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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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Michael Jackson’s death begs the question:  Is propofol safe?

Propofol is the most commonly used intravenous anesthetic drug in the United States today. In the hands of trained anesthetic professionals, propofol is very safe.  Propofol in always injected directly into an intravenous line, and the onset of sedation occurs within seconds.  The depth of sedation is dependent on the dose administered.  Anesthesiologists commonly administer a dose sufficient to induce unconsciousness, which occurs within 15 seconds after the dose is injected from a syringe into a dripping intravenous line.   The dose is based on the patient’s weight, the patient’s age, and the depth of sleep desired.  In general, patients who weigh less, have advanced age, or have serious medical problems require less propofol.

Propofol is a hypnotic, or sleep-inducing drug.  It is not a potent pain-reliever, and for painful surgical procedures,  drugs such as narcotics or inhaled anesthetics are commonly administered in addition to propofol to blunt pain or deepen anesthesia.

The major hazard with propofol is that patients may stop breathing after a bolus dose, or they may obstruct their upper airway (think of severe snoring that transitions into total obstruction of air moving through the upper airway).  Anesthesia professional are trained to manage these issues, and to keep adequate oxygen delivery and breathing to their patients.

Some non-anesthesiologists are trained to manage the cessation of breathing or the obstruction of breathing caused by anesthetics such as propofol.  These non-anesthesiologists include certified registered nurse anesthetists; emergency room doctors; ear, nose, and throat (ENT) surgeons; and oral surgeons who administer anesthetics.  The majority of physicians, including internal medicine doctors, family practitioners, cardiologists, pediatricians, other surgeons, obstetricians, gynecologists, gastroenterologists, and psychiatrists do not have the necessary training to safely administer propofol.

Propofol is commonly administered in ICU’s (Intensive Care Units) to sedate critically ill patients who are on ventilators.  Most of these patients have an endotracheal tube inserted into their trachea (windpipe).  This type of tube is  very stimulating (consider violently you cough and choke when any fluid or food enters your windpipe).  To tolerate the presence of such a tube, most patients require an intravenous sedative such as propofol to sedate them enough so they do not attempt to cough or pull the endotracheal tube out.  The endotracheal tube is usually connected to a ventilator machine, which mechanically pumps an oxygen-enriched mixture into and out of the patient’s lungs.  In this setting, the propofol is ordered by an ICU physician, and is administered through an electronic infusion pump.  The ICU physician does not stay present in the ICU room minute-to-minute, rather an ICU nurse monitors the management of the pump, the propofol infusion, and the patient’s ICU care.  The physician does not have to be present because the endotracheal tube is safely in place, the ventilator is connected, and the ICU nurse is trained to handle the sedation in this setting.  If the patient needs increased sedation, the ICU nurse will increase the propofol dose.  If the endotracheal tube were to become dislodged, the ICU nurse would page a physician who is present in the hospital—this would usually be an ICU physician or an emergency room physician (in a smaller hospital or some community hospitals).

The package insert included with every ampoule of Diprivan (the brand-name for the generic drug propofol) reads:   “DIPRIVAN Injectable Emulsion should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure. Sedated patients should be continuously monitored, and facilities for maintenance of a patent airway, providing artificial ventilation, administering supplemental oxygen, and instituting cardiovascular resusciation must be immediately available …  For sedation of intubated, mechanically ventilated patients in the Intensive Care Unit (ICU), DIPRIVAN Injectable Emulsion should be administered only by persons skilled in the management of critically ill patients and trained in cardiovascular resuscitation and airway management.”

The circumstance of a physician or individual without appropriate anesthesia airway training supervising or administering propofol outside a health care setting, as occurred in the Michael Jackson case, is beyond any standard practice of prescribing or administering the drug safely.

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For consideration of Online Psychiatry treatment, see this link.

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan: