1. JOHN L. ATLEE, MD Professor of Anesthesiology Department of Anesthesiology Medical College of Wisconsin Milwaukee, Wisconsin BRENDA A. BUCKLIN, MD Associate Professor of Anesthesiology Department of Anesthesiology University of Colorado Health Sciences Center Denver, Colorado MARK A. CHANEY, MD Associate Professor of Anesthesiology Department of Anesthesia and Critical Care University of Chicago Pritzker School of Medicine Chicago, Illinois DONN M. DENNIS, MD, FAHA Joachim S. Gravenstein, MD, Professor of Anesthesiology Department of Anesthesiology University of Florida College of Medicine Gainesville, Florida Vice President-Pharmacology, ARYx Therapeutics, Inc. Santa Clara, California JOHN ELLIS, MD Professor of Anesthesiology Department of Anesthesia and Critical Care University of Chicago Pritzker School of Medicine Chicago, Illinois JOEL M. GUNTER, MD Professor of Clinical Anesthesia and Pediatrics Department of Anesthesia University of Cincinnati School of Medicine Attending Anesthesiologist Department of Anesthesia Childrens Hospital Medical Center Cincinnati, Ohio ROSEMARY HICKEY, MD Professor and Program Director Department of Anesthesiology University of Texas Health Science Center at San Antonio San Antonio, Texas BRIAN M. ILFELD, MD Associate Professor Department of Anesthesia University of California, San Diego San Diego, California DONALD A. KROLL, MD, PHD Staff Anesthesiologist Department of Surgery Veterans Affairs Medical Center Biloxi, Mississippi TERRI G. MONK, MD Professor Department of Anesthesiology Duke University Medical Center Durham, North Carolina TIMOTHY E. MOREY, MD Associate Professor of Anesthesiology Department of Anesthesiology University of Florida College of Medicine Gainesville, Florida MICHAEL J. MURRAY, MD, PHD Professor of Anesthesiology and Chair Department of Anesthesiology Mayo Clinic College of Medicine Jacksonville, Florida NADER D. NADER, MD Associate Professor of Anesthesiology, Surgery and Pathology State University of New York at Buffalo School of Medicine Buffalo, New York MICHAEL F. OCONNOR, MD Associate Professor Department of Anesthesia and Critical Care University of Chicago Pritzker School of Medicine Chicago, Illinois KERRI M. ROBERTSON, MD Associate Clinical Professor of Anesthesiology Chief, General, Vascular, High-Risk Transplant and Surgical Critical Care Medicine Division Chief, Transplant Services Duke University School of Medicine Department of Anesthesiology Durham, North Carolina SCOTT R. SPRINGMAN, MD Professor Departments of Anesthesiology and Surgery University of Wisconsin Medical School Madison, Wisconsin KEVIN K. TREMPER, MD Professor and Chairman Department of Anesthesiology University of Michigan Medical Center Ann Arbor, Michigan B. CRAIG WELDON, MD Associate Professor Department of Anesthesiology and Pediatrics Duke University School of Medicine Durham, North Carolina Section Editors FM-X2215 8/19/06 3:25 PM Page ii

2. 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 COMPLICATIONS IN ANESTHESIA, 2nd edition ISBN-13: 978-1-4160-2215-2 ISBN-10: 1-4160-2215-5 Copyright 2007, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elseviers Health Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 239 3804, fax: (+1) 215 239 3805, e-mail: healthpermissions@elsevier.com. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com), by selecting Customer Support and then Obtaining Permissions. Library of Congress Cataloging-in-Publication Data Complications in anesthesia / [edited by] John L. Atlee. -- 2nd ed. p. ; cm. Includes bibliographical references and index. ISBN 1-4160-2215-5 1. Anesthesia--Complications. I. Atlee, John L. [DNLM: 1. Anesthesia--adverse effects. 2. Anesthetics--adverse effects. WO 245 C7369 2007] RD82.5.C63 2007 617.96041--dc22 2006040549 Executive Publisher: Natasha Andjelkovic Developmental Editor: Jean Nevius Publishing Services Manager: Tina Rebane Project Manager: Amy Norwitz Marketing Manager: Dana Butler Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment, and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on his or her own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Editors assumes any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. The Publisher FM-X2215 8/19/06 3:25 PM Page iv

3. To all who have contributed to this work, and to the patients we serve. FM-X2215 8/19/06 3:25 PM Page v

4. An ounce of prevention is worth a pound of cure. ANONYMOUS Preface vii The second edition of Complications in Anesthesia, like its first edition, is intended to provide all practitioners of anes- thesia and critical care medicine with a comprehensive source of information for most complications that might be faced in clinical practice. Topics are addressed in ten sections: Pharmacology; General Anesthesia; Regional Anesthesia and Pain Management; Cardiothoracic and Vascular Surgery; Physiologic Imbalance and Coexisting Disease; Equipment and Monitoring; Pediatrics and Neonatology; Neurosurgery, Ophthalmology, and ENT; Other Surgical Subspecialties (subdivided into Obstetrics and Gynecology, General Surgery, Urologic Surgery, and Orthopedic Surgery); and Special Topics (subdivided into Postanesthesia Care Unit, Diagnostic or Therapeutic Intervention, and Medicolegal Aspects). Section Editors were selected based on their special expertise and knowledge of the topics addressed in each section. Each chapter is presented in a highly structured format (in accordance with problem-based learning) under the fol- lowing headings and subheadings: Case Synopsis, Problem Analysis (divided into Definition, Recognition, Risk Assessment, Implications), Management, and Prevention; in chapters with more than one topic, each topic is addressed using the same headings. Schematics, figures, and tables are used liberally to illustrate key points or to summarize impor- tant information. Key references are listed at the end of each chapter under Further Reading, avoiding in-text citations that might distract the reader. Some chapters contain foot- notes that provide further explanations. In this way, the reader can gain useful insight into a topic of interest in the minimal amount of time and with maximal retention. Also, thumb indexing and liberal cross-referencing are intended to reduce the need for time-consuming index searches. Finally, under Further Reading, in text, or in footnotes, there are ref- erences to Web sites for more or updated information. In that way, the reader can keep abreast of new developments. I hope this unconventional treatment of complications in anesthesia and critical care will serve several purposes: first, to permit quick location and researching of topics of interest to busy practitioners in the least amount of time; second, to organize the thought processes involved in medical decision- making in an attractive formati.e., akin to Sherlock Holmes who done it?; and third and most importantly, to reduce the risk to our patients for unexpected and untoward events. John L. Atlee, MD FM-X2215 8/19/06 3:25 PM Page vii

5. Mark Abel, MD Clinical Assistant Professor, Department of Anesthesiology, Mount Sinai Medical Center, New York, New York Vaporizers Gaury S. Adhikary, MD, FRCA Assistant Professor, Department of Anesthesiology, University of Michigan Hospitals, Ann Arbor, Michigan Carbon Dioxide Absorbers Maurice S. Albin, MD, MSc (Anes) Professor of Anesthesiology, Department of Anesthesiology, University of Alabama School of Medicine, Birmingham, Alabama Venous Air Embolism Stacey L. Allen, MD Assistant Professor of Anesthesiology, Department of Anesthesiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas Corneal Injury; Open Globe Injury Steven J. Allen, MD Professor of Anesthesiology, Ohio State University College of Medicine; Chief Executive Officer, Columbus Childrens Hospital, Columbus, Ohio Autonomic Hyperreflexia Jonathan M. Anagnostou, MD Associate Professor of Clinical Anesthesia, Department of Anesthesia, Indiana University School of Medicine; Staff Anesthesiologist, Medical Director of Respiratory Care, Department of Anesthesia, Respiratory Care, Indiana University Hospital, Indianapolis, Indiana Blood and Blood Products: Hepatitis and HIV Maged Argalious, MD Staff Anesthesiologist, Departments of General Anesthesiology and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, Ohio Complications of Trauma Surgery George A. Arndt, MD Professor (CHS), Department of Anesthesiology, University of Wisconsin Medical School, Madison, Wisconsin Difficult Airway: Cannot Ventilate, Cannot Intubate Lori A. Aronson, MD, FAAP Assistant Professor of Clinical Anesthesia and Pediatrics, Department of Anesthesia, University of Cincinnati College of Medicine; Assistant Professor, Clinical Anesthesia and Pediatrics, Department of Anesthesia, Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio Hypoxemia John L. Atlee, MD Professor of Anesthesiology, Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin Adenosine; Disorders of Potassium Balance; Nonbarbiturate Anesthetics; Chemotherapeutic Agents; Cardiac Risk Assessment; Postobstruction Pulmonary Edema; Perioperative Tachyarrhythmias; Tachyarrhythmias with Ventricular Preexcitation; Long QT Syndromes and Ventricular Arrhythmias; Patients with Cardiac Rhythm Management Devices; Disorders of Water Homeostasis: Hyponatremia and Hypernatremia Michael S. Avidan, MD Associate Professor of Anesthesiology and Surgery; Division Chief, CT Anesthesiology and CT Intensive Care, Washington University School of Medicine, St. Louis, Missouri HIV Infection and AIDS Isaac Azar, MD Professor of Anesthesiology, Albert Einstein College of Medicine; Consultant, Department of Anesthesiology, Beth Israel Medical Center, New York, New York Scavenging Systems James E. Baker, MD, FRCPC Assistant Professor and Anesthesiologist, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California Postoperative Pulmonary Hypertension Narayan Baliga, MD Staff Anesthesiologist, Kenosha Hospital and Medical Center, Kenosha, Wisconsin Difficult Airway: Opiate-Induced Muscle Rigidity Shahar Bar-Yosef, MD Assistant Professor, Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, North Carolina Complications of Laparoscopic Surgery Contributors ix FM-X2215 8/19/06 3:25 PM Page ix

6. Juliana Barr, MD Associate Professor, Department of Anesthesiology, Stanford University School of Medicine, Stanford, California; Staff Intensivist and Anesthesiologist, Veterans Affairs Palo Alto Health Care System, Anesthesiology Service, Palo Alto, California Reversal Agents: Naloxone and Flumazenil Curtis L. Baysinger, MD Associate Professor, Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee Hypertensive Disorders of Pregnancy Eric Bedell, MD Associate Professor, Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas Posterior Fossa Surgery Joan Benca, MD Associate Professor, Department of Anesthesiology, University of Wisconsin Hospital and Clinics, Madison, Wisconsin Bronchospasm Patrick E. Benedict, MD Assistant Professor of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan Transesophageal Echocardiography David G. Bjoraker, MD Associate Professor, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida Anaphylaxis and Anaphylactoid Reactions Susan Black, MD Professor, Department of Anesthesiology, University of Alabama School of Medicine, Birmingham, Alabama Antidepressants William S. Blau, MD, PhD Associate Professor of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina Opioid Tolerance Steffan Blumenthal, MD Assistant Professor, Department of Anesthesiology and Reanimation, Orthopedic University Clinic Balgrist/Zurich, Zurich, Switzerland Interscalene Nerve Block: Potential Severe Complications John C. Boncyk, MD Assistant Professor, Department of Anesthesiology, University of Wisconsin Hospital and Clinics, Madison, Wisconsin Perioperative Hypoxia Alain Borgeat, MD Professor and Chief of Staff, Department of Anesthesiology and Reanimation, Orthopedic University Clinic Balgrist/Zurich, Zurich, Switzerland Interscalene Nerve Block: Potential Severe Complications Lois L. Bready, MD Professor and Vice Chair, Department of Anesthesiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas Corneal Injury Thomas P. Broderick, MD Assistant Professor, Department of Anesthesiology, University of Wisconsin Hospital and Clinics, Madison, Wisconsin Preanesthetic Evaluation: Inadequate or Missing Test Result David L. Brown, MD Edward Rotan Distinguished Professor and Chairman, Department of Anesthesiology and Pain Medicine, M.D. Anderson Cancer Center, Houston, Texas Celiac Plexus Block: Side Effects and Complications Adrie Bruijinzeel, MD Assistant Professor, Department of Psychiatry, Evelyn and William McKnight Brain Institute, University of Florida College of Medicine, Gainesville, Florida Chemical Dependency: Opioids Brenda A. Bucklin, MD Associate Professor of Anesthesiology, Department of Anesthesiology, University of Colorado Health Sciences Center, Denver, Colorado Fetal Distress Matthew D. Caldwell, MD Assistant Professor, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan Pulmonary Artery Pressure Monitoring William R. Camann, MD Associate Professor, Department of Anesthesia, Harvard Medical School; Director of Obstetric Anesthesia, Brigham and Womens Hospital, Boston, Massachusetts Pulmonary Aspiration in the Parturient Maria I. Castro, PhD Assistant Professor, Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas Class II Antiarrhythmic Drugs: -BlockersHeart Block or Bradycardia Kevin P. Chan, MD Fellow in Cardiovascular Anesthesia, Stanford University School of Medicine, Stanford, California Nonbarbiturate Anesthetics Mark A. Chaney, MD Associate Professor of Anesthesiology, Department of Anesthesia and Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois Perioperative Myocardial Ischemia and Infarction; Adverse Neurologic Sequelae: Central Neurologic Impairment; Hypercoagulable States: Thrombosis and Embolism Amit V. Chawla, MD Consultant, Department of Anesthesia, Guys Hospital, London, United Kingdom Inspiratory and Expiratory Gas Monitoring x Contributors FM-X2215 8/19/06 3:25 PM Page x

7. Contributors xi David C. H. Cheng, MD, MSc, FRCPC Professor and Chair, Department of Anesthesia and Perioperative Medicine, University of Western Ontario; Anesthesiologist in Chief, London Health Sciences Center and St. Josephs Health Care, London, Ontario, Canada Fast-Track Cardiac Surgery S. Devi Chiravuri, MD Assistant Professor, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan Rapid Fluid and Blood Delivery Systems Gordon Lee Collins, MD Clinical Fellow, Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Complications after Pneumonectomy Lois A. Connolly, MD Associate Professor, Department of Anesthesiology, Medical College of Wisconsin, Froedtert Memorial Lutheran Hospital, Milwaukee, Wisconsin Unstable Cervical Spine, Atlantoaxial Subluxation D. Ryan Cook, MD Professor of Anesthesiology, Department of Anesthesiology, Childrens Hospital of Pittsburgh, Pittsburgh, Pennsylvania Hypoglycemia and Hyperglycemia Scott D. Cook-Sather, MD Assistant Professor of Anesthesia, Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania School of Medicine; Associate Anesthesiologist, Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania Ophthalmic Problems and Complications Victoria Coon, CRNA, MS Perioperative Director and Anesthesiology Department Administrator, Kaiser Permanente, West Los Angeles, Los Angeles, California Quality Assurance; Cost Containment John R. Cooper, Jr., MD Clinical Associate Professor of Anesthesiology, University of Texas Health Science Center; Associate Chief, Cardiovascular Anesthesia; Co-Director, Cullen Cardiovascular Research Laboratories, Texas Heart Institute, Houston, Texas Troubleshooting Common Problems during Cardiopulmonary Bypass Charles J. Cot, MD Director of Clinical Research in Pediatric Anesthesia, Department of Anesthesiology, Massachusetts General Hospital, Boston, Massachusetts Sedation of Pediatric Patients Douglas B. Coursin, MD Professor of Anesthesiology and Internal Medicine, Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin Adrenal Insufficiency James C. Crews, MD Associate Professor of Anesthesiology, Section of Regional Anesthesia and Acute Pain Management, Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina Infectious Complications of Central Neuraxial Block Deborah A. Davis, MD Clinical Professor of Anesthesiology, Department of Anesthesiology, Thomas Jefferson University Jefferson Medical College, Philadelphia, Pennsylvania; Pediatric Anesthesiologist/Intensivist, Nemours Cardiac Center, A.I. duPont Hospital for Children, Wilmington, Delaware Pulmonary Hypertension Martin L. De Ruyter, MD Associate Professor of Anesthesiology, Department of Anesthesiology, Kansas University School of Medicine, Kansas City, Kansas Hyperglycemia and Diabetic Ketoacidosis; Sarcoidosis Hernando De Soto, MD Associate Professor, Department of Pediatric Anesthesia, University of Florida Health Science Center; Staff Anesthesiologist/Medical Director of the OR, Department of Anesthesiology, SHANDS Jacksonville, Jacksonville, Florida Difficult Pediatric Airway Donn M. Dennis, MD, FAHA Joachim S. Gravenstein, MD, Professor of Anesthesiology, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida; Vice President- Pharmacology, ARYx Therapeutics, Inc., Santa Clara, California Class III Antiarrhythmic Drugs: Potassium Channel Blockers; Class IV Antiarrhythmic Drugs: Calcium Channel Blockers Ronak Desai, DO Resident, CA-2, Department of Anesthesia and Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois Peripheral Vascular Surgery Cheryl DeSimone, MD Associate Professor of Anesthesiology, Obstetrics and Gynecology, Department of Anesthesiology, Albany Medical College; Director of Obstetric Anesthesia, Albany Medical Center, Albany, New York Embolic Events of Pregnancy Cyrus DeSouza, MB,BS, FANZCA Acting Assistant Professor, Cardiothoracic Anesthesiologist, Department of Anesthesiology, University of Washington Medical Center, Seattle, Washington; Staff Specialist Anaesthetist, Department of Anaesthetics, St. Georges Hospital, Sydney, NSW, Australia Chronotropic Drugs Clifford S. Deutschman, MD Professor, Department of Anesthesia and Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania Sepsis, Systemic Inflammatory Response Syndrome, and Multiple Organ Dysfunction Syndrome FM-X2215 8/19/06 3:25 PM Page xi

8. Pema Dorje, MD Clinical Assistant Professor, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan Arterial Blood Pressure Monitoring Anthony R. Doyle, BSc, MB,BS, FRCA Formerly, Visiting Instructor in Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan; Consultant Anaesthetist, Dorset County Hospital, Dorchester, United Kingdom Fires in the Operating Room Kenneth Drasner, MD Professor, Department of Anesthesiology and Perioperative Care, University of California, San Francisco, San Francisco, California Local Anesthetic Neurotoxicity: Cauda Equina Syndrome Catherine Drexler, MD Vice Chair, Department of Anesthesiology, Columbia- St. Marys-Milwaukee Campus, Milwaukee, Wisconsin Angioedema and Urticaria Ellen Duncan, MD Tejas Anesthesia, San Antonio, Texas Open Globe Injury Martin W. Dnser, MD Resident in Anesthesiology and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria Vasopressors: Vasoconstrictor Drugs Jrg Dziersk, MD, FRCA Assistant Professor of Anesthesiology, Department of Anesthesiology, University of Washington School of Medicine, Seattle, Washington Vasodilator Drugs Michael P. Eaton, MD Associate Professor, Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York Proportioning Systems; Patient Warming Systems Charles E. Edmiston, Jr., MS, PhD Associate Professor, Department of Surgery; Director, Surgical Microbiology Research Laboratory, Medical College of Wisconsin, Milwaukee, Wisconsin Nosocomial Infections: Bacterial Pneumonia James B. Eisenkraft, MD Professor of Anesthesiology, Mount Sinai School of Medicine, New York, New York Vaporizers John Ellis, MD Professor of Anesthesiology, Department of Anesthesia and Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois Carotid Endarterectomy; Thoracic Aortic Aneurysm Brenda G. Fahy, MD, FCCP, FCCM Professor, Department of Anesthesiology, University of Kentucky; Director of Critical Care, Department of Anesthesiology, AB Chandler Medical Center, Lexington, Kentucky Disorders of Water Homeostasis: Hyponatremia and Hypernatremia Zhuang T. Fang, MD, MSPH Assistant Clinical Professor, Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California Unanticipated Hospital Admission and Readmission Doron Feldman, MD Associate Professor of Clinical Anesthesiology, State University of New York at Buffalo School of Medicine; Attending in Anesthesiology, Childrens Hospital of Buffalo, Buffalo, New York The Hostile-Combative Patient Lynne R. Ferrari, MD Associate Professor, Department of Anesthesia, Harvard Medical School; Medical Director, Perioperative Services, Childrens Hospital, Boston, Massachusetts Adenotonsillectomy Matthew P. Feuer, MD Staff Anesthesiologist, Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington Spinal Anesthesia: PostDural Puncture Headache Stephanie S. F. Fischer, MD Visiting Associate in Cardiothoracic and Critical Care, Division of Pediatric Anesthesiology, Duke University School of Medicine, Durham, North Carolina Cardiomyopathies M. Pamela Fish, MB,ChB Associate Professor, Department of Anesthesiology, Stanford University School of Medicine, Stanford, California; Staff Physician, Veterans Affairs Palo Alto Health Care System, Palo Alto, California Antiemetic Drugs Randall Flick, MD, MPH Assistant Professor of Anesthesiology and Pediatrics, Department of Anesthesiology and Pediatrics, Mayo Clinic College of Medicine; Chair, Section of Pediatric Anesthesiology, Mayo Clinic, Rochester, Minnesota Anterior Mediastinal Mass Michael P. Ford, MD Assistant Professor of Anesthesiology, Department of Anesthesiology, University of Wisconsin Medical School, Madison, Wisconsin Preanesthetic Evaluation: False-Positive Tests; Difficult Airway: Cannot Ventilate, Cannot Intubate Jennifer T. Fortney, MD Assistant Clinical Professor, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina Fat Embolism Syndrome xii Contributors FM-X2215 8/19/06 3:25 PM Page xii

9. Contributors xiii James M. T. Foster, MD Clinical Assistant Professor of Anesthesiology, Department of Anesthesiology, State University of New York at Buffalo School of Medicine; Director of Anesthesiology Services, Kaleida Health, Buffalo, New York The Hostile-Combative Patient Melissa Franckowiak, MD Resident, Department of Anesthesiology, State University of New York at Buffalo School of Medicine, Buffalo, New York Cardioversion Eugene B. Freid, MD Associate Professor, Departments of Anesthesiology and Pediatrics, University of North Carolina Hospitals, Chapel Hill, North Carolina Succinylcholine Kimberly Frost-Pineda, MD Assistant in Psychiatry, Department of Psychiatry, Director of Public Health Research, University of Florida College of Medicine, Gainesville, Florida Chemical Dependency: Opioids; Chemical Dependency: Nonopioids Jeffrey L. Galinkin, MD Associate Professor, Department of Anesthesia, Childrens Hospital, Denver, Colorado Fetal Intrauterine Surgery Arjunan Ganesh, MD Assistant Professor of Anesthesia, Department of Anesthesia, University of Pennsylvania School of Medicine; Assistant Anesthesiologist, Department of Anesthesiology and Critical Care Medicine, Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania Upper Respiratory Tract Infection Hind M. Gautam, MD Clinical Assistant Professor, Department of Anesthesiology, Veterans Affairs Medical Center, Buffalo, New York Magnetic Resonance Imaging Rodolfo Gebhardt, MD Assistant Professor of Clinical Anesthesiology, Department of Anesthesiology, Department of Clinical Anesthesiology, Veterans Affairs Medical Center, Buffalo New York Uncontrolled Pain Jeremy M. Geiduschek, MD Clinical Professor, Department of Anesthesiology, University of Washington School of Medicine; Director, Clinical Anesthesia Services, Department of Anesthesiology, Childrens Hospital and Regional Medical Center, Seattle, Washington Intraoperative Cardiac Arrest J. C. Gerancher, MD Associate Professor and Section Head, Regional Anesthesia and Acute Pain Management, Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina Epidural Anesthesia: Unintended Intrathecal Injection; Epidural Anesthesia: Unintended Subdural Injection Mark S. Gold, MD Distinguished Professor and Chief, Departments of Psychiatry, Neuroscience, Anesthesiology, Community Health and Family Medicine, Evelyn and William McKnight Brain Institute, University of Florida College of Medicine, Gainesville, Florida Chemical Dependency: Opioids; Chemical Dependency: Nonopioids Stuart Grant, MD Assistant Professor, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina Continuous Nerve Blocks: Perineural Local Anesthetic Infusion Glenn P. Gravlee, MD Professor, Department of Anesthesiology, Ohio State University Hospitals, Columbus, Ohio Hemodilution and Blood Conservation Ivar Gunnarsson, MD Landsptalihsklasjkrahs, Reykjavik, Iceland Oxygen Flush Valve Mary Ann Gurkowski, MD Professor of Anesthesiology, University of Texas Health Science Center at San Antonio; Clinical Staff/Director of Medical Students, Department of Anesthesiology/Cross- appointed to Otorhinolaryngology, University Hospital; Attending Staff, Department of Anesthesiology, Audie Murphy Veterans Affairs Hospital, San Antonio, Texas Foreign Body Aspiration Jacob Gutsche, MD Physician, Department of Anesthesia, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania Sepsis, Systemic Inflammatory Response Syndrome, and Multiple Organ Dysfunction Syndrome Thomas S. Guyton, MD Staff Anesthesiologist, Methodist Healthcare of Memphis, Memphis, Tennessee Magnesium; Antibiotics Ali Habibi, MD Adjunct Clinical Faculty, Anesthesiology, Stanford University School of Medicine, Stanford, California Antihistamines: H1- and H2-Blockers Saeed Habibi, MD Chair, Department of Anesthesiology, Columbia St. MarysMilwaukee Campus, Milwaukee, Wisconsin Angioedema and Urticaria Charles B. Hantler, MD Professor, Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Bradyarrhythmias H. David Hardman, MD, MBA Assistant Clinical Professor, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina Extremity Tourniquets FM-X2215 8/19/06 3:25 PM Page xiii

10. Barry A. Harrison, MB,BS Assistant Professor of Anesthesiology, Department of Anesthesiology, Mayo Clinic College of Medicine, Jacksonville, Florida Hyperglycemia and Diabetic Ketoacidosis; Sarcoidosis Joy L. Hawkins, MD Professor of Anesthesiology and Director of Obstetric Anesthesia, University of Colorado School of Medicine, Denver, Colorado Nonobstetric Surgery during Pregnancy Christopher M. B. Heard, MB,ChB, FRCA Research Assistant Professor, Department of Anesthesiology and Division of Pediatric Critical Care, State University of New York at Buffalo School of Medicine; Assistant Attending, Childrens Hospital of Buffalo, Buffalo, New York Magnetic Resonance Imaging; Alleged Malpractice; The Hostile- Combative Patient Stephen O. Heard, MD Interim Chair, Professor of Anesthesiology and Surgery, University of Massachusetts Medical School, Worcester, Massachusetts Perioperative Care of Immunocompromised Patients James R. Hebl, MD Assistant Professor, Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota Anticoagulants and Peripheral Nerve Block Robert F. Helfand, MD Associate Professor, Cleveland Clinic Lerner College of Medicine; Staff Anesthesiologist; Vice Chairman, Department of General Anesthesiology; Section Head of Orthopedic Anesthesia, Glickman Urological Center, Cleveland Clinic Foundation, Cleveland, Ohio Thromboembolic Complications Rosemary Hickey, MD Professor and Program Director, Department of Anesthesiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas Intracranial Hypertension George A. Higgins, BSN, MS, CRNA Adjunct Faculty, Department of Nursing, University of Southern California; Senior Nurse Anesthetist, Department of Anesthesiology, Department of Veterans Affairs Medical Center, Los Angeles, California Embolization Procedures Scott Holliday, MD Resident, Department of Anesthesiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas Foreign Body Aspiration William Hope, MD, PhD Assistant Professor, Department of Anesthesiology, Medical College of Wisconsin, Froedtert Memorial Lutheran Hospital East, Milwaukee, Wisconsin Laryngeal and Tracheal Injury Terese T. Horlocker, MD Professor, Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota Spinal Hematoma; Persistent Paresthesia Liana Hosu, MD Assistant Professor of Anesthesia and Pediatrics, Department of Anesthesiology, University of Cincinnati College of Medicine; Staff Anesthesiologist, Department of Anesthesiology, Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio Postoperative Apnea in Infants Kate Huncke, MD Clinical Associate Professor, Department of Anesthesiology, New York University School of Medicine, New York, New York Radiation Oncology Samuel A. Irefin, MD Associate Professor of Anesthesiology, Cleveland Clinic Lerner College of Medicine; Staff Anesthesiologist, Department of Anesthesiology and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, Ohio Complications of Thyroid Surgery William Jacobs, MD Associate Professor, Departments of Psychiatry and Anesthesiology, University of Florida College of Medicine, Gainesville, Florida Chemical Dependency: Opioids; Chemical Dependency: Nonopioids Eric Jacobsohn, MB,ChB, MHPE, FRCPC Associate Professor of Anesthesiology, Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri Complications after Pneumonectomy J. Michael Jaeger, MD, PhD Associate Professor of Anesthesiology and Neurological Surgery; Director, Thoracic Anesthesia, Department of Anesthesiology, University of Virginia Health Sciences Center, Charlottesville, Virginia Class IV Antiarrhythmic Drugs: Calcium Channel Blockers Michael F. M. James, MB,ChB, PhD, FRCA, FCA(SA) Professor and Head, Department of Anesthesia, University of Cape Town; Professor and Chief Anaesthetist, Department of Anaesthesia, Groote Schuur Hospital, Cape Town, Western Cape, South Africa Complications of Adrenal Surgery Gregory M. Janelle, MD Assistant Professor, Chief of Cardiovascular Anesthesia, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida Phosphodiesterase Inhibitors David R. Jobes, MD Professor of Anesthesia, Department of Anesthesia and Critical Care Medicine, Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania Complications of Massive Transfusion xiv Contributors FM-X2215 8/19/06 3:25 PM Page xiv

11. Contributors xv Nicola Jones, MA, MB,BS, DTM&H, MRCP, MRCPath, PhD Consultant in Microbiology and Infectious Diseases, Departments of Microbiology and Infectious Diseases, Nuffield Department of Clinical Laboratory Sciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom HIV Infection and AIDS Shailendra Joshi, MD Assistant Professor of Anesthesiology, Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, New York, New York Arteriovenous Malformation: Normal Perfusion Pressure Breakthrough Zeev N. Kain, MD Professor of Anesthesiology, Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut Perioperative Psychological Trauma Wendy B. Kang, MD Associate Professor and Chair, Residency Education Committee, Department of Anesthesiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas Retrobulbar Block Shubjeet Kaur, MD Clinical Vice Chair, Department of Anesthesiology, University of Massachussets Memorial Medical Center, Worcester, Massachusetts Perioperative Care of Immunocompromised Patients Robert D. Kaye, MD Assistant Professor of Clinical Anesthesiology and Pediatrics, State University of New York at Buffalo School of Medicine; Attending Anesthesiologist, Childrens Hospital of Buffalo, Buffalo, New York Alleged Malpractice Paul E. Kazanjian, MD Clinical Assistant Professor, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan Fires in the Operating Room; Pulmonary Artery Pressure Monitoring Jeffrey S. Kelly, MD Associate Professor of Anesthesiology, Section of Critical Care, Wake Forest University School of Medicine, Winston-Salem, North Carolina Complications from Toxic Ingestion Kevin J. Kelly, MD Professor and Chair, Department of Pediatrics; Associate Dean, School of Medicine, Childrens Mercy Hospital and Clinics, University of Missouri, Kansas City, Missouri Latex Reactions in Health Care Personnel Robert E. Kettler, MD Associate Professor, Department of Anesthesiology, Medical College of Wisconsin, Froedtert Memorial Lutheran Hospital East, Milwaukee, Wisconsin Patients with Seizure Disorders; Latex Reactions in Health Care Personnel Jonathan T. Ketzler, MD Associate Professor of Anesthesiology; Associate Director, Trauma and Life Support Center, Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin Adrenal Insufficiency Evan D. Kharasch, MD, PhD Assistant Dean for Clinical Research; Professor and Research Director, Department of Anesthesiology, University of Washington School of Medicine, Seattle, Washington Volatile Anesthetics: Organ Toxicity M. Sean Kincaid, MD Resident, Department of Anesthesiology, University of Washington Medical Center, Seattle, Washington Head Injury Kathryn P. King, MD Associate Clinical Professor, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina Methylmethacrylate Kai T. Kiviluoma, MD, PhD Associate Professor, Department of Anaesthesiology, University of Oulu Faculty of Medicine; Head of the Department, Paediatric Anaesthesia, Oulu University Hospital, Oulu, Finland Disorders of Potassium Balance Jerome M. Klafta, MD Associate Professor and Associate Chair for Education, Department of Anesthesia and Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois Mediastinal Masses Pattricia S. Klarr, MD Clinical Assistant Professor, Department of Anesthesiology, University of Michigan Medical School; Associate Clinical Director, Department of Anesthesiology, University of Michigan Medical Center, Ann Arbor, Michigan Laser Complications Sandra L. Kopp, MD Instructor, Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota Supraclavicular and Infraclavicular Block: Pneumothorax Donald A. Kroll, MD, PhD Staff Anesthesiologist, Department of Surgery, Veterans Affairs Medical Center, Biloxi, Mississippi Quality Assurance; Cost Containment; Adverse Outcomes: Withheld Information or Misinformation Kenneth Kuchta, MD Assistant Clinical Professor, Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California Misidentification of a Patient FM-X2215 8/19/06 3:25 PM Page xv

12. C. Dean Kurth, MD Professor of Anesthesia and Pediatrics, University of Cincinnati College of Medicine, Anesthesiologist-in-Chief; Chair, Institute for Pediatric Research; Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio Postoperative Apnea in Infants Arthur M. Lam, MD, FRCPC Professor of Anesthesiology, Department of Anesthesiology, University of Washington School of Medicine; Head of Neuroanesthesia, Harborview Medical Center, Seattle, Washington Head Injury Jeffrey L. Lane, MD Assistant Professor of Clinical Anesthesia and Director, Human Simulation Laboratory, Department of Anesthesia, Indiana University School of Medicine; Staff Anesthesiologist, Clarian Health Partners, Indianapolis, Indiana Postoperative Respiratory Insufficiency Paul B. Langevin, MD Associate Professor, Department of Anesthesiology, Veterans AffairsWest Haven, West Haven, Connecticut Chemotherapeutic Agents Melissa A. Laxton, MD Assistant Professor of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina Pituitary Tumors: Diabetes Insipidus Marcia M. Lee, MD, MBA Assistant Chief, Department of Anesthesiology, Kaiser PermanenteSouth Bay, Harbor City, California Awareness under Anesthesia Mijin Lee, MD Assistant Clinical Professor, Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California Anesthesia for Electroconvulsive Therapy Peter J. Lee, MD, MPH Formerly, Assistant Professor, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan Central Venous Pressure Monitoring Philip Levin, MD Associate Professor, Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California Postoperative Delirium Jerrold H. Levy, MD Professor and Department Chair/Research, Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia Perioperative Hypertension Ian Lewis, MB,BS, MRCP, FRCA Associate Professor, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan Surgical Diathermy and Electrocautery Ray P. Liao, MD Acting Assistant Professor, Department of Anesthesiology, University of Washington School of Medicine, Seattle, Washington Inotropic Drugs Spencer S. Liu, MD Clinical Professor of Anesthesiology, Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington Spinal Anesthesia: PostDural Puncture Headache Emilio B. Lobato, MD Professor of Anesthesiology, Department of Anesthesiology, University of Florida College of Medicine; Chief, Cardiovascular Anesthesia, Department of Anesthesia Service, Malcom Randall Veterans Affairs Hospital, Gainesville, Florida Digitalis Robert G. Loeb, MD Associate Professor of Anesthesiology, University of Arizona College of Medicine, Tucson, Arizona Flowmeters Celeste M. Lombardi, MD Fellow in Interventional Pain Medicine, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida Chronic Nonsteroidal Anti-inflammatory Drug Use Prashant Lotlikar, MD Clinical Assistant Professor, Department of Anesthesiology, University of Texas Health Science Center, Texas Heart Institute, Houston, Texas Troubleshooting Common Problems during Cardiopulmonary Bypass Michelle L. Lotto, MD Assistant Professor of Anesthesiology, Department of General Anesthesiology and Critical Care Medicine, Cleveland Clinic Lerner College of Medicine; Associate Staff Anesthesiologist, Cleveland Clinic Foundation, Cleveland, Ohio Complications of Spinal Surgery Katarzyna Luba, MD Assistant Professor of Clinical Anesthesiology, Department of Anesthesia and Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois Perioperative Management of Patients with Muscular Dystrophy Stewart J. Lustik, MD Associate Professor of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York Proportioning Systems; Patient Warming Systems Vinod Malhotra, MD Professor and Vice Chair for Clinical Affairs, Department of Anesthesiology, Weill Medical College of Cornell University, New YorkPresbyterian Hospital, New York, New York Complications of Transurethral Surgery xvi Contributors FM-X2215 8/19/06 3:25 PM Page xvi

13. Contributors xvii Christina M. Matadial, MD Assistant Professor, Department of Anesthesiology, Leonard M. Miller School of Medicine at the University of Miami; Staff Physician, Department of Anesthesiology, Jackson Memorial Hospital, Miami, Florida Surgery in the Morbidly Obese Viktoria D. Mayr, MD Resident in Anesthesiology and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria Vasopressors: Vasoconstrictor Drugs Deborah A. McClain, MD Chief, Anesthesiology Section, Veterans Affairs Medical Center, Biloxi, Mississippi Delayed Emergence Thomas McCutchen, MD Assistant Professor, Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina Epidural Anesthesia: Unintended Intrathecal Injection; Epidural Anesthesia: Unintended Subdural Injection David L. McDonagh, MD Resident, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina Autonomic Dysreflexia Susan B. McDonald, MD Staff Anesthesiologist, Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington Side Effects of Neuraxial Opioids Lynda J. Means, MD Professor of Anesthesia and Surgery, Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana Postobstruction Pulmonary Edema in Pediatric Patients Mark Meyer, MD Assistant Professor of Clinical Anesthesia, Department of Anesthesia, University of Cincinnati College of Medicine; Assistant Professor, Clinical Pediatrics, Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio Perioperative Aspiration Pneumonitis Mohammed Minhaj, MD Assistant Professor, Department of Anesthesia and Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois Adverse Neurologic Sequelae: Peripheral Nerve Injury Vivek Moitra, MD Assistant Professor of Anesthesiology, Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, New York, New York Carotid Endarterectomy Constance L. Monitto, MD Assistant Professor of Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institute, Baltimore, Maryland Muscle Relaxants Terri G. Monk, MD Professor, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina Intraoperative Penile Erection; Complications of Radical Urologic Surgery Lisa M. Montenegro, MD Assistant Professor of Anesthesiology, University of Pennsylvania School of Medicine and Childrens Hospital of Philadelphia; Attending Anesthesiologist, Department of Anesthesiology, Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania Complications of Massive Transfusion Timothy E. Morey, MD Associate Professor of Anesthesiology, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida Magnesium; Antibiotics Lucille A. Mostello, MD Assistant Professor of Anesthesiology and Pediatrics, Department of Anesthesiology, George Washington University School of Medicine; Staff Anesthesiologist, Department of Anesthesiology, Childrens National Medical Center, Washington, DC Latex Allergy Isobel Muhiudeen-Russell, MD Professor, Department of Anesthesia, University of California, San Francisco, San Francisco, California Postoperative Pulmonary Hypertension J. Thomas Murphy, MD, FRCPC Associate Professor, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, Kentucky Disorders of Water Homeostasis: Hyponatremia and Hypernatremia Catherine Friederich Murray Research Associate, Department of Anesthesiology, Mayo Clinic College of Medicine, Jacksonville, Florida Parkinsons Disease; Alzheimers Disease Michael J. Murray, MD, PhD Professor of Anesthesiology and Chair, Department of Anesthesiology, Mayo Clinic College of Medicine, Jacksonville, Florida Parkinsons Disease; Alzheimers Disease David Muzic, MD Fellow in Cardiac Anesthesia, Department of Anesthesia and Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois Adverse Neurologic Sequelae: Central Neurologic Impairment Nader D. Nader, MD Associate Professor of Anesthesiology, Surgery and Pathology, State University of New York at Buffalo School of Medicine, Buffalo, New York Uncontrolled Pain; Hemodynamic Instability; Cardioversion FM-X2215 8/19/06 3:25 PM Page xvii

14. Carsten Nadjat-Haiem, MD Assistant Professor, Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California Syringe Swaps Mohamed Naguib, MB,Bch, MSc, FFARCSI, MD Professor, Department of Anesthesia, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa Myasthenic Disorders Bhiken Naik, MD Fellow, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida Intrathecal Opiates; Ketamine; Steroids David A. Nakata, MD Associate Clinical Professor and Vice Chair, Residency Development, Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana Postoperative Peripheral Neuropathy; Intractable Nausea and Vomiting Charles A. Napolitano, MD, PhD Associate Professor; Director, Division of Cardiothoracic Anesthesia; Co-Director, Residency Program, Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas Class II Antiarrhythmic Drugs: -BlockersHeart Block or Bradycardia Bradly J. Narr, MD Associate Professor and Chair, Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota Porphyrias Krishna M. Natrajan, MB,BS, FRCA Assistant Professor of Adult and Pediatric Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Washington School of Medicine; Attending Anesthesiologist, Department of Anesthesiology, University of Washington Medical Center, Seattle, Washington Inotropic Drugs Norah Naughton, MD Associate Professor of Anesthesiology and Associate Professor of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan Intracranial Pressure Monitoring Patrick Neligan, MD Assistant Professor, Department of Anesthesia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania Metabolic Acidosis and Alkalosis Philippa Newfield, MD Assistant Clinical Professor of Anesthesia and Neurosurgery, University of California, San Francisco, School of Medicine; Attending Anesthesiologist, Department of Anesthesiology, California Pacific Medical Center, San Francisco, California Intracranial Aneurysms: Rebleeding; Intracranial Aneurysms: Vasospasm and Other Issues Hector F. Nicodemus, MD Pediatric Anesthesiologist, Department of Anesthesiology, Holy Cross Hospital, Silver Spring, Maryland Delayed Emergence in Pediatric Patients Susan C. Nicolson, MD Professor of Anesthesia, Department of Anesthesia, University of Pennsylvania School of Medicine; Division Director, Cardiothoracic Anesthesia, Department of Anesthesiology and Critical Care Medicine, Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania Upper Respiratory Tract Infection Susan H. Noorily, MD Clinical Professor, Department of Anesthesiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas Laryngoscopy and Microlaryngoscopy Mark Nunnally, MD Assistant Professor, Department of Anesthesia and Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois Postoperative Acute Renal Failure; Metabolic Acidosis and Alkalosis Christopher J. OConnor, MD Associate Professor, Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois Abdominal Aortic Aneurysm Repair Michael F. OConnor, MD Associate Professor, Department of Anesthesia and Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois Thermally Injured Patients Jerome F. OHara, Jr., MD Associate Professor, College of Medicine, Case Western Reserve University; Vice Chairman, Department of General Anesthesiology; Section Head of Anesthesia, Glickman Urological Center, Urology Department, Cleveland Clinic Foundation, Cleveland, Ohio Complications of Lithotripsy Maria A. K. O .. hrn, MD Anesthesiology Associates of North Florida, PA, North Florida Regional Medical Center, Gainesville, Florida Nondepolarizing Neuromuscular Relaxants Nollag ORourke, MD Fellow in Obstetric Anesthesia, Department of Anesthesia, Brigham and Womens Hospital, Boston, Massachusetts Pulmonary Aspiration in the Parturient Sheela S. Pai, MD Assistant Professor, Department of Anesthesiology, Baylor College of Medicine; Staff Anesthesiologist, Department of Anesthesiology and Critical Care, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas Mechanical Assist Devices Craig M. Palmer, MD Professor of Clinical Anesthesiology; Director, Obstetric Anesthesia, University of Arizona College of Medicine, Tucson, Arizona Preterm Labor xviii Contributors FM-X2215 8/19/06 3:25 PM Page xviii

15. Contributors xix C. Lee Parmley, MD, JD Professor of Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee Autonomic Hyperreflexia Komal Patel, MD Fellow in Cardiac Anesthesia, Department of Anesthesia and Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois Hypercoagulable States: Thrombosis and Embolism D. Janet Pavlin, MD Professor, Department of Anesthesiology, University of Washington School of Medicine; Head of Teaching and Research in Ambulatory Anesthesia, Department of Anesthesia, University of Washington Medical Center, Seattle, Washington Postoperative Urinary Retention Padmavathi Perala, MD Anesthesiologist, Department of Anesthesiology, Veterans Affairs Medical Center, Buffalo, New York Hemodynamic Instability Patricia H. Petrozza, MD Professor of Anesthesiology, Associate Dean for Graduate Medical Education, Wake Forest University School of Medicine, Winston-Salem, North Carolina Pituitary Tumors: Diabetes Insipidus Linda S. Polley, MD Associate Professor, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan Postpartum Hemorrhage David Porembka, FCCM Professor of Anesthesia, Surgery and Internal Medicine (Cardiology), Department of Anesthesiology; Associate Director of Surgical Intensive Care; Director of Perioperative Echocardiography, University of Cincinnati College of Medicine, Cincinnati, Ohio Postoperative Respiratory Failure Claudia Praetel, MD Research Fellow, Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, New York, New York Nitrous Oxide: Neurotoxicity Joseph Previte, MD Associate Professor of Pediatrics and Anesthesiology, Project Leader of Anesthesia Centricity IS, Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio Anesthetic Complications of Fetal Surgery: EXIT Procedures; Perioperative Aspiration Pneumonitis Richard C. Prielipp, MD, FCCM JJ Buckley Professor and Chair, Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota Hypothyroidism: Myxedema Coma; Hyperthyroidism: Thyroid Storm William Prince, MD Department of Anesthesiology, Kaiser Permanente Oakland Medical Center, Oakland, California Central Venous Pressure Monitoring Lester T. Proctor, MD Professor, Departments of Anesthesiology and Pediatrics, University of Wisconsin Medical School, Madison, Wisconsin Blood and Blood Products: Transfusion Reaction Donald S. Prough, MD Professor and Chair, Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas Perioperative Fluid Management; Posterior Fossa Surgery M. J. Pekka Raatikainen, MD Division of Cardiology, Oulu University Central Hospital, Oulu, Finland Adenosine; Class III Antiarrhythmic Drugs: Potassium Channel Blockers Lee M. Radke, DDS Assistant Professor, Oral and Maxillofacial Surgery, Medical College of Wisconsin, Froedtert Memorial Lutheran Hospital, Milwaukee, Wisconsin Dental Injuries Sivam Ramanathan, MD Professor of Anesthesiology, University of Pittsburgh School of Medicine, Magee-Womens Hospital, Pittsburgh, Pennsylvania Humidifiers; Peripartum Neurologic Complications James G. Ramsay, MD Professor of Anesthesiology, Program Director, Anesthesiology Critical Care Medicine, Department of Anesthesia, Emory University School of Medicine; Anesthesiology Service Chief, Department of Anesthesiology, Emory University Hospital, Atlanta, Georgia Central Venous Pressure Monitoring Monica N. Riesner, MD Lecturer, Obstetric Anesthesia, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan Postpartum Hemorrhage Edward T. Riley, MD Associate Professor, Department of Anesthesia, Stanford University School of Medicine, Stanford, California Antihistamines: H1- and H2-Blockers Pamela R. Roberts, MD, FCCM, FCCP Professor and Division Chief, Critical Care Medicine, John A. Moffitt Endowed Chair, Department of Anesthesiology, University of Oklahama Health Science Center, Oklahoma City, Oklahoma Hypothyroidism: Myxedema Coma; Hyperthyroidism: Thyroid Storm FM-X2215 8/19/06 3:25 PM Page xix

16. Kerri M. Robertson, MD Associate Clinical Professor of Anesthesiology; Chief, General, Vascular, High-Risk Transplant and Surgical Critical Care Medicine Division; Chief, Transplant Services, Duke University School of Medicine, Department of Anesthesiology, Durham, North Carolina Postoperative Hepatic Dysfunction; Complications of Carcinoid Tumors; Complications of Deliberate Hypotension: Visual Loss Marnie Robinson, MD Assistant Professor of Anesthesiology and Pediatrics, Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio Anesthetic Complications of Fetal Surgery: EXIT Procedures John B. Rose, MD Director, Pain Management Service, Department of Anesthesiology and Critical Care Medicine, Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania Delayed Emergence in Pediatric Patients Mark I. Rossberg, MD Assistant Professor of Anesthesiology, Department of Anesthesia and Critical Care Medicine, Johns Hopkins Medical Institute, Baltimore, Maryland Postintubation Croup David M. Rothenberg, MD Professor of Anesthesiology; Associate Dean, Academic Affiliations; Co-Medical Director, Surgical Intensive Care Unit, Rush University Medical Center, Chicago, Illinois Acute Pancreatitis Daniel D. Rubens, MB,BS, FANZCA Assistant Professor, Department of Anesthesia, University of Washington School of Medicine, Childrens Hospital and Regional Medical Center, Seattle, Washington Intraoperative Cardiac Arrest Senthilkumar Sadhasivam, MD Assistant Professor in Anesthesia and Pediatrics, Department of Anesthesia, University of Cincinnati College of Medicine, Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio Postoperative Nausea and Vomiting Tetsuro Sakai, MD, PhD Resident, Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania Complications in Orthopedic Outpatients Not Receiving Peripheral Nerve Blocks Francis V. Salinas, MD Clinical Assistant Professor, Department of Anesthesiology, University of Washington School of Medicine; Staff Anesthesiologist, Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington Local Anesthetic Systemic Toxicity Theodore J. Sanford, Jr., MD Clinical Professor of Anesthesiology, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan Difficult Airway: Opiate-Induced Muscle Rigidity Ramachandran Satya-Krishna, MD, FRCA Lecturer, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan; Consultant, Department of Anaesthesia, John Radcliffe Hospital, Oxford, United Kingdom Anesthesia Circuit Scott R. Schulman, MD Associate Professor of Anesthesiology and Pediatrics, Division of Pediatric Anesthesia and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina Malignant Hyperthermia Annette Schure, MD Anesthesiologist and Pediatric Anesthesiologist, Department of Anesthesia, Tufts-New England Medical Center, Boston, Massachusetts Thoracic Aortic Aneurysm Jeffrey J. Schwartz, MD Associate Professor, Department of Anesthesiology, Yale University School of Medicine; Attending Physician, Department of Anesthesiology, Yale-New Haven Hospital, New Haven, Connecticut Electrical Safety Christian Seefelder, MD Assistant in Anaesthesia, Harvard Medical School; Instructor in Anaesthesia, Department of Anaesthesiology, Perioperative and Pain Medicine, Childrens Hospital, Boston, Massachusetts Air Emboli Rajamani Sethuraman, MD, FRCA Consultant Anaesthetist, Department of Anaesthesia, Princess Alexandra Hospital, Essex, United Kingdom Intravenous Drug Delivery Systems Christoph N. Seubert, MD Assistant Professor, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida Barbiturates: Porphyrias Jack S. Shanewise, MD Chief, Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, New York, New York Transesophageal Echocardiography Kelly T. Shannon, MD Associate Professor of Anesthesiology, University of Pittsburgh School of Medicine; Associate Chief, Department of Anesthesiology, Magee-Womens Hospital, Pittsburgh, Pennsylvania Humidifiers Gauhar Sharih, MD, FRCA Formerly, Visiting Instructor, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan; Specialist Registrar, Department of Anaesthetics, City Hospital, Birmingham, West Midlands, United Kingdom Inspiratory and Expiratory Gas Monitoring xx Contributors FM-X2215 8/19/06 3:25 PM Page xx

17. Contributors xxi Aarti Sharma, MD, DA(UK) Assistant Professor of Anesthesiology, Department of Anesthesiology, Weill Medical College of Cornell University; Attending Anesthesiologist, Department of Anesthesiology, New YorkPresbyterian Hospital, New York, New York Complications of Deliberate Hypotension: Visual Loss Robert N. Sladen, MD Professor and Vice Chair, Department of Anesthesiology; Chief, Division of Critical Care, College of Physicians and Surgeons of Columbia University, New York, New York Postoperative Acute Renal Failure; Hypothermia Peter D. Slinger, MD Professor of Anesthesia, Department of Anesthesiology, Toronto General Hospital, Toronto, Ontario, Canada One-Lung Ventilation Tod B. Sloan, MD Professor of Anesthesiology, University of Colorado Health Sciences Center, Denver, Colorado Spinal Cord Injury Jonathan H. Slonin, MD Chief Resident, Department of Anesthesiology, Leonard M. Miller School of Medicine at the University of Miami, Miami, Florida Surgery in the Morbidly Obese Paul Smythe, MD Assistant Professor of Anesthesiology, University of Michigan Medical School; Adjunct Clinical Lecturer in Dentistry, Department of Oral and Maxillofacial Surgery/Hospital Dentistry, University of Michigan School of Dentistry, Ann Arbor, Michigan Intracranial Pressure Monitoring Jennifer E. Souders, MD Clinical Associate Professor, Department of Anesthesiology, University of Washington School of Medicine, Seattle, Washington Venous Air Embolism Scott R. Springman, MD Professor, Departments of Anesthesiology and Surgery, University of Wisconsin Medical School, Madison, Wisconsin Preanesthetic Evaluation: False-Positive Tests; Preanesthetic Evaluation: Inadequate or Missing Test Result James M. Steven, MD Associate Professor of Anesthesia and Pediatrics, Department of Anesthesia, University of Pennsylvania School of Medicine; Chief Medical Officer, Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania Upper Respiratory Tract Infection Robert K. Stoelting, MD Emeritus Professor and Chair, Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana Postoperative Peripheral Neuropathy; Intractable Nausea and Vomiting Mark D. Stoneham, MD, FRCA Honorary Senior Clinical Lecturer, Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, United Kingdom Pulse Oximetry E. Price Stover, MD* Clinical Assistant Professor, Department of Anesthesia, Stanford University Medical Center, Stanford, California Nonbarbiturate Anesthetics Laura Stover, MD, MASc, FRCP(C) Acting Instructor, Department of Anesthesiology, University of Washington School of Medicine; Acting Instructor, Department of Cardiothoracic Anesthesiology, University of Washington Medical Center, Seattle, Washington; Assistant Professor of Anesthesiology, Hamilton Health Sciences, Hamilton, Ontario, Canada Drugs Affecting the Renin-Angiotensin System Vijayendra Sudheendra, MD Clinical Instructor, Department of Surgery and Anesthesiology, Brown University School of Medicine; Staff Anesthesiologist, Miriam Hospital, Providence, Rhode Island; Chief of Anesthesia, East Bay Surgery Center, Swansea, Massachusetts Complications of Transurethral Surgery Kevin J. Sullivan, MD Assistant Professor of Anesthesiology, Mayo Clinic College of Medicine; Clinical Assistant Professor of Pediatrics, University of Florida College of Medicine, Jacksonville; Staff Member, Department of Anesthesiology, Nemours Childrens Clinic; Staff Pediatric Anesthesiologist and Intensivist, Department of Anesthesia and Critical Care Medicine, Wolfson Childrens Hospital, Jacksonville, Florida Anticholinergics; Hypothermia in Pediatric Patients Christer H. Svensn, MD Associate Professor, Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas Perioperative Fluid Management James F. Szocik, MD Associate Professor, Department of Anesthesiology, University of Michigan Medical School; Chair, Technical Support Committee, Department of Anesthesiology, University of Michigan Medical Center, Ann Arbor, Michigan Pipeline Source Failure Kenichi A. Tanaka, MD Assistant Professor, Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia Perioperative Hypertension Mark D. Tasch, MD Associate Professor of Clinical Anesthesia, Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana Pulmonary Aspiration *Deceased FM-X2215 8/19/06 3:25 PM Page xxi

18. Peter Tassani-Prell, MD Professor of Cardiac Anesthesia, Department of Anesthesia, German Heart Center Munich, Mnchen, Germany Anticoagulation Initiation and Reversal for Cardiac Surgery; Bleeding after Cardiac Surgery Lisa Thannikary, MD Adjunct Assistant Professor, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida Intrathecal Opiates; Ketamine; Steroids Klaus D. Torp, MD Assistant Professor of Anesthesiology, Department of Anesthesiology, Mayo Clinic College of Medicine, Jacksonville, Florida Perioperative Management of Dialysis-Dependent Patients Laurence C. Torsher, MD Assistant Professor of Anesthesiology, Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota Perioperative Care for Patients with Hepatic Insufficiency (Cirrhosis) Mark F. Trankina, MD Staff Anesthesiologist, Carraway Methodist Medical Center and University of Alabama Hospital at Birmingham, Birmingham, Alabama Class I Antiarrhythmic Drugs: Ventricular Proarrhythmia Kenneth W. Travis, MD Associate Professor Emeritus, Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire Postobstruction Pulmonary Edema Lawrence C. Tsen, MD Associate Professor of Anesthesia, Department of Anesthesia, Harvard Medical School; Director of Anesthesia, Center for Reproductive Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Womens Hospital, Boston, Massachusetts Antepartum Hemorrhage Avery Tung, MD Associate Professor, Department of Anesthesia and Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois Major Organ System Dysfunction after Cardiopulmonary Bypass; Mechanical Assist Devices; Thermally Injured Patients Manuel C. Vallejo, MD, DMD Associate Professor, Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania Peripartum Neurologic Complications Gail A. Van Norman, MD Clinical Associate Professor of Anesthesiology, Affiliate Associate Professor of Medical History and Ethics, University of Washington School of Medicine, Seattle, Washington; Physician, Department of Anesthesiology, St. Joseph Medical Center, Tacoma, Washington Patient Confidentiality; Do-Not-Resuscitate Orders in the Operating Room; The Jehovahs Witness Patient Karen M. Van Tassel, MD Chief Resident, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina Malignant Hyperthermia Gurinder M. S. Vasdev, MB,BS Assistant Professor of Anesthesiology, Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota Cardiopulmonary Bypass in Pregnancy Melissa M. Vu, MD Instructor of Anesthesiology, Department of Anesthesiology, Mayo Clinic College of Medicine, Jacksonville, Florida Hyperthermia Mehernoor F. Watcha, MD Associate Professor of Anesthesia, Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania School of Medicine, Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania Postoperative Nausea and Vomiting Eileen Watson, MD Clinical Assistant Professor, Department of Anesthesiology, State University of New York at Buffalo; Attending Anesthesiologist, Childrens Hospital of Buffalo, Buffalo, New York Hemodynamic Instability B. Craig Weldon, MD Associate Professor, Department of Anesthesiology and Pediatrics, Duke University School of Medicine, Durham, North Carolina Cardiomyopathies; Emergence Agitation Robert S. Weller, MD Associate Professor of Anesthesiology, Department of Anesthesiology, Wake Forest University School of Medicine; Staff Anesthesiologist, Department of Anesthesiology, North Carolina Baptist Hospitals, Inc., Winston-Salem, North Carolina Psoas Compartment Block: Potential Complications Lynda Wells, MD Associate Professor of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia Pediatric Neurosurgery Volker Wenzel, MD, MSc Associate Professor of Anesthesiology and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria Vasopressors: Vasoconstrictor Drugs Harshdeep Wilkhu, MD Clinical Assistant Professor, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida Nonbarbiturate Anesthetics xxii Contributors FM-X2215 8/19/06 3:25 PM Page xxii

19. Contributors xxiii Brian A. Williams, MD Associate Professor, Department of Anesthesiology, University of Pittsburgh School of Medicine; Director of Outpatient Regional Anesthesia Service, Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Complications in Orthopedic Outpatients Not Receiving Peripheral Nerve Blocks Glyn D. Williams, MB,ChB, FFA Associate Professor, Department of Anesthesia, Stanford University School of Medicine, Lucile Packard Childrens Hospital, Palo Alto, California Catheter Ablation for Arrhythmias Lisa Wise-Faberowski, MD Assistant Professor, Departments of Anesthesiology and Pediatrics, University of Colorado School of Medicine, Denver, Colorado Antidepressants; Air Emboli Eric P. Wittkugel, MD Associate Professor of Clinical Anesthesia and Critical Care; Staff Anesthesiologist; Director, Preoperative Services, Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio Pediatric Laryngospasm David J. Wlody, MD Clinical Associate Professor of Anesthesiology and Vice Chair for Clinical Affairs, Department of Anesthesiology, State University of New York-Downstate Medical Center; Interim Chair, Department of Anesthesiology, Long Island College Hospital, Brooklyn, New York Postpartum Headache Other Than PostDural Puncture Headache Gilbert Y. Wong, MD Assistant Professor of Anesthesiology and Consultant Physician, Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota Celiac Plexus Block: Side Effects and Complications Brian J. Woodcock, MD Assistant Professor of Anesthesiology, Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan Mechanical Ventilators Christopher C. Young, MD, FCCM Assistant Clinical Professor of Surgery, Associate Clinical Professor of Anesthesiology, Chief of Critical Care Medicine Division, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina Hypothermia William L. Young, MD James P. Livingston Professor and Vice Chair, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco General Hospital, San Francisco, California Arteriovenous Malformation: Normal Perfusion Pressure Breakthrough Christine M. Zainer, MD Assistant Professor of Anethesiology, Department of Anesthesiology, Medical College of Wisconsin, Froedtert Memorial Lutheran Hospital East, Milwaukee, Wisconsin Herbals and Alternative Medicine Mark A. Zakowski, MD Chief, Section of Obstetric Anesthesia, Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California Peripartum Neurologic Complications Paul B. Zanaboni, MD, PhD Anesthesiologist, St. Johns Mercy Health Care, St. Louis, Missouri Bradyarrhythmias R. Victor Zhang, MD, PhD Assistant Professor, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida a2-Adrenoreceptor Agonists FM-X2215 8/19/06 3:25 PM Page xxiii

20. First, I wish to acknowledge the contributions to this work of my wife Barbara, my in-house administrative and editorial assistant. Thank you, Barbara! Your literary skills (you did major in English and minor in Philosophy) were much needed and greatly appreciated! I am deeply indebted to the Section Editors for this edition of Complications in Anesthesia, some of whom were Section Editors for the first edi- tion as well. Organizing the topics for their sections or subsections, recruiting con- tributors, and seeing to it that the chapter manuscripts were submitted and pre-edited in a timely fashion were some of their tasks. Special appreciation goes to Natasha Andjelkovic (Executive Publisher), Jean Nevius (Senior Developmental Editor), and Amy Norwitz (Senior Project Manager). Once again, I salute Lewis Reines (former President of WB Saunders) and Leslie Day (former Medical Editor at WB Saunders), who in 1996-1997 convinced me of the need for this conceptu- ally new work as a resource for busy practitioners in anesthesia and critical care. Finally, I express my sincere appreciation to John P. Kampine, MD, PhD, former Professor and Chair of the Department of Anesthesiology at the Medical College of Wisconsin, and to my colleagues in that department (some of whom have con- tributed to this work) for providing me the time and encouragement for yet again undertaking this work. John L. Atlee, MD Acknowledgments xxv FM-X2215 8/19/06 3:25 PM Page xxv

21. VASOACTIVE DRUGS Vasodilator Drugs Jrg Dziersk 1 Case Synopsis A 90-year-old man with severe aortic stenosis, stable angina, and pulmonary hyperten- sion has surgery under general anesthesia for a femoral neck fracture. Owing to the associated cardiac morbidities, the anesthesiologist inserts a pulmonary artery catheter. Despite maintenance of normoxemia and mild hypocapnia, the patients pulmonary artery pressure rises from 60/25 to 70/35 mm Hg and is associated with signs of right ventricular strain. A nitroglycerin infusion is started at 0.2 g/kg per minute. The pulmonary artery pressure returns to near baseline values, and the systemic blood pressure decreases from 125/90 to 75/30 mm Hg. PHARMACOLOGY PROBLEM ANALYSIS Definition Left-sided heart disease (e.g., mitral valve disease, aortic stenosis, left ventricular failure) often causes significant pul- monary venous pressure elevation and leads to compensa- tory pulmonary artery (PA) hypertension. Chronic elevation of PA pressure promotes compensatory right ventricular (RV) hypertrophy and pulmonary vascular remodeling. This, in turn, results in increased pulmonary vascular resist- ance (PVR). For such patients, acute (or acute-on-chronic) increases in PA pressure are often poorly tolerated. The consequences are RV dilatation, significant tricuspid regur- gitation, and reduced cardiac output secondary to reduced venous return and impaired left ventricular filling. Together, they may lead to a downward spiral. When RV systolic pressure exceeds aortic blood pressure, RV coronary perfu- sion is limited to diastole, which may further impair RV performance. Vasodilating drugs act by reducing the contraction of vascular smooth muscle cells through a reduction in cyto- plasmic Ca2+ concentration [Ca2+ ]. Vascular smooth muscle relaxation may be mediated by the following: Increased intracellular cyclic adenosine monophosphate (e.g., 2-adrenoceptor agonists, epoprostenol) Increased intracellular cyclic guanosine monophosphate (e.g., nitric oxide, nitroglycerin, sodium nitroprusside, brain natriuretic peptide) KATP channel-opening-related hyperpolarization (e.g., diazoxide) 1-Adrenoceptor antagonism (e.g., phentolamine) Ca2+ channel blockade (e.g., diltiazem, nicardipine, verapamil) Reduction of central sympathetic tone (e.g., clonidine) Properties of an ideal vasodilator for perioperative use include (1) short onset time, (2) short to intermediate duration of action, (3) elimination independent of organ function (i.e., renal or hepatic), and (4) lack of serious side effects or toxicity. At this time, there is no single drug that meets all these criteria. Clinical actions, mechanisms of action, and side effects of vasodilators currently available for intra- venous or inhalational administration are listed in Table 1-1. Recognition Systemic vasodilatation causes a decline in systemic blood pressure, the extent of which depends on circulating blood volume and venous return (cardiac preload), the adequacy of compensatory mechanisms (i.e., reflex increase in heart rate and contractility), and the cardiac ejection fraction (normal or reduced). The skin appears warm and may be flushed, with a shortened capillary refill time. Organ dys- function may occur if systemic blood pressure is below the respective autoregulation threshold or if flow in a vascular territory is pressure dependent (e.g., in the presence of coro- nary artery disease, renal artery stenosis, head injury). Myocardial injury, acute renal failure, or neurologic deficits are typical examples of complications of systemic hypoten- sion. Computation of systemic vascular resistance quantifies the average degree of vasodilatation (or vasoconstriction) in the whole body, but it requires a precise measurement of mean arterial pressure and central venous pressure, as well as a determination of cardiac output. A PA catheter equipped for thermodilution cardiac output is necessary. In the presence of PA hypertension, systemic vasodilata- tion may allow right-to-left shunting of blood through a patent foramen ovale, leading to a diminished arterial oxygen saturation. Reduced RV preload due to venous pool- ing and RV myocardial perfusion pressure may compromise RV performance and result in a low cardiac output state. Risk Assessment Vasodilator therapy has an increased potential to cause com- plications in patients with the following conditions: Hypovolemia Stenotic valvular lesions (especially severe aortic stenosis) Hypertrophic-obstructive cardiomyopathy 3 Ch001-X2215 8/12/06 3:05 PM Page 3

22. 4 Section 1 Pharmacology Table 11 Vasodilators Available for Intravenous or Inhalational Administration Principal Action and Drug Class and Drug* Terminal Half-life Mechanism of Action Side Effects and Problems 1-Antagonists Arterial > venous vasodilatation Labetalol 5-8 hr Competitive adrenoceptor blockade Bradycardia (1: = 1:7) Drug fever Phentolamine 19 min (IV) Competitive 1- = 2-adrenoceptor Reflex tachycardia blockade Hypoglycemia Direct action on VSM Urapidil 2.7 hr Competitive 1-adrenoceptor blockade 2-Adrenoceptor Competitive 2-adrenoceptor block Agonists Clonidine 8-16 hr Central sympathetic vasomotor tone Bradycardia Inhibits peripheral NE release Potentiates anesthetic/narcotic sedation Slow IV onset (30-60 min) Nitric Oxide and Activation of guanylyl cyclase cGMP Donors Nitric oxide 6 sec Inhibits platelet aggregation Pulmonary edema secondary to contaminants (NO2) and metabolites (peroxynitrite) Methemoglobinemia Nitroglycerin 2-8 min Venous > arterial vasodilatation Tachyphylaxis NO or S-nitrosothiol release by Methemoglobinemia metabolism activation of guanylyl cyclase Sodium nitroprusside 3-4 min Arterial venous vasodilatation Cyanide toxicity, especially with higher NO release by red cell metabolism doses and lengthy infusions activation of guanylyl cyclase Thiocyanate toxicity (lengthy infusions) Methemoglobinemia Reflex tachycardia Calcium Channel Block L-type Ca2+ channels Vasodilatation unpredictable Blockers Primary arterial dilators (no Little effect in PA HTN venodilatation at therapeutic doses) Diltiazem 3-6 hr Moderate negative inotrope AV conduction blockade Nicardipine 8.6 hr Does not block L-type cardiac Ca2+ (infusions 48 hr) channels (little or no effect on contractility or AV conduction) Verapamil 2-8 hr Significant negative inotrope Depresses sinus node Blocks AV node conduction Longer half-life with chronic use Angiotensin-Converting Arterial vasodilatation Enzyme Inhibitors Vascular remodeling Enalaprilat 11 hr Inhibits generation of angiotensin II Possibly severe (first dose) Stimulates kallikrein-kinin system Acute renal failure K+ , especially with renal failure No effect on PA HTN (given acutely) Slow IV onset (>15 min) Prostaglandins with Activation of adenylyl cyclase cAMP Severe systemic hypotension with IV VSM Relaxing Effect dosing (common) Inhibition of platelet aggregation and adhesion Alprostadil (PGE1) 5-10 min Stimulates coughing (inhalational use) Epoprostenol (PGI2) 3-5 min Iloprost 13-30 min Natriuretic Peptides Arterial and venous vasodilatation Brain natriuretic 18 min Stimulation of natriuretic peptide peptide receptor A activation of guanylyl cyclase domain cGMP Inhibits renin-aldosterone axis Miscellaneous Agents Adenosine 7.5) may produce further pulmonary vasorelaxation but adversely affects oxygen delivery and enzyme function. High endogenous catecholamine levels cause pul- monary vasoconstriction through the stimulation of 1- adrenoceptors. These high levels can be avoided or treated by providing adequate anesthetic depth and postoperative analgesia. Finally, it should be remembered that lung inflation above functional residual capacity causes a progressive increase in PVR. Ventilator settings should be adjusted, based on the patients pulmonary function, to provide ade- quate oxygenation and carbon dioxide elimination while keeping mean intrathoracic pressure to a minimum. Pharmacologic pulmonary vasodilatation without con- comitant systemic vasodilatation, as was required in the case described here, can be attained in two ways: 1. Inhalation of a short-acting vasodilator, such as nitric oxide (NO) or prostacyclin (epoprostenol) 2. Coadministration of an intravenous pulmonary vasodila- tor (e.g., nitroglycerin, nitroprusside, epoprostenol) and a pulmonary vasculature-sparing vasoconstrictor (e.g., vasopressin or its synthetic analogue terlipressin). NO activates soluble guanylyl cyclase to increase cyclic guanosine monophosphate levels in vascular smooth muscle. It is inactivated by the heme moiety of hemoglobin and superoxide anions and has a blood half-life of approxi- mately 6 seconds. Therefore, inhaled NO affects predominantly PHARMACOLOGY Chapter 1 Vasodilator Drugs 5 Table 11 Vasodilators Available for Intravenous or Inhalational Administrationcontd Principal Action and Drug Class and Drug* Terminal Half-life Mechanism of Action Side Effects and Problems Diazoxide 20-45 hr Opens KATP channels hyperpolarization Sodium and water retention and arteriolar vasodilatation Hyperglycemia Fenoldopam 5-10 min Dopamine (DA1) agonist Reflex tachycardia arteriolar vasodilatation Hypokalemia Nausea Hydralazine 2-4 min Arterial vasodilatation only Slow IV onset (5-15 min) Reflex tachycardia (quite common) Sodium and water retention Lupus-like syndrome (slow acetylators) *Drugs with vasodilator activity used principally for their sympathomimetic effects (e.g., 2-adrenoceptor agonists, phosphodiesterase-3 inhibitors) are not included. Urapidil is widely used in Europe but is currently not available in the United States. AV, atrioventricular; cAMP, cyclic adenosine monophosphate; cGMP, cyclic guanosine monophosphate; HTN, hypertension; IV, intravenous; NE, norepinephrine; NO, nitric oxide; NO2, nitrogen dioxide; PA, pulmonary artery; PG, prostaglandin; VSM, vascular smooth muscle. Ch001-X2215 8/12/06 3:05 PM Page 5

24. the tone of pulmonary vessels in ventilated lung areas but has negligible effects on systemic vascular resistance. Broader application is currently limited by its very high cost and the special equipment required for its administration. Prostacyclin (PGI2, epoprostenol) and its synthetic ana- logue iloprost are the most potent pulmonary vasodilators known. Their main application is continuous infusion in cases of severe pulmonary hypertension. Their vasodilator action is mediated by cyclic adenosine monophosphate. Intravenous administration frequently causes prohibitive systemic hypotension, but when administered via inhala- tion, the effectiveness is comparable to that of inhaled NO. Arginine vasopressin is a vasoactive nonapeptide pro- duced in the hypothalamus. It is an agonist at three specific receptor types. Stimulation of the V1a receptor results in con- traction of systemic vascular smooth muscle by means of an intracellular activation pathway shared with angiotensin II. Successful use of arginine vasopressin in vasodilatory shock after cardiopulmonary bypass and in hyperdynamic septic shock has been reported. The advanced cardiovascular life support guidelines of 2000 recommend vasopressin as an alternative to epinephrine in patients with refractory ventricular fibrillation. In contradistinction to the pul- monary vascular effects of other vasoconstrictors (e.g., 1- adrenoceptor agonists, angiotensin II), vasopressin has been shown to cause pulmonary and cerebral artery vasodilatation, possibly through receptor-mediated local NO release. It may be the vasopressor drug of choice in patients with signifi- cantly elevated PVR or RV failure. PREVENTION Preventing the complications of vasodilator use is based on an understanding of the patients pathophysiology and the pharmacology of available drugs. Vasodilators are used to advantage based on their specific profiles, always keeping in mind any undesired or dangerous side effects. For instance,in a patient with aortic stenosis and coronary artery disease, both systemic hypotension and tachycardia must be avoided. In the case described in this chapter, nitroglycerin would be a reasonable choice for treatment of pulmonary hypertension, because it produces less relaxation of systemic resistance vessels than do other pulmonary vasodilators and does not cause a reflex tachycardia. Use of vasodilators in the perioperative period should take into account the common occurrence of hypovolemia due to preoperative fluid restriction, intraoperative fluid shifts or blood loss, and globally or regionally reduced sym- pathetic tone in anesthetized patients. Careful dose titration of vasodilators is advisable and is facilitated by using drugs with short half-lives. Vasodilator therapy for pulmonary hypertension coincides with the appropriate manipulation of physiologic factors known to affect PVR. Inhalational administration of NO or epoprostenol, if feasible, may help avoid unwanted systemic venodilatation or arterial vasodilatation effects. Finally, always keep in mind that adrenoceptor antago- nists and vasodilators attenuate sympathetic responses, possibly masking the clinical signs of inadequate depth of anesthesia.The use of a depth-of-anesthesia monitor is encour- aged, especially when neuromuscular blockers are used. Further Reading Balser JR, Butterworth J: Cardiovascular drugs. In Hensley FA Jr, Martin DE, Gravlee GP (eds): A Practical Approach to Cardiac Anesthesia, 3rd ed. Philadelphia, JB LippincottWilliams & Wilkins, 2003. Barnes PJ, Liu SF: Regulation of pulmonary vascular tone. Pharmacol Rev 47:87-131, 1995. Eagle KA, Berger PB, Calkins H, et al: ACC/AHA Guideline Update on Peri- operative Cardiovascular Evaluation for Noncardiac Surgery, 2002. American College of Cardiology Web site available at http://www.acc.org/ clinical/ guidelines/perio/dirIndex.htm Frishman WH, Sonnenblick EH, Sica DH (eds): Cardiovascular Pharmacotherapeutics, 2nd ed. New York, McGraw-Hill, 2003. Katzung BG (ed): Basic & Clinical Pharmacology, 9th ed. New York, Lange Medical Books/McGraw-Hill, 2004. Malouf JF, Enriquez-Sarano M, Pellikka PA, et al: Severe pulmonary hypertension in patients with severe aortic valve stenosis: Clinical profile and prognostic implications. J Am Coll Cardiol 40:789-795, 2002. Olschewski H, Rose F, Schermuly R, et al: Prostacyclin and its analogues in the treatment of pulmonary hypertension. Pharmacol Ther 102:139-153, 2004. Reich DL, Bodian CA, Krol M, et al: Intraoperative hemodynamic predic- tors of mortality, stroke, and myocardial infarction after coronary artery bypass surgery. Anesth Analg 89:814-822, 1999. 6 Section 1 Pharmacology Ch001-X2