What’s New in Anesthesiology

213 Pages·1988·8.945 MB·English

by  P. Foëx, B. Leone (auth.), T. H. Stanley (eds.)

WHAT'S NEW IN ANESTHESIOLOGY
DEVELOPMENTS IN CRITICAL CARE
MEDICINE AND ANESTHESIOLOGY
Prakash, O. (ed.): Applied Physiology in Clinical Respiratory Care. 1982.
ISBN 90-247-2662-X.
McGeown, Mary G.: Clinical Management of Electrolyte Disorders. 1983.
ISBN 0-89838-559-8.
Scheck, P.A., Sj6strand, U.H., and Smith, R.B. (eds.): Perspectives in High
Frequency Ventilation. 1983. ISBN 0-89838-571-7.
Stanley, T.H., and Petty, W.e. (eds.): New Anesthetic Agents, Devices and Mo
nitoring Techniques. 1983. ISBN 0-89838-566-0.
Prakash, O. (ed.): Computing in Anesthesia and Intensive Care. 1983.
ISBN 0-89838-602-0.
Stanley, T.H., and Petty, W.C. (eds.): Anesthesia and the Cardiovascular
System. 1984. ISBN 0-89838-626-8.
Van Kleef, l.W., Burm, A.G.L., and Spierdijk, l. (eds.): Current Concepts in
Regional Anaesthesia. 1984. ISBN 0-89838-644-6.
Prakash, O. (ed.): Critical Care of the Child. 1984. ISBN 0-89838-661-6.
Stanley, T.H., and Petty, w.e. (eds.): Anesthesiology: Today and Tomorrow.
1985. ISBN 0-89838-705-1.
Rahn, H., and Prakash, O. (eds.): Acid-base Regulation and Body Temperature.
1985. ISBN 0-89838-708-6.
Stanley, T.H., and Petty, W.C. (eds.): Anesthesiology 1986.
1986. ISBN 0-89838-779-5.
de Lange, S., Hennis, P.l., and Kettler, D. (eds.): Cardiac Anaesthesia: Prob
lems and Innovations. 1986. ISBN 0-89838-794-9.
Stanley, T.H., and Petty, W.e. (eds.): Anesthesia, the Heart and the Vascular
System. 1987. ISBN 0-89838-851-1.
Stanley, T.H. (ed.): What's New in Anesthesiology. 1988. ISBN 0-89838-367-6.
WHAT'S NEW
IN ANESTHESIOLOGY
edited by
T.H. STANLEY
Department of Anesthesiology,
The University of Utah Medical School,
Salt Lake City, USA
1988 MARTIN US NIJHOFF PUBLISHERS
a member of the KLUWER ACADEMIC PUBLISHERS GROUP
DORDRECHT / BOSTON / LANCASTER
Distributors
for the United States and Canada: Kluwer Academic Publishers, 101 Philip
Drive, Assinippi Park, Norwell, MA 02061, USA
for the UK and Ireland: Kluwer Academic Publishers, MTP Press Limited,
Falcon House, Queen Square, Lancaster LAI IRN, UK
for all other countries: Kluwer Academic Publishers Group, Distribution Center,
P.O. Box 322, 3300 AH Dordrecht, The Netherlands
Library of Congress Cataloging in Publication Data
What's new in anest-hesinlogy.
(DevelopmenLs in cr-it-u::al care medicine and
anaestheS]nulgy)
11 Present-at-inns of t-he 33rd Annual Postgraduat.e
Course in AnesUwsio1ogy which took place ... in Sale
Lake Cit-y, Ut-ah, Febr'uary 19-23, 198811--Pref.
Includes bibliographies.
1. Anesthesiolugy--C()ngresses. 2. Medical innova
t-ions--Congresses. I. Stanu,y, Theodor'e H.
(Theodor'e, Henry), 1940- IT. Utah Post.-
graduat.e Cour'se in Anesthesinlogy U3rd : 1988 :
Salt. Lake Cit.y, lJt.ah) TTT. Series. [DNl.M:
L. Anest.hesiology--congresses. W3 UT294 33r'd 1988 I
WO 200 W555 1988]
RD78.4.W47 1988 617' .96 87-34751
ISBN-13: 978-94-010-7713-2 e-ISNB-13: 978-94-009-2689-9
DOl: 10,1007/978-94-009-2689-9
Copyright
© 1988 by Martinus Nijhoff Publishers, Dordrecht.
Softcover reprint of the hardcover 1st edition 1988
All rights reserved. No part of this publication may be reproduced, stored in a
retrieval system, or transmitted in any form or by any means, mechanical,
photocopying, recording, or otherwise, without the prior written permission of
the publishers,
Martinus Nijhoff Publishers, P.O. Box 163, 3300 AD Dordrecht,
The Netherlands.
v
PREFACE
Theodore H. Stanley, M.D.
What's New in, Anesthesiology in 1988 contains the Refresher Course
manuscripts of the presentations of the 33rd Annual Postgraduate Course
in Anesthesiology which took place at the Marriott Hotel Convention Center
in Salt Lake City, Utah, February 19-23, 1988. The chapters reflect new
data, ideas and concepts within the general framework of most recent
developments in "evaluation and monitoring cardiac function before,
during and after surgery," "new anesthetics and their actions on the
heart and peripheral vasculature, and other organ systems," "metabolism
and elimination of anesthetics and anesthetic adjuvants," and "recent
developments in the anesthetic management of patients with congenital
heart disease, renal and pulmonary dysfunction, and diabetes insipidus."
In addition, there are chapters on new developments in "obstetrics,"
"regional anesthesia," and "anesthetic management of the newborn." The
purposes of the textbook are to 1) act as a reference for the anesthesio
logists 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 sixth 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
TABLE OF CONTENTS
List of Contributors ix
Understanding Left Ventricular Function
Pierre Fo~x, M.D. and B. Leone, M.D.
Monitoring Myocardial Oxygen Balance: Physiologic Basis and Clinical
Application
Paul G. Barash, M.D. 9
The Right Ventricle: Forgotten Too Long!
Pierre Foex, ~1.D., C. Arvieux, ~1.D., and J. G. Ramsay, M.D. 21
Update on Interactions Between Calcium Antagonists and Anesthetics
Robert G. Merin, M.D. 29
Complications Associated with the Placement of the Pulmonary Artery
Catheter
Alan Jay Schwartz, M.D., M.S. Ed. 35
Non-Invasive Monitoring
Paul G. Barash, M.D. 41
Histamine Release and Neuromuscular Blocking Drugs: Clinical Pharmacology
and Circulatory Mechanisms
John J. Savarese, M.D. 49
Anesthesia and the Aging Heart
Robert G. Merin, M.D. 53
Cardiovascular Effects of Isoflurane
Pierre Fo~x, M.D. 61
Anesthesia for Major Vascular Surgery - Current Concepts
Norman J. Clark, M.D. 69
Reversal of Neuromuscular Blockade: Changin0 Concepts
John J. Savarese, M.D. 87
Pharmacologic Antagonists in Anesthetic Practice
Peter L. Bailey, M.D. 91
Metabolism and Elimination of Neuromuscular Blocking Drugs: (1) New
Observations on Old Drugs; (2) New Patterns in New Drugs
John J. Savarese, M.D. 111
Prognosis Following Acute Renal Failure
Alan S. Tonnesen, M.D. 115
VIII
Pulmonary Edema: Is Your Fluid Management Breathtaking?
Paul G. Barash, M.D. 123
Cardiovascular Physiology of Congenital Heart Disease
Alan Jay Schwartz, M.D., M.S. Ed. 131
Anesthetic Management of the Child with Congenital Heart Disease for
Non-Cardiac Surgery
Alan Jay Schwartz, M.D., Ed. 141
~1.S.
Hormonal Regulation of Renal Function During Anesthesia
Alan S. Tonnesen, M.D. 149
Safety and Efficacy with Intravenous Regional Anesthesia
Alon P. Winnie, M.D. 155
Management of SIADH and Diabetes Insipidus
Alan S. Tonnesen, M.D. 161
Techniques of Brachial Plexus Block
Alon P. Winnie, M.D. 167
Local Anesthetic Adjuvants for Brachial Plexus Anesthesia
Alon P. Winnie, M.D. 173
Physiology of Pregnancy
Thomas H. Joyce, III, M.D. 189
Anesthesia for Cesarean Section
Thomas H. Joyce, III, M.D. 195
Resuscitation of the Newborn
Alan Jay Schwartz, M.D., M.S. Ed 199
Central Nervous System and Epidural and Spinal Opiates in Obstetrics
Thomas H. Joyce, III, M.D. 209
IX
LIST OF CONTRIBUTORS
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.
Clark, N.J.
Department of Anesthesiology, University of Utah School of Medicine,
Salt Lake City, UT 84132, U.S.A.
Foex, P.
Nuffield Department of Anesthetics, The Radcliffe Infirmary, Oxford OX2
6HE, United Kingdom
Joyce, T.H.
Department of Anesthesiology, Jefferson Davis Hospital, Baylor College
of Medicine, Houston, TX 77019, U.S.A.
Merin, R.
Department of Anesthesiology, University of Texas, Medical School at
Houston, Houston, TX 77004, U.S.A.
Savarese, J. J.
Department of Anesthesia, Massachusetts General Hospital, Boston, MA
02114, U.S.A.
Schwartz, A.J.
Associate Dean for Academic Affairs, Hahnemann University, Philadelphia,
PA 19102, U.S.A.
Tonnesen, A.S.
Department of Anesthesiology, University of Texas Health Science Center
at Houston, Houston, TX 77004, U.S.A.
Winnie, A.P.
Department of Anesthesiology, University of Illinois College of Medicine
at Chicago, 1740 IrJest Traylor Street, Chicago, IL 60612, U.S.A.
1
UNDERSTANDING LEFT VENTRICULAR FUNCTION
P.FOEX and B.LEONE
The characteristics of cardiac muscle contraction and relaxation have
been extensively investigated using isolated heart muscle preparations. In
such preparations, the effects of changes in preload (Starling's law of the
heart) and in contractility have been clearly defined, and many indices of
contractility described. These indices, exta1sively validated in isolated
heart muscle preparations, have been used to assess the inotropic state of the
intact heart. However, the intact heart is not a band of muscle lifting a
weight, it is a muscle pump ejecting a viscous fluid (the blood) into
viscoelastic systems (the systemic and pulmonary circulations). In order to
characterize the behaviour of the cardiac pump, the dynamic relationships
between pressure and dimensions may be more appropriate than the analysis of
pressure alone.
Pressure-dimensions relationships:
The idea of representing ventricular contraction and relaxation in terms
of the instantaneous relationship between pressure and volume is not new.
Frank described such a relationship for the frog heart in 1895 (1).
Pressure-dimension loops can be constructed for the ejecting ventricle if,
besides intraventricular pressure, volume, diameter, or chord
~ocardial
length are measured throughout the cardiac cycle (2,3,4). The loop consists
of four segments, representing isovolurnic contraction, ejection, isovolurnic
relaxation, and ventricular filling; these are delineated by four events:
mitral valve closure, aortic valve opening, aortic valve closure, and mitral
valve opening (Fig 1).
The effect of volume loading is to displace the end-diastolic point of
the loop along the end-diastolic pressure dimension line, which represents the
static compliance of the ventricle (Fig 2). The line becomes steeper as
loading increases.
Ejection
AVc
AVo
IsoYolumic Isoyolumic
relaxation contraction
Figure 1. Diagrammatic
of a
repres~tation ~essure­
dimensl.on loop. The phases of
ttohgee cthaerdr iwaci th~ ctlhee atirmee sr eporfe mseinttreadl MVo MVc
valve closure (MVc) , aortic valve
opening (AVo), aortic valve
Filling
(AVc) and mitral valve
clos~re
openmg (MVo).
Dimensions
ES2
ES1
Fi~r~2. An increase in
pr~o displaces the end-
aiastolic pressure-dirnension
point lEDl to ED2) along the end-
aiasto ic
pressure~imension
line. Note that the
displacement of end-systolic
pressure-dimension point 1ESI to
ES2) is nuch smaller, hence the ED2
increase in stroke volume ~
lrepresented by the width of the ED1
oop).
Dimensions
As a volume load is administered, the end-systolic dimensions increase to a
lesser extent than the end-diastolic dimensions, and the stroke volume
increases.
Increases in the resistance to ejection displace the end-systolic points
of the loop along a straight line, the end-systolic pressure-dirnension line
(5). As resistance increases, so do the end-systolic dimensions.
Conversely, reductions in resistance allow the ventricle to oontract to
smaller end-systolic dimensions (Fig 3).