 breaths per minute.
metastatic cancer,or oliguria do not often survive CPR. Nevertheless,the new ACLS guidelines de-emphasize endo-
tracheal intubation during CPR due to a high incidence of
incorrectly placed ETTs.Mask ventilation or alternative air-
2. How do chest compressions produce a cardiac output?
ways,such as the laryngeal mask or the esophageal-tracheal
It used to be assumed that chest compressions produced Combitube, may be preferable in situations where the
a cardiac output by directly compressing the ventricles rescuer is not properly trained or skilled in ETT placement.
against the vertebral column.This was thought to produce It is now mandatory to confirm correct ETT placement by
systole,with forward flow out ofthe aorta and pulmonary both physical examination and a secondary device,such as
artery,and backward flow prevented by closure ofthe atrio- capnography,a colorimetric carbon dioxide (CO ) detector,
2
ventricular (AV) valves. or an esophageal detector device.During two-person CPR,
This explanation is probably not completely valid. ventilation in the intubated patient should be performed
Echocardiographic images during arrest show that the AV with every fifth compression.With an unprotected airway
valves are not closed during chest compressions.There are or during one-rescuer CPR the compression to ventilation
F06624-Ch01 2/14/05 3:06 PM Page 3
FIGURE 1.1 Algorithm for ventricular fibrillation and pulseless ventricular tachycardia.From ACLS Provider Manual,American Heart
Association,2001.
3