Stoelting's Anesthesia and Co-Existing Disease, 5th Edition PDF
Preview Stoelting's Anesthesia and Co-Existing Disease, 5th Edition
C O N T R I B U T O R S Shamsuddin Akhtar, MD Viji Kurup, MD AssistantProfessor, Department ofAnesthesiology, Assistant Professor,Department ofAnesthesiology, YaleUniversity SchoolofMedicine; AttendingPhysician, YaleUniversity School ofMedicine;AttendingPhysician, Yale-NewHaven Hospital,New Haven,Connecticut Yale-New HavenHospital, NewHaven, Connecticut Michael S. Avidan, MBBCH, FCA Associate Professorof Anesthesiology and Surgery,Washington William L. Lanier, Jr., MD University ofSt.Louis; DivisionChief, CTAnesthesiology and CT Professor ofAnesthesiology, Mayo Clinic CollegeofMedicine, IntensiveCare, Barnes-JewishHospital, St. Louis,Missouri Rochester, Minnesota Bruno Bissonnette, MD Charles Lee, MD Professorof Anaesthesia,University ofToronto; Directorof Assistant Professor ofAnesthesiology, Loma LindaUniversity NeurosurgicalAnaesthesia, TheHospitalfor SickChildren, School ofMedicine;Director ofAcute/Perioperative Pain Toronto,Ontario, Canada Service, Loma LindaUniversity MedicalCenter,Loma Linda, California Ferne R. Braveman, MD Professorof Anesthesiology, Vice-Chair forClinical Affairs, Igor Luginbuehl, MD Director, Sectionof ObstetricalAnesthesiology, Co-Director, Assistant Professor,University ofToronto; Staff Anesthesiologist, ObstetricalAnesthesiology Fellowship Program,YaleUniversity TheHospital forSick Children,Toronto, Ontario, Canada SchoolofMedicine; AttendingPhysician, Yale-NewHaven Hospital,New Haven,Connecticut Inna Maranets, MD Assistant Professor,Department ofAnesthesiology, Susan Garwood, MBCHB YaleUniversity School ofMedicine;AttendingPhysician, Associate Professor,Department of Anesthesiology, Yale-New HavenHospital, NewHaven, Connecticut YaleUniversity SchoolofMedicine; AttendingPhysician, Yale-NewHaven Hospital,New Haven,Connecticut Katherine E. Marschall, MD Assistant Professor,Department ofAnesthesiology, Marbelia Gonzalez, MD YaleUniversity School ofMedicine;AttendingPhysician, AttendingAnesthesiologist,Hartford Anesthesiology Associates, Yale-New HavenHospital, NewHaven, Connecticut HartfordHospital, Department ofAnesthesiology, Hartford, Connecticut Linda J. Mason, MD ProfessorofAnesthesiologyandPediatrics,LomaLindaUniversity Ala´ Sami Haddadin, MD, FCCP SchoolofMedicine;DirectorofPediatricAnesthesiology, AssistantProfessor ofAnesthesiology, YaleUniversity School LomaLindaUniversityMedicalCenter,LomaLinda, ofMedicine;AttendingPhysician, Yale-New HavenHospital, California NewHaven,Connecticut Raj K. Modak, MS, MD Adriana Herrera, MD Assistant Professor ofAnesthesiology, YaleUniversity School AssistantProfessor, Department ofAnesthesiology, Yale ofMedicine; AttendingPhysician, Yale-NewHaven Hospital, University SchoolofMedicine; AttendingAnesthesiologist, New Haven,Connecticut Yale-NewHaven Hospital,New Haven,Connecticut Jeffrey J. Pasternak, MS, MD Zoltan G. Hevesi, MD Assistant Professor ofAnesthesiology, Mayo ClinicCollege Associate Professorof Anesthesiology and Surgery,University ofMedicine, Rochester, Minnesota ofWisconsin;MedicalDirector ofTransplant Anesthesiology, University ofWisconsinHospital andClinics, Madison, Wisconsin Wanda M. Popescu, MD Assistant Professor ofAnesthesiology, YaleUniversity Roberta L. Hines, MD School ofMedicine;AttendingPhysician, Yale-New Haven NicholasM.Greene Professor andChairman,Department of Hospital, NewHaven, Connecticut;AttendingPhysician, Anesthesiology, YaleUniversity School ofMedicine,NewHaven, Veterans Administration Hospital,West Haven, Connecticut Connecticut v CONTRIBUTORS Christine S. Rinder, MD Russell T. Wall, III, MD Associate Professor ofAnesthesiology, YaleUniversity School Professor ofAnesthesiology, Associate Dean,Georgetown of Medicine;AttendingPhysician, Yale-NewHaven Hospital, University School ofMedicine;Vice-Chair and Program Director, New Haven,Connecticut Department ofAnesthesiology, GeorgetownUniversity Hopsital, Washington, DC Jeffrey J. Schwartz, MD Associate Professor, YaleUniversity School ofMedicine; Matthew C. Wallace, MD AttendingPhysician, Yale-NewHaven Hospital,New Haven, Fellowin Cardiothoracic Anesthesiology, YaleUniversity School Connecticut ofMedicine,Department ofAnesthesiology, NewHaven, Connecticut Hossam Tantawy, MD Assistant Professor, Department ofAnesthesiology, Kelley Teed Watson, MD YaleUniversity School ofMedicine;AttendingPhysician, AssistantClinical Professor,YaleUniversity School ofMedicine, Yale-New HavenHospital, NewHaven, Connecticut New Haven,Connecticut;Cardiac Anesthesiologist, Carolina Cardiac Surgeryat SelfRegional Healthcare,Greenwood, South Nalini Vadivelu, MD Carolina Associate Professor, Department ofAnesthesiology, YaleUniversity School ofMedicine;AttendingPhysician, Yale-New HavenHospital, NewHaven, Connecticut vi P R E F A C E In 1983, the first edition of Anesthesia and Co-Existing management of anesthesia. Common diseases receive more Disease was published with the stated goal ‘‘to provide a con- attention, but uncommon diseases, especially those with cise description of the pathophysiology of disease states and uniquefeaturesthatcouldbeofsignificanceintheperiopera- their medical management that is relevant to the care of the tiveperiod,arealsoincluded.Referencesaremadetothemost patient in the perioperative period.’’ The result was a very up-to-date diagnostics, guidelines, and recommendations useful basic reference text and review guide that continued for medical management. There is liberal use of figures and through three more editions and became one of those excep- tables to clarify the text. A consistency in writing style tional works that is a ‘‘must have’’ in every anesthesiologist’s was sought to make this multiauthored book read as though personal library. writtenbyonlyafewindividuals.Wearehonoredtohavehad This fifth edition of Anesthesia and Co-Existing Disease the opportunity to carry on the tradition of this legendary marks a turning point and yet a continuation in the history workandwehopethatDrs.StoeltingandDierdorfarepleased ofthisbook.Drs.RobertK.StoeltingandStephenF.Dierdorf with our efforts. havepassedtheeditorial‘‘baton’’tous.Togetherwithagroup The editors wish to recognize the invaluable secretarial ofgiftedmedicalauthors,wehaveproducedthislatestedition. assistance of Gail Norup in the preparation of this As with the previous editions, our goal has been to provide manuscript. readers with a current and concise description of the patho- physiology of co-existing diseases, current treatment of these Roberta L. Hines, MD entities, and the impact that such diseases might have on the Katherine E.Marschall, MD vii 1 C H A P T E R Ischemic Heart Disease Shamsuddin Akhtar Angina Pectoris Preoperative Assessment of Patients with Known or (cid:1) Diagnosis Suspected Ischemic Heart Disease (cid:1) Treatment (cid:1) History (cid:1) Physical Examination Acute Coronary Syndrome (cid:1) Specialized Preoperative Testing (cid:1) ST Elevation Myocardial Infarction (cid:1) Unstable Angina/Non–ST Elevation Management of Anesthesia in Patients with Known or Myocardial Infarction Suspected Ischemic Heart Disease Undergoing Noncardiac Surgery Complications of Acute Myocardial (cid:1) Risk Stratification Strategy Infarction (cid:1) Management after Risk Stratification (cid:1) Cardiac Dysrhythmias (cid:1) Intraoperative Management (cid:1) Pericarditis (cid:1) Postoperative Management (cid:1) Mitral Regurgitation (cid:1) Ventricular Septal Rupture Cardiac Transplantation (cid:1) Congestive Heart Failure and Cardiogenic (cid:1) Management of Anesthesia Shock (cid:1) Postoperative Complications (cid:1) Myocardial Rupture (cid:1) Anesthetic Considerations in Heart (cid:1) Right Ventricular Infarction Transplant Recipients (cid:1) Cerebrovascular Accident Perioperative Myocardial Infarction (cid:1) Pathophysiology (cid:1) Diagnosis of Perioperative Myocardial Infarction Ischemic heart disease is present in an estimated 30% of arteryatherosclerosisaremalegenderandincreasingage(Table patients who undergo surgery in the United States. The aging 1-1). Additional risk factors include hypercholesterolemia, ofthepopulationincreasesthelikelihoodthatpatientsunder- hypertension, cigarette smoking, diabetes mellitus, obesity, going surgery will have co-existing ischemic heart disease. a sedentary lifestyle, and a family history of premature devel- Angina pectoris, acute myocardial infarction, and sudden opmentofischemicheartdisease.Psychologicalfactorssuchas deathareoftenthefirstmanifestationsofthisdisease.Cardiac typeApersonalityandstresshavealsobeenimplicated.Patients dysrhythmias are the major cause of sudden death. The two with ischemic heart disease can present with chronic stable most important risk factors for the development of coronary angina or with acute coronary syndrome. The latter includes 1 ANESTHESIA AND CO-EXISTING DISEASE TABLE 1–1 Risk Factors for Development of Ischemic coronary blood flow (oxygen supply) and myocardial oxygen Heart Disease consumption(oxygendemand)canprecipitateischemia,which frequentlymanifests as angina pectoris. Stableanginatypically Malegender developsinthesettingofpartialocclusionorchronicnarrowing Increasingage ofasegmentofcoronaryartery.Whentheimbalancebetween Hypercholesterolemia myocardialoxygensupplyanddemandbecomesextreme,con- Hypertension gestiveheartfailure,electricalinstabilitywithdysrhythmias,and Cigarettesmoking Diabetes mellitus myocardialinfarction (MI) can result. Anginapectoris reflects Obesity intracardiacreleaseof adenosineandbradykininduring ische- Sedentary lifestyle mia. These substances stimulate cardiac chemical and mecha- Genetic factors/family history nosensitive receptors whose afferent neurons converge with upper thoracic sympathetic fibers and other somatic nerve fibers in the spinal cord and ultimately produce thalamic and cortical stimulation that results in the typical chest pain of angina pectoris. These substances also slow atrioventricular Ischemic type Stable angina chest pain nodalconductionanddecreasecontractility,therebyimproving the balance between myocardial oxygen demand and supply. New onset or change from baseline Atherosclerosisisthemostcommoncauseofimpairedcoronary bloodflowresultinginanginapectoris. Diagnosis Acute Coronary Syndrome Angina pectoris is typically described as retrosternal chest dis- comfort, pain, pressure, or heaviness. The chest discomfort 12-lead ECG often radiates to the neck, left shoulder, left arm, or jaw and occasionally to the back or down both arms. Angina may also be perceived as epigastric discomfort resembling indigestion. No ST segment ST segment Somepatientsdescribeanginaasshortnessofbreath,mistaking elevation elevation asenseofchestconstrictionasdyspnea.Theneedtotakeadeep breath,ratherthantobreatherapidly,oftenidentifiesshortnessof breathasananginalequivalent.Anginapectorisusuallylastssev- Troponin/CK-MB Troponin/CK-MB Troponin/CK-MB negative positive positive eralminutesandiscrescendo/decrescendoinnature;asharppain thatlastsonlyafewsecondsoradullachethatlastsforhoursis rarely caused by myocardial ischemia. Physical exertion, emo- NSTEMI STEMI tional tension, and cold weather may induce angina; rest and/ or nitroglycerin relieve it. Chronic stable angina refers to chest painordiscomfortthatdoesnotchangeappreciablyinfrequency Unstable Myocardial orseverityover2monthsorlonger.Unstableanginabycontrast angina infarction isdefinedasanginaatrest,anginaofnewonset,oranincreasein Figure 1-1(cid:1)Terminology of acute coronary syndrome. CK-MB, creatine theseverityorfrequencyofpreviouslystableangina.Noncardiac kinase, myocardial bound isoenzyme; ECG, electrocardiogram; NSTEMI, chest pain is often exacerbated by chest wall movement and non–ST elevation myocardial infarction; STEMI, ST elevation myocardial associated with tenderness over the involved area, which is infarction.(AdaptedfromAlpertJS,ThygesenK,AntmanE,BassandJP:Myo- often a costochondral junction. Sharp retrosternal pain exacer- cardial infarction redefined—a consensus document of The Joint European bated by deep breathing, coughing, or change in body position SocietyofCardiology/AmericanCollegeofCardiologyCommitteefortherede- finitionofmyocardialinfarction.JAmCollCardiol2000;36:959–969.) suggestspericarditis.Esophagealspasmcanproduceseveresub- sternalpressure thatmay be confused with angina pectoris and mayberelievedbyadministrationofnitroglycerin. ST elevation myocardial infarction (STEMI) on presentation Electrocardiography and unstable angina/non–ST elevation myocardial infarction Standard Electrocardiography With myocardial ischemia, (UA/NSTEMI)(Fig.1-1). thestandard12-leadelectrocardiogram(ECG)demonstratesST segment depression (characteristic of subendocardial ischemia) ANGINA PECTORIS that coincides in time with anginal chest pain. This may be accompaniedbytransientsymmetricalT-waveinversion.Patients The coronary artery circulation normally supplies sufficient with chronically inverted T waves resulting from previous MI blood flow to meet the oxygen demands of the myocardium may manifest a return of the T waves to the normal upright inresponsetowidelyvaryingworkloads.Animbalancebetween position(‘‘pseudonormalization’’)duringmyocardialischemia. 2
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