Clinical Case for Discussion: You are scheduled to anesthetize a 71-year-old male for an arthroscopic rotator cuff repair. His blood pressure when you meet him in pre-op is 178/108 mmHg. The nurses and the surgeon are alarmed. What would you do?
Discussion: You assess the patient carefully. A review of his chart shows he’s been taking anti-hypertensive oral medications for ten years. His current regimen includes daily atenolol, lisinopril, and amlodipine, with his most recent doses taken this morning with a sip of water. He was seen in his internist’s office one week ago, and at that time his blood pressure was 140/88. His cardiac, renal, and neurologic histories are negative. He walks three miles per day. His resting EKG shows left ventricular hypertrophy, and his BUN and creatinine are normal.
The patient’s physical exam is unremarkable except that he appears nervous. Should you cancel the case and send him back to his internist to adjust the blood pressure medical therapy regimen? Should you lower his blood pressure acutely with intravenous antihypertensive drugs, and then proceed with the surgery?
Hypertension, defined as two or more blood pressure readings greater than 140/90 mm Hg, is a common affliction found in 25% of adults and 70% of adults over the age of 70 (Miller’s Anesthesia, 7th Edition, Chapter 34, Preoperative Evaluation). Over time, hypertension can cause end-organ damage to the heart, arterial system, and kidneys. Hypertensive and ischemic heart disease are the most common types of organ damage associated with hypertension. Anesthesiologists are always wary of cardiac complications in hypertensive patients.
Chronic hypertension is a serious health hazard. But what about a single, markedly-elevated blood pressure value prior to elective surgery? Are there any data to guide our decision about whether to proceed with surgery? There are. A 2004 publication by Howell (Howell SJ et al: Hypertension, hypertensive heart disease and perioperative cardiac risk. Br J Anaesth 2004; 92:570-583) is a meta-analysis of 30 studies examining the relationship between hypertensive disease, elevated admission arterial pressure, and perioperative cardiac outcome. This paper found little evidence for perioperative complications in patients with admission arterial pressures of less than 180 mm Hg systolic or 110 mm Hg diastolic. This paper recommends that anesthesia and surgery not be cancelled for blood pressures lower than 180/110 mm Hg.
Based on the Howell study, Miller’s Anesthesia recommends that elective surgery be delayed for hypertension until the blood pressure is less than 180/110 mm Hg.
In my prior career as an internal medicine doctor, I saw many hypertensive patients who’d presented for surgery with elevated blood pressures, yet whose blood pressure was adequately controlled in clinic. The anxiety and stress of anticipated surgery can elevate blood pressure acutely. If surgery is cancelled because of this hypertension and the patient is referred back to the primary care internist, the blood pressure is often well-controlled in the office setting on the same drug regimen that gave poor blood pressure control on admission to surgery. A primary care provider will be reluctant to add further medications in the office setting if the blood pressure is not elevated in clinic.
What about emergency surgery? What if a patient presents for urgent surgery for acute cholecystitis, and his blood pressure is 190/118 mm Hg? For urgent or emergent surgery, consider titrating intravenous antihypertensive drugs such as labetolol (5–10 mg q 5–10 minutes prn) or hydralazine (5–10 mg q 5–10 minutes prn) to decrease blood pressure prior to initiating anesthesia. Because the eventual induction of general anesthesia with intravenous and volatile anesthetics will lower blood pressure by vasodilation and cardiac depression, any pre-induction antihypertensives must be titrated with great care. Once doses of labetolol or hydralazine are injected, there is no way to remove the effect of that drug. For critically ill patients, consider monitoring with an arterial line and infusing a more titratable and short-acting drug such as nitroprusside for blood pressure control.
Let’s return to the anesthetic for your elective shoulder surgery patient with the blood pressure of 178/108 mmHg. You begin by administering 2 mg of midazolam IV. Three minutes later his blood pressure decreases to 160/95. You anesthetize him with 50 micrograms of fentanyl and 140 mg of propofol IV, and insert a laryngeal mask airway. In the next 20 minutes, while the patient is moved into a lateral position for the surgery, his blood pressure drops to 95/58. Because most anesthetics depress blood pressure by vasodilation or cardiac depression, it’s common for patients such as this one to require intermittent vasopressors to avoid hypotension, especially at moments when surgical stimulus is minimal. One of the recommendations of the Howell study is that intraoperative arterial pressure be maintained within 20% of the preoperative arterial pressure. This recommendation can be a challenge, especially if the preoperative blood pressure was elevated. A 20% reduction from 178/108 (mean pressure = 131 mm Hg) would be 146/88. A 20% reduction from the mean pressure of 131 mm Hg would be a mean pressure of 104 mm Hg. You choose to treat the patient’s hypotension with 10 mg of IV ephedrine, which raises the blood pressure to 140/85. Fifteen minutes later, the surgeon makes his incision, and the blood pressure escalates to 180/100. You treat this by deepening anesthesia with small, incremental doses of fentanyl and propofol. The surgery concludes, you awaken the patient without complications, and his blood pressure in the Post Anesthesia Care Unit is 150/88 mm Hg.
This pattern of perioperative blood pressure lability is common in hypertensive patients, and will require your vigilance to avoid extremes of hypotension or hypertension. Remember that based on the Howell study, Miller’s Anesthesia recommends elective surgery be delayed for hypertension until the blood pressure is less than 180/110 mm Hg. Armed with this information, you’ll cancel fewer patients for preoperative hypertension.
Introducing …, THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a legal mystery. Publication date September 9, 2014 by Pegasus Books.
The first four chapters are available for free at Amazon. Read them and you’ll be hooked! To reach the Amazon webpage, click on the book image below:
Stanford professor Dr. Nico Antone leaves the wife he hates and the job he loves to return to Hibbing, Minnesota where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in this remote Midwestern town. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.
Equal parts legal thriller and medical thriller, The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ Fargo, The Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a final twist that will leave readers questioning what is of value in the world we live in.
Bang-Up Debut Novel, November 16, 2014
By Norm Goldman “Publisher & Editor of Bookpleasures”
This part legal and medical thriller is structured with a mixed bag of situations involving relationships, jealousy, evil, lies, courtroom drama, operating room mishaps as well as moments that engender conflicting and unexpected outcomes. Noteworthy is that as the suspense builds readers will become eager to uncover the truth involving a mishap concerning Nico and a surgical procedure that has unanticipated ramifications.
This is a bang-up debut from a writer who understands timing and is able to deliver hairpin turns, particularly involving the courtroom drama,that you would expect from a book of this genre.
TwinCities.com PIONEER PRESS Entertainment
by Mary Ann Grossman, Entertainment Editor, St. Paul Pioneer Press email@example.com, January 4, 2015
“The Doctor & Mr. Dylan” by Rick Novak (Pegasus Books, $17.50)
Dr. Nico Antone doesn’t hide the fact he hates his wife, but he says he didn’t kill her during an operation. The authorities think otherwise and his trial is the riveting suspense in this novel that is part medical thriller, part legal thriller, part exploration of family relationships.
Nico is an anesthesiologist (as is the author) who leaves his wife, their plush life in California and his job at Stanford to move to his hometown of Hibbing so their son, Johnny, has a better chance of getting into a prestigious college. Johnny hates the idea of moving to a small, cold town, but he’s popular from the first day in school. Nico doesn’t do so well. He’s envied by Bobby, an anesthetist who’s jealous of the better-educated Nico. But it’s hard to take Bobby seriously, since he thinks he’s the young Bob Dylan and lives in the house where Bobby Zimmerman grew up. To complicate matters, Nico is attracted to the mother of the young woman his son is dating. When the two teens get in trouble, Nico’s furious, rich wife comes to Minnesota and needs an emergency operation that puts her on Nico’s operating table.
Novak grew up in Hibbing, where he worked in the iron ore mines and played on the U.S. Junior Men’s Curling championship teams of 1974 and ’75. After graduating from Carleton College, he earned a medical degree at the University of Chicago and spent 30-plus years at Stanford Hospital, where he was an associate professor of anesthesia and Deputy Chief of the Anesthesia Department. His courtroom scenes are based on his experiences as an expert witness.
The Physician’s Late-Night Reading List
Two Pritzker alums pen captivating tales
By Brooke E. O’Neill, University of Chicago Pritzker School of Medicine, editir, Medicine on the Midway Magazine
For most physicians, writing — patient notes, case histories, perhaps journal articles — is part of the job. But for anesthesiologist-novelist Rick Novak, MD’80, and neurosurgeon-memoirist Moris Senegor, MD’82, it’s a second career that consumes early morning hours long before they step into the OR.
Fans of John Grisham will find a kindred spirit in Novak, whose fast-paced medical thriller, The Doctor & Mr. Dylan (Pegasus Books, 2014), transports readers to rural Northern Minnesota, where an accomplished physician and a deranged anesthetist who thinks he’s rock legend Bob Dylan see their worlds collide in the most unexpected ways.
Delivering real-life twists and turns — and a love letter to the Bay Area — is Senegor’s Dogmeat: A Memoir of Love and Neurosurgery in San Francisco (Xlibris, 2014), a coming-of-age tale chronicling the author’s away rotation with renowned neurosurgeon Charles Wilson, MD, at the University of California, San Francisco. Brutally honest, it spares no details of a time Senegor, who also served as a resident under the University of Chicago’s famed neurosurgery chair Sean Mullan, MD, describes as “one of the biggest failures of my life.”
One a vividly imagined nail-biter, the other an intimate peek into the surgical suite, both books deliver an ample dose of intensity and drama.
The Doctor and Mr. Dylan (Pegasus Books, 2014) by Rick Novak, MD’80
“I thought it was a novel way of killing someone,” said Rick Novak, deputy chief of anesthesiology at Stanford University, describing the imagined hospital death that was the genesis of his dark thriller The Doctor & Mr. Dylan. A huge Bob Dylan fan — the rock icon was born in Novak’s hometown of Hibbing, Minnesota, where the story takes place — he then dreamed up a possible culprit: a psychotic anesthetist who thinks he’s Dylan.
From there, the words flowed. “I would write whenever I was with my laptop and had a free moment: in mornings, in evenings, in gaps between cases,” said Novak, who also blogs about anesthesia topics. “I don’t sleep much.”
After finishing the manuscript — one year to write, another to edit — came the challenge of finding a publisher. “In anesthesia, I’m an expert,” Novak said. “In the literary world, I’m an unknown.” After 207 responses of “no, thanks” or no answer at all, he landed an agent. Two months later, she informed him that Pegasus Books had bought his debut novel.
“I started crying,” Novak admits. “I have a third grader and at the time the big word the class was learning was ‘perseverance.’ That was it exactly.”
Dr. Joseph Andresen, Editor, Santa Clara County Medical Association Medical Bulletin, from the January/February 2015 issue:
BOOK REVIEW “THE DOCTOR AND MR. DYLAN”
This past month, Dr. Rick Novak handed me a hardbound copy of his debut novel The Doctor and Mr. Dylan. Rick and I go way back. It was my first week of residency at Stanford when we first met. A newcomer to the operating room, all the smells and sounds were foreign to me despite my previous three years in the hospital as an internal medicine resident. Rick, a soft spoken Minnesotan at heart, in his second year of residency, took me under his wing and guided me through those first few bewildering months, sharing his experience and wisdom freely.
Fast-forward 30 years later. Dr. Rick Novak, a novel and mystery author? This was new to me as I sat down and opened the first page of The Doctor and Mr. Dylan. I have to admit that I didn’t know what to expect. Few books highlight a physician/anesthesiologist as a protagonist, and few books feature a SCCMA member as a physician/author. However, a medical-mystery theme novel wasn’t at the top of my must read list. With my 50-hour workweek, living and breathing medicine, imagining more emotional stress and drama was the furthest thing from my mind. However, three days later, as I turned the last page, and read the last few words. “life is a series of choices. I stuck my forefinger into the crook of the steering wheel, spun it hard to the left and …” This completed my 72-hour journey of and free moments I had, completely immersed in this story of life’s disappointments, human imperfections, and simple joys.
Rick, I can’t wait for your next book. Bravo!
Hibbingite writes twisted medical tale
HIBBING — Readers who are looking for a whodunit that will keep them up all night are in for a treat.
Hibbing native Rick Novak recently released his first book “The Doctor and Mr. Dylan,” a fiction set in Hibbing that merges anesthesia complications, a tumultuous marriage and the legend of Bob Dylan.
“The dialogue is sometimes funny, and there are lots of plot twists,” he said.
Novak said the book will not only entertain readers, but teach them about anesthesiology, Dylanology, the stressful race for elite college admission, and life on the Iron Range.
“The book is very conversational and streamlined,” he said. “I try to write as one would tell a story out loud.”
Novak said “The Doctor and Mr. Dylan” took him three years to perfect. He is currently working on his second book.
This review is from: The Doctor and Mr. Dylan (Kindle Edition)
Just finished Dr. Novak’s delightful novel. I sincerely enjoyed his honest take about the pressures and values that exist within California’s Silicon Valley. He also brought the North Country of Minnesota to life with memorable characters and a twisting, addictive plot. Buried beneath the fun and funny story is a deeper message about how to best care for your kids, your relationships and yourself. Very well written and highly recommended.
Learn more about Rick Novak’s fiction writing at rick novak.com by clicking on the picture below: