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clinical cases in anesthesia PDF

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The Curtis Center 170 S Independence Mall W 300E Philadelphia,Pennsylvania 19106 Clinical Cases in Anesthesia ISBN:0-443-06624-8 Third Edition Copyright © 2005,1995,1989 by Elsevier Inc.All rights reserved. No part ofthis publication may be reproduced or transmitted in any form or by any means,electronic or mechanical,including photocopying,recording,or any information storage and retrieval system,without permission in writing from the publisher.Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia,PA,USA:phone:(+1) 215 238 7869,fax:(+1) 215 238 2239,e-mail: [email protected] may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com),by selecting “Customer Support”and then “Obtaining Permissions.” 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 Publisher: Natasha Andjelkovic Editorial Assistant: Rachel Poyatt Publishing Services Manager: Joan Sinclair Project Manager: Cecelia Bayruns Marketing Manager:Emily McGrath-Christie 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

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Actual case studies in a Q & A format explore contemporary problems in anesthesia, and provide practical solutions based on a careful examination of all of the important scientific and clinical principles for each case. The 3rd Edition offers brand-new coverage of key topics in the cardiovascular, r
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