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THE ANESTHESIA CONSULTANT

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com

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The Ten Commandments in the Old Testament of the Bible described a path toward a proper life. In anesthesia, I see commandments as guidelines for how to be a safe and excellent anesthesiologist. Based on forty years of clinical practice and administration in both community and academic anesthesiology, here are Ten Commandments of Anesthesia as I see them:

1. Be a doctor, not a propofol technician. Prior to my anesthesia training, my advisor told me, “In a few weeks I can teach you how to inject the Pentothal, put in an endotracheal tube, and turn on the isoflurane. That would seem to be the essence of anesthesia practice, but you must become more than a technician. You’re a physician who must become expert in all aspects of medical care before, during, and after a surgical procedure.” Anesthesiologists are tasked with the screening and evaluation of their patients prior to surgery, with keeping their patients safe during surgery, and with treating all medical problems immediately following the anesthetic care and surgery. You learn to inject propofol and intubate a patient in the first few months, but it’s a lifetime journey to master the medical aspects of evaluating and treating the heart, lungs, brain, kidneys and vital signs during anesthesia care. At Stanford our department is called the Department of Anesthesiology, Perioperative, and Pain Medicine.  The goal is to be a perioperative (“around the time of operation”) doctor, not a technician.
2. Always think Airway-Breathing-Circulation, or A-B-C. When emergencies or complications occur in anesthesia care during induction, during surgery, or after surgery, always think Airway-Breathing-Circulation in that order. Other medical professionals may become fixated in abnormal heart rhythms or in ACLS protocols, but you’re an airway expert, and you must assure airway and breathing are controlled. The notion of C-A-B, short for Chest Compressions-Airway-Breathing—in that order—is pertinent for Basic Life Support responders in out of hospital cardiac arrest, but has no place in the operating room. I recommend copies of the Stanford Emergency Manual be present in your operating room suites, on your Code Blue carts, and in your Post Anesthesia Care Unit (PACU) to guide A-B-C care.
3. The endotracheal tube is your friend. You’re trained as an airway expert, and you’re an expert in the placement of breathing tubes into the trachea. If your patient has an airway complication, a breathing complication, or a cardiac complication during or after surgery and anesthesia, it’s your job to assure the airway is secure. Bag-mask ventilation and laryngeal mask airways are part of your armamentarium, but if it’s an emergency, you’re an expert in the placement of endotracheal tubes. Secure the airway with an ET tube. The ET tube is your friend.
4. If you think an endotracheal intubation might be difficult, use a video laryngoscope on the first attempt. This is a corollary of Commandment #3. For routine intubation, a traditional laryngoscope such as a Miller #2 or a Mac #3 is adequate most of the time, but in an emergency, a difficult airway, a re-intubation, a bloody airway, or in a hypoxic patient, utilize a videoscope for your first look. The video laryngoscope is the finest invention in anesthesia practice in the past twenty-five years. Use it.
5. Choose the simplest anesthesia technique possible. The KISS Principle states, “Keep It Simple Stupid.” There are a myriad of options during intraoperative anesthesia care. The simplest technique that works for all three parties (the surgeon, the anesthesiologist, and the patient) is the advisable technique. As an example, for a carpal tunnel surgery at the wrist, options include local anesthesia with intravenous sedation, a Bier block (intravenous regional anesthetic) with or without intravenous sedation, general anesthesia with propofol/sevoflurane with the airway management by a face mask, LMA, or an endotracheal tube, or an ultrasound-guided regional infraclavicular nerve block without or with sedation/general anesthesia. Discussions with the surgeon and the patient reveal the patient wants to be asleep, and the surgeon is happy to inject local anesthesia into the wrist. The simplest technique will then be intravenous sedation (with IV or vapor general anesthesia as a backup), along with local anesthesia infiltration by the surgeon.
6. Minimize intravenous narcotics. Surgery hurts, and most patients will have some degree of pain postoperatively. The simplest way to block postoperative pain is with local anesthetics, either by infiltration of the surgical site by the surgeon or by a nerve block administered by the anesthesiologist. Minimizing IV narcotics is an important strategy to decrease nausea, vomiting, and sedation in the immediate postoperative period. For certain surgeries, local anesthesia cannot blunt all the surgical pain, and some degree of intravenous narcotics are necessary. My advice, based on 40 years of personally administering over 30,000 anesthetics of every type: minimize the narcotic doses and administer your final dose of IV narcotic 45-60 minutes prior to the end of a general anesthetic. With this approach your patients will wake comfortably without undue sedation or excessive nausea. I recommend sevoflurane—an easy to use, rapid onset, rapid offset inhaled vapor with negligible side effects—as the primary anesthetic, and I recommend ventilating away the sevoflurane at the conclusion of the surgery to effect wakefulness.
7. Wake up patients in the operating room, and extubate them awake. When I began in private practice 38 years ago, my mentor told me, “Always extubate your patients awake,” and I’ve found that advice to be valid. The most reliable way to avoid airway, breathing, and cardiac disasters in anesthesia is to awaken your patients in the operating room, where you have all your monitors, airway equipment, and medications immediately at hand. Rapid wake-up anesthesia techniques are preferred by surgeons in craniotomies, carotid endarterectomies, facelifts, rhinoplasties, laparoscopies, thoracic surgeries, arthroscopies, and pediatric surgeries. I can’t name a surgery where it’s preferable for the patient to be asleep or unconscious on arrival to the PACU. Based on decades of experience in expert witness consultation regarding airway disasters in malpractice litigation, I believe you’re less likely to have an airway complication if you extubate your patients awake. Bringing a patient to the PACU still under general anesthesia passes on the responsibility of awakening the patient to the PACU nurse, who has nursing skills but lacks the expertise of an anesthesiologist. Don’t bring unconscious patients to the PACU with an ET tube, LMA, or an oral airway in place. Your patient isn’t just paying you to put them to sleep, but to wake them up as well. Learn how to wake patients promptly. Don’t succumb to production pressure or surgeon disgust that you are lingering in the operating room for an extra 5 or 10 minutes after surgical closure while you wake the patient. You’ve been watching the surgeon(s) operate for hours. They can watch you for a short period of time while you supervise the safe landing of the anesthesia plane.
8. If you’re considering placing an arterial line, do so. In a hospital setting, some surgical procedures routinely require minute-to-minute monitoring of the arterial pressure, which requires an arterial line. Examples include craniotomies, chest surgeries, open heart surgeries, major vascular surgeries, or emergency trauma surgeries. In addition, some patients are sick enough to require minute-to-minute monitoring of their arterial pressure, which mandates an arterial line. Examples include patients in any form of shock, patients with serious respiratory or cardiac disease, or patients undergoing extremely long durations of anesthesia. An arterial line is an outstanding monitor, benefiting you with continuous information regarding hypotension or hypertension, and enabling you to treat these changes immediately. An arterial line enables you to draw an arterial blood gas at any time, which allows you to treat blood gas abnormalities immediately. An arterial line also enables you to draw any blood test at any time, bringing the full power of your hospital laboratory into your operating room. Arterial lines are not difficult to insert into the radial artery, yet frequent application of this technology is often confined to anesthesia specialists in the cardiac, neuro, trauma, and vascular subspecialties. All anesthesiologists need to retain the skills to quickly place an art line. The benefit/risk ratio is high. You’ll rarely regret placing an art line after you’ve done so.
9. The motto of the American Society of Anesthesiologists is a single word: Vigilance. The practice of anesthesia has been described as 99% boredom and 1% panic, but we must always remain vigilant. We’re the guardians of the vital signs of heart rate, blood pressure, oxygen saturation, respiratory rate, and temperature. Constant vigilance to the audible tone of the pulse oximeter, the visual tracing of the end-tidal CO2 square wave, and the latest blood pressure reading are the hallmarks of minute-to-minute anesthesia management. Your anesthesia monitors have audible alarms. Never disable or silence the alarm tones. Always remain vigilant.
10. Don’t be an a–hole. Be kind to nurses, surgeons, and patients. Just because you went to school until you were thirty years old or longer, you’re not entitled to condescend to those around you. Nurses are your co-workers and allies. Surgeons are necessary—no one comes to an operating room to have anesthesia without surgery. Without surgeons meeting the patients via their clinics, you wouldn’t have anyone to anesthetize. Honor your patients above all. Whenever you’re making a clinical decision, first do whatever is in the best interest of your patient.

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