Anesthesiology 1986: Annual Utah Postgraduate Course in Anesthesiology 1986

295 Pages·1986·9.511 MB·English

by  D. Ryan Cook M.D. (auth.), Theodore H. Stanley MD, W. Clayton Petty MD (eds.)

ANESTHESIOLOGY 1986
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, V.H., and Smith, R.B. (eds.): Perspectives in High
Frequency Ventilation. 1983. ISBN 0-89838-571-7.
Stanley, T.H., and Petty, W.C. (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 0-89838-705-1.
Rahn, H., and Prakash, O. (eds.): Acid-base Regulation and Body Temperature.
1985. ISBN 0-89838-708-6.
Stanley, T.H., and Petty, w.e. (eds.): Anesthesiology 1986.
1986. ISBN 0-89838-779-5.
ANESTHESIOLOGY 1986
Annual Utah Postgraduate Course
in Anesthesiology 1986
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.
1986 MARTINUS NIJHOFF PUBLISHERS ....
a member of the KLUWER ACADEMIC PUBLISHERS GROUP ••
DORDRECHT / BOSTON / LANCASTER .~
IV
Distributors
for the United States and Canada: Kluwer Academic Publishers, 190 Old Derby
Street, Hingham, MA 02043, USA
for the UK and Ireland: Kluwer Academic Publishers, MTP Press Limited,
Falcon House, Queen Square, Lancaster LAI lRN, 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
Utah Postgraduate Course in Anesthesiology (31st ;
1986 : Salt Lake, Utah)
Anesthesiology 1986.
(Developments in critical care medicine and
anesthesiology)
31st Annual Postgraduate Course in Anesthesiology
held Feb. 14-18, 1986 in Salt Lake City.
Includes bibliographies.
1. Anesthesiology--Congresses. I. Stanley,
Theodore H. (Theodore Henry), 1940- II. Petty, W.
Clayton (William Clayton), 1938- . III. Title.
IV. Series. [DNLM: 1. Anesthesiology--congresses.
W3 UT294 31st 1986 / WO 200 U89 1986aJ
RD78.4.U83 1986 617'.96 85-29663
ISB~-13:978-94-01Oc8387-4 e-ISB~-13: 978-94-009-4251-6
DOl: 10.1007/978-94-009-4251-6
Copyright
© 1986 by Martinus Nijhoff Publishers, Dordrecht.
Softcoverreprintofthehardcover 1st edition 1986
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.
Anesthesiology 1986 contains the Refresher Course manuscripts of the
presentations of the 31st Annual Postgraduate Course in Anesthesiology
which took place at the Westin Hotel Utah Convention Center in Salt
Lake City, Utah, February 14-18, 1986. The chapters reflect recent and
future developments in anesthetic techniques, monitoring instruments
and devices, and anesthetic drugs. The purposes of the textbook are to
1) act as a reference for the anesthesiologists attending the meeting,
and 2) serve as a vehi cl e to bri ng many of the 1 atest 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 anesthesi a expressed at the conference. Thi s book and its chapters
should not be considered complete treatises on the subjects addressed
but rather attempts to summarlze the most salient points. This textbook
is the fourth 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.
TABLE OF CONTENTS
PHARMACOLOGY
The New Neuromusucular Blocking Agents
D. Ryan Cook, M.D. 1
Pharmacology of Local Anesthetic Agents
Benjamin J. Covino, Ph.D., M.D. 6
Anticholinesterase Agents: Their Mechanism of Action and Use
Richard J. Kitz, M.D. 11
Intravenous Induction Agents - Pros and Cons
Ne~
Paul F. White, Ph.D., M.D. 15
PHYSIOLOGY
Non-Respiratory Functions of the Lung
D. Ryan Cook, M.D. 29
Myocardial Ischemia: Pathophysiology and Detection
Dennis T. Mangano, Ph.D., M.D. 36
Brain Protection
Harvey M. Shapiro, M.D. 50
Liver Blood Flow and Anesthesia
Leo Strunin, M.D. 64
ISSUES
Epidural Steroid Injections for Low Back Pain
Bradford D. Hare, Ph.D., M.D. 76
Near Misses in Anesthesia: A Strategy for Their Prevention
Ri~hard J. Kitz, M.D. 83
Risk Management in Anesthesia
W. Clayton Petty, M.D. 88
Viral Hepatitis
Leo Strunin, M.D. 95
Controversies in Outpatient Anesthesia
Paul F. White, Ph.D., M.D. 102
VIII
TABLE OF CONTENTS (CONTINUED)
CLINICAL CONSIDERATIONS
Choice of Drugs for Spinal and Epidural Anesthesia
Benjamin G. Covino, Ph.D., M.D. llS
Non-Obstetrical Surgery for the Pregnant Patient
Francis M. James, III, M.D. 122
Preganancy Induced Hypertens ion: The Problem and It s Management
Francis M. James, III, M.D. 132
Ischemic Heart Disease: Assessment Using Non-Routine Tests
Dennis T. Mangano, Ph.D., M.D. 148
Malignant Hyperthermia
John F. Ryan. M.D. 161
Induction of Anesthesia in Pediatric Patients
John F. Ryan. M.D. 179
Anesthetic Management: Cerebrovascular Surgery
Harvey M. Shapiro, M.D. 186
Postoperative Pain Management with "On Demand" Analgesia
Paul F. White, Ph.D., M.D. 198
MONITORING
Intraoperative Monitoring of Sensory Evoked Potentials
Betty L. Grundy, M.D. 211
Monitoring Spinal Cord Function During Spinal Surgery
Betty L. Grundy, M.D. 231
Monitoring Depth of Anesthesia with the EEG
Albert Wauqu1er, Ph.D. 242
MISCELLANEOUS
Statistics for the Anesthesiologist
Nathan L. Pace, M.D. 255
Closed Absorption System - A New Look
Lucien E. Morris, M.D. 268
IX
Contributing Authors
Cook, D.R., MD, Department of Anesthesiology, Children'S Hospital of
Pittsburgh, 125 DeSoto Street, Pittsburgh PA 15213, USA
Covino, B.G., MD, Ph D, Department of Anesthesia, Brigham and Women's
Hospital. 75 Francis Street, Boston MA 02115, USA
Grundy, B.L., MD, Anesthesia Service, Veterans Administration Medical
Center, 1601 SW Archer Road, Gainesville FL 32602, USA
Hare, B.D., MD, Ph D, Department of Anestesiology, University of Utah,
50 North Medical Drive, Salt Lake City UT 84132, USA
James, F.M., III, MD, Department of Anesthesia, Wake Forest University,
Medical Center, 300 South Hawthorne Road, Winston-Salem NC 27103,
USA
Kitz, R.J., MD, Department of Anesthesia, Massachusetts General Hospital,
Boston MA 02114, USA
Mangano, D.T., MD, Ph D, Anesthesia Service, Veterans Administration
Medical Center, 4150 Clement Street, San Francisco CA 94121, USA
Morris, L.E., MD, Department of Anesthesiology, Medical College of Ohio,
3000 Arljngton Avenue, C.S. 10008, Toledo OH 43699, USA
Pace, N.L., MD, Department of Anesthesiology, University of Utah, 50
North Medical Drive, Salt Lake City UT 84132, USA
Petty, W.C., MD, Department of Anesthesiology, University of Utah, 50
North Medical Drive, Salt Lake City UT 84132, USA
Ryan, J.F., MD, Department of Anesthesia, Massachusetts General
Hospital, Boston MA 02114, USA
Shapiro, H.M., Mn, Neuroanesthesia Research, M-029, University of
California at San Diego, La Jolla CA 92093, USA
Stanley, T.K., MD, Department of Anesthesiology, University of Utah,
50 North Medical Drive, Salt Lake City UT 84132, USA
x
Strunin, L., MD, Department of Anesthesia, Foothills Hospital,
University of Calgary, 1403-29 Street NW, Calgary, Alberta, Canada
T2N 2T9
Wauquier, A., Ph 0, Department of Neuropharmacology, Janssen
Pharmaceutica, Turnhoutseweg 30, 2340 Beerse, Belgium
White, P.F., MD, Ph 0, Outpatient Anesthesia Service, Department of
Anesthesia, Stanford University Medical Center, Stanford CA 94305,
USA
THE NEW NEUROMUSCULAR BLOCKING AGENTS
D. RYAN COOK, M.D.
At racur ium , a muscle relaxant of intermediate duration, is
metabolized by nonspecific esters and spontaneously decomposes by
Hofmann degradation. Both processes are sensitive to pH and
temperature. Under physiologic conditions the breakdown of atracurium
is mainly by ester hydrolysis; Hofmann elimination plays a minor role.
Deficient or abnormal pseudocholinesterases have little or no effect
on atracurium degradation.
We and others have studied the effects of both age (1,2) and
potent inhalation agents on dose-response relationships of atracurium
in infants, children, and adolescents (3,4). On a weight basis
(ug/kg) the ED95 for atracurium was similar in infants (1-6 months of
age) and adolescents. whereas children had a higher dose requirement.
2
On a surface area basis (ug/m ) the ED95 for atracurium was similar in
2
children and adolescents; the ED95 (ug/m ) for atracurium in infants
was much lower.
At equipotent doses (1 x ED95) the duration of effect (time from
injection to 9510 recovery) was 23 minutes in infants and 29 minutes in
children and adolescents, compared with 44 minutes in adults. The
time from injection to T25 (twenty-five percent neuromuscular
transmission) was 10 minutes in infants, 15 minutes in children and