Perioperative Critical Care Cardiology

285 Pages·2007·3.36 MB·English

by  J.L. Atlee

Perioperative Critical Care Cardiology
2nd edition
J.L.Atlee
A.Gullo
G.Sinagra
J.- L.Vincent
J.L.Atlee • A.Gullo • G.Sinagra • J.-L.Vincent (Eds)
Perioperative
Critical Care Cardiology
2nd edition
3
1
JOHNL.ATLEE ANTONINOGULLO
Department ofAnesthesiology Department ofAnaesthesia and
University ofWisconsin (Madison) Intensive Care
Medical College ofWisconsin (Milwaukee) Policlinic University Hospital
Hartland,USA Catania,Italy
GIANFRANCOSINAGRA JEAN-LOUISVINCENT
Cardiovascular Department Department ofIntensive Care
Ospedali Riuniti and University Erasme University Hospital
ofTrieste,Italy Brussels,Belgium
Library ofCongress Control Number:2006937626
ISBN-10 88-470-0557-4 Springer Milan Berlin Heidelberg New York
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Preface to the 2nd edition
Perioperative critical care cardiology (PCCC) includes the cardiovascular
management of patients with any underlying diseases or imposed conditions
(whether natural or iatrogenic) that involve or affect the heart–including,
acute or chronic mechanical heart failure (HF).This can result from ischemic
heart disease, diabetes mellitus, uncontrolled hypertension, arrhythmias that
compromise heart function, circulatory shock, or dilated or obstructive car-
diomyopathy. Patients needing therapy for HF are especially challenging to
clinicians involved their perioperative care.
While PCCC has traditionally been within the context of anesthesia and
surgery,we now must consider the implications of other therapeutic interven-
tions outside of surgery in critically ill patients. Thus, we may become
involved in any stage of their care,including specialized diagnostics,nonsur-
gical interventions,both during and after such intervention,all ofwhich occur
outside of traditional OR settings. Interventions can include percutaneous
coronary angioplasty; aortic, endovascular or intracranial aneurysm repair;
specialized imaging (magnetic resonance imaging and the like); radiation
oncology;etc.Any ofthese “non-OR”interventions performed in a critically ill
patient require the same level of care provided to surgical patients,including:
1) preprocedural patient evaluation and risk stratification; 2) periprocedural
care; 3) post-procedural care (post-anesthetic care unit) and 4) any needed
critical care (intensive care unit) for whatever reason.Also, as perioperative
physicians,we must be able to anticipate and plan for any needed therapy that
may improve our patient’s well-being or physical status.
Professor Gullo generously provided me with the opportunity to organize
the topics for this 2nd edition of Perioperative Critical Care cardiology.I gave
this serious thought at the time of A.P.I.C.E. 20, and we agreed there to the
Table of Contents. I hope this volume adequately addresses the “idealls” set
forth above.
The first chapter addresses sudden death (SD) in HF,including strategies
for stratifying risk and therapy. An important conclusion is that despite
advances in therapy for improving the prognosis for these patients, SD
remains a leading cause for death.As the authors suggest,new,non-pharmaco-
logic strategies (discussed in more detail later in this book) may offer some
VI Preface
hope. However, most, today, are ill-affordable to most of the world. Our best
hope for now may be high-risk behavior modification,including more healthy
diets and exercise.Next,two chapters address 1) the etiology and pathophysi-
ology of HF, and 2) cardiac protection for non-cardiac surgery. The first of
these is required reading for anyone who treats patients with or at risk for HF.
The second addresses drug-protection against myocardial ischemia, arrhyth-
mias and HF in noncardiac surgical patients. Prof. Gombotz and colleagues
deal with anesthetic preconditioning as protection in a later chapter (CH 14)
on prevention and management of cardiac dysfunction during and after car-
diac surgery. Chapters 4-6 address hypertensive crises, atrial fibrillation and
diabetes mellitus in patients with HF,and bedside monitoring for circulatory
failure.CH 6 is especially interesting in that it discusses the merits and disad-
vantages of available, relatively noninvasive strategies for bedside hemody-
namic monitoring,a field of technology that is rapidly evolving.CH 7 by Prof.
Auler et al. on perioperative cardiac risk stratification was a “must” for this
work,and is up to date and current with the available literature.CH 8 by Prof.
Vincent and Holsten addresses invasive and noninvasive monitoring in
patients with acute HF;including,an analysis of the advantages and disadvan-
tages of pulmonary artery catheter (PAC) monitoring.A relatively noninvasive
alternative is needed.Two chapters follow,one on electrocardiography in heart
failure and another on pacemaker and internal cardioverter-defibrillator ther-
apies in HF,interposed between which is an extremely relevant chapter on the
management of patients with acute HF.In addition to monitoring and drugs
for management of acute HF,this latter chapter also addresses devices as ther-
apy for acute HF.Next,Prof.Weil and colleagues provide us with a up-to-date
review of recent advances in cardiopulmonary resuscitation, a topic not
addressed in the first edition of this work. The management of circulatory
shock is discussed by Prof.Vincent and Rapotec in the following chapter. It
describes four types of circulatory shock (hypovolemic, distributive, cardio-
genic and obstructive),which dictates the diagnosis and management of each.
Prevention and management of cardiac dysfunction after cardiac surgery fol-
lows (Prof.Gombotz and colleagues),and this in turn by a chapter on differen-
tial monitoring and therapy for systemic or pulmonary arterial hypertension.
The last chapter,based on a registry of data in Trieste,Italy,reviews the natur-
al history ofdilated cardiomyopathy.
Again,I express my appreciation to Prof.Gullo for recruiting me to orga-
nize the topics for this edition of PCCC,and to my co-editors Profs.A.Gullo,
G. Sinagra, and J-L Vincent for their valauable contributions and support in
this collegial,international effort.
Milwaukee,November 2006 John L.Atlee,MS (Pharmacology)
MD,FACA,FACC,FAMA
Preface to the 1st edition
The peri-operative period represents a crucial phase not only for the patient,but
also for the surgical and anaesthesiological team which must coordinate harmo-
niously to ensure the patient’s rapid functional recovery.Therefore,an interdisci-
plinary approach to peri-operative care is essential,both in terms of clinical
competency and of instrumental monitoring.Obviously,patient monitoring and
all diagnostic and treatment procedures must be modulated in relation to the
actual situation.Above all,the pre-operative evaluation of the patient’s health
conditions and surgical needs has to follow standardized protocols.It is impor-
tant to determine the functional state of the patient and,in particular,the func-
tional reserves ofthe cardiovascular system.
Determining the surgical indications and carrying out the intervention both
depend on the rigorous control ofthe patient’s homeostasis throughout the peri-
operative phase.Anesthesiological protocols are by now codified and familiar to
all experienced operators.On this basis,I wished to offer votaries ofthis field,in
particular anesthesiologists,surgeons,cardiologists,internists and intensive care
physicians,an update on the more relevant problems that arise during peri-oper-
ative care. The focus of this volume is on surgery patients (including those
undergoing non-cardiac interventions) whose clinical conditions require special
strategies for the prevention and eventual treatment ofcritical conditions.
Considering the innumerable pathophysiological and clinical situations that
may develop in the peri-operative period,continuous education is essential.It is
particularly opportune to stress the importance offirst-hand experience and the
ability to interpret the multiplicity of the hemodynamic complications that can
occur in the delicate phase ofthe peri-operative period.
Sure progress has come from the availability ofsophisticated means ofhemo-
dynamic monitoring,particularly the noninvasive techniques such as trans-
esophageal echocardiography (TEE) and intra-esophageal echo Doppler ultra-
sound.In addition to methods for monitoring blood pressure,it is now routine to
perform bedside monitoring of cardiac volumes,myocardial contractility,and
organ perfusion based on entidal CO levels.These methods are now common-
2
place in modern clinical practice.
In this context,the management of arrhythmias assumes an important role.
The correct and timely diagnosis of arrhythmias and the appropriate use of the
VIII Preface
different anti-arrhythmic drugs depend on an accurate knowledge of current
medical practices.Therefore,the chapter on temporary pacing for the treatment
of dangerous arrhythmias is extremely important basically for the training
process.
The contributions on monitoring for myocardial ischaemia in the peri-opera-
tive period and on the principal trials of novel clinical approaches to acute
myocardial infarction are germane to this volume.Another interesting contribu-
tion focuses on dilated cardiomyopathy and on the different therapeutic options
for this disorder.In addition,two chapters are dedicated to the care of patients
undergoing surgical intervention for myocardial revascularization. These
patients require different strategies ofintervention to improve ventricular failure
and to treat secondary complications due to cardiac dysfunction.Finally,this vol-
ume could not fail to include a chapter on cardiogenic pulmonary edema that
often characterizes the clinical iterofpatients with cardiac insufficiency.
In light of this brief preface,I have valid motives to retain that this volume
will arouse interest in both researchers and experts ofthis subject.It will also be
informative for young physicians who are completing their training.
I wish to thank all the authors for their valuable contributions and for helping
to bring this initiative to a fulfillment.I particularly thank my friends and col-
leagues J.L.Atlee and J.-L.Vincent,with whose efforts this volume became possi-
ble.
Trieste,November 2000
Antonino Gullo
University Medical School
Trieste,Italy
Table of Contents
1.Sudden Death in Heart Failure:Risk Stratification and Treatment Strategies
M.Zecchin,G.Vitrella,G.Sinagra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2.Etiology and Pathophysiology ofHeart Failure
P.Foëx,G.Howard-Alpe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.Cardiac Protection for Noncardiac Surgery
P.Foëx,G.Howard-Alpe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.Hypertensive Urgencies and Emergencies
J.L.Atlee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
5.Heart Failure,Atrial Fibrillation,and Diabetes Mellitus
A.Aleksova,A.Perkan,G.Sinagra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
6.Circulatory Failure:Bedside Functional Hemodynamic Monitoring
C.Sorbara,S.Romagnoli,A.Rossi,S.M.Romano . . . . . . . . . . . . . . . . . . . . . . 89
7.Perioperative Cardiac Risk Stratification
F.R.B.G.Galas,L.A.Hajjar,J.O.C.Auler jr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
8.Hemodynamic Monitoring in Patients with Acute Heart Failure
J.-L.Vincent,R.Holsten . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
9.Electrocardiography ofHeart Failure:Features and Arrhythmias
J.L.Atlee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
10.Management ofPatients with Acute Heart Failure
W.G.Toller,G.Gemes,H.Metzler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
11.Pacemaker and Internal Cardioverter-Defibrillator Therapies
J.L.Atlee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
X Table of Contents
12.Updates on Cardiac Arrest and Cardiopulmonary Resuscitation
G.Ristagno,A.Gullo,W.Tang,M.H.Weil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
13.Circulatory Shock:Hypovolemic,Distributive,Cardiogenic,Obstructive
J.-L.Vincent,A.Rapotec . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
14.Prevention and Management ofCardiac Dysfunction during and after
Cardiac Surgery
W.Moosbauer,A.Hofer,H.Gombotz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
15.Management ofSystemic and Pulmonary Hypertension
P.Giomarelli,S.Scolletta,B.Biagioli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
16.Recent Advances in the Natural History ofDilated Cardiomyopathy:
A Review ofthe Heart Muscle Disease Registry ofTrieste
M.Moretti,A.Di Lenarda,G.Sinagra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279