CONTROVERSIES IN CARDIOVASCULAR ANESTHESIA

CONTROVERSIES IN CARDIOVASCULAR ANESTHESIA

edited by

PHILLIP N. FYMAN

ALEXANDER W. GOTTA

~.

" KLUWER ACADEMIC PUBLISHERS

Boston Dordrecht London

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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

IX

X111

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

35

55

83

99

115

vii

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

ix

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

xi

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.

xiii

xiv Preface

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.

CONTROVERSIES IN CARDIOVASCULAR ANESTHESIA