PITFALLS OF TOTAL INTRAVENOUS ANESTHESIA

Clinical Case:  You are doing Total Intravenous Anesthesia  (TIVA) for a laparoscopic cholecystectomy on a healthy 40 year old woman.  Midway through the surgery, the patient’s heart rate suddenly climbs to 160, and the blood pressure climbs to 190/110.  What do you do?

Discussion:   Your own heart rate hits 170.  You check the ABC’s of Airway, Breathing, and Circulation, and note that the endotracheal tube is still in the trachea, and both lungs are being ventilated with clear breath sounds.  The oxygen saturation is 100%.  You check the anesthetic drugs, and confirm that  both the propofol and remifentanil pumps are running properly.  A check of the IV shows the Lactated Ringers is not dripping, despite the fact that the roller clamp is wide open.  The IV is in the left arm, which is positioned abducted at 90 degrees.  You inspect the IV insertion site and find that the IV has infiltrated.

You turn on sevoflurane at 4% and nitrous oxide at 70%, and scramble to restart an IV in the outstretched arm.  In  minutes you have a new IV, and you give a bolus of 140 mg of propofol.  The heart rate decreases to 80 beats per minute, and the blood pressure decreases to 110/50.  You decrease the sevoflurane to 1.5 %, discontinue the nitrous oxide, and reconnect the TIVA infusions of propofol and remifentanil.

Don’t believe it could happen?   Tong described intraoperative awareness  during TIVA for  laparoscopy, due to physician error in  improperly positioning the latch of the movable lever in the propofol syringe driver at the top of the plunger (Can J Anaesth. 1997 Jan;44(1):4-8.), so that no propofol was infusing.   Several series of TIVA cases document incidence of awareness ranging from 2 patients out of 1000,  or .2%  (Nordstrom O, Acta Anaesthesiol Scand. 1997 Sep;41(8):978-84.), to 8 patients out of 90, or 8.8% (Miller DR, Can J Anaesth. 1996 Sep;43(9):946-53.)  Any technical error, such as the pump(s) not being turned on, the pump(s) malfunctioning, the syringes being empty, stopcocks being closed rather than open, or the IV infiltrating, can lead to failure of TIVA technique.  In addition, inadequate narcotic or propofol infusion rates can lead to inadequate anesthetic depth.  When coupled with neuromuscular paralysis, the most prominent signs of inadequate anesthetic depth will be tachycardia and hypertension.

TIVA is a viable option for general anesthesia because of the availability of ultra-short acting narcotics such as remifentanil and hypnotics such as propofol.  Learning this sort of technique is part of a complete residency experience.  There is less gas pollution when TIVA is used.  If you ever need to give an anesthetic in outer space or at zero gravity, your experience with TIVA will be invaluable.

Will you find much TIVA practiced in the private practice world of anesthesia?  My observation is that most private cases involving general anesthesia with muscle relaxation include inhalational anesthetic.  Propofol infusions are often included, and at times so are remifentanil infusions.  But to insure lack of awareness,  the potent anesthetic vapors  of sevoflurane, desflurane, or isoflurane are still the mainstays of awareness prevention when muscle relaxants are used.  The KISS Principle, or Keep It Simple Stupid, dictates that it is easier to turn on one vaporizer than to fidget with multiple syringe pumps.  (The vaporizer needs to include liquid anesthetic, and it needs to be turned on to an adequate concentration, or awareness can still occur.)

Some may suggest that all anesthetics be monitored by  continuous bispectral index (BIS) monitors to insure lack of awareness.  A case of awareness despite BIS monitoring has been published, (Kurehara K, Masui 2001 Aug;50(8):886-7.) in which a 77 year old patient had  awareness during a thoracotomy  despite BIS scores that indicated adequate hypnotic depth.  A recent prospective study (Ekman A, Acta Anaesthiol Scand 2004 Jan; 48(1):20-6.) documented explicit recall in 2 of 4945 patients (.04%) in general anesthetics requiring  muscle relaxation, using BIS monitoring.  This was significantly lower than their historical control rate of .18% of explicit recall in paralyzed patients without BIS monitoring.  But note than that even with BIS monitoring, the incidence of recall is not zero.  Whatever technique or monitors are employed, the skill and vigilance of the attending anesthesiologist will be  of highest  importance in maintaining adequate anesthesia drug administration.

Patients expect their anesthesiologist to keep them safe, to keep them asleep during the surgery, and to wake them up after the surgery.  Patients ask me about the risk of intra-operative awareness dozens of times per year.  The amount of times I want this to occur for my patients, or for yours, is zero.  Diversify your anesthetic regimen.  Don’t bet the ranch on your IV.

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:

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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.

REVIEWS:

5.0 out of 5 stars The Doctor and Mr Dylan, March 3, 2015
By
prabha venugopal (chicago, il USA) – See all my reviews
Verified Purchase(What’s this?)
Gripping from the beginning to the end. Very well written, bringing to the forefront all the human emotions seen in an operating room spill over into real life. I cannot wait for Dr. Novak to wrote another book! As another physician in the same profession, my admiration for his book knows no limits.

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 mgrossman@pioneerpress.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.

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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.

5.0 out of 5 stars I Sense We Have Another F.Scott Fitzgerald Emerging on the Literary Scene, December 1, 2014
By
Deann Brady (Sunnyvale, CA USA) – See all my reviews
(REAL NAME)
I found Rick Novak’s first novel, “The Doctor and Mr. Dylan,” a most exciting combination of biting sarcasm, mystery and daily activity spun with fresh new phrases that made me turn my ear back to listen to the literary cadence of his words again and again even though, on the other hand, I was anxious to turn the pages to see what would happen next. His brilliant handling of scenes is reminiscent of The Great Gatsby by F. Scott Fitzgerald. A compelling read!Deany Brady, author of “An Appalachian Childhood”

By

allan mishra

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:

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