Oxford Textbook of Cardiothoracic Anaesthesia

533 Pages·2015·53.3 MB·English

by  Marco Ranucci

Oxford Textbook of
Cardiothoracic
Anaesthesia
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Oxford Textbook of
Cardiothoracic
Anaesthesia
Edited by
R. Peter Alston
Consultant in Anaesthesia, Critical Care and Pain Medicine
Royal Infirmary of Edinburgh
Edinburgh
UK
Paul S. Myles
Professor, Director of the Department of Anaesthesia and Perioperative Medicine
Alfred Hospital and Monash University
Melbourne
Australia
Marco Ranucci
Professor, Head of Clinical Research in the Department of Anesthesia
and Intensive Care
IRCCS Policlinico San Donato, San Donato Milanese
Milan
Italy
1
1
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Foreword
It is always wise to look ahead, but difficult to look farther than you can see.
Winston Churchill
It is a privilege and great pleasure for me to be asked to write a echocardiography. This great increase in information reflects the
few words as a Foreword to the Oxford Textbook of Cardiothoracic vast amount of knowledge and multiple skills that contemporary
Anaesthesia, which is a new, fine contribution to the ever grow- anaesthesiologists require to practise cardiothoracic anaesthesia
ing development of this speciality. Like all similar modern text- and critical care.
books, it contains the recent relevant literature up to 2014 and a All technical books become dated and the subspecialty of car-
gel of the anaesthetic wisdom of many well-known anaesthesiolo- diothoracic anaesthesia is no exception. No doubt that there will
gists, in this field. Many of them have been my associates, who be further editions of this book. I note that many of the Forewords
I have enjoyed meeting through the European Association of of previous books have written of the astonishing changes of the-
Cardiothoracic Anaesthesiologists (EACTA) since its establish- ory and practice in a very short time, even in 1949. In Modern
ment in 1986. I congratulate them all for their monumental work. Practice in Anaesthesia (1949), the author wrote ‘I think the newer
My long association with cardiac anaesthesia began long before methods (of intravenous barbiturates and curare) will push ether
EACTA, in the days when we were only able to carry out two open- into the background. The administration of ether and chloroform
heart procedures each week. This was because our only Melrose should still be taught for there are times when their use is advis-
non-disposable rotating drum oxygenator required to be dis- able’. So what can we predict in the faster pace of life nowadays
mantled, sterilized, and reassembled before being available for a and the exponential rise in the evolution and knowledge of our
further patient after 48 hours. Successful repair of a regurgitant specialty?
mitral valve did not come easily in those pioneering days and was At least this robust volume will not progress to be so large
associated with a high mortality. that it follows the prodigious and comprehensive Oxford English
At that time there were no textbooks available for information Dictionary, which may only be available online in future. However,
on how to conduct the anaesthesia for open-heart surgery and we the sources of teaching and knowledge in our speciality will con-
relied on word of mouth and rather limited journal literature. My tinue to include books and journals (my personal choice), perhaps
only sources of information then were from such books as Synopsis digitized online, but also from e-learning updates and such facili-
of Anaesthesia (1947) and Modern Practice in Anaesthesia (1954), ties as learning the mysteries of TOE from dedicated websites and
unsurprisingly with no mention of open-heart surgery. Since simulators.
then my modest bookshelf tells me that there has been an ever I am sure that both trainees and established cardiothoracic
increasing number of books relating to this specific speciality, up- anaesthesiologists will enjoy this latest book. Its contents are also
to-date at their time of publication. Journal publications have like- a mine of information useful to the providers of anaesthesia for
wise expanded enormously and the practising anaesthetist may patients with heart disease requiring non-cardiac surgery, and no
be hard put to find the time to keep abreast of the many aspects doubt other anaesthesiologists will dip into it too.
of the specialty, let alone the essential skills and knowledge of
transoesophageal echocardiography (TOE) and transthoracic Dr John Manners

Preface
In comparison with many other areas of medicine, cardiothoracic if not the practical skill to operate the CPB machine, and expertise
anaesthesia is a relatively young speciality, underpinned by sev- in the pharmacological and mechanical support of the circulation
eral historic innovations in a little over 100 years. The first step to are essential. In the past, mechanical support was limited to intra-
overcome was the pneumothorax problem, conquered at the end aortic balloon pumps, but increasingly cardiac anaesthesiologists
of the nineteenth century. Other major advances occurred with need to know how to use ventricular assist devices, and extracor-
developments in cardiopulmonary bypass (CPB), lung isolation, poreal membrane oxygenation is regaining popularity. For these
intraoperative transoesophageal echocardiography (TOE), and reasons, chapters that address all these areas have been included
mechanical support for the failing heart. These successes aside, in this textbook.
the evolution of cardiothoracic anaesthesia has, at times, wan- Whilst there are many intraoperative skills that are essential
dered down some blind alleys and several misconceptions held to cardiothoracic anaesthesia, it is also important to appreciate
back progress. For this reason, and to place contemporary prac- how patients with heart and lung disease are diagnosed. What is
tices in context, we begin in the first chapter with a review of the even more important is a clear understanding of the factors that
history of cardiothoracic anaesthesia, including the errors, lest we must be considered when evaluating whether a patient should be
be condemned to repeat the mistakes of the past. managed surgically, rather than medically. Moreover, cardiotho-
Editing this book has given us pause for thought in regard to the racic surgery has an associated mortality and comes with adverse
knowledge and skills, over and above those of a specialist anaes- events, so knowledge of how to quantify operative risk is also valu-
thetist, that are necessary for the subspecialty of cardiothoracic able. Therefore, there are chapters in this textbook that cover diag-
anaesthesia. As a distillation of that thought, this textbook aims nosis, surgical selection, and risk estimation.
to provide the theoretical knowledge required to inform optimum TOE is a hallmark of modern cardiac anaesthesia. Indeed,
clinical practice. Where possible, this has been done using an there are several excellent textbooks devoted solely to this subject.
evidenced-based approach but not to the detriment of undervalu- For this reason, although echocardiography images have been
ing extensive clinical experience. Cardiothoracic surgery is now used to illustrate anatomy and pathophysiology, we have chosen
routinely performed around the world and there is a universal not to provide a comprehensive overview of TOE in this text-
need for subspecialty training in cardiothoracic anaesthesia. We book. Increasingly however, ultrasonic imaging is being applied
are therefore delighted that, in addition to an international edi- perioperatively, not only to diagnose and monitor treatment of
torship, authors of renown from around the world accepted our cardiovascular dysfunction, but also to diagnose other organ dys-
invitations to write chapters for this textbook. function and to assist the safe insertion of central venous catheters,
Whilst in the past too much importance may have been placed intra-aortic balloon pumps, tracheostomies, and other procedural
on physiological and other surrogate measures rather than true interventions. It is for these reasons that we have included a chap-
patient-centred outcomes, a sound knowledge of the basic sciences ter specifically on the use of ultrasound imaging in the critical
underpinning our speciality remain essential to current practice care unit.
in cardiothoracic anaesthesia. Additionally, the specific problems Although surgery has been the mainstay of the treatment of
in haemostasis and coagulation related to cardiac surgery make coronary artery, congenital and valvular heart diseases, to their
this field an optimal playing ground for point-of-care monitoring credit and to the benefit of a great many patients, cardiologists
of the haemostatic system. Therefore, we have included chapters have evolved beyond providing diagnostic and pharmacological
on the relevant anatomy, physiology, pathophysiology, and phar- treatments of heart disease to include interventional therapies.
macology, and consideration is given to inflammation, hypother- First, there was angioplasty and stenting, and there are now inter-
mia, coagulation, anticoagulation, and transfusion medicine. ventions to treat congenital heart disease and to implant prosthetic
Core skills for a cardiothoracic anaesthetist include competency heart valves. Moreover, cardiologists can treat conduction abnor-
in lung isolation and one-lung ventilation techniques, the ability malities and life threatening arrhythmias with permanent pace-
to invasively monitor the cardiovascular system, and the knowl- makers and automatic implantable cardioverter-defibrillators.
edge and experience to interpret the measurements intra- and There are also some areas of cardiothoracic anaesthesiology that
postoperatively. In addition, a good theoretical knowledge of CPB, require extra attention, including: paediatric and adult congenital
viii preface
heart disease, off-pump coronary artery bypass grafting surgery, if cardiothoracic anaesthesiology is to continue to advance. We
thoracic aortic surgery, video-assisted thoracoscopic surgery, otherwise risk repeating errors of the past, when techniques and
bronchoscopy, and the management of patients with heart disease drugs were introduced without proper evaluation, personal and
undergoing non-cardiac surgery. Chapters in this textbook cover institutional dogma reigned and harmful or otherwise ineffec-
the anaesthetic considerations of each of these procedures. tive interventions continued to be used despite evidence to the
Cardiothoracic anaesthesia does not end with the transfer of the contrary. Although many of us learnt cardiothoracic anaesthesia
patient to a critical care area and a continuum of care is required in an apprenticeship model, we should improve how we educate
to achieve good outcomes after cardiothoracic surgery. Today, and train future generations. Finally, cardiothoracic surgery and
postoperative critical care is a spectrum that varies from immedi- anaesthesia need to be delivered in an architecturally designed
ate tracheal extubation in the operating room and management in environment that is conducive to safe, effective care. Hybrid
an extended recovery room and/or transfer to a high dependency operating suites now have a place, combining interventional
unit, through to elective postoperative care in a cardiothoracic cardiology and surgical procedures. For these reasons, we are
intensive care unit. Fast-track anaesthetic techniques contrib- pleased that this book finishes with chapters on teamwork,
ute to enhanced recovery after heart surgery and effective pain training, error, research, audit, and designing a cardiothoracic
management techniques, including thoracic epidural and para- operating room.
vertebral analgesia, are essential to postoperative recovery from We have enjoyed editing this textbook and are grateful to all the
cardiothoracic surgery and there are also options to reduce the authors who have contributed to it. Our hope is that it will provide
risk of chronic pain. We have therefore included chapters dealing both current and future cardiothoracic anaesthesiologists with
with these and other aspects of the postoperative critical care of the theoretical concepts and knowledge to allow them to effec-
patients following cardiothoracic surgery. tively and safely provide anaesthesia and critical care for patients
The safe delivery of cardiothoracic anaesthesia and critical undergoing cardiothoracic surgery.
care requires the anaesthetist to not only have extensive knowl-
edge and skills as described in this textbook, but to consider R. Peter Alston,
non-technical skills and team behaviours. The delivery of such Paul S. Myles,
complex care needs to be audited and aspects of our practice Marco Ranucci
must be critically examined with randomized controlled trials Editors
Contents
Abbreviations xi 12 Extracorporeal membrane oxygenation 131
Thomas Langer, Eleonora Carlesso, and Luciano Gattinoni
List of contributors xv
13 Mechanical support of the circulation 139
Vladimir Saplacan, Mario Gaudino, and Massimo Massetti
1 An history of cardiothoracic anaesthesia 1
R. Peter Alston 14 Hypothermia and circulatory arrest 149
Jeremy M. Bennett, Andrew Shaw, and Chad Wagner
2 Anatomy and pathology of the heart
and major vascular system 15 15 Myocardial protection during
Neil Hauser, Adriaan Myburgh, and Justiaan Swanevelder cardiac surgery 157
Michael G. Irwin and Gordon Tin Chun Wong
3 Cardiovascular physiology,
pathophysiology, and monitoring 33 16 Antithrombotic and antiplatelet therapy 165
Philip J. Peyton David Royston
4 Thoracic anatomy, physiology, 17 Haemostasis management 181
and pathophysiology 47 David Royston
David J. R. Duthie
18 Blood management 191
5 The inflammatory response to Gavin J. Murphy, Nishith N. Patel, and Nicola Curry
cardiothoracic surgery 61 19 Anaesthesia for adult cardiac surgery 203
William T. McBride and Esther R. McBride
R. Peter Alston
6 Cardiovascular and pulmonary
20 Anaesthesia for off-pump coronary
pharmacology 69 artery bypass grafting 221
David Smith
Yatin Mehta and Madhur Malik
7 Diagnosis and assessment of cardiac disease 83 21 Paediatric cardiac and thoracic
Silvana F. Marasco and Martin G. Hiscock
anaesthesia 229
8 Diagnosis and assessment of lung disease 91 Marco Ranucci, Giuseppe Isgrò,
Giorgio Della Rocca and Cecilia Coccia and Anna Cazzaniga
9 Structural cardiac intervention 99 22 Anaesthesia for thoracic aortic surgery 251
Mario Carminati and Angelo Micheletti Donna Greenhalgh
10 Blood gases, clinical chemistry, 23 Anaesthesia for heart transplantation 261
and acid–base 111 Andy Gaunt and Nandor Marczin
David Story and Philip J. Peyton 24 Anaesthesia for adult patients with acquired
11 Cardiopulmonary bypass 117 heart disease for non-cardiac surgery 271
Marco Ranucci Alastair F. Nimmo and Matthew T. Royds