Table Of ContentANESTHESIA, THE HEART AND THE VASCULAR SYSTEM
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., Sjostrand, 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.C. (eds.): Anesthesiology: Today and Tomorrow.
1985. ISBN 0-89838-705-l.
Rahn, H., and Prakash, O. (eds.): Acid-base Regulation and Body Temperature.
1985. ISBN 0-89838-708-6.
Stanley, T.H., and Petty, w.e. (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.
ANESTHESIA, THE HEART
AND THE VASCULAR
SYSTEM
Annual Utah Postgraduate Course in
Anesthesiology 1987
edited by
THEODORE H. STANLEY, MD
W. CLAYTON PETTY MD
Department of Anesthesiology
The University of Utah Medical School
Salt Lake City
U.S.A.
1987 MARTINUS NIJHOFF PUBLISHERS ••
a member of the KLUWER ACADEMIC PUBLISHERS GROUP r::r.
DORDRECHT / BOSTON / LANCASTER
Distributors
jar the United States and Canada: Kluwer Academic Publishers, P.O. Box 358,
Accord Station, Hingham, MA 02018-0358, USA
jar the UK and Ireland: Kluwer Academic Publishers, MTP Press Limited,
Falcon House, Queen Square, Lancaster LAI lRN, UK
jar 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
ISBN-13: 978-94-010-7979-2 e-ISBN-13: 978-94-009-3295-1
DOT: 10/1007/978-94-009-3295-1
Copyright
© 1987 by Martinus Nijhoff Publishers, Dordrecht.
Softcover reprint of the hardcover 1s t edition 1987
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.
W. Clayton Petty. M.D.
Anesthesia. the Heart and the Vascular System contains the Refresher
Course manuscripts of the presentations of the 32nd Annual Postgraduate
Course in Anesthesiology which took place at the Westin Hotel Utah
Convention Center in Salt Lake City. Utah. February 20-24. 1987. The
chapters reflect new data and concepts within the general framework of
"risk. preoperative evaluation and monitoring." "cerebral. pulmonary and
peripheral vascular disease." "new agents. their advantages and their
problems" and "pediatric. cardiac and non-cardiac surgery." The purposes
of the textbook are to 1) act as a reference for the anesthesiologists
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 sub
jects addressed but rather attempts to summarize the most salient points.
This textbook is the fifth in a continuing series documenting the pro
ceedings 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.
YO
TABLE OF CONTENTS
Diabetes: Preoperative Evaluation and Intraoperative Management
Simon de Lange, M.D., Ph.D., FFARCS
What Are Minimum Monitoring Requirements and What Do Echocardiography,
EEG's and Oximetry Offer Us?
Michael F. Roizen, M.D.
18
Management of Electrolyte Abnormalities
K. C. Wong, M.D., Ph.D. 21
Does Choice of Anesthetic Make a Difference?
Michael F. Roizen, M.D. 37
Anesthesia and the Hypertensive Patient
Edward D. Miller, Jr., M.D. 42
Anesthesia for Congenital Cardiac Disease
James F. Arens, M.D. 52
Anesthetic Considerations for Cerebral Vascular Surgery
John D. Michenfelder, M.D. 65
Care of the Pacemaker Patient Undergoing General Surgery
James R. Zaiden, M.D. 73
Anesthetic Considerations in Patients for Vascular Surgery
James F. Arens, M.D. 78
Protecting the Brain During and After Vascular Insufficiency
John D. Michenfelder, M.D. 91
Deliberate Hypotension
Edward D. Miller, Jr., M.D. 97
Anesthetic Management of Pulmonary Thromboendarterectomy
Simon de Lange, M.D., Ph.D., FFARCS 105
Anesthesia for Adult Cardiac Surgery
James F. Arens, M.D. 113
The Renin-Angiotensin System in Anesthesia
Edward D. Miller, Jr., M.D. 125
Mechanisms for Myocardial Ischemia During Anesthesia
Sebastian Reiz, Ph.D., M.D. 130
Mechanisms and Management of Cardiac Arrhythmias
Ronald L. Katz, M.D. 136
VIII
Invasive and Noninvasive Monitoring of Myocardial Ischemia During Non
Cardiac Surgery
Sebastian Reiz. Ph.D .• M.D. 164
Effect of Inhalation-Anesthetics on Cardiac Conduction
James R. Zaiden. M.D. 170
Isoflurane and Coronary Blood Flow Regulation
Sebastian Reiz. Ph.D •• M.D. 173
Wildlife Capture: Are the Stresses Applicable to Humans?
J. C. Haigh. BVMS. MSc. MRCVS 178
Neonatal Anesthesia
Frederick A. Berry. M.D. 191
Cardiovascular Effects of Anesthetics in the Young
George A. Gregory. M.D. 202
Pharmacokinetics and Pharmacodynamics of Intravenous Anesthetic
Agents in the Pediatric Cardiovascular Patient
William J. Greeley. M.D. 204
Persistent Pulmonary Hypertension in the Newborn: Causes and
Therapeutic Horizons
Frederick A. Berry. M.D. 211
Effects of Cardiopulmonary Bypass on the Pediatric Patient
William J. Greeley. M.D. 216
Postoperative Care of Pediatric Cardiac Surgery Patients
George A. Gregory. M.D. 224
IX
Contributing Authors
Arnes, J.F., MD, Department of Anesthesiology, University of Texas Medical
Branch, Galveston, Texas, USA
Berry, F.A., MD, Department of Anesthesiology, University of Virginia
Medical Center, Charlottesville, Virginia, USA
Greenley, W.J., MD, Department of Anesthesiology, Duke University Medical
Center, Durham, North Carolina, USA
Gregory, G.A., MD, Department of Anesthesia, University of California, San
Francisco, San Francisco, California
Haigs, J.C., BVMS, MSc, Western College of Veterinary Medicine, Department
Herd Medicine & Theriogenology, University of Saskatchewan, Saskatoon,
Canada
Katz, R.L., MD, Department of Anesthesiology, UCLA School of Medicine, Los
Angeles, California, USA
Lange, de, S., MD, Ph D, Department of Anesthesiology, Academisch
Ziekenhuis, Leiden, The Netherlands
Michenfelder, J.D., MD, Department of Anesthesiology, Mayo Clinic,
Rochester, Minnesota, USA
Miller, Jr., E.D., MD, Department of Anesthesiology, University of Virginia
Medical Center, Charlottesville, Virginia, USA
Reiz, S., Ph D, MD, Department of Anesthesiology, Umea University, Umea,
Sweden
Roizen, M.F., MD, Department of Anesthesia & Critical Care, University of
Chicago Medical Center, Chicago, Illinois, USA
Wong, K.C., MD, Ph D, Department of Anesthesiology, University of Utah
School of Medicine, Salt Lake City, Utah, USA
Zaiden, J.R., MD, Department of Anesthesiology, Emory University School of
Medicine, Atlanta, Georgia, USA
DIABETES: PREOPERATIVE EVALUATION AND INTRAOPERATIVE MANAGEMENT
Simon de Lange, M.D.
Diabetes is the commonest endocrine disorder occurring in about 2-3%
of the western population. It has a high incidence of associated
complications which often require surgical intervention. Indeed, it has
been estimated that, largely because of these complications, 50% of all
diabetic patients will require surgery at some time during their 1 i ves
(1) •
The disease diabetes mellitus is considered to increase
perioperative risk. These conclusions are based on large retrospective
studies without matched patient controls (2, 3). Recently other but
smaller retrospective studies in well-run clinics have indicated that,
when matched for operative procedure, cardiovascular disease, sex, age
and weight, there was no significant difference in mortality or morbidity
in diabetic patients when compared to non-diabetic patient groups (4, 5).
Al.though it should be added that this observation does not apply to
diabetic patients undergoing open heart surgery (6). Thus, it would
appear that the disease diabetes mel 1 i tus itsel f does not necessari ly
increase perioperative morbidity and mortality; the end organ
complications of diabetes determine the risk factor.
The overall goal in the management of the diabetic surgical patient
should be to ensure that the morbidity or mortality does not exceed that
found in a similar non-diabetic population. This will necessitate careful
evaluation of the complications of diabetes, especially the late vascular
complications, as well as the status of the glycaemic and metabolic
control.
As diabetes is considered to represent at least two disease
processes, which may require different perioperative management; the
currently used classification will be presented.
2
CLASSIFICATION OF DIABETES
A new classification has recently become established (7); two main
types are described in idiopathically occurring diabetes:
Type I, insulin-dependent diabetes mellitus (100M) which was
formerly known as juvenile onset diabetes but can occur at any age. The
disease may be unstable (brittle diabetes) and glycaemic control
difficult. Insulin is mandatory to prevent ketosis and maintain life.
Management is with subcutaneously administered insulin once to four times
daily but recently a continuous subcutaneous infusion is being
popularized. This latter technique must be combined with frequent home
monitoring of blood glucose, (preferably using a reflectance meter) to
achieve "tight control" as well as careful attention to diet. It is known
as the open-loop technique in contrast to the closed-loop method (the
artificial pancreas) where the data from a continuous blood glucose
monitor is computerized and controls the rate of an insulin infusion.
Although this technique has been effectively used in open heart surgery
it needs close supervision and is complex and expensive (6).
Type II, non-insulin-dependent diabetes mellitus (NIOOM) was
previously called maturity onset diabetes but can also occur at any time
during life. This disease manifests itself in both the obsese and non
obese population. There is peripheral insulin resistance and ketosis may
occur during severe stress. Type II patients are usually treated by diet
alone or by diet and oral hypoglycaemic drugs. However, if glycaemic
control is poor, due for instance to the transient stress of illness or
surgery, insulin therapy is advisable. When intermittent insulin therapy
is considered it is important to exclusively use very pure insulins of
the modern human type in order to reduce the risk of sensitisation.
Finally, other types of diabetes are described which are associated
with various hormonal diseases, the effect of drugs or gestation.
PREOPERATIVE EVALUATION
This should include an assessment of the glycaemic and metabolic
control; cardiovascular status and assessment of diabetic neuropathy and
nephropathy if present.
Much of the evaluation may be done during the visit to the
preanaesthetic clinic in consultation with the endocrinologist and save
hospitalization time. Nevertheless it is still advisable to admit the
patient 2 or 3 days preoperatively in order to permit further studies and
