ADVANCES IN Anesthesia

Transcription

1 ADVANCES IN Anesthesia CONTENTS VOLUME Associate Editors vii Contributors ix Anesthetic Considerations for Nonobstetric Surgery During Pregnancy By Howard H. Bernstein and Jerome You Case 1 1 Teratogenic Risk of Anesthesia 2 Inhaled anesthetic agents 2 Nitrous oxide 2 Other inhaled anesthetic agents 2 Intravenous anesthetics 3 Narcotics 3 Sedatives 3 Intravenous Anesthetics 7 Airway Anatomy 8 Pulmonary Function 8 Laproscopic Surgery 11 Appendectomy 12 Cholecystectomy 13 Adnexal Surgery 14 Case 2 15 Case 3 19 Case 4 19 Case 5 20 Present and Future Anticoagulants By Marc E. Stone and Linda Shore-Lesserson The Current Understanding of Coagulation: a Cell-Based Model 30 Limitations of the Standard Agents Heparin and Warfarin 31 Heparin 31 Warfarin 34 Alternatives to Heparin and Warfarin 37 Antithrombotic Agents 38 Low molecular weight heparins 38 Pentasaccharides selective factor Xa inhibitors 39 Heparinoids 41 xi

2 Direct thrombin inhibitors 41 Argatroban 42 Hirudin and lepirudin 42 Bivalirudin 43 The rise and fall of ximelagatran 44 Antiplatellet Agents 46 Aspirin 47 Thienopyridines ticlopidine and clopidogrel 49 Glyoprotein IIb/IIIa receptor inhibitors 51 Point-of-Care Platelet Function Testing 52 Summary 55 Off-Pump Coronary Artery Bypass Surgery Outcomes and Management By Aras Omar Ali, Patrick Möhnle, and Nanette Schwann History 67 Physiology and Outcomes in Off-Pump Coronary Artery Bypass Surgery Versus Coronary Artery Bypass Grafting 68 Inflammation and immune mechanisms 68 Hematologic changes 69 Neurologic injury 70 Myocardial function 70 Pulmonary function 71 Renal function 71 Gastrointestinal complications 71 Wound infections 72 Graft patency, graft function, survival 72 Death 72 Economics 72 Summary 73 Hemodynamic Management During Off-Pump Coronary Artery Bypass Surgery 74 Monitoring 74 Hemodynamic management 76 Management of myocardial ischemia 78 Special Techniques to Reduce Ischemic Complications 79 Preconditioning 79 Intra-aortic balloon pump 79 Axial blood flow pump 79 Perfusion assistance machine 79 Other techniques 80 Summary 80 Fatigue in Anesthesia the Impact on Patient and Provider Safety: Update on Work-Hour Limitations By Michael D. Nevarez and Steven K. Howard xii The Risks to Safety, Performance, and Health 85 Impacts on safety 86

3 Performance risks 87 Attentional failures 88 Alcohol correlations 88 Long-term performance effects 89 Health correlations 89 Sleep Physiology 91 Sleep a basic need 91 Circadian clock 92 In the Wake of Work Hours Reform 93 Subjective findings 93 Additional findings 94 Meeting the challenges of implementation 95 Further Risks in the Health Care Setting 96 Barriers to Change 97 Managing Alertness in Health Care: A Proposed Solution 97 Education 97 Alertness strategies 98 Planned naps 98 Caffeine 98 Good sleep habits 99 Modafinil: another alertness-enhancing drug 99 Healthy sleep diagnosis and treatment of sleep disorders 100 Scheduling issues 100 Summary 102 Update on Unintended Intraoperative Awareness By Christopher D. Kent and Karen B. Domino Definition and Incidence 109 Etiology 111 Strategies for Prevention of Awareness 113 Brain Function Monitoring in the Assessment of Depth of Anesthesia 116 Complications Associated with Awareness and Explicit Recall 119 Medicolegal Implications of Awareness 121 Implications for Departments 121 Summary 122 Appendix 1: Summary of American Society of Anesthesiologists Practice Advisory 122 Preoperative evaluation 122 Preinduction phase of anesthesia 123 Intraoperative monitoring 123 Intraoperative and postoperative management 123 Anesthesia for Awake Intracranial Procedures By Heidi M. Koenig Background of Awake Intracranial Procedures 127 Indications 128 Contraindications 129 xiii

4 Patient Selection 130 Surgical Planning and Lesion Localization 130 Preoperative Evaluation 132 Stereotactic frame application and scanning 132 The Scalp Block 133 Preparation in the Surgical Suite 133 Surgical Incision and Bone Flap Removal 135 Intraoperative Testing 135 Testing for Selected Neurosurgical Procedures 135 Seizure focus excision 135 Arteriovenous malformation or tumor resection 136 Deep brain stimulators 136 Complications 137 Airway obstruction/hypoventilation 137 Shortness of breath 138 Tight brain 139 Intraoperative seizure 139 Large blood loss 139 Thirst 139 Uncomfortable position 140 Nausea and vomiting 140 Urinary urgency 140 Claustrophobia 140 Intolerance of the process 140 Anesthetic Techniques 140 Asleep-awake-asleep 141 Conscious sedation-awake-conscious sedation 142 Monitored care 142 Anesthetic Medications 143 Sedatives 143 Dexmedetomidine 143 Propofol 145 Postanesthesia Care Unit 146 Summary 146 Acknowledgments 147 Diversity and Disparities in Health and Health Care: Why it Matters to Anesthesiology By Jennifer Thomas-Goering and Carmen R. Green xiv History 151 Why Should Health Care Disparities Matter to Anesthesiologists? 153 The Role of Gender and Race on Health Status and Medical Care 154 The Role of Physician Variability in Decision Making 154 Disparities in Pain Care 155 Why is Racial, Ethnic, and Gender Diversity Important to Anesthesiology? 156

5 Transforming the professional and institutional climate to support diversity and eliminate disparities 156 Recommendations for the Future 157 Anesthesia for Sites Outside the Operating Room By Alice L. Landrum Guideline Development 163 Indications for Anesthesia 164 General Requirements for Anesthetics Outside the Operating Room 165 Unique Considerations for Each Area 166 Radiology suite 166 Aortic endovascular procedures 167 Neurovascular procedures 167 Interventional uroradiology 167 CT 168 Positron emission tomography 168 Myelography 169 MRI 169 Cardiac Catheterization Laboratory 171 Radiation Therapy 172 Gastrointestinal Endoscopy Suite 172 Psychiatric Unit 172 Summary 173 Off-Label Uses of Dexmedetomidine By Keyuri Popat, Ronaldo Purugganan, and Imrana Malik Pharmacology 177 Metabolism 178 Elimination 178 Mechanism of Action 178 Clinical Effects 178 Sedation 178 Respiratory stability 179 Hemodynamic profile 179 Dosing 179 Off-Label Use of Dexmedetomidine 180 Off-label use of dexmedetomidine in the operating room 181 Regional anesthesia 181 Awake fiberoptic intubation/airway surgery 182 Cardiothoracic surgery 183 Neurosurgery 184 Non intensive care unit out-of-operating-room use of dexmedetomidine 184 Mediastinal mass 184 xv

6 Obesity 185 Off-label uses of dexmedetomidine in the intensive care unit 185 Prolonged duration of administration 185 No loading dose 186 Greater-than-recommended dosage 186 Pediatric intensive care unit patients 186 Sedative-hypnotic withdrawal 187 Use of dexmedetomidine in noninvasive procedures 187 Use of Dexmedetomidine by Nonanesthesiologists 187 Safety Considerations 187 Adverse reactions 188 Drug interactions 188 Tolerance and withdrawal 188 Pregnancy 188 Anesthesia for Robotic Heart Surgery By Steven Haddy and Mark Cunningham Anesthetic Technique 193 Positioning 194 Temperature management 195 Lung separation 195 Fluid management 196 Monitors 196 Echocardiography 197 Cardiopulmonary Bypass 198 Venous cannulation and drainage 198 Arterial cannulation and aortic occlusion 200 Left ventricular venting 202 Retrograde cardioplegia 202 Anticoagulation 203 Deairing procedures 203 Specific Surgeries 203 Coronary artery bypass 203 Valve repair and replacement 204 Miscellaneous conditions 204 Postoperative Management 204 Summary 205 Index 207 xvi