Anesthesia and the Cardiovascular System: Annual Utah postgraduate course in anesthesiology 1984 (Developments in Critical Care Medicine and Anaesthesiology, 6)

Coronary artery disease (CAD) continues to be a significant problem in the United States as substantiated by the following statistics. 10,000,000 patients with CAD 4,000,000 patients with previous MIs 1,300,000 new MIs/year 700,000 deaths(CAD)/year 400,000 cardiac catheterizations/year 150,000 CABG surgeries/year It appears that the prognosis (medical or surgical) in CAD is related to the development and severity of: 1. dysrhythmias 2. myocardial infarction 3. ventricular dysfunction Preoperative assessment of the significance of these is a critical part of our management. THE SIGNIFICANCE OF DYSRHYTHMIAS IN CAD 1. Incidence. With acute myocardial infarction virtually all patients develop premature ventricular contractions within the first five days. Within 1-3 weeks following infarction, 73-94% of patients develop one or more dysrhythmias. With chronic CAD, the incidence of patients in whom dysrhythmia is the predominant manifestation is unknown. It is known, however, that the most common dysrhythmias with chronic CAD are premature ventricular contractions (PVCs). Also, if chronic PVCs are frequent, multiform, or R-on-T, they are predictive of multivessel disease or significant ventricular dysfunction. Front Matter....Pages I-IX Preoperative Evaluation of the Patient with Cardiac Disease Perioperative Alteration of Left Ventricular Function....Pages 1-12 Preoperative Evaluation of the Patient with Congenital Heart Disease....Pages 13-19 Autonomic Nervous System and Anesthetic Management....Pages 20-28 Management of the Diabetic Patient — Preoperative, Intraoperative (During Bypass) and Postoperative....Pages 29-36 Preoperative Hypertension....Pages 37-49 Calcium Antagonists and Anesthesia....Pages 50-58 Rationale and Problems of Pulmonary Vascular Pressure Monitoring: An Update....Pages 59-66 High Dose Opioids for Coronary Artery Surgery....Pages 67-71 Rational use of Inhalation Agents for Coronary Artery Surgery....Pages 72-83 Prevention, Recognition and Management of Intraoperative Myocardial Ischemia....Pages 84-91 Anesthetic Management of Children with Congenital Heart Disease....Pages 92-98 Technical Aspects of Performance of Cardiopulmonary Bypass: The Pump the Oxygenator, Pitfalls, Disasters and Nuances....Pages 99-112 Cerebral Blood Flow During Bypass (Is Pressure Important?)....Pages 113-118 Hypertension During and after Cardiopulmonary Bypass....Pages 119-130 The Coagulation System: What we Monitor and How....Pages 131-140 Vasodilators....Pages 141-146 Drug Therapy Coming off Bypass....Pages 147-152 Mechanisms and Management of Cardiac Arrhythmias....Pages 153-179 Anesthetic Care of the Patient in Shock....Pages 180-184 Current Concepts of Massive Transfusion Therapy....Pages 185-194 Cardiovascular and Biochemical Responses to Deliberate Hypotension....Pages 195-201 Postoperative Management of Cardiac Patients: Cardiac Vs. Non-Cardiac Surgery....Pages 202-210 Early Extubation ... For....Pages 211-213 Early Extubation ... Against....Pages 214-216 Anesthesia and Cardiac Transplantation....Pages 217-224 The Artificial Heart....Pages 225-235 There is a tendency of an increasing number of signals and derived variables to be incorporated in the monitoring of patients during anesthesia and in intensive care units. The addition of new signals hardly ever leads to thedeletion of other signals. This is probably based on a feeling of insecurity. We must realize that each new signal that is being monitored brings along its cost, in terms of risk to the patient, investment and time. It is therefore essential to assess the relative contribution of this new signal to the quality of the monitoring process; i. e. given the set of signals already in use, what is the improvement when a new signal is added? Beyond a certain point the addition of new information leads to new uncertainty and degrades the result (Ream, 1981) In the diagnostic process, it is possible to evaluate'result'in an objective, qualitative way. The changes in the sensitivity and specificity of the diagnosis as a result of the addition or deletion of a certain variable can be calculated on the basis of false negative, false positive, correct negative and false negative scores. Different methods for multiple regression analysis have been implemented on computers (Gelsema, 1981) which can support such decision processes. In monitoring, the situation is much more complex. Many definitions of monitoring have been given; the common denominator is that monitoring is a continuous diagnostic process based upon a (semi)continuous flow of information. This makes simple assessment methods useless. Serious disturbances of fluid and electrolyte balance are frequently encountered in acutely ill patients; somewhat less often in the chronically sick. There seems to be a trend for such cases to increase, due probably to an increase in major surgical procedures on older patients whose renal function is less than adequate. There are already many publications dealing with the physiology of the homeo­ stasis of fluid and electrolytes, and others dealing with the clinical aspects of the subject. It is often assumed that a knowledge of the basic principles of physiology will enable the doctor to prescribe suitable intravenous therapy. In practice this is often found not to be so and the evidence for this is the frequency of calls for help with electrolyte problems from well-qualified and experienced doctors who are undoubtedly equipped with adequate or even excellent knowledge of the basic It is not an unusual observation that knowledge of theory and principles involved. principles does not necessarily lead to successful practice in this or any other art or craft. Most doctors already possess knowledge of the physiology of the internal envi­ ronment, but some are aware of being unable to deal effectively with clinical problems related to fluid and electrolyte disturbances and seek guidance to translate theoretical knowledge into practice. Edited By Omar Prakash ; Associate Editors, Simon H. Mey And Richard W. Patterson. This Volume Represents Selected Topics In Computing In Anesthesia And Intensive Care And Contains The Proceedings Of The Second International Symposium, Held In Rotterdam, September 6-10, 1983--pref. Includes Bibliographical References. Edited By Paul A. Scheck, Ulf H. Sjöstrand, R. Brian Smith. Papers Presented At The International Symposium On High Frequency Ventilation, Held Sept. 1982 At Erasmus University Medical School. Includes Bibliographical References And Index. By Mary G. Mcgeown. Includes Bibliographical References (page 185) And Index.