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CONTROVERSIES IN CARDIOVASCULAR ANESTHESIA
edited by
PHILLIP N. FYMAN
ALEXANDER W. GOTTA
~.
" KLUWER ACADEMIC PUBLISHERS
Boston Dordrecht London
Distributors
for the United States and Canada: Kluwer Academic Publishers, 101 Philip Drive, Assinippi Park, Norwell, MA, 02061, USA
for the UK and Ireland: Kluwer Academic Publishers, Falcon House, Queen Square, Lancaster LAllRN, UK
for all other countries: Kluwer Academic Publishers Group, Distribution Centre, P. O. Box 322, 3300 AH Dordrecht, THE NETHERLANDS
Library of Congress Cataloging-in-Publication Data
Controversies in cardiovascular anesthesia.
Includes bibliographies and index. 1. Cardiovascular system-Surgery. 2. Anesthesia. I. Fyman,
Phillip. II. Gotta, Alexander W. [DNLM: 1. Anesthesia. 2. Cardiovascular System-surgery. WG 168 C764] RD597.C67 1988 617'.96741 87-24774
[SBN-13: 978-1-4612-8993-7 00[: [0.1007/978-[-4613-1771-5
Copyright © 1988 by Kluwer Academic Publishers, Boston.
Softcover reprint of the hardcover 1st edition 1988
e-[SBN-13: 978-1-4613-1771-5
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 publisher, Kluwer Academic Publishers, 101 Philip Drive, Assinippi Park, Norwell, MA 02061.
We would like to acknowledge the encouragement of James Cottrell, M.D. and the support of our families, that was necessary to write this book.
Phillip N. Fyman, M.D. Alexander W. Gotta, M.D.
CONTENTS
Contributing Authors
Preface
1. An inhalation anesthetic technique is preferable for patients undergoing coronary artery bypass grafting JAN L. KRAMER, DAVID J. WAGNER, AND STEPHEN J. THOMAS
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2. An intravenous technique is preferable for patients undergoing coronary 13 artery bypass grafting JAMES B. STREISAND, THEODORE H. STANLEY, AND PAUL S. NELSON
3. Blood gas values should be corrected for body temperature during hypothermia ENRICO M. CAMPORESI AND RICHARD E. MOON
4. Blood gases should not be temperature corrected during hypothermia PAUL L. GOLDINER, YASU OKA, AND EDWARD SVADJIAN
5. High pump flows and pressure are desirable during cardiopulmonary bypass KETAN SHEVDE AND SARADA MYLAVARAPU
6. Low pressure during cardiopulmonary bypass is preferable J.G. REVES, ANN GOVIER, AND NARDA CROUGHWELL
7. Pulmonary artery catheters should be used routinely in all patients undergoing coronary artery bypass grafting MARTIN J. LONDON AND DENNIS T. MANGANO
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55
83
99
115
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viii Contents
8. Routine insertion of pulmonary artery catheters is not necessary in all patients undergoing coronary artery bypass grafting PHILLIP N. FYMAN AND LAWRENCE KUSHINS
9. General anesthesia is preferable for patients undergoing carotid endarterectomy CAROL L. LAKE
10. Regional anesthesia is preferable for patients undergoing carotid endarterectomy PIERRE CASTHELY AND JOHN DLUZNESKI
Index
129
143
169
185
CONTRIBUTING AUTHORS
Enrico M. Camporesi, M.D. Professor of Anesthesiology Duke Unviersity Medical Center Durham, North Carolina 27710
Pierre Casthcly, M.D. Associate Professor of Anesthesiology State University of New York Health Science Center at Brooklyn Brooklyn, New York
Narda Croughwell, CRNA Research coordinator Division of Cardiothoracic Anesthesia Duke University Medical Center Durham, North Carolina
John Dluzneski, M.D. Fellow in Cardiac Anesthesia State University of New York Health Science Center at Brooklyn Brooklyn, New York
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x Contributing Authors
Phillip N. Fyman, M.D. Attending Anesthesiologist Long IslandJewish Medical Center New Hyde Park, New York 10042
Paul L. Goldiner, M.D. Professor and Chairman Department of Anesthesiology Albert Einstein College of Medicine Bronx, New York
Alexander W. Gotta, M.D. Professor of Clinical Anesthesiology State University of New York Health Science Center at Brooklyn Brooklyn, New York
Ann Govier, M.D. Staff Anesthesiologist Department of Cardiothoracic Anesthesia Cleveland Clinic Cleveland, Ohio
Jan L. Kramer, M.D. Fellow in Cardiac Anesthesia New York University Medical Center New York, New York 10016
Lawrence Kushins, M.D. Director, Cardiac Anesthesia Long IslandJewish Medical Center New Hyde Park, New York
and Clinical Assistant Professor of Anesthesiology State University of New York School of Medicine at Stony Brook Stony Brook, New York
Carol L. Lake, M.D. Associate Professor of Anesthesiology University of Virginia School of Medicine Charlottesville, Virginia
Martin]. London, M.D. Assistant Professor of Anesthesiology University of California, San Francisco San Francisco, California
Dennis T. Mangano, Ph.D., M.D. Professor of Anesthesiology University of California, San Francisco San Francisco, California
Richard E. Moon, M.D. Assistant Professor of Anesthesiology Duke University Medical Center Durham, North Carolina 27710
Sarada Mylavarapu, M.D. Fellow in Cardiac Anesthesia Maimonides Medical Center Brooklyn, New York 11219
Paul S. Nelson, M.D. Fellow in Anesthesiology University of Utah School of Medicine Salt Lake City, Utah 84132
Yasu Oka, M.D. Professor of Anesthesiology Albert Einstein College of Medicine Bronx, New York
J. G. Reves, M.D. Professor of Anesthesiology Director, Cardiothoracic Anesthesia Duke University Medical Center Durham, North Carolina
Ketan Shevde, M.D. Director, Cardiac Anesthesia
and Acting Director Department of Anesthesiology Maimonides Medical Center Brooklyn, New York 11219
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xii Contributing Authors
Theodore H. Stanley, M.D. Professor of Anesthesiology
and Research Professor of Surgery University of Utah School of Medicine Salt Lake City, Utah 84132
James B. Streisand, M.D. Assistant Professor of Anesthesiology University of Utah School of Medicine Salt Lake City, Utah 84132
Edward Svadjian, M.D. Assistant Professor of Anesthesiology Albert Einstein College of Medicine Bronx, New York
Stephen]. Thomas, M.D. Associate Professor of Anesthesiology Director of Cardiothoracic Anesthesia New York University Medical Center New York, New York 10016
David]. Wagner, M.D. Fellow in Cardiac Anesthesia New York University Medical Center New York, New York 10016
PREFACE
On 16 October 1846, an itinerant New England dentist named William T.G. Morton proved the anesthetic effect of diethyl ether in a public demonstration in the "ether dome" of the Bulfinch Building of the Massachusetts General Hospital in Boston. The patient, Gilbert Abbott, suffered no pain, and the surgeon, Dr. John C. Warren, was able to complete a suture ligature of a vascular tumor of the jaw without the hurry that until then was so necessary. The operation proved a failure, since the tumor recurred; but the demonstration of ether's anesthetic effect was a great success. Operative pain was conquered, and surgery could advance from a crude and unscientific practice where speed was paramount, and the major body cavities could not be entered, into the unique blend of science and art that it is now. "Gentlemen, this is no humbug," supposedly muttered Warren, perhaps the last noncontroversial assessment of anesthesiology to be made by a surgeon. The screams of resisting patients in pain were stilled, and quiet entered the operating room for the first time.
But the new science of pain relief was quickly wrapped in controversy. An argument immediately arose as to who could legitimately claim primacy for the discovery. Morton's attempt to hide the true nature of his anesthetic agent, coupled with an effort to patent the discovery, clouded his reputation and stimulated other claimants to push themselves forward. The anesthesiologists of Georgia still honor the memory of Crawford Long, while the people of Boston maintain the controversy with a monument in the Public Garden, dedicated to the discovery of ether anesthesia, yet bearing the name of no one.
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While most surgeons (and all patients) readily accepted intraoperative pain relief, a few protested, claiming that pain was part of the healing process, and that to contain pain would limit healing. Fortunately, this nonsense died quickly.
Chloroform's anesthetic ability was proved only one year after the ether demonstration, and each drug's adherents trumpeted the peculiar benefits of their favorite. Chloroform, the nonflammable, but dangerous drug, with a propensity to sudden and unexplained death, became the primary agent of the physician anesthetist in Great Britain and Europe. Ether, flammable, but safer, found its greatest use in the United States.
But the infant specialty of Anesthesiology almost died in its cradle, smothered by the "religious controversy." "No!" roared the theologians of Great Britain, "you can not relieve the pain of childbirth, since the Bible demands that women shall bear their children in pain and sorrow, and it is sinful so to oppose Biblical demands." Vainly did the anesthestists protest that Adam slept while Eve was created, suggesting the divinity as the first anesthesiologist. This controversy reached a happy conclusion in 1853, when Queen Victoria received chloroform at the hands of John Snow for the delivery of Prince Leopold. Obviously, what is acceptable to the Queen and Head of the Church of England must be acceptable to all.
But controversy still exists, and arguments must be played out one against the other, conclusions drawn and repeatedly challenged. What "fact" is inviolate, what "truth" infallible? It is only in the heat of discussion that contention is tempered into truth. Controversy is necessary if we are to find our way through a maze of disjointed and seemingly unrelated facts to a modus operandi guaranteeing our patients the optimal care they deserve.
Anesthesia for cardiovascular surgery has its own range of arguments, and we have gathered opinions from a host of knowledgeable scientist-practitioners who present their viewpoints with clarity and vigor. Each presents many questions; each presents answers, contentious, controversial, debatable, but all worth pondering and considering. Come join us on a review of the controversies we consider most important. Debate with the experts, and perhaps they will help you formulate useful plans that will help you in the management of your patients.
P.N.F.
A.W.G.