Stoelting's Anesthesia and Co-Existing Disease, 5th Edition

684 Pages·2008·5.38 MB·English

by  Roberta L. Hines MD

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