ROBOT SURGERY . . . A VIEW FROM THE ANESTHESIOLOGY COCKPIT

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.
email rjnov@yahoo.com
phone 650-465-5997

Almost every anesthesiologist in America has experience with surgery using the da Vinci robot system. Is robot surgery a miraculous futuristic device that advances surgery to a higher plain? Or is it an expensive gadget for hospitals and surgeons to market and attract potential patients?

To answer these questions let’s first review some history. Until the 1990s most abdominal surgery was done through an open incision. To remove a gall bladder or an appendix, the surgeon made an incision into the abdomen, inserted his hands and instruments, cut out the tissue under direct vision, and then sewed the abdomen together again. A gall bladder incision might be five inches long. An appendix incision might be 2½ inches long. The surgical times were short—a private practice surgeon could complete an open gall bladder surgery in 30 – 40 minutes, or an open appendectomy in 20 – 25 minutes. A disadvantage was that the patient had pain from the incision, and the recovery time was days to weeks before the patient could return to normal activities.

Laparoscopy

Enter laparoscopy, a true major advance in surgery. The first video laparoscopic gall bladder resection (cholecystectomy)  was performed in 1987. A quantum advance occurred in the 1990s when video laparoscopic surgery became widespread. Laparoscopy required only small incisions in the abdomen, through which slender instruments were inserted. The interior of the abdomen was insufflated (blown up like a balloon) and one of the slender instruments held a camera. The image of the inside of the abdomen was visualized on a video screen while the surgeon manipulated instruments seen on that two-dimensional view. My colleague and Stanford clinical faculty member Camran Nezhat, the author of multiple textbooks on the topic, was a leading pioneer in the development of video laparoscopy. Laparoscopic surgery took longer than open surgery—a laparoscopic gall bladder or laparoscopic appendectomy usually lasted about twice as long as an open surgery—but the significant advantage was the lack of a painful open incision, which led to significantly less postoperative pain and a shorter postoperative recovery time. Many patients could be discharged the same day as their surgery, and most returned to normal activities sooner than if they had open surgery.  Video laparoscopy surgical equipment and the longer operating times were increased expenses, but the advantages of outpatient surgery and quicker recovery made the new technique the standard of care for many surgeries within the abdomen.

Anesthesia for laparoscopy was similar to the anesthetic for open abdominal surgery. Patients were asleep and paralyzed, and their breathing is done by a ventilator. The laparoscopy patient had a tense abdomen—it was essentially a balloon full of carbon dioxide—that usually required smaller volume breaths from the ventilator, but in most ways the two anesthetics were alike. 

da Vinci robot

Using the da Vinci robot for abdominal surgery is an extension of laparoscopic techniques, but the instruments are connected to robot arms rather than held by surgeons. The da Vinci surgeon sits at a console in the corner of the operating room, with his back to the patient and his face in a 3-D viewer, which gives a high-definition, magnified view of the surgical site. Assistant surgeon(s) and techs stand at the patient’s side, watch the surgery on video screens, and assist during the operation. The surgeon manipulates handles on the da Vinci device, which move the instruments within the patient’s body. The three-dimensional view within the abdomen is superior to a two-dimensional view on a video screen. I’ve personally had the opportunity to look through the 3-D viewer into the abdomen, and it’s a remarkable phenomenon. It’s as if you were a microscopic insect inside the patient, and looking around at the intestines, liver, arteries and veins that surround you. Another touted advantage of the robot is the ability for the surgeon to make precise movements via the robot’s mechanism. 

surgeon (at left) with his back to the operating room table and patient

The non-profit SRI (Stanford Research Institute) developed the early da Vinci system in the late 1980s with funding from the National Institutes of Health. The system was thought to have promise in allowing surgeons to operate remotely on surgeons wounded on battlefields. (When you read on you’ll realize how improbable this application would be.) 

In the 1990s, John Freund negotiated an option to acquire SRI’s intellectual property, and started a company named Intuitive Surgical Devices, Inc. The company’s prototype was ready for clinical testing in 1997. In 2000 the Federal Drug Administration (FDA) approved use of the da Vinci Surgical System for laparoscopic surgery, and Intuitive raised $46 million in an initial public offering. One year later the FDA approved use of the system for prostate surgery. In subsequent years the FDA approved the system for thoracoscopic surgery, cardiac procedures, and gynecologic procedures.

The da Vinci Surgical System spread slowly at first. Sixty hospitals in the United States used the system in 2002, but this number grew to 431 hospitals by 2014. Approximately 1,500 United States  hospitals now have the da Vinci Surgical System, according to Modern Healthcare. The system costs approximately $2 million, and there are costs for maintenance and for the non-reusable instruments held by the arms during surgery. A robotic surgery generally costs anywhere from $3,000 to $6,000 more than traditional laparoscopic surgery.  In 2016 Healthline wrote, “To justify its price — roughly 10 times that of a traditional laparoscopic surgery — da Vinci would need to do a lot better overall.” 

For abdominal surgery, use of the robot is as follows: The assembled robot is draped in sterile plastic and positioned distant to the patient, while the anesthesiologist induces general anesthesia and inserts an endotracheal breathing tube into the patient’s windpipe. The circulating nurse then preps the patient’s abdomen with antiseptic solution and the scrub tech surrounds the patient’s abdomen with sterile drapes. The surgeons insert a trocar to inflate the abdomen with carbon dioxide gas, and then make the incisions required for the insertion of the instruments into the patient’s body. When the robot is finally moved in over the patient and the instruments are connected to the robot arms, the anesthesiologist has limited access to the patient’s head, neck, and chest, due to the size, breadth and girth of the robot. The anesthesiologist’s station is within 4 – 6 feet of the patient’s head. At least one surgical assistant and one scrub tech stand at the patient’s side throughout the surgery. At a university teaching hospital, this number could be significantly greater. 

anesthesiologist (at right) during robotic surgery

The anesthetic for robotic abdominal surgery is no different than the technique for laparoscopy, except for one important feature. Robotic surgeries take longer than the same surgery done via traditional laparoscopy—a fact that makes most robotic procedures tedious for anesthesia personnel. Robot surgeries take up more of an operating room’s most precious resource—time. Hospital operating room resources—nurses, techs, orderlies, and administrative staff—are paid by the hour. Longer surgeries mean longer staffing hours and greater expense.

Do anesthesiologists prefer, enjoy, or feel challenged by these robotic surgery cases? In a word—no. There is little that is unique or challenging after one has done a few of these cases. In general anesthesiologists prefer surgery that is fast, efficient, safe, and effective.

1248 papers on “robot surgery” in 2019 to date

What does the world’s medical literature have to say about robotic surgery? When I entered the keywords “robot surgery, 2019” into the Pubmed search engine today, I discovered 1,248 papers published on robot surgery in the first 11 months of 2019. This is an exceptionally large number of publications. Robot surgery is a hot topic in the community of academic surgery. Multiple surgical specialties, including general, gynecology, cardiac, thoracic, cancer, and head and neck surgeons, are writing about their experiences with the da Vinci robot. You’ll find individual case reports, series of cases, meta-analyses, and comparison of current outcomes/complications to historical controls. 

Pertinent studies include the following:

Gall bladder surgery: In a 2019 study in the American Journal of Surgery, a national databank review of gall bladder resections (cholecystectomy) showed that the direct cost of robotic cholecystectomy was significantly higher than laparoscopic cholecystectomy, with no added benefit. The conclusion of the study was that “routine use of the robotic platform for cholecystectomy should be discouraged until costs are reduced.” 

Prostatectomy: A randomized controlled trial compared robotic surgery with open surgery for patients with localized prostate cancer, and showed that both robotic and open surgery achieved similar results in terms of key quality of life indicators at three months. 

Kidney surgery: A study published in the Journal of the American Medical Association (JAMA) showed the percentage of radical nephrectomies using the robot increased from 1.5% in 2003 to 27.0% in 2015. There were no significant differences between robot-assisted vs laparoscopic radical nephrectomy in major postoperative complications. The robot-assisted procedures had both longer operating times and higher direct hospital costs. 

Gynecology: The mortality in benign minimally invasive gynecologic surgery was low, and the mortality for laparoscopic vs robotic approaches was similar. 

Rectal surgery: JAMA publication showed that for patients with rectal carcinoma, robot-assisted laparoscopic surgery did not significantly reduce the risk of conversion to open laparotomy, when compared with conventional laparoscopic surgery. These findings suggested that robot-assisted laparoscopic surgery did not confer an advantage in rectal cancer resection. 

What will be the future direction of robotic surgery? Currently Intuitive Surgical and the da Vinci Surgical System have a monopoly. No other company has any significant market share. In 2017 Intuitive Surgical had $3.12 billion in total revenue, with a net income of $660 million. Their stock price is currently $549/share, up 300% from $178/share in January of 2016. The volume of robotic surgeries continues despite a paucity of published data that robotic surgery is any better. The cost of these procedures is high, and most hospitals are losing money on robot cases. Hospital executives seem to see the robot as a loss leader. No administrator wants to lead an old-fashioned hospital that doesn’t have a robot, while their competitor hospital across town is advertising robotic surgery on the side of buses traveling down Main Street.

Robotic surgery is a technology looking for a reason to exist, and a solution looking for a problem. Robotic surgery is not nearly the advance that laparoscopy was. Technology is pervasive and is changing healthcare. Enter any hospital today and you’ll see doctors and nurses peering into computer screens. They are pointing, clicking, entering information, and typing in findings on their patients. Where are the patients? Often they’re looking at the backs of these same doctors and nurses who are sitting at the computer terminals. Medicine, as I was taught in the 20th Century, was a profession dedicated to caring for and healing people. Modern medicine is increasingly pushing the hands of doctors and nurses toward keyboards and gadgets.

a doctor charting on electronic medical records
a da Vinci surgeon at work

The surgeon with his face in a robot console’s 3-D viewer, while his back is to his patient, is a powerful metaphor for the technologic trend in medical care. I believe patients want to see our faces, and we need to look into their eyes. I doubt that great American physicians from our past—William Osler, Harvey Cushing, the Mayo Brothers, or Norm Shumway—would be fans of robotic surgery.


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The most popular posts for laypeople on The Anesthesia Consultant include:
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Why Did Take Me So Long To Wake From General Anesthesia?
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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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ANESTHESIOLOGISTS, DON’T BE AFRAID TO CUT INTO A PATIENT’S NECK

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.
email rjnov@yahoo.com
phone 650-465-5997

You’re an anesthesiologist. You’ve lost the airway on your obese anesthetized gynecology patient, your multiple attempts to intubate the trachea have failed, you cannot mask ventilate the patient, and insertion of a laryngeal mask airway did not help. Your patient’s skin and lips are purple and you are terrified. What do you do?

  1. Call a surgeon stat to do a tracheostomy
  2. Ask the gynecologist to cut an airway into the patient’s neck
  3. Keep trying to intubate the trachea yourself
  4. Insert a needle into the cricothyroid membrane, and begin jet ventilation
  5. Cut an airway into the neck yourself.

A study in the October 2019 issue of Anesthesiology showed that when a “can’t intubate, can’t oxygenate” crisis occurred, there were delays finding someone prepared to cut a surgical airway into the front of the neck in time to save the patient’s life. The study looked at malpractice closed claims and found: 1) Outcomes remained poor in malpractice closed claims related to difficult tracheal intubation; 2) The incidence of brain damage or death at induction of anesthesia was 5.5 times greater in the years 2000 – 2012 than in the years 1993 – 1999; 3) Inadequate planning and judgement errors contributed to the bad outcomes; and 4) Delays in placing a surgical airway during “can’t intubate, can’t oxygenate” emergencies were a major issue.

A closed claims study is akin to a large mortality and morbidity (M & M) conference. A closed claims study tells us which complications led to malpractice settlements. Each malpractice closed claim marks a negligent practice which caused an adverse outcome.

I’d like to focus on one specific aspect of this important study: anesthesiologists need to lose their reluctance to cut a surgical airway into a patient’s neck in a “can’t intubate, can’t oxygenate” airway emergency. A surgical airway is an invasive airway via the front of the patient’s neck into their trachea. Waiting for a surgeon to cut a surgical airway, or fearing to cut a surgical airway yourself, could cost your patient his or her life. Delay or failure in placing a surgical airway was described in 10 of the specific 12 cases listed in the Appendix of this Anesthesiology closed claims study, as follows:

Case 1: “Eventually a surgical airway was performed after the patient arrested.”

Case 2: “A surgical airway was performed after the patient arrested.”

Case 3: “The surgeon was called to the room to perform an emergency surgical airway, but there were not any instruments available in the room. The patient sustained anoxic brain injury and later died.”

Case 4: “Ventilation was difficult and the patient arrested. The surgeon arrived and attempted to perform an emergency surgical airway, at which time the anesthesiologist successfully intubated the patient’s trachea as the hematoma was drained. The patient was resuscitated but later died of anoxic brain damage.”

Case 5: “The anesthesiologist asked the surgeon to perform an emergency cricothyrotomy. However, the surgeon insisted that an electrocautery to be set up first. Nine minutes after cardiac arrest, a surgical airway was secured by the surgeon. The patient was resuscitated but remained in a persistent vegetative state.”

Case 6: “An ear-nose-throat surgeon was called to perform a surgical airway, who suggested a supraglottic airway be inserted instead. After the supraglottic airway was placed, the patient became impossible to ventilate and went into cardiac arrest. The surgical airway was placed with some difficulty. The patient sustained severe hypoxic brain and died.”

Case 8: “The surgeon performed a cricothyrotomy after the patient had marked bradycardia and hypotension.”

Case 10: “A surgeon was called to place a cricothyrotomy. The patient was resuscitated but had severe anoxic brain damage and died.”

Case 11: “Multiple intubation attempts and supraglottic airway insertion were made for more than an hour before a surgical airway was performed. At that time, the patient was asystolic and had a tension pneumothorax. The patient died.”

Case 12: “The patient had a hypoxic cardiac arrest. The surgeon arrived 22 min after induction and secured an emergency surgical airway. The patient was resuscitated but sustained hypoxic brain damage requiring assistance with activities of daily living.”

It’s tragic that 10 of the 12 listed cases involved delayed or failed front of neck access to the airway. In an editorial in the same issue of Anesthesiology, authors Takashi and Hillman wrote, “Decision to provide a surgical airway was frequently delayed by repeated attempts at tracheal intubation, anesthesia care providers being hesitant to initiate surgical procedures, or surgeons being reluctant to perform tracheostomy or simply not available.”

The American Society of Anesthesiologists Difficult Airway Algorithm, shown below, clearly describes invasive airway (i.e. surgical airway) access via the front of the neck when attempts to intubate the trachea and oxygenate the patient both fail.

“Can’t intubate, can’t oxygenate” events are rare, but they do occur with a published incidence of 1 in 50,000 anesthetics, per the fourth national audit project in the United Kingdom.  

The brain can be permanently damaged following episodes in which the brain sees no oxygen for five minutes or longer.

Approaches to front of neck access include either cannula techniques or surgical techniques, with significant differences:

Cannula Technique:

This involves inserting a large bore IV catheter through the cricothyroid membrane.

Because the lumen of a 14-gauge IV catheter is small, ventilation requires a high-pressure jet oxygen delivery system. In a publication from 2016, the failure rate with cannula techniques was 42% in “can’t intubate, can’t oxygenate” emergencies. Failure can occur because of kinking, malposition, or displacement of the needle/cannula. Because of the high failure rates, use of the cannula technique is discouraged.

Surgical Technique:

Most surgeons are trained to perform tracheostomies during their residencies, but when a “can’t intubate, can’t oxygenate” emergency occurs, tracheostomy is not the preferred procedure.

Tracheostomy – tube is inserted between tracheal rings

  Cricothyroidotomy, a technique which is faster and requires less surgical skill, can be performed by anesthesiologists, and is the preferred procedure.

In a cricothyroidotomy, the cricothyroid membrane is divided by a surgical incision made with a wide scalpel (#10 scalpel).

a cricothyrotomy is inserted in the cricothyroid space, cephalic to the trachea

Using the scalpel, bougie, tube (SBT) technique,

a bougie is inserted into the trachea through the incision. A lubricated 6.0 mm cuffed endotracheal tube is advanced over the bougie into the trachea, and the bougie is removed as demonstrated in this video link: 

This technique has been specifically endorsed in the United Kingdom in the algorithm from their Difficult Airway Society.  The British Difficult Airway Society guideline for a Can’t Intubate, Can’t Oxygenate crisis follows: 

How to train anesthesiologists to perform SBT cricothyroidotomy:

Are anesthesiologists trained to perform cricothyroidotomy? Not really. Even though the procedure is the last safety valve on the Difficult Airway Algorithm, most anesthesiologists have minimal or no experience in this life-saving procedure. How can we train anesthesiologists to perform cricothyroidotomies? 

In my residency in the 1980s we were trained to do cricothyroid injections of cocaine prior to awake fiberoptic intubation procedures. Each resident performed dozens of these injections, and I became extremely comfortable locating and piercing the cricothyroid membrane with a needle. In 35 years and 25,000+ anesthetics, I’ve never needed to place a surgical airway through that same membrane, but I feel confident I could do so with the scalpel, bougie, tube technique. 

The problem is that most anesthesiologists have never had to perform this front of neck access procedure on a patient. The stakes are high, because there is little time for failure. After several minutes of “can’t intubate, can’t oxygenate,” someone needs to take a scalpel to the cricothyroid membrane. That someone can and often should be the anesthesiologist.

In the October 2013 American Society of Anesthesiologists Monitor we read, “Perhaps the most important problem encountered in “can’t intubate, can’t oxygenate”  is a delay in recognition or institution of emergency airway management. . . . While someone clearly needs to make the decision to obtain a surgical airway, both the surgeons and the anesthesiologist may feel uncomfortable in this role. Retrospective studies, including closed claims analysis, demonstrate that most patients are already in cardiac arrest before emergency invasive airway attempts are performed. While decisive and timely action is clearly needed, the decision to pursue a surgical airway is not an easy one; . . . In fact, there is little legal risk from a surgical airway attempt – no matter how messy – if the patient survives, but enormous liability if the procedure is not attempted.”

In a study from Great Britain, 104 anaesthetists received a structured training session on performing cricothyrotomy. These anaesthetists then took part individually in a simulated “can’t intubate, can’t oxygenate” event using simulation and airway models, to evaluate how well they could perform front‐of‐neck access techniques. First‐pass tracheal tube placement was obtained in 101 out of the 104 cricothyroidotomies (p = 0.31). They concluded that anaesthetists can be trained to perform surgical front of neck access to an acceptable level of competence and speed via simulator training

What needs to happen? Anesthesiology residents need to be trained to do front of neck access, and they need to be trained not to delay if the procedure is indicated. This training needs to be a requirement for all anesthesia professionals. Mid-career anesthesiologists pay for weekend Continuing Medical Education courses on subjects such as ultrasound-directed regional blocks or transesphogeal echocardiography. While these topics are important, they are not life-saving skills such as front of neck access. Anesthesiologists in training, practicing anesthesiologists, and Certified Registered Nurse Anesthetists (CRNAs) must receive hands-on education on performing front of neck access, as well as the reasoning behind not delaying the procedure. 

You’re an anesthesiologist or a CRNA. What should you do now?

  1. Familiarize yourself with the anatomy of the cricothyroid membrane on each of your patients.
  2. Have a scalpel, bougie, tube kit containing a #10 scalpel, a bougie, and a #6 cuffed endotracheal tube included with each difficult airway cart at each facility you anesthetize at.
  3. I now carry a scalpel, bougie, tube kit in my briefcase which I take with me every day at work. In the current model of private practice in California, where we work at multiple different freestanding surgery centers and surgeon offices, this is a reliable means to assure that I have front of neck access equipment with me wherever I anesthetize patients.
  4. Review and rehearse the anatomy and skills necessary to perform front of neck surgical cricothyroidotomy.
  5. Work to avoid “can’t intubate, can’t oxygenate” events. Evaluate each airway prior to surgery. If a significant concern exists regarding a difficult intubation, a difficult mask ventilation, or difficult front of neck access, use your judgment and perform an awake intubation. Securing an airway prior to anesthesia induction is a reliable way to avoid “can’t intubate, can’t oxygenate” disasters.

The closed claims study on difficult tracheal intubation in the October 2019 issue of Anesthesiology should serve as a bellwether for our profession. The practices of waiting for surgeons to arrive to do front of neck access, or of anesthesiologists delaying front of neck access in a “can’t intubate, can’t oxygenate” emergency must cease. Emergency front of neck access must be a core skill that all anesthesiologists are both willing and able to perform when a patient is turning purple before their eyes. 

We owe it to our patients to be ready to save their lives.


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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
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The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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EXTUBATION IS RISKY BUSINESS. WHY THE CONCLUSION OF GENERAL ANESTHESIA CAN BE A CRITICAL EVENT

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.
email rjnov@yahoo.com
phone 650-465-5997
preparing to remove an endotracheal tube from a patient

Every general anesthetic has risk. In the immortal words of Forrest Gump, “Sh*t happens.” The conclusion of most general anesthetics requires the removal of a breathing tube. The removal of this airway tube, an event called “extubation,” is a critical and sometimes dangerous event. Extubation is risky business.

The most invasive type of airway tube used in anesthesia is called an endotracheal tube, or ET tube. At the onset of general anesthesia anesthesiologists place an ET tube through the mouth, past the larynx (voice box), and into the trachea (windpipe). The ET tube is a conduit to safely transfer oxygen and anesthesia gases into and out of the lungs.

After a surgery is finished, anesthetic gases and intravenous anesthesia drugs are discontinued, and the patient wakes up within 5 to 15 minutes. If the patient has an ET tube, it is usually removed. Anesthesiologists are vigilant during extubation. In contrast, other operating room professionals are usually relaxed and winding down at this time, because the surgical procedure is finished. Extubation is not a time to relax. The incidence of respiratory complications (e.g. low oxygen saturations or airway obstruction) occurred at a significantly higher rate following extubation than during induction of anesthesia (P < 0.01).

The Difficult Airway Society Guidelines for the Management of Tracheal Extubation state that “tracheal extubation is a high-risk phase of anesthesia. The majority of problems that occur during extubation and emergence are of a minor nature, but a small and significant number may result in injury or death.”

Let’s examine five actual post-extubation scenarios that caused death, complications, or a near-miss: 

  1. During my first month of anesthesia training at a county hospital in San Jose, California, I chose to try to wake up a healthy patient without the presence of my faculty member. When I removed the endotracheal tube, the patient was unable to breathe and his oxygen level dropped acutely. I didn’t know what to do, and in a panic I paged my faculty member. He entered the operating room, elbowed me aside, assessed the diagnosis of laryngospasm, applied an anesthesia mask over the patient’s face, and began a chin-lift maneuver while forcing positive pressure oxygen into the patient via the mask. Within ten seconds the patient coughed, began breathing, and the oxygen level rose to safe levels. I was aghast with the acute deterioration I had neither predicted nor known how to remedy. The faculty member looked me in the eye and said, “Don’t take out the endotracheal tube until the patient opens his eyes.” I took that endotracheal tube out too early because I was inexperienced—still years away from finishing my anesthesia training. Laryngospasm occurs when the vocal cords clamp together following removal of the ET tube. This is usually caused by saliva or blood on the vocal cords during an intermediate phase of anesthesia. Laryngospasm is a vocal cord reflex which closes the cords to protect the trachea from aspirating fluid into the lungs. When the vocal cords remain closed, no oxygen can pass and an individual can die. The Difficult Airway Society Guidelines for the Management of Tracheal Extubation (see below), published in 2012, recommend to “wait until awake, eye opening/obeying commands,” just as my faculty member advised me in 1986.
Difficult Airway Society Guidelines “low risk” algorithm
NOTE: “Wait until awake (eye opening/obeying commands)”
  • A 40-year-old male presented for outpatient surgery on his nose. His past medical history was positive for obesity (220 pounds, 5 feet 6 inches tall) and hypertension. Anesthesia was induced with propofol, fentanyl, and rocuronium, and an ET tube was easily placed. The surgery concluded 2 hours later and the anesthetics were discontinued. The patient began to cough. The anesthesiologist decided to extubate the trachea at that time. After extubation the patient continued to make respiratory efforts, but no airflow was noted. The blood oxygen saturation dropped to a dangerous level of 78%. The anesthesiologist was unable to reintubate the trachea due to poor visibility. The oxygen saturation dropped to 50%. Seven minutes later, the anesthesiologist was finally able to replace the ET tube. Copious secretions were suctioned out of the tube, ventilation remained difficult, and the oxygen saturation level remained in the 50% range. The patient’s ECG deteriorated into a cardiac arrest. He was resuscitated, and 20 minutes later his oxygen saturation finally rose to 94%. A chest x-ray showed pulmonary edema, meaning that the lungs were full of fluid. The diagnosis was laryngospasm leading to negative pressure pulmonary edema. When a patient powerfully attempts to inhale against the obstructed vocal cords of laryngospasm, the negative pressure of each inhale moves fluid from blood vessels into the airway spaces of the lungs, a phenomenon is called negative pressure pulmonary edema. This patient was eventually declared brain dead due to prolonged his prolonged low oxygen levels.
Chest X-ray showing increased lung water in negative pressure pulmonary edema
  • A 40-year-old male presented for a routine elective upper GI endoscopy procedure. He was morbidly obese, with a weight of 380 pounds and a height of 5 feet 4 inches. The anesthesiologist induced anesthesia with propofol and paralyzed the patient with rocuronium in order to place the ET tube prior to the procedure. The procedure lasted only 15 minutes. The paralysis was reversed by the drug combination of neostigmine 5 mg and Robinul 1 mg, and patient was extubated awake. In the first minute it became clear that the patient was still partially paralyzed and unable to ventilate himself. The blood oxygen level dropped acutely to life-threatening levels. The anesthesiologist then performed an emergency reintubation to replace the ET tube to again ventilate oxygen into the patient’s lungs to save his life. (Note- this case occurred in 2015, prior to the availability of sugammadex, a new intravenous drug which rapidly and reliably reverses rocuronium paralysis in a minute or less.) 
  • An 80-year-old female presented for elective right elbow surgery. She was obese (220 pounds, 5 feet tall), had a past history of congestive heart failure, and had her aortic valve replaced two years earlier. She had a history of shortness of breath climbing one flight of stairs. The anesthesiologist induced anesthesia with propofol and rocuronium, and placed an ET tube. At the conclusion of surgery, the anesthetics were discontinued. While the ET tube remained in place, her blood pressure climbed to a high of 200/120, her heart rate climbed to 120 beats per minute, and white froth began to occlude the inside of the ET tube. This fluid was pouring out of her lungs due to acute congestive heart failure caused by marked hypertension. During extubation, 10 – 30 % increases in both heart rate and blood pressure can occur. Hypertension and increased heart rate must be monitored and treated during the extubation of patients with cardiac disease. The patient was ventilated with 100% oxygen, an arterial line was placed in the radial artery in her wrist to continually monitor her elevated blood pressure, and an emergency infusion of an ICU antihypertensive drug called nitroprusside was started. The nitroprusside decreased the blood pressure to 150/80, she was re-sedated with propofol, and she was transferred to an ICU with the ET tube still in place. A myocardial infarction was ruled out by blood tests. The ET tube was removed in the ICU the following morning. She walked out of the hospital two days later. 
  • A healthy 4-year-old female had a general anesthetic for elective surgery to reconstruct her middle ear. After a ninety-minute surgery, the anesthetics were discontinued. Five minutes later she opened her eyes. Just seconds prior to the planned extubation, the patient vomited 100 milliliters of brown solid and liquid material which overflowed from her mouth. The anesthesiologist inserted a suction catheter into her mouth to remove the vomitus. The lung examination with a stethoscope confirmed normal breath sounds. The patient’s vital signs remained normal and the ET tube was removed. The patient suffered no respiratory distress, and the lungs were free from of the stomach contents. The cuffed ET tube prevented aspiration of the vomitus into her lungs. If her ET tube had been removed at any point prior to the vomiting, it’s likely the solid and liquid stomach contents would have descended into her lungs, clogged and obstructed her lower airways, and required insertion of a new ET tube and transfer to an ICU for treatment of aspiration of stomach contents into the lungs. 

My advice to anesthesia professionals regarding extubation is to:

  • Review the Difficult Airway Society Guidelines for the Management of Tracheal Extubation. The guidelines advise awake extubation. My advice, in line with this publication, is: The ET tube is your friend. Don’t pull it out until you’re certain you don’t need it any more. Prior to extubation, many patients will struggle and move prior to the time they open their eyes or can obey commands. An onlooking surgeon will at times say, “can you take the tube out now? The patient is going to rip their sutures out or have bleeding from the surgical site.” At times anesthesiologists will comply and remove the ET tube earlier at this request. Most of the time there will be no serious complication, but there will at times be complications of airway obstruction, laryngospasm, or low oxygen levels. If a bad outcome occurs, the anesthesiologist will own the complication. No one will blame the surgeon.
  • Pass the American Board of Anesthesiologists oral board examination, and become board-certified in anesthesiology. The time spent studying for the oral boards will make you a safer and smarter anesthesiologist who is better prepared to handle emergency situations. A study in Anesthesiology showed rates for death and failure to rescue from crises were greater when anesthesia care was delivered by non-board certified midcareer anesthesiologists. In the Stanford Department of Anesthesiology, we administer mock oral board examinations to the residents and fellows twice a year. Managing a sudden hypoxic episode is a common question during the oral exam. If you can think well in a room in front of two examiners, you are more likely to think well in a true emergency when your patient’s life is at stake.
  • If you have access to anesthesia simulator sessions, enroll yourself. Like the flight simulator training that commercial pilots are required to complete, anesthesia simulators hone the emergency skills of individual anesthesiologists.

What if you’re a patient and you’re contemplating surgery? How can you optimize your chances to avoid an anesthetic complication? I offer these suggestions:

  • Choose to have your surgery at a facility that is staffed with American Board of Anesthesiology board-certified physician anesthesiologists.
  • Ask a knowledgeable medical professional to recommend a specific anesthesiologist at your facility, and request that specific anesthesiologist for your care.
  • Inquire about who would manage your crisis if you have one during or after your surgery. Will your anesthesia professional be a physician anesthesiologist, a Certified Registered Nurse Anesthetist (CRNA), or an anesthesia care team made up of both? If an anesthesia care team is attending to you, how many rooms is each physician anesthesiologist supervising? How far away or how many minutes away will your physician anesthesiologist be while you are asleep?
  • In the future, quality of care data will be available on facilities and physicians, including anesthesiologists. These metrics will allow patients to compare facilities and physicians. Do your homework with whatever data is publicized. Research the facility you are about to be anesthetized in.
  • You are a higher risk patient if you have: significant obesity, obstructive sleep apnea, heart problems, breathing problems, age > 65, if you’re having regular dialysis, emergency surgery, abdominal surgery, chest surgery, major vascular surgery, cardiac surgery, brain surgery, regular dialysis, a total joint replacement, or a surgery involving a high blood loss. Be aware you’re at a higher risk, and ask more questions of your surgeon and your anesthesia provider. 

Neither anesthesia providers nor patients want to be victims of an anesthetic emergency that leads to a bad outcome.

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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
Will I Have a Breathing Tube During Anesthesia?
What Are the Common Anesthesia Medications?
How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
What Are the Anesthesia Risks For Children?
The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
10 Trends for the Future of Anesthesia
Should You Cancel Anesthesia for a Potassium Level of 3.6?
12 Important Things to Know as You Near the End of Your Anesthesia Training
Should You Cancel Surgery For a Blood Pressure = 178/108?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?



LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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DOCTOR VITA IS COMING

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.
email rjnov@yahoo.com
phone 650-465-5997
artificial_intelligence_ai_healthcare

My name is Rick Novak, and I’m a double-boarded anesthesiologist and internal medicine doctor and a writer of medical fiction. I’m here to talk about Doctor Vita, a vision of the future of Artificial Intelligence in Medicine.

I’m an Adjunct Clinical Professor of Anesthesiology, Perioperative and Pain Medicine at Stanford and the Deputy Chief of the department. I don’t tout myself as an expert in AI technology, but I am an expert in taking care of patients, which I’ve done in clinics, operating rooms, intensive care units, and emergency rooms at Stanford and in Silicon Valley for over 30 years.

AI is already prevalent in our daily life. Smartphones verbally direct us to our destination through mazes of highways and traffic. Self-driving cars are in advanced testing phases. The Amazon Echo brings us Alexa, an AI-powered personal assistant who follows verbal commands in our homes.Artificial intelligence in medicine (AIM) will grow in importance in the decades to come and will change anesthesia practice, surgical practice, perioperative medicine in clinics, and the interpretation of imaging. AI is already prevalent in our daily life. Smartphones verbally direct us to our destination through mazes of highways and traffic. Self-driving cars are in advanced testing phases. The Amazon Echo brings us Alexa, an AI-powered personal assistant who follows verbal commands in our homes. AIM advances are paralleling these inventions in three clinical arenas:

Surgical Robot

1. Operating rooms: Anesthesia robots fall into two groups: manual robots and pharmacological robots. Manual robots include the Kepler Intubation System intubating robot:

designed to utilized video laryngoscopy and a robotic arm to place an endotracheal tube, the use of the DaVinci surgical robot to perform regional anesthetic blockade, and the use of the Magellan robot to place peripheral nerve blocks.

Magellan robot for placing regional anesthetic blocks

Pharmacological robots include the McSleepy intravenous sedation machine, designed to administer propofol, narcotic, and muscle relaxant:

McSleepy anesthesia robot

and the iControl-RP machine, described in The Washington Post as a closed-loop system intravenous anesthetic delivery system which makes its own decisions regarding the IV administration of remifentanil and propofol. This device monitors the patient’s EEG level of consciousness via a BIS monitor device as well as traditional vital signs. One of the machine’s developers, Mark Ansermino MD stated, “We are convinced the machine can do better than human anesthesiologists.” The current example of surgical robot technology in the operating room is the DaVinci operating robot. This robot is not intended to have an independent existence, but rather enables the surgeon to see inside the body in three dimensions and to perform fine motor procedures at a higher level. The good news for procedural physicians is that it’s unlikely any AIM robot will be able to independently master manual skills such as complex airway management or surgical excision. No device on the horizon can be expected to replace anesthesiologists. Anesthetizing patients requires preoperative assessment of all medical problems from the history, physical examination, and laboratory evaluation; mask ventilation of an unconscious patient; placement of an airway tube; observation of all vital monitors during surgery; removal of the airway tube at the conclusion of most surgeries; and the diagnosis and treatment of any complication during or following the anesthetic.

IBM Watson AI Robot

2. Clinics: In a clinic setting a desired AIM application would be a computer to input information on a patient’s history, physical examination, and laboratory studies, and via deep learning establish a diagnosis with a high percentage of success. IBM’s Watson computer has been programmed with over 600,000 medical evidence reports, 1.5 million patient medical records, and two million pages of text from medical journals. Equipped with more information than any human physician could ever remember, Watson is projected to become a diagnostic machine superior to any doctor. AIM machines can input new patient information into a flowchart, also known as a branching tree. A flowchart will mimic the process a physician carries out when asking a patient a series of increasingly more specific questions. Once each diagnosis is established with a reasonable degree of medical certainty, an already-established algorithm for treatment of that diagnosis can be applied. Because anesthesiology involves preoperative clinic assessment and perioperative medicine, the role of AIM in clinics is relevant to our field.

Artificial Intelligence and X-ray Interpretation

3. Diagnosis of images: Applications of image analysis in medicine include machine learning for diagnosis in radiology, pathology, and dermatology. The evaluation of digital X-rays, MRIs, or CT scans requires the assessment of arrays of pixels. Future computer programs may be more accurate than human radiologists. The model for machine learning is similar to the process in which a human child learns–a child sees an animal and his parents tell him that animal is a dog. After repeated exposures the child learns what a dog looks like. Early on the child may be fooled into thinking that a wolf is a dog, but with increasing experience the child can discern with almost perfect accuracy what is or is not a dog. Deep learning is a radically different method of programming computers which requires a massive database entry, much like the array of dogs that a child sees in the example above, until a computer can learn the skill of pattern matching. An AIM computer which masters deep learning will probably not give yes or no answers, but rather a percentage likelihood of a diagnosis, i.e. a radiologic image has a greater than a 99% chance of being normal, or a skin lesion has a greater than 99% chance of being a malignant melanoma. In pathology, computerized digital diagnostic skills will be applied to microscopic diagnose. In dermatology, machine learning will be used to diagnosis skin cancers, based on large learned databases of digital photographs. Imaging advances will not directly affect anesthesiologists, but if you’re a physician who makes his or her living by interpreting digital images, you should have real concern about AIM taking your job in the future.

There’s currently a shortage of over seven million physicians, nurses and other health workers worldwide. Can AIM replace physicians? Contemplate the following . . . 

All medical knowledge is available on the Internet:

Most every medical diagnosis and treatment can be written as a decision tree algorithm:

Voice interaction software is excellent:

The physical exam is of less diagnostic importance than scans and lab tests which can be digitalized:

Computers are cheaper than the seven-year post-college education required to train a physician:

versus an inexpensive computer:

There is a need for cheaper, widespread healthcare, and the concept of an automated physician is no longer the domain of science fiction. Most sources project an AIM robot doctor will likely look like a tablet computer. For certain applications such as clinical diagnosis or new image retrieval, the AIM robot will have a camera, perhaps on a retractable arm so that the camera can approach various aspects of a patient’s anatomy as indicated. Individual patients will need to sign in to the computer software system via retinal scanners, fingerprint scanners, or face recognition programs, so that the computer can retrieve the individual patient’s EHR data from an Internet cloud. It’s possible individual patients will be issued a card, not unlike a debit or credit card, which includes a chip linking them to their EHR data.

What will be the economics of AI in medicine? Who will pay for it? America spends 17.8% of its Gross National Product on healthcare, and this number is projected to reach 20% by 2025. Entrepreneurs realize that healthcare is a multi-billion dollar industry, and the opportunity to earn those healthcare dollars is alluring.

It’s inevitable that AI will change current medical practice. Vita is the Latin word for “life.” I’ve coined the name “Doctor Vita” for the AI robot which will someday do many of the tasks currently managed by human physicians.

These machines will breathe new life into our present healthcare systems. In all likelihood these improvements will be more powerful and more wonderful than we could imagine. A bold prediction: AI will change medicine more than any development since the invention of anesthesia in 1849. Doctor Vita from All Things That Matter Press describes a fictional University of Silicon Valley Medical Center staffed by both AI doctors and human doctors. How physicians interact with these machines will be a leading question for our future. AI in medicine will arrive in decades to come. Michael Crichton wrote Jurassic Parkin 1990, 29 years ago, and we still do not see genetically recreated dinosaurs roaming the Earth. But we will see AI in medicine within 29 years. You can bet on it.

Here’s a dilemma: In 2018 and 2019 autopilots drove two Boeing 737 Max airplanes to crashes despite the best efforts of human pilots to correct their course. To date there have been 3 deaths of drivers in self-driving Tesla automobiles. What will happen when AI intersects with medicine and we have machines directing medical care? In the spirit of Jules Verne, this century’s trip around the world, to the center of the earth, to the moon, or beneath the ocean’s surface is the coming of Artificial Intelligence in Medicine.

For the bibliography click here.

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The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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ANESTHESIOLOGIST BURNOUT

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.
email rjnov@yahoo.com
phone 650-465-5997

Regarding anesthesiologist burnout: What if I told you 50% of physician anesthesiology trainees suffer burnout, and those trainees average $220,000 in educational debt by the age of 32? 

The term “burnout” was coined in the 1970s by American psychologist Herbert Freudenberger, who used the term to describe the consequences of severe stress and high ideals in helping professions such as doctors and nurses, who sacrifice themselves for others.

The symptoms of physician burnout are recognized as: 

  • Exhaustion
  • Emotional detachment, i.e. feeling alone in the world
  • Self-doubt
  • Feeling helpless, trapped, and defeated
  • Increasingly cynical and negative outlook
  • Decreased satisfaction and sense of accomplishment

Our specialty’s premiere journal Anesthesiology recently published a study by Dr. H. Sun titled, “Repeated Cross-sectional Surveys of Burnout, Distress, and Depression among Anesthesiology Residents and First-year Graduates.” The study reported that “Based on survey data from 2013 to 2016, the prevalence of burnout, distress, and depression in anesthesiology residents and first-year graduates was 51%, 32%, and 12%, respectively. More hours worked and student debt were associated with a higher risk of distress and depression, but not burnout. Perceived institutional and social support and work-life balance were associated with a lower risk of burnout, distress, and depression.”

I completed two residencies in the 1980s at Stanford University Hospital, the first in internal medicine and the second in anesthesiology. The internal medicine residency required 100-hour weeks of service. I worked 30-hour shifts in the hospital every third night on most rotations, without a day off afterwards. The anesthesia residency was 80 hours per week with in-hospital night call.

Were residents burned out in the 1980s? I believe they were, but no one was publishing data on burnout then. Fellow residents I knew committed suicide, became addicted to fentanyl and overdosed, or dropped out of their residencies. We had a battlefield mentality—everyone was stressed, but we marched onward with the goal of finishing our training and entering the early career years. The plot of a popular 1970s medical novel, The House of God by Samuel Shem, involved a cohort of Boston medical interns who had burnout symptoms, and began to cynically dislike their patients and their own lives. In the end these young doctors dropped out of their internal medicine residencies to join cushier specialties such as radiology, dermatology, pathology, ophthalmology, and (gasp) anesthesiology. 

Now we learn that anesthesiology residents have a 50% incidence of burnout. In the Sun study the mean physician age was 32 years, the mean number of hours worked per week was 61, the mean number of night calls/night shifts per month was 5, and 37% of the doctors were females. Females were more likely than males to suffer from burnout (54% vs. 49%, P = 0.002). Seventy-eight percent of the respondents reported having student loan debt, with a median amount of $220,000. 

In 1980 I graduated from the University of Chicago School of Medicine with $23,000 in student debt. In 1984 the average debt for students who graduated from a private medical school was $27,000. Per Consumer Price Index data, $1 in 1980 equaled $3.11 in 2019. Adjusting for inflation, the average student debt from 1984 calculates to $83,970 in 2019 dollars, or roughly 40% of what today’s students are borrowing.  

Among medical specialties studied, anesthesiology has a higher rate of burnout (approximately 48%) than the all-physician average (46%).  Anesthesiology ranks seventh on the list of burnout by specialty, with emergency medicine, internal medicine, neurology, and family medicine having the four highest rates.  

Medical school application rates remain high. In 2019 there were 849,678 applications to U.S. medical schools, and 21,622 students matriculated. The average student applied to 16 schools. It’s terrific that bright students are still interested in becoming physicians. Are they driving themselves toward the twin brick walls of physician burnout and six-figure educational debt? Yes, many of them are.  

The current political healthcare debate includes the prospect of Medicare for All. How would Medicare for All affect anesthesiology? Medicare pays anesthesiologists approximately 20% of what commercial insurance pays anesthesiologists. If Medicare for All ever becomes a reality, those young anesthesiologists who already own $220,000 in student debt will see their income plummet. Paying off their debt will take significantly longer, adding stress to an already stressed young physician’s life. 

If you’re a patient reading this, you might wonder how all this might affect you. Consider this: we all want our doctors to be emotionally and physically healthy. We all want our caretakers to be content, well-reimbursed, non-burned out professionals rather than stressed-out MDs in chronic debt. 

What can be done about physician burnout? Per the Sun article, “Perceived institutional and social support and work-life balance were associated with a lower risk of burnout, distress, and depression,” and “those who believed they maintained an appropriate balance between personal and professional lives and who were satisfied with the level, accessibility, and acceptability of workplace resources were much less likely to suffer from burnout, distress, and depression.” Stanford Medical Center recently hired Tait Shanafelt MD as their first Chief Wellness Officer, in an effort to provide programs with a supportive medical center environment for Stanford physicians. 

I still recommend a career path toward medical school for motivated and qualified students, with these reservations: 

1. It’s important that your medical school and your residency training program have intact resources to support psychologically stressed/burned out/depressed enrollees; and 

2. You need to carefully examine your projected economic stress, i.e. the debt you will incur in your medical training vis-à-vis your expected income in the medical specialty you hope to enter.   

Anticipate psychological stress and debt in your medical training. You’ll need to be well informed and supported in your journey to become a physician in 21st Century America.

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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
Will I Have a Breathing Tube During Anesthesia?
What Are the Common Anesthesia Medications?
How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
What Are the Anesthesia Risks For Children?
The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
10 Trends for the Future of Anesthesia
Should You Cancel Anesthesia for a Potassium Level of 3.6?
12 Important Things to Know as You Near the End of Your Anesthesia Training
Should You Cancel Surgery For a Blood Pressure = 178/108?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?


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THE ELECTRIC CHAIR AND ANESTHESIOLOGY

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.
email rjnov@yahoo.com
phone 650-465-5997

What do the electric chair and anesthesiology have in common? The pertinent Venn diagram includes capital punishment, death by lethal injection, electrocution, and anesthesiology ethics. Anesthesiologists inject intravenous drugs to keep people alive during surgery. No anesthesiologist would be involved in lethal injection procedures or in recommending methods for killing another human being. Lethal injection requires someone to administer anesthetic medications in high concentrations without supporting breathing or cardiac function. On August 15, 2019 the state of Tennessee executed Steven West by electrocution for raping a 15-year-old girl and then killing both her and her mother in 1986. 

When given the option of lethal injection or the electric chair, West chose the chair. Uncertainties regarding current lethal injection drug regimens may have played a part in a recent inmate execution via the electric chair. Let’s look at the issues.

lethal injection table

Capital punishment by lethal injection is a relatively recent development. In 1982 Texas became the first state in the United States to use lethal injection to carry out capital punishment. The three intravenous drugs usually involved in lethal injection were (1) sodium thiopental, a barbiturate drug that induces sleep, (2) pancuronium, a drug that paralyzes all muscles, making movement and breathing impossible, and (3) potassium chloride, a drug that induces ventricular fibrillation of the heart, causing cardiac arrest.  

A barrier to lethal injection arose in January 2011 asHospira Corporation, the sole manufacturer of sodium thiopental, announced that they would stop manufacturing the drug. Hospira had planned to shift production of thiopental from the United States to Italy, but theEuropean Union also banned the export of thiopental for use in lethal injection.

Several death-row inmates have brought courtroom challenges claiming lethal injection violated the ban on “cruel and unusual punishment” found in the Eighth Amendment to the United States Constitution. There are drug regimen factors and technical factors regarding lethal injection problems. Regarding drug regimen factors, alternative sedative drugs such as midazolam, fentanyl, Valium, or hydromorphone have been considered to replace sodium thiopental, but there have been legal challenges as to whether inmates are indeed unconscious under these newer lethal injection recipes. The potential of cruel and unusual punishment can occur if the sedative combination does not reliably induce sleep, so that the individual to be executed is awake and aware when the paralyzing drug freezes all muscular activity. About ten years ago I was contacted by the Deputy Attorney General of a Southern state, who asked me if I would testify that a massive overdose of a single-drug intravenous anesthetic would reliably render an individual unconscious and anesthetized. The Deputy AG sent me the position paper authored by the opposition’s expert for the abolitionist argument. That paper was a massive treatise authored by an MD-PhD anesthesiologist-pharmacologist. The paper was approximately 80 pages long with hundreds of references. The abolitionist movement against capital punishment is strong. I declined to testify in support of the state’s lethal injection protocol. 

There are also technical factors involved with intravenous injection. A 100-fold overdose of a sedative should render an inmate asleep, correct? Not necessarily. What if the intravenous catheter or needle is incorrectly positioned, and the drug does not enter the vein in a reliable fashion? Is this a possibility? It is. If the catheter is not inserted by a trained medical professional it’s possible that the catheter will be outside of the vein, and the intended medications will spill into the soft tissues of the arm. The intended site of action of intravenous anesthetic drugs is the brain. To reach the brain the drug must be correctly delivered into a vein. Cases in which failure to establish or maintain intravenous access have led to executions lasting up to 90 minutes before the execution was complete. Thus the role of a medical professional to insert the intravenous catheter and administer the lethal injection is critical. The dilemma is that medical professionals are trained to save lives, not to execute people. The Hippocratic Oath clearly states that physicians must “do no harm” to their patients.

The American Medical Association states, “A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution.”

The American Society of Anesthesiologists states, “Although lethal injection mimics certain technical aspects of the practice of anesthesia, capital punishment in any form is not the practice of medicine . . . The American Society of Anesthesiologists continues to agree with the position of the American Medical Association on physician involvement in capital punishment. The American Society of Anesthesiologists strongly discourages participation by anesthesiologists in executions.”

The American Nurses Association states, “The American Nurses Association is strongly opposed to nurse participation in capital punishment. Participation in executions is viewed as contrary to the fundamental goals and ethical traditions of the profession.”

Without a trained medical professional to administer the intravenous catheter and inject the drugs in a reliable fashion, the practice of lethal injection has stalled in the State of California. Since 2006 there have been no death penalty executions by lethal injection in the state of California. In February 2006, U.S. District Court Judge Jeremy D. Fogel blocked the execution of a convicted murderer because of concerns that if the three-drug lethal injection combination was administered incorrectly it could lead to suffering for the condemned, and potential cruel and unusual punishment. This led to a moratorium of capital punishment in California, as the state was unable to obtain the services of a licensed medical professional to carry out an execution. There are currently over 700 inmates on death row in California.

Death by electrocution reentered the news this month. In the electrocution method, the condemned inmate is strapped to a wooden chair and high levels of electric current are passed through electrodes attached to the head and one leg. Lethal injection has been considered a more humane method of capital punishment than the electric chair. Tennessee provided inmates with a choice of the electric chair or lethal injection, and inmate Steven West chose the electric chair. Will electrocution replace lethal injection as the most common form of capital punishment in the United States? There is no current trend to support this. In 2018 there were 23 capital punishment executions by lethal injection, and only 2 by the electric chair. In 2019 there have been 10 capital punishment executions by lethal injection, and only one by electrocution.

Challenges to lethal injection are ongoing, and are in the domain of lawyers and courtrooms. If current lethal injection methods are ruled cruel and inhumane or if they are ruled unconstitutional, and states cling to the goal of capital punishment, we may see more headlines like this month’s electric chair execution from Tennessee. 

For previous columns regarding lethal injection procedures, see

JANUARY 2014 LETHAL INJECTION WITH MIDAZOLAM AND HYDROMORPHONE . . AN ANESTHESIOLOGIST’S OPINION, and

APRIL 2014 LETHAL INJECTION IN OKLAHOMA . . . AN ANESTHESIOLOGIST’S VIEW.

LETHAL EXECUTION USING FENTANYL . . . AN ANESTHESIOLOGIST’S OPINION https://wordpress.com/post/theanesthesiaconsultant.com/2738

APRIL 2014 LETHAL INJECTION IN OKLAHOMA – AN ANESTHESIOLOGIST’S VIEW

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The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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DO DOCTORS EVER RIDE IN AMBULANCES?

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.
email rjnov@yahoo.com
phone 650-465-5997

Do doctors ever ride in ambulances? Ambulances are a territory usually staffed by Emergency Medical Technician (EMT) personnel, but yes, in certain emergencies doctors do ride in ambulances.

In the process of doing 30,000 anesthetics, I’ve taken several rides in the back of an ambulance with my patients. Why? Sixty-six percent of surgeries in the United States take place as an outpatient, and many of these surgeries are performed at freestanding facilities distant from hospitals. When a patient decompensates emergently at a freestanding ambulatory surgery center or in an operating room at a doctor’s office, the facility will call for an ambulance staffed with EMT personnel. If the patient is unstable, a physician, usually an anesthesiologist, will need to accompany the patient and the EMTs to the hospital emergency room.

The following are examples of cases in which I or my colleagues have ridden in ambulances from freestanding surgery centers to the Stanford Emergency Room and Stanford Hospital in Palo Alto, California:

  1. A 3-year-old girl developed negative pressure pulmonary edema with plummeting pulse oximetry readings 10 minutes after a tonsillectomy. Her breathing tube had been removed, but she developed upper airway obstruction in the Post Anesthesia Care Unit (PACU) and needed urgent reintubation. She was extubated one hour later at the surgery center after treatment with diuretic, oxygen, and ventilation via the tube. She was then transferred to the hospital for overnight observation of her airway, pulmonary function, and oxygenation. The duty in the ambulance included monitoring her oxygenation, her airway and her breathing.  The presence of an anesthesiologist was reassuring to the stunned parents who had no expectation of a complication after a common surgery such as a tonsillectomy. The patient was discharged the following day without further complication.
  2. A 75-year-old female underwent lateral epicondylitis release surgery on her right elbow, and developed acute pulmonary edema with failing oxygen saturation levels at the conclusion of surgery. The patient had a past history of aortic stenosis, and had her aortic valve replaced with a small metal valve two years earlier. She was active, although she did experience mild shortness of breath on walking stairs. She was obese with a BMI=35. She received a general anesthetic with an endotracheal tube. The surgery was simple and the surgical duration was only 17 minutes. When the anesthetics were discontinued at the end of surgery, her blood pressure climbed to markedly high levels, and her heart failed to pump effectively against the elevated blood pressure. Pulmonary edema fluid filled her lungs and filled the hoses of the anesthesia machine. Her oxygenation returned to normal after titrating her BP down with a nitroprusside drip, and her blood pressure needed to be monitored continuously by an arterial line inserted into her radial artery at the wrist. The duty in the ambulance included ventilating the patient via the Ambu bag, keeping the patient sedated, watching the arterial line pressure continuously, and titrating the level of the vasodilating nitroprusside infusion. She remained intubated overnight in the hospital and was extubated the next day. She survived without any further complication and did not have a myocardial infarction. 
  3. A healthy 45-year-old woman developed acute hypotension 6 hours following a laparoscopic hysterectomy. The surgery was done in a small community hospital where there was no ICU, blood bank, or emergency room. The patient had multiple low-normal blood pressure readings over the first 5 hours postoperatively, and was being observed by the nursing staff. At hour 6 her blood pressure dropped to a dangerously low level and her hematocrit level on a portable device came back as 9.9%, indicative of a severe acute anemia. She was transferred urgently to the hospital. The duty in the ambulance included resuscitation with IV fluids, and observation of her airway and breathing as her level of consciousness dropped. She required repeat surgery at the hospital to control the intraabdominal bleeding, as well as preoperative transfusion to treat her anemia and hypovolemic shock.

These three cases are examples of surgical patients who became acutely ill miles from the nearest hospital. Each case illustrates how a failure of airway, breathing, or circulation can lead to an emergency. The problem in the first case was airway obstruction leading to pulmonary edema. The problem in the second case was lungs filled with fluid which made normal breathing impossible. The problem in the third case was bleeding which caused the normal circulation of blood within the body to be inadequate.

Why did an anesthesiologist travel with each patient? 

  1. Each patient was extremely sick and required acute monitoring and treatment, and medical decisions needed to be made during the trip to the hospital. EMTs are trained in resuscitation, but EMT training is only a fraction of anesthesiologist training. Having the anesthesiologist who was already resuscitating the patient continue to care for the patient en route to the hospital was the wisest course.
  2. Acute medical emergencies are defined by resuscitation of Airway-Breathing-Circulation. Anesthesiologists are the physicians with the highest level of airway skills, as well they are experts in acute resuscitation. If any physician is to travel with the patient, an anesthesiologist is the wisest choice to manage Airway-Breathing-Circulation in ongoing emergencies.
  3. Medical-legal risk is minimized if the most highly trained physician involved in the case continues to manage the case. The handoff or transfer of medical care from one practitioner to another is a high risk time for errors. The anesthesiologist  is responsible for the safety and care of his or her patient, and the highest continuity of care occurs when the anesthesiologist who managed the emergency attends to the patient during the transfer to the hospital.

I’ve been the Medical Director at a freestanding surgery center near Stanford for the past 17 years. Surgery centers strive to minimize the potential of emergencies in outpatient surgeries. Medical Directors work to limit the types of cases performed in a freestanding surgery center. This includes avoiding procedures that cause major pain, bleeding, or disruption of physiology. Typical surgeries performed in freestanding centers include:

  • Arthroscopic orthopedic surgeries
  • Simple ear nose and throat surgeries
  • GI endoscopies and colonoscopies
  • Simple general surgery procedures
  • Simple ophthalmologic surgeries
  • Plastic surgeries

Surgery centers also strive to operate on healthier patients who lack major comorbidities. Surgery centers are reluctant to approve general anesthesia in a freestanding outpatient setting to patients who have: 

  • Severe sleep apnea
  • Severe cardiac problems such as shortness of breath or ongoing chest pain
  • Severe morbid obesity or super-morbid obesity
  • Renal dialysis
  • Severe abnormal airways
  • Markedly abnormal blood pressures, heart rates, or blood oxygen levels

Regarding ambulance rides, no one is going to advocate that MDs take over EMTs roles regarding riding in ambulances. But when surgery or anesthesia leads to an acute event at a site distant from a hospital, the anesthesiologist involved in that patient’s care is responsible for that patient’s safety and for the ongoing care and resuscitation. The anesthesiologist will be riding in the ambulance and doing what anesthesiologists routinely do–managing Airway-Breathing-Circulation.

If any anesthesia professionals have stories regarding their own emergency ambulance rides resuscitating patients, I invite you to share them with my readers. 

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The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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REGARDING THE FRENCH ANESTHESIOLOGIST ACCUSED OF MURDER

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.
email rjnov@yahoo.com
phone 650-465-5997
RMJAPURVG5IFIP5JZYX75LU3QY A French anesthesiologist was accused of poisoning patients to trigger cardiac arrests during surgery. Nine patients died. Dr. Frédéric Péchier is apparently suspected of injecting lethal doses of potassium chloride or anesthetics into intravenous bags either prior to or during simple surgeries. This allegedly caused patients to have cardiac arrests, giving Dr. Péchier  a setting to arrive on scene quickly after the event and “rescue” the patients. It is alleged that this gained him the respect of fellow doctors and the admiration of his victims. The 47-year-old physician denied the charges. Prosecutors said Péchier was the only medical doctor present during all the incidents where traces of poison were found or when the overdoses were diagnosed. Frederic Pechier was arrested and now stands charged in twenty-four cases, nine of which resulted in death. He worked as an anesthesiologist in the eastern French city of Besançon. I have no inside knowledge on the cases except for what has been reported in the lay press, but I can present a possible and plausible explanation for what the prosecutors are theorizing. Let’s begin with a discussion of intravenous (IV) potassium injection. In the 1990s Dr. Jack Kevorkian devised an assisted-suicide machine for patients who wanted to end their lives. The machine gave three sequential IV injections. The first drug was sodium pentothal, which induced sleep. The second drug was pancuronium, which paralyzed the muscles and stopped movement and breathing. The third drug was potassium chloride, which caused cardiac arrest and stopped the heartbeat. IV potassium in high doses is lethal. I authored a chapter on Disorders of Potassium Balance in Complications in Anesthesia, 3rdEdition, 2017, edited by Drs. Lee Fleisher and Stanley Rosenbaum. Potassium plays an important role in the chemistry of excitable cells such as cardiac muscle cells. Potassium is the principal cation or element inside the cells, and disorders of potassium balance can cause life-threatening arrhythmias. More than 98% of total body potassium is located inside cells, rather than in the bloodstream. The normal serum potassium concentration in the bloodstream is 3.5-5.3 mEq/L, but the potassium concentration inside a cell is about 30-40 times higher. When the serum potassium level rises acutely, cardiac arrythmias result. A high index of suspicion is required to diagnose an elevated concentration of potassium in the bloodstream (hyperkalemia). Acute hyperkalemia presents with electrocardiogram (ECG) changes including  narrowed peaked T waves, widening of the QRS complex, and progression to ventricular tachycardia, fibrillation, or a cessation of the heartbeat. Normal healthy patients almost never have hyperkalemia. Dialysis patients who are without functioning kidneys are at the highest risk for hyperkalemia. Other causes of hyperkalemia are massive transfusion due to the potassium accumulated in blood bags during preservation, episodes of massive cell damage such as major trauma or third-degree burns, or accidental iatrogenic injections of intravenous potassium in a medical  setting. The treatment of hyperkalemia is very specific. The cardiac effects of hyperkalemia are reduced by calcium gluconate or calcium chloride, which antagonize the effect of the elevated potassium concentration on heart cell membranes. As well, administration of intravenous glucose and insulin decreases the serum potassium concentration by shifting potassium from the bloodstream into cells.   If the French patients had acute hyperkalemia due to a massive overdose of potassium injected into an IV bag, an initial presentation would likely be cardiac rhythm disturbances which deteriorated into ventricular fibrillation and a cardiac arrest. This would not respond to traditional therapy such as shocking the patient or administering IV adrenalin, because the etiology of the problem—hyperkalemia—would remain untreated. If a physician somehow guessed that the serum potassium was elevated and administered IV calcium followed by IV insulin and glucose, this could lead to successful resuscitation. However, we must note that there is no time to measure the blood potassium level in an acute setting such as a cardiac arrest, and there would be no reason at all for a healthy patient undergoing a routine surgery to have an acute hyperkalemic episode. If a healthy patient had a cardiac arrest and a doctor guessed that calcium, insulin, and glucose would revive the patient, and if the potassium concentration in the patient’s blood was assayed later and found to be markedly elevated, then this would be a very suspicious set of circumstances. Let’s move on to the discussion of an overdose of IV local anesthetic drug.  An IV injection of the local anesthetic bupivacaine (Marcaine) in a high concentration is known to cause cardiac arrest. There is only one reliable and specific antidote for an overdose of IV bupivacaine, and that is the IV injection of intralipid. If a healthy patient had a cardiac arrest and a doctor guessed that an injection of intralipid would revive the patient, and if the bupivicaine concentration in the patient’s blood was assayed later and found to be markedly elevated, then this would also be a very suspicious set of circumstances. How could these drugs—potassium or bupivacaine—ever wind up in a patient’s IV? I am forced to speculate, but consider this:  Prior to surgery all patients have an IV placed in their arm and a liter bag of fluid—either sodium chloride or Lactated Ringer’s solution—is attached to that IV. The IV line is the route in which anesthesiologists inject drugs into the patient’s bloodstream to induce sleep. The contents of the plastic IV bag of 1000 milliliters of normal saline or Lactated Ringer’s solution drips into the patient’s bloodstream over the first hour of surgery. If an individual injected a toxic dose of potassium or bupivacaine into the liter bag, in an undetected fashion in a preoperative setting, then that toxic dose would be infused over the first hour of the anesthetic when the individual who introduced the toxin is not present in the operating room at all. When the cardiac arrest predictably occurs, the individual could arrive on scene with the antidote of either calcium-insulin-glucose or intralipid, and be cited as a hero. Once again, at this time I have no specific knowledge about the medical evidence from France, But let’s hope none of the facts point to murder. I’m a great believer in the professionalism of physicians, and I would prefer that nothing illegal, immoral, or unethical happened with these cases. Stay tuned in the months to come to learn what evidence is presented, and eventually we’ll all learn what happened in the trial of Dr. Frédéric Péchier. * * The most popular posts for laypeople on The Anesthesia Consultant include: How Long Will It Take To Wake Up From General Anesthesia? Why Did Take Me So Long To Wake From General Anesthesia? Will I Have a Breathing Tube During Anesthesia? What Are the Common Anesthesia Medications? How Safe is Anesthesia in the 21st Century? Will I Be Nauseated After General Anesthesia? What Are the Anesthesia Risks For Children? The most popular posts for anesthesia professionals on The Anesthesia Consultant  include: 10 Trends for the Future of Anesthesia Should You Cancel Anesthesia for a Potassium Level of 3.6? 12 Important Things to Know as You Near the End of Your Anesthesia Training Should You Cancel Surgery For a Blood Pressure = 178/108? Advice For Passing the Anesthesia Oral Board Exams What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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INTRAVENOUS CAFFEINE FOLLOWING GENERAL ANESTHESIA

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.
email rjnov@yahoo.com
phone 650-465-5997

Data exists that intravenous caffeine may be effective in assisting the awakening of patients following general anesthesia. Will future anesthesiologists routinely use caffeine to wake patients after surgery? Will a shot of IV espresso be the stimulus for you to return to consciousness after your general anesthetic? Perhaps. 

Caffeine is the most popular and commonly used psychoactive drug in the world.In 2014 85% of American adults consumed some form of caffeine daily, 164 mg/person/day on the average.1A cup of coffee contains from 80 to 120 mg of caffeine.A 12-ounce cola contains from 30 to 50 mg. Currently intravenous caffeine is marketed as a three milliliter ampule that contains only 20 mg/ml of caffeine, or 60 mg total. Multiple commercial energy drinks include significantly higher doses of caffeine per the chart below

The safety of caffeine has been well established, and the energy drink market is expected to reach 83.4 billion dollars by 2024.

The market share for leading energy drink brands is shown below.

 

Intravenous caffeine post-surgery is not a new idea. When I first went into the private practice of anesthesia in 1986, gray-haired anesthesiologists at our community hospital in Fremont, California occasionally injected 100 mg of caffeine into a patient’s IV after a surgery if the patient was slow to wake. “It helps a lot!” my fellow anesthesiologists reported. I tried it on several of my patients who had prolonged awakening after general anesthesia. It seemed to speed the time to eye opening, but I had no metrics or data to evaluate whether this was a bona fide finding. Now we have more information.

The Department of Anesthesia and Critical Care at my alma mater the University of Chicago School of Medicine published two landmark papers on IV caffeine and anesthesia awakening. The first studies were conducted on rats.2Researchers placed rats in a gas-tight anesthesia box where the animals were exposed to 3% isoflurane until they became unconscious. The rats were then removed from the box, 2% isoflurane was delivered to them via an anesthesia nose cone, an intravenous line was inserted into their tails, and the rats were returned to the anesthesia box. After a total of 45 minutes of exposure to isoflurane, either IV caffeine 25 mg/kg or a placebo was injected into the IV. Anesthesia was terminated 5 minutes later and the rats were placed on their backs on a table. The recovery time was the time from when the animals were removed from the anesthesia box until they stood with four paws on the table. Rats who received IV caffeine doses awakened more quickly (in as quick as only 40% of the time) compared to those who received placebo.

In a second experiment they exposed rats to propofol anesthesia. The researchers placed the rats in a gas-tight anesthesia box where they were exposed to 3% isoflurane until they became unconscious. The rats were then removed from the box, an intravenous line was inserted into their tails, and they were allowed to wake up. A bolus of 4 mg/kg propofol was injected into the IV along with either 25 mg/kg caffeine or a placebo. Those treated with caffeine woke within an average of 6 minutes compared to 9.8 minutes for controls. There were no vital signs differences between the groups treated with caffeine or placebo in either rat experiment.

The Chicago researchers followed the rat studies with a randomized controlled study on human volunteers.3Eight healthy males each underwent two general anesthetics, one with IV caffeine and one without. The induction was with IV propofol, a laryngeal mask airway (LMA) was placed, and anesthesia was continued with isoflurane for one hour. Ten minutes before the termination of each anesthetic, the subjects were randomized to receive either IV caffeine 15 mg/kg or a saline placebo. (Note that this dose approximates 1000 mg of caffeine for a 70 kg adult, a large dose.) The recovery time was charted as the time from when the isoflurane was discontinued until the time the patient first gagged on the LMA. The average recovery time in the caffeine group was 9.6 minutes versus 16.5 minutes in the control group (P=0.002), a 42% reduction in time. Once again, there were no vital signs differences between the subjects treated with caffeine or with placebo.

Why does caffeine accelerate awakening from anesthesia? The Chicago researchers cited two mechanisms: caffeine acts by inhibiting phosphodiesterase to elevate intracellular cAMP, and it also antagonizes adenosine receptors A1and A2A. Caffeine reversibly blocks the action of adenosine on its receptors and consequently prevents the onset of drowsiness induced by adenosine.

Currently the only medical uses for caffeine are to treat neonatal apnea and to treat migraine or postdural puncture spinal headaches. Despite the fact that caffeine is considered safe,caffeine overdose can result in a central nervous system overstimulation called caffeine intoxication which typically occurs only after ingestion of large amounts of caffeine, (e.g. more than 400–500 mg at a time).4This is only half the dose that Chicago researchers administered in their human study. Symptoms of caffeine intoxication include restlessness, anxiety, a rambling flow of thought and speech, irritability, and irregular or rapid heartbeat.5Massive overdoses of caffeine can result in death. The LD50(lethal dose in 50% of cases) of caffeine in humans is estimated to be 150–200 mg per kilogram of body mass (i.e. 100-130 cups of coffee for a 70 kilogram adult).6

It’s too soon for caffeine use to become routine in the operating room. The Chicago researchers did not envision caffeine as a routine reversal agent for all general anesthetics. Anesthesiologists are skilled at weaning their patients from anesthetics for timely wakeups after the conclusion of most surgeries, but there are always outliers who are slow to wake. For these patients, a dose of IV caffeine may be helpful without introducing any increased risk. The Chicago researchers wrote, “the judicious use of caffeine could provide a tool to accelerate emergence in those individuals who manifest unanticipated prolonged emergence times and populations, such as the elderly, that are prone to prolonged emergence and recovery. . . . Further work is needed, and will follow, to extend these findings to other anesthetics including common IV agents like propofol, as well as demonstrating that these results are reproducible in patient populations, including females, older individuals, and those with chronic medical conditions undergoing operative procedures who receive multiple classes of pharmacologic agents in the course of a normal anesthetic.”

We may see intravenous caffeine following general anesthesia in the future for selected patients. Those private anesthesiologists I worked with in 1986 may have been correct when they injected IV caffeine into their sleepy patients after surgery and judged that “It helps a lot!”

References:

  1. Mitchell DC, et al (January 2014). “Beverage caffeine intakes in the U.S”. Food and Chemical Toxicology. 63: 136–42.
  2. Wang Q, et al. Caffeine accelerates recovery from general anesthesia, J Neurophysiol, 2014 Mar;111(6), 1331-1340.
  3. Fong R, et al. Caffeine accelerates emergence from isoflurane anesthesia in humans, Anesthesiology. 2018 Nov;129(5):912-920.
  4. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). American Psychiatric AssociationISBN 978-0-89042-062-1.
  5.  “Caffeine (Systemic)”. MedlinePlus. 25 May 2000. 
  6.  Holmgren P, Nordén-Pettersson L, Ahlner J (January 2004). “Caffeine fatalities–four case reports”. Forensic Science International. 139 (1): 71–3.

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The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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DOCTOR BY DAY, SCI-FI WRITER BY NIGHT

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.
email rjnov@yahoo.com
phone 650-465-5997

This week the Palo Alto (California) Weekly ran a feature story on Rick Novak and Doctor Vita

Doctor by day, sci-fi novelist by night

Longtime Atherton resident spotlights AI and medicine in books

Dr. Rick Novak poses for a portrait at Stanford Hospital in Palo Alto on May 23. Photo by Magali Gauthier/The Almanac

Between his time in the operating room, teaching, and raising his three sons, Atherton resident Dr. Rick Novak has found time to write two novels.

Novak, 65, an anesthesiologist at the Waverley Surgery Center in Palo Alto, recently published his latest, “Doctor Vita,” a story about an artificial intelligence (AI) physician module that goes awry.

It’s a science fiction novel that explores how technological breakthroughs like artificial intelligence and robots will affect medical care — and already have.

The Almanac, an Embarcadero Media publication which serves Menlo Park, Atherton, Woodside, and Portola Valley California, featured a story “Fiction or the Future?” on Rick Novak and Doctor Vita the same week.

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SURGICAL CASES IN FOREIGN LANDS—INTERPLAST

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.
email rjnov@yahoo.com
phone 650-465-5997

Interplast1-750x403

International Plastic Surgery

Imagine . . . rare unrepaired surgical cases in foreign lands, coupled with surgeons in America who rarely have the opportunity to operate on such cases. A win-win situation would be to fly American medical teams overseas to help these patients. This model for plastic and reconstructive surgery was born at Stanford University Medical Center in the 1960s in an organization named Interplast. During my anesthesia training at Stanford in the 1980s I was present through the growth years of Interplast, when traveling teams were dispatched to countries around the world to perform reconstructive surgeries on cleft lip and palate patients. Interplast was founded by Donald Laub MD, who was the Chief of the Division of Plastic and Reconstructive Surgery at Stanford from 1968-1980.

220px-DRLaub

Donald Laub MD

The idea for Interplast grew from the surgical history of Antonio Victoria, a 13-year-old with cleft lip and palate deformities that made him a social outcast in his home country of Mexico. Antonio arrived at Stanford University Medical Center in 1965. Dr. Robert Chase restored the boy’s appearance with three operations. Dr. Laub witnessed Antonio’s transformation and the idea for Interplast germinated.

In 1969 Dr. Laub founded Interplast (now called ReSurge International) with a mission statement to transform lives through the art of plastic and reconstructive surgery. Dr. Laub chronicles his history on his website Many People, Many Passports. Dr. Laub was the first academic to develop and lead multidisciplinary teams on humanitarian surgical trips to developing countries. The teams included plastic surgeons, anesthesiologists, pediatricians, and nurses experienced in the care of cleft palate reconstructions. The first trip to Mexicali was financed with a mere $500 of donations. Through contact with the governments and medical authorities in four countries, initial trips were scheduled to Mexico, Guatemala, Honduras, and Nicaragua. Seven hundred and fifty patients received treatment during the first five years, and an additional 150 were transported to Stanford for reconstructions in California. Through the 1970s and 1980s Interplast made trips to multiple other countries. The teams were made up of volunteers, and the trips were financed by charity donations.

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Cleft lip deformity before and after reconstruction

Cleft lip and cleft palate deformities were common in Mexico and Central America, and the chances for surgical repair in the poor areas of these countries were minimal. Individuals with other deformities such as extensive burn scars were also social pariahs because of their appearance. Interplast made it a humanitarian goal to reconstruct these patients as well.

In addition to reconstructing patients, Interplast doctors educated local physicians in modern techniques. This was the medical equivalent of “give a man a fish and he eats for a day, but teach a man to fish and he will eat for a lifetime.” The opportunity to reconstruct patients with deforming diagnoses uncommon in the United States was life-changing for the American doctors as well. In the United States, the specialty of plastic surgery was seen as one concerned with enhancing the cosmetic appearance of cash-paying customers who desired a more youthful or beautiful appearance. In the third world, helping change a deformed child’s appearance was a unique emotional reward for American physicians who traveled there.

The administration of the Stanford University School of Medicine understood the value of the program. Stanford lent financial support to Interplast and financed Interplast rotations as part of the residency training programs in plastic surgery and anesthesiology. In our final year of anesthesia residency, each resident was assigned to a one week Interplast trip to perform anesthetics overseas. The week was not a vacation—we were paid during that week and the expenses of our airfare were covered by Interplast. Trip members typically lodged with members of the local community.

In 1986 I was assigned to San Pedro Sula, Honduras for my Interplast experience. Two weeks before we were to depart, our team assignment was changed to Montego Bay, Jamaica. I asked my faculty member if that was a positive change and he remarked, “You just traded the dusty streets of San Pedro for a Caribbean resort city. What do you think?”

Each Interplast anesthesia team included one faculty member and one or more resident. For my trip the anesthesia staff consisted only of myself and one Stanford attending—thus I received both an introduction to international pediatric anesthesia and one-on-one teaching from an experienced professor.

A striking difference between Interplast anesthesia and American anesthesia was the lack of sophisticated equipment overseas. Interplast members carried no narcotic medications across borders, for obvious political reasons. All postoperative pain was treated with local anesthesia injections from the surgeons (if local anesthetics were available), or by verbal reassurance from the nurses in the Post Anesthesia Recovery Unit (PACU). The PACU was often full of children screaming in pain after their palate surgeries. There are many nerve endings in the human palate, and after cleft palate reconstruction the pain is roughly equivalent to the pain of a tonsillectomy without any narcotic analgesia. It was difficult to listen to the children crying, but in time their pain would subside.

In the 1980s Interplast teams carried halothane, a potent liquid general anesthetic, as well as a halothane vaporizer to convert the drug into an inhaled gas. General anesthetics were initiated by holding a mask over a child’s face while they inhaled halothane vapor until they fell asleep. We started intravenous lines after the induction of anesthesia, but we had very few medications to inject into those IVs. Because there were dozens of cases to be done, the anesthesia attending and the anesthesia resident each did their cases alone and independently, in adjoining operating rooms. The rooms were primitive and usually had piped in oxygen, but lacked nitrous oxide availability.

Complications were rare, but their incidence was not zero. The combination of tiny patients, a paucity of medical drugs, a relatively inexperienced (i.e. not fully trained yet) anesthesia resident working alone, no ICU, no laboratory, and no emergency backup made every case an adventure. We had no complications on our trip, but there were a few anecdotes of cardiac or respiratory arrests from my colleagues who went to other countries.

As a partially-trained resident, I’d anesthetized less than 20 children in my life by the time of my Interplast trip. I was nervous during every anesthetic induction and every anesthetic wakeup. There were no American lawyers or malpractice suits to worry about in Montego Bay, but my job required me to accept responsibility for a child’s life. I’d take a child from his or her parents prior to the surgery and I didn’t want anything but a happy ending for that child, his parents, or me at the end of the day. We performed anesthetics from dawn until dusk. The lines of patients awaiting surgery were long, and each family clamored for the opportunity for their child to receive life-changing free surgeries from the American team.

Dr. Laub set the tone for Interplast. He made 159 trips and personally performed over 1500 operations overseas. He was and is a giving, confident, warm, and intellectual visionary. HIs office was decorated with a 1986 photograph of himself and President Reagan in Washington DC, marking the 1986 Private Sector Initiatives award Dr. Laub received for the creation of Interplast.In 2000 Dr. Laub was diagnosed with an aggressive intravascular central nervous system lymphoma. He survived the malignancy but retired from active clinical practice. I admire him for his surgical skills, entrepreneurial skills and positive attitude. No matter what difficulties arose in one’s life, Dr. Laub was ready to listen, quick to smile, and in closing he’d say, “May the wind always be at your back.”

Dr. Laub recently authored Second Lives, Second Chances: A Surgeon’s Stories of Transformation, a book describing his life, his founding of Interplast, and his pioneer work in trans-gender surgery. The link to the book can be found here.

I’ve continued to anesthetize children throughout my career. Anesthetizing toddlers by yourself is not like riding a bike. Once you learn to do it, the skills must be retained with frequent repetition or else you run the risk of being unsafe. The majority of anesthesiologists cease anesthetizing children soon after residency, and choose not to build on the pediatric anesthesia skills they learned as trainees. I feel fortunate that my practice still includes anesthetizing children every week. In part I owe this to Interplast for introducing me to my early pediatric anesthesia experiences.

A medical career requires years of memorizing facts as well as tireless nights and days attending to sick patients to learn the art and science of healing. Interplast taught more—the doctors and nurses who journeyed to foreign lands to improve the lives of poor children reaped the emotional benefits of being a medical professional. Nothing in our job feels better than helping a sick child become healthier or helping a family gain a new lease on that child’s future.

Interplast has now become Resurge International (REF https://www.resurge.org). To date Resurge has performed 95,000 operations in 15 countries. The times are different, but the issues are still the same. Opportunities with Resurge are described on their website.

We’re lucky in America. Despite criticisms of our medical system and its costs, the availability of outstanding medical care is just a few miles down the road for most of us. Interplast patients were elated to benefit from American medicine abroad.

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MEDICARE FOR ALL and Anesthesiology

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.
email rjnov@yahoo.com
phone 650-465-5997

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Multiple Democratic candidates for President of the United States are advocating Medicare for All. Medicare for All would decimate the specialty of physician anesthesiologists in America. Medicare for All would cause an exodus from the specialty of anesthesiology.

I’m an independent voter—neither a Democrat nor a Republican, and this column is not in opposition to Democratic candidates or in any way supportive to a Republican agenda. My aim is to inform my readers, both anesthesia professionals and laypersons, that if Medicare for All becomes reality, there will be a dire consequence regarding anesthesia staffing and services to patients.

The Medicare pay rate for anesthesiologists is a mere fraction of the current insurance pay rate. Based on the 2018 American Society of Anesthesiologists report, the national average insured conversion factor for anesthesia (the amount paid for a 15-minute time period of service) was $76.32. The current national Medicare conversion factor for anesthesia is $22.18, or only 29% of the 2018 overall mean commercial conversion factor.

Anesthesia practices have varying ratios of insured patients, Medicare patients, Medicaid patients (which pay slightly less than Medicare), and patients with no insurance (who often pay zero). What happens if every anesthesia patient pays only Medicare rates in a Medicare for All future? Let’s look at some examples.

If a practice currently has 75% insured patients and 25% Medicare/Medicaid patients, the income for that practice would be (.75 X $76) + (.25 X $22) = $62.50 per unit. Under Medicare for All, their income would be $22.18 per unit. This is a pay cut of $40.32 per unit, or a decrease in pay to 35% of their prior income.

If a practice currently has 50% insured patients and 50% Medicare/Medicaid patients, the income for that practice would be (.50 X $76) + (.50 X $22) = $49 per unit. Under Medicare for All, their income would be would be $22.18 per unit. This is a pay cut of $26.82 per unit, or a decrease in pay to 45% of their prior income.

If a plumber, an accountant, a truck driver, an attorney, or a fast-food worker was forced to take a pay cut to 35%-45% of their previous income, they would be upset. Would they be looking for another career? Probably.

If a physician anesthesiologist is forced to take a pay cut to 35%-45% of their previous income, they will be upset too. Will they be looking for another career? Probably.

Expect the exodus from physician anesthesiology to look like this:

  • Older anesthesiologists would simply retire, rather than work for 35%-45% of their prior income.
  • Medical students who are evaluating different specialties for their lifetime vocation would look at anesthesiology and flee. Even prior to its arrival, it’s possible that the specter of Medicare for All in the near future will drive students away from careers in anesthesiology. Medicare pay rates for anesthesiology are significantly lower than Medicare pay rates for all other specialties. See the graph below, which shows the ratio of commercial pay rates/Medicare rates for various services. For most medical services, the ratio of the average insured payment/Medicare payment is between 1.0 and 2.0. This means that, at the lowest, the average Medicare rates are about 50% of insured rates. You’ll recall that the Medicare anesthesia rate is only 29.1% of insured rates.

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The declining number of the oldest and the youngest physician anesthesiologists would radically decrease the census of anesthesiologists in the United States. This likely would lead to an increased role for certified nurse anesthetists (CRNAs), and an eventual increase in the number of schools training CRNAs, but in the short term there would be no way to staff adequate numbers of anesthesia professionals. It’s possible the U.S. may increase immigration of anesthesiologists from other countries where, their pay rate is less than the new Medicare for All pay rate is in America.

Might Medicare for All be forced to quickly increase anesthesiology payment rates to secure an adequate number of physician anesthesiologists? Perhaps, but I wouldn’t bet on it. Medicare has always been a zero-sum system. If anesthesiologists are going to be paid more, then someone else would be paid less, and it would be hard to predict which specialties would be on the end of that further pay cut.

But take a deep breath and relax. Medicare for All will be debated for some time. Even if a liberal Democrat wins the presidency and Congress gains a majority of Democrats in both the Senate and the House, they will all have to overcome multiple powerful lobbies, including the medical insurance industry, hospitals, the pharmacology industry, and organized physician groups. Currently there are so many jobs and so much money involved in the health care systems in American that the battle of Medicare for All will be a true war. Patients would have a significant transition as well. David Brooks wrote in The New York Times on March 4, 2019, “Right now, roughly 181 million Americans receive health insurance through employers. About 70 percent of these people say they are happy with their coverage. Proponents of Medicare for All are saying: We’re going to take away the insurance you have and are happy with, and we’re going to replace it with a new system you haven’t experienced yet because, trust us, we’re the federal government!”

If you’re a layperson, you may think Anesthesiologists are overpaid right now, that’s the true problem with what you’re discussing in this column. Keep in mind that anesthesiologists must complete four years of college, four years of medical school, and at least four years of post-medical school internship and residency training to become board-eligible for work as a physician anesthesiologist. LINK. This means they are at a minimum 30 years old, have borrowed hundreds of thousands in student loans to pay for their training, and have endured significant delayed gratification compared to others they went to college with. Procedural specialties such as surgery and anesthesiology are higher paying than primary care specialties such as internal medicine or pediatrics. Why? The work of procedural physicians requires specialized skills, and their work incurs more risk than interviewing and examining patients in a clinic. I have worked as both an internal medicine doctor and an anesthesiologist, and I can attest that it is almost impossible to harm a patient in an internal medicine clinic, while it is possible to lose a patient to anoxic brain damage in five minutes in an operating room as an anesthesiologist if you err. Risk during an anesthesia career is omnipresent.

As I stated on the home page of my blog, “The profession of medicine offers a lifetime of fascination, and no specialty is more fascinating than anesthesiology.” In addition, freeing patients from pain and ushering them through surgery safely is a wonderful vocation. But if anesthesiology jobs someday pay 35%-45% of their current income, the exodus of anesthesiologists will occur despite the fascination and emotional rewards of the profession.

Life will go on, there will just be less anesthesiologists, which will be OK unless you need one for your upcoming surgery.

Further information on proposed Medicare for All is available at their home page at http://www.medicareforall.org/pages/Know.

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The most popular posts for laypeople on The Anesthesia Consultant include:

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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FREE SOLO

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.
email rjnov@yahoo.com
phone 650-465-5997

Every anesthesia provider must learn to free-solo anesthesia early in his or her career. The 2018 movie Free Solo showcases Alex Honnold as he became the first person to free solo climb the 3000-feet high El Capitan wall of granite in Yosemite National Park without ropes or safety gear. This has been called the greatest feat in rock climbing history, and the movie is nominated for a 2019 Academy Award in the Feature Documentary category.

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FREE SOLO movie poster 2018

Believe it or not, but Free Solo could have been an anesthesiologist’s movie. How can that be? “Free-soloing” describes the most anxiety–producing event in every anesthesiologist’s life: the transition from anesthesia training when your faculty member is backing up your every move and every mistake, to the real world of anesthesia when you have to do scary cases alone without assistance.

During the dayshift, working alone is seldom an issue for any anesthesiologist. A typical hospital will have dozens of other anesthesia providers working in the same building. Within seconds or minutes, any anesthesiologist can be assisted or bailed out by a colleague.

Unlike Alex Honnold, the anesthesiologist is not putting their own life at risk—rather it is their patient who is at risk. The degree of risk is variable. For healthy patients undergoing elective surgery the anesthetic risks are minimal, and are similar to the risks of driving on a freeway in an automobile. For emergency surgeries, cardiac surgeries, chest surgeries, brain surgeries, or for anesthetics on patients with significant heart, lung, blood pressure, or airway problems, the risks of anesthesia are higher. The patient is totally dependent on their anesthesiologist to return them to consciousness safely.

Commercial aviation is sometimes compared to anesthesia practice. When commercial pilots take off in airliners, their passengers are totally dependent on the pilot to return them to the ground safely. But in commercial aviation there is one important difference: by law there must be a second pilot in the cockpit.

In anesthesia there is no guaranteed second anesthesiologist. There are multiple different models of anesthesia care. In an anesthesia care team, a physician anesthesiologist supervises up to four operating rooms and each operating room is staffed with a certified registered nurse anesthetist (CRNA). In a university hospital, a faculty member may supervise two operating rooms each with a resident anesthesiologist-in-training in attendance. In many hospital operating rooms, a solitary physician anesthesiologist attends to his or her patient alone. In seventeen “opt-out” states in America a solitary CRNA can attend to a patient without any physician anesthesiologist backup. Working alone may be less safe. A 2019 study from Europe reported an outcome advantage for anesthesiologist working in teams: The study showed that anesthesia given by teams of anesthesiologists and anesthesia nurses was associated with decreased 30-day postoperative mortality and a shorter length of stay when compared with solo anesthesiologists. There was no evidence for the specific cause of the decreased mortality.

Because of manpower necessities, there will never be a law mandating a second anesthesiologist for every surgery as there is in commercial aviation. There will always be emergencies at 2 a.m. or on weekend afternoons when all other anesthesiologists are elsewhere. As well, there are tens of thousands of freestanding surgery centers and office operating rooms where only one anesthesia professional is present.

Is there any data in the medical literature documenting that inexperienced anesthesia professionals have a greater incidence of adverse outcomes? Per Pubmed, there is no such publication. But there is no publication that denies the truth of this correlation. There is a paucity of data on the topic. The issue has not been rigorously studied in a scientific basis.

I review malpractice legal cases, and I can attest that inexperienced anesthesia personnel (who are less than board-certified physician anesthesiologists) are involved in many cases. I believe recent graduates are at particular risk when they work alone. In most cases with severe complications, the anesthesia professional (an MD or a CRNA) was managing the anesthetic alone until it was too late to save the patient.

During physician anesthesia training, a faculty member teaches, supervises, advises, and bails out each resident should there be a mishap. Following their three years of residency, a graduate is free to take a job as an attending anesthesiologist in any hospital system, multi-specialty clinic, or anesthesia group who will hire him or her. This is when the free-soloing begins.

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Let me cite some examples of anesthesia free-soloing:

  1. The new graduate is on duty at 2 a.m., and a three-hundred-pound man arrives at the emergency room with the abdominal emergency of a dying, obstructed intestine. The surgeon decides the case is an emergency and cannot wait until morning. The typical anesthetic for this surgery is a rapid-sequence induction of intravenous general anesthesia, followed by the placement of a hollow breathing tube through the mouth into the patient’s windpipe. This sounds easy enough, except when it isn’t. Morbidly obese patients can be very difficult to intubate, and without a properly placed breathing tube these patients can be difficult to keep oxygenated. Five minutes without oxygen causes irreversible brain death. Sound scary? It is.
  2. The new graduate is on duty at 3 p.m. at a community hospital. A two-year-old girl arrives at the emergency room gasping for breath, crowing with each inspiration, febrile, drooling, and barely conscious. Both the emergency room physician and the anesthesiologist quickly make the diagnosis of acute epiglottitis, a rare bacterial infection which causes the epiglottis (the flap which covers the windpipe when you swallow) to become inflamed and swollen. This causes a severe obstruction during each inhaled breath. The patient needs a breathing tube within minutes, before the swollen epiglottis cuts off all passage for air inflow into the lungs. I had this very case during my first year in private practice. I’d read about the proper management, but I’d never seen acute epiglottitis myself. The appropriate treatment is to bring the patient to the operating room urgently, and to staff an experienced head and neck surgeon at the bedside. The anesthesiologist’s job is to induce sleep with an inhaled anesthetic (sevoflurane) via a mask, while carefully supporting the airway and facilitating the passage of oxygen and anesthesia gas in and out of the lungs until the patient falls asleep. Once the patient is asleep, a physician or nurse must place an IV catheter in the patient’s arm, and then the anesthesiologist must insert a lighted scope into the patient’s mouth, locate the swollen epiglottis and the opening to the windpipe below it, and insert a tiny hollow plastic breathing tube into the windpipe. If anything goes wrong and the breathing tube cannot be inserted before the child turns blue, the surgeon must immediately slice into the child’s neck and insert a breathing tube through the skin. Once again, five minutes without oxygen causes irreversible brain damage. Sound scary? It is.
  3. The new graduate is on duty alone at a dental office, anesthetizing a 17-year-old male for wisdom teeth removal. After the induction of general anesthesia but before the beginning of surgery, the anesthesiologist administers a requested dose of intravenous antibiotic. Minutes later, the patient’s blood pressure drops from 120/80 to 60/30, the heart rate climbs from 80 to 160 beats per minute, and the normal lung sounds convert to tight wheezes. Hopefully the anesthesiologist will make the correct diagnosis of an anaphylactic allergic reaction—most likely due to the antibiotic. The effective treatment requires perfect management of the patient’s airway, breathing, and circulation. The specific treatment for anaphylaxis requires intravenous injection of epinephrine (adrenaline). A misdiagnosis leading to the omission of epinephrine can be fatal. If the blood pressure remains low and the lungs continue to deteriorate, there will be a lack of oxygen delivery to the brain. Once again, five minutes without oxygen causes irreversible brain damage. Sound scary? It is.

What can be done to make free-soloing safer for patients? In my opinion, the best safety ropes are these:

  1. Most hospitals have an emergency room physician on duty at all hours. These MDs are multi-talented and have the acute care skills necessary to assist an anesthesiologist in an emergency. Rather than waiting until a patient has a cardiac arrest or until an airway is lost and the patient’s brain is losing oxygen, an anesthesia professional can consult the ER doctor in advance, e.g. requesting them to assist with a difficult induction of anesthesia on a morbidly obese adult or with a child with a difficult airway.
  2. Even if no experienced anesthesiologist is present in the hospital, there is always an experienced physician anesthesiologist colleague available on the other end of a phone call. Young or inexperienced anesthesia professionals can telephone senior anesthesiologists prior to the anesthetic, whenever a situation arises in which they are doubtful, insecure, or uncomfortable. It’s difficult to admit a lack of confidence, but it’s better to do this than to review a terrible complication with the senior anesthesiologist the next day, like two firefighters gazing over the burned basement remains of a previously preserved house.
  3. Most American anesthesia training programs are now utilizing simulation training facilities to prepare residents for severe acute care scenarios. A simulator lab has a surrogate patient and a full battery of vital sign monitors under the control of a teacher. The teacher can dial in a variety of emergencies and observe the pupil’s response to the emergencies. Feedback is given afterward regarding observed errors and any needed improvements in management. If a young physician anesthesiologist has faced emergencies in the simulator, we believe the anesthesiologist will be better prepared to free-solo following their training.
  4. The Stanford Anesthesiology department authored the Stanford Cognitive Aid Emergency Manual, a booklet of itemized recipes and checklists for all common dire emergencies one might see in an operating room. A PDF of this booklet is available for free of charge download here. Using the Stanford Cognitive Aid Emergency Manual in the operating room will help prevent medical errors, even by inexperienced anesthesia professionals.
  5. Whenever possible, solo anesthesiologists should have already passed the American Board of Anesthesiologists written and oral examinations, and therefore be board-certified. It’s a fact that one can practice anesthesiology in the United States without being board certified, but the ABA oral examination forces graduates to answer difficult questions in the pressure cooker of an oral exam room. Board-certified anesthesiologists will be better prepared for the pressure cooker of an operating room emergency as well.

If you’re a patient, should you worry about your anesthetist free-soloing during your surgery?

Let me reassure you. If you’re having an elective surgery in a hospital in the daytime, there are usually multiple backup anesthesia providers to assist with any problems. But for emergencies in the middle of the night, on weekends, or at freestanding surgical facilities with only one anesthesiologist present, your anesthesia care and outcome will be solely dependent on the skills, training, and experience of the solitary individual who is attending to you.

I’ve stood at the bottom of El Capitan in Yosemite National Park and looked upward at the vertical granite face with awe. I could never climb El Capitan, with or without ropes. I respect what Alex Honnold did at the highest level. He is brave beyond measure and he was willing to put his life on the line. Anesthesiologists, particularly junior anesthesiologists, must free-solo as well. No Hollywood cameras will be rolling, but the adrenaline will be pumping through their veins just as if they themselves were climbing El Capitan.

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The most popular posts for laypeople on The Anesthesia Consultant include:

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8-YEAR-OLD CONGOESE BOY DIES FROM ANESTHESIA. WHAT HAPPENED?

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.
email rjnov@yahoo.com
phone 650-465-5997

8-year-old Matadi Sela Petit, who journeyed from the Democratic Republic of Congo to Los Angeles for surgery, died at Cedars-Sinai Hospital on December 16, 2018, from what has been described as “a rare genetic reaction to the anesthesia.” Matadi was born with a cleft lip and a tumor on the left side of his face/cheek that grew into the size depicted in this photograph:

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Matadi Sela Petit

The Dikembe Mutombo Foundation, created by retired National Basketball Association star Dikembe Mutombo, sponsored the boy to come from Congo to the United States for the surgery. Matidi’s cleft lip was treated earlier with help from the foundation.

According to The Washington Post, “The Dikembe Mutombo Foundation . . . headed by the former NBA star said that during the delicate surgery on Dec. 16, the boy suffered a rare and unexpected genetic reaction to anesthesia.”

This was a tragic outcome, and my sympathies go out to the patient’s family, to the Foundation, and also to the physicians who treated the boy. Cedars-Sinai is an outstanding medical center—one of the finest in the United States—and has a reputation of having an outstanding medical staff.

What “genetic reaction” could have occurred during the anesthetic? No details have been released in the press, and readers are left to puzzle over what went wrong. As a practicing pediatric anesthesiologist, I’m interested in what happened. I have no access to medical records, nor any inside information on the case, but based on my education and experience my impressions follow below.

Regarding “a rare and unexpected genetic reaction to anesthesia,” the phrase used in the press release to describe the event, I see these possibilities:

  1. Malignant Hyperthermia. Malignant Hyperthermia (MH) is a disease in which a severe reaction occurs during general anesthesia, only among patients who are genetically susceptible. Symptoms include hypermetabolism, muscle rigidity, high fever, acidosis, sudden high blood potassium levels, and a risk of cardiac arrest. MH can only occur in patients who have the genetic predisposition to the disease, and who are then exposed to a potent anesthetic gas (e.g. sevoflurane, desflurane, or isoflurane), or the intravenous muscle relaxant succinylcholine. The treatment for MH involves emergency intravenous injection of the antidote dantrolene, immediate cooling of the patient, and immediate treatment for acidosis and elevated potassium concentration. The treatment for MH is usually effective if the diagnosis is made promptly. The quoted mortality rate for MH is now less than 5%. A potent anesthetic gas such as sevoflurane is commonly used in most pediatric anesthetics, and could have been used in Matidi’s case. Succinylcholine carries a Black Box Warning from the U.S. Food and Drug Administration regarding its use in pediatric patients, and it was unlikely to be used in this Matidi’s anesthetic. Even if Matidi had a previous surgery for his cleft palate, it is not unheard of for a patient to fail to develop MH on their first exposure to potent inhaled anesthetics, and yet develop MH on a later exposure.
  2. An occult muscular dystrophy. A patient who has an undiagnosed genetic muscular dystrophy can develop a sudden cardiac arrest after the administration of the muscle relaxant succinylcholine. Administration of succinylcholine to a patient with an occult muscular dystrophy can cause sudden cardiac arrhythmias, and for this reason succinylcholine carries a Black Box Warning from the U.S. Food and Drug Administration, restricting its use in pediatric patients to emergencies. Because of the Black Box Warning against using succinylcholine in pediatric anesthesia, it is unlikely succinylcholine was used in this patient’s anesthetic.
  3. The mass effect of the tumor in this patient’s face. If one can assume Matidi was born with this tumor, then the existence of this congenital mass lesion next to his airway and breathing passages is a genetic issue. From the photograph of Matidi, the tumor dominated his face. The tumor pushed his mouth to the right, and likely encroached on breathing anatomy. Once general anesthesia is induced, large tumors like this can compress the airway further. Every general anesthetic requires safe management of A-B-C, or Airway-Breathing-Cardiac, in that order. A child such as Matidi with markedly abnormal facial anatomy brings the risk of the loss of control of the airway at any point during the anesthesia or surgery. Loss of airway means there is no clear path for oxygen to traverse from the anesthesia machine through the head and neck to the lungs. Lack of oxygen to the lungs can lead to lack of oxygen to the brain and heart. Five minutes of oxygen depletion to the brain can cause anoxic brain damage. Oxygen depletion to the heart can cause cardiac arrest. Airway problems related to congenital diseases are discussed in the article Specific Genetic Diseases at Risk for Sedation/Anesthesia Complications, in the journal Anesthesia & Analgesia.

After scouring the world’s anesthesia literature and textbooks, I can find no other plausible “genetic reaction to anesthesia” to explain this patient’s death.

This patient’s care will be discussed in peer review and quality assurance committees at the hospital where the event occurred. There is always an autopsy on any unexpected death in an operating room, and more information may come from that. But whenever there is an adverse patient outcome, for medical-legal reasons, do not expect the healthcare professionals to reveal the specifics of what happened to the outside world.

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The most popular posts for laypeople on The Anesthesia Consultant include:

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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DOCTOR VITA AND THE BS IN HEALTHCARE

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.
email rjnov@yahoo.com
phone 650-465-5997

Last week Lawton Burns PhD and Mark Pauly PhD of the Wharton School of Business at the University of Pennsylvania published a landmark economic article entitled, “Detecting BS in Health Care.” Yes, you did not read that wrong—the academic paper used the abbreviation “BS” to describe the bull—- in the healthcare industry.

BS in Health Care

 

As a practicing physician, I find it to be a fascinating paper, and I recommend you click on the link and read it. The authors begin with a discussion of the art and value of BS detection. They mention that Ernest Hemingway was once asked, “Is there one quality needed to be a good writer, above all others?”

Hemingway replied, “Yes, a built-in, shock-proof, crap detector.”

The authors write, “While flat-out dishonesty for short term financial gains is an obvious answer, a more common explanation is the need to say something positive when there is nothing positive to say. . . . The incentives to generate BS are not likely to diminish—if anything, rising spending and stagnant health outcomes strengthen them—so it is all the more important to have an accurate and fast way to detect and deter BS in health care.”

The authors list their Top 10 Forms of BS in Health Care. The first four forms of BS weave a common theme:

  1. Top-down solutions: High-level executives and top management in the health care industry are supposed to engineer alternative payment models, but nothing has worked to date.
  2. One-size-fits-all, off-the-shelf: Leadership of industry and government assume one solution will work for multiple organizations, without customization.
  3. Silver-bullet prescriptions: A “silver bullet” is described as something that will cure all ills, and must be implemented because it been “decided that it is good for you,” Electronic health records (EHRs) are a prime example of a silver-bullet prescription. The federal government pushed the use of EHRs, claiming the systems would reduce costs and improve quality—but Burns and Pauly argue EHRs “eventually raised costs and only mildly touched a few quality dimensions.”
  4. Follow the guru: We must follow a visionary guru with a mystical revelation about what needs to be done. The authors describe how, in health care, Harvard professor Michael Porter and former CMS (Center of Medicare and Medicaid) administrator Don Berwick launched theories based on population health, and per-capita cost, to little success.

The current U.S. healthcare market is dominated by large corporations, led by businessmen who outline a yellow brick road for physicians to lead patients along. There is minimal effective policy-making from physicians. Healthcare stocks consistently grow in value, with little relationship to an improvement in clinical care, value, or cost. The government is involved as well, as in their mandate for Electronic Health Records (EHRs), a technology change that cost a lot of money, while forging a barrier between clinicians and the patients we are trying to interview, examine, and care for.

Where will the current trends take us? Will businessmen and/or the government prescribe health care? Will more and more computers and machines dominate health care?

Self-driving cars, Siri, Alexa, automated checkouts at Safeway, and IBM’s Watson are technologic realities. Will we someday see a self-driving physician with the voice of Siri and the brains of Watson?

Call that device “Doctor Vita.”

The saga of Doctor Vita arrives in 2019 from All Things That Matter Press.

 

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The most popular posts for laypeople on The Anesthesia Consultant include:

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IS SUBLINGUAL SUFENTANIL DANGEROUS?

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.
email rjnov@yahoo.com
phone 650-465-5997

Is sublingual sufentanil dangerous? The United States Food and Drug Administration (FDA) voted to approve the narcotic sufentanil for sublingual use in November of 2018. Sublingual sufentanil is 5-10 times more potent than fentanyl, and dissolves under the tongue in seconds.

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In an era of opioid overdose crisis, we now have a new, even more potent pill form of opiate.

Opioid deaths 1999-2017Sublingual sufentanil is approved for use only in medical settings, for the treatment of moderate to severe acute pain. But it is also possible that sublingual sufentanil will become the most dangerous street opiate ever known. This column reviews the arrival of sublingual sufentanil, from the viewpoint of a practicing anesthesiology attending.

Raeford Brown, Jr., MD, chair of the Anesthetic and Analgesic Drug Products Advisory Committee, and professor of anesthesiology and pediatrics at the University of Kentucky, disagreed with the FDA approval for sublingual sufentanil, citing the drug’s risk for “diversion, abuse, and death.” He cited the possible harms of such a “dangerous” drug — estimated to be 500-600 times more potent than morphine — coming to market in a tablet form. He warned of the risks of diversion of sufentanil by anesthesiologists and other medical personnel. He was quoted, “Sufentanil is a very potent opioid that is in a preparation that will be easily divertible. In the IV formulation, it has been a drug of abuse for health care providers.”

I agree with Dr. Brown. Sublingual sufentanil raises dangerous concerns. Sublingual sufentanil has the potential become the hydrogen bomb of all opiates—the mother of all lethal street drugs.

I have extensive experience administering intravenous sufentanil to patients. Intravenous sufentanil was FDA-approved in 1984. Its original primary use was as an anesthetic for cardiac surgery. I practiced cardiac anesthesia from 1985 until 2000. In the 1980s, cardiac anesthesia was achieved by high dose narcotic techniques, specifically with high dose fentanyl (100 micrograms/kg) techniques. For a 70-kilogram patient, this required injecting 7000 micrograms of fentanyl, or 140 ml of fentanyl (nearly two and an half sixty-milliliter syringes full of fentanyl) at the time of anesthetic induction. When intravenous sufentanil was approved at the same 50 mcg/ml concentration as fentanyl, but with a potency of 10 X of fentanyl, the narcotic induction only required 14 ml of sufentanil total. I can still remember my wide-eyed professors saying, “With sufentanil, the entire cardiac anesthetic is here in one syringe.” The use of sufentanil for cardiac anesthesia faded as anesthesiologists began using lower doses of narcotic as part of early-extubation techniques in the late 1990s.

We also used intravenous sufentanil to supplement anesthesia for non-cardiac surgeries. The most common method was to dilute the sufentanil 10:1 with saline, to a concentration of 5 mcg/ml. At this concentration, sufentanil was indistinguishable from fentanyl at 50 mcg/ml. After several years it became apparent that there was no advantage of using sufentanil IV over fentanyl IV in non-cardiac anesthesia, and the administration of IV sufentanil dwindled. The intravenous sufentanil form of the drug was also approved for epidural anesthesia. Over time, the use of sufentanil for epidural anesthesia also decreased, also supplanted by fentanyl.

Just when it looked like sufentanil was a drug nobody really neededà enter AcelRx Pharmaceuticals, a San Francisco Bay Area company which manufactured and tested a sublingual sufentanil product designed to melt under a patient’s tongue. Pamela Palmer, the founder and Chief Medical Officer of AcelRx, received her MD and PhD at Stanford, and is an acquaintance of mine. Dr. Palmer is an anesthesiologist who is brilliant and well informed regarding the pharmacology of sufentanil and the use of sufentanil in anesthetic practice.

Because sufentanil is highly lipid (fat) soluble, it is quickly absorbed into the bloodstream through the mucosal lining of the mouth. AcelRx will market the drug under the name Dsuvia, in a sublingual sufentanil tablet system (SSTS) which consists of a single-dose applicator prefilled with a single 3-mm-diameter 30-mcg tablet, administered by a healthcare professional no more frequently than hourly.

sublingual sufentanil

A radio frequency identification (RFID) cartridge, requiring the patient’s thumbprint, helps reduce unauthorized dosing. The device is tethered to the patient’s bed to reduce risk of product loss. Each tablet is pre-loaded into a single-dose applicator within a pouch so it is suitable for field/trauma use. Both the fixed drug and dose and lockout time interval eliminate the end-user programming error risk associated with Patient Controlled Analgesia (PCA) intravenous narcotic pumps.

Studies documented the efficacy and safety of the SSTS in the treatment of postoperative pain in patients following open abdominal surgery compared with placebo.

SSTS was rated a success by significantly more patients when compared to intravenous PCA morphine. There was a faster onset of analgesia and both higher patient and nurse satisfaction scores with the SSTS as measured by validated questionnaires.

Dsuvia will be marketed as “postoperative, sublingual, patient controlled analgesia.” Once administered under the tongue, the sufentanil tablets typically dissolve within 5  minutes. The FDA approved the drug to be used in hospital settings only, for the treatment of moderate-to-severe acute pain, where a narcotic is needed and rapid onset is desired, but the route of administration does not require intravenous access. Typical settings would be the surgical wards after major orthopedic or general surgery procedures. The chief competition for Dsuvia will likely be Patient Controlled Analgesia (PCA) intravenous narcotic pumps, a commonly used analgesic method in which patients push a bedside button and self-administer intravenous narcotic (e.g. morphine, fentanyl, or Dilaudid) on demand through their IV line.

The most significant risk involving sublingual sufentanil is its potency, specifically its extreme potency as a respiratory depressant. The product description by AcelRx states that sufentanil has a “high therapeutic index” of 26,716. The Therapeutic Index is the ratio that compares the blood concentration at which a drug becomes toxic and the concentration at which the drug is effective. The larger the therapeutic index (TI), the safer the drug is. The TI affirms that sufentanil toxicity starts at a concentration of 26716 times its therapeutic concentration, but this ignores the risk of respiratory depression at much, much lower doses. A patient treated with an overdose of sufentanil will stop breathing at a dose only slightly greater, i.e. in the ballpark of only 2 – 4 times greater, than its therapeutic concentration. Like all opiates, sufentanil has side effects of respiratory depression, sedation, nausea and constipation. Respiratory depression is the reason why opiate overdose patients die. Opiate overdoses do not cause death because of an inherent “toxicity” of the drug concentration in the blood, but rather because of respiratory depression. People simply stop breathing.

Regarding sufentanil, the National Institute of Health website states: WARNINGS: Serious, life-threatening, or fatal respiratory depression has been reported with the use of opioids, even when used as recommended. Respiratory depression, if not immediately recognized and treated, may lead to respiratory arrest and death. Sufentanil Citrate injection should be administered only by persons specifically trained in the use of anesthetic drugs and the management of the respiratory effects of potent opioids, including respiration and cardiac resuscitation of patients in the age group being treated. Such training must include the establishment and maintenance of a patent airway and assisted ventilation. Adequate facilities should be available for postoperative monitoring and ventilation of patients administered anesthetic doses of Sufentanil Citrate Injection. It is essential that these facilities be fully equipped to handle all degrees of respiratory depression. Management of respiratory depression may include close observation, supportive measures, and use of opioid antagonists, depending on the patient’s clinical status.

There is also hope that sublingual sufentanil will have battlefield applications. A statement from FDA Commissioner Scott Gottlieg, MD on November 2, 2018 read: “(Sublingual sufentanil) has some unique features in that the drug is delivered in a stable form that makes it ideally suited for certain special circumstances where patients may not be able to swallow oral medication, and where access to intravenous pain relief is not possible. This includes potential uses on the battlefield. For this reason, the Department of Defense (DoD) worked closely with the sponsor on the development of this new medicine. This opioid formulation, along with Dsuvia’s unique delivery device, was a priority medical product for the Pentagon because it fills a specific and important, but limited, unmet medical need in treating our nation’s soldiers on the battlefield. The involvement and needs of the DoD in treating soldiers on the battlefield were discussed by the advisory committee . . . The FDA has made it a high priority to make sure our soldiers have access to treatments that meet the unique needs of the battlefield, including when intravenous administration is not possible for the treatment of acute pain related to battlefield wounds.”

In conclusion, will sublingual sufentanil be dangerous or not?

My assessment of sublingual sufentanil, based on the information above, is as follows:

  1. Sublingual sufentanil (SS) can be useful in hospitalized post-operative patients following major, painful surgeries such as orthopedic total joint replacements or intra-abdominal surgeries. SS could replace PCA intravenous morphine or fentanyl.
  2. The market share, or prevalence of SS use will largely depend on its cost versus intravenous PCA units. AcelRx will market the drug beginning in early 2019, at a wholesale price of $50 to $60 per dose. https://www.washingtonpost.com/national/health-science/fda-approves-a-powerful-new-opioid/2018/11/02/88cd27e6-deaf-11e8-85df-7a6b4d25cfbb_story.html?utm_term=.f4efacea46ad
  3. SS will not be frequently used in Post Anesthesia Care Units, Intensive Care Units, or the Emergency Department, because patients in these settings all have intravenous lines in place, and can receive traditional IV narcotics as needed. There is no need or demand for a sublingual narcotic product in these settings.
  4. If SS tablets are diverted or stolen and are taken outside of medical settings, they can cause death. Overdoses as low as two to four times a therapeutic dose could cause respiratory depression and death. If hospital personnel divert the drug for recreational use, these personnel will be at high risk for mortality.
  5. If SS ever reaches the streets as a recreational drug or heroin substitute, users will achieve opiate overdose and death at a very high rate. If anyone naively believes the drug will not reach the streets, consider that manufactured forms of all the other pill forms of opiates, i.e. Percocet, Vicodin, and Oxycodone, eventually reached the streets. What will prevent this new drug from doing the same?
  6. Efforts to educate street users regarding the dangers of this new drug will likely fail. There can be no safe use of SS outside a medical setting. People will likely overdose and die.
  7. Regarding battlefield use: In military settings where IVs are not common, the capacity to administer potent sublingual narcotic may become standard. But misuse and abuse in the military and on the battlefield are also possible. Tales of rampant drug abuse by soldiers in the Vietnam War are part of the lore of that conflict. Access to sublingual sufentanil in the military would need to be strictly confined and monitored.
  8. An added note: An intentional overdose with SS is probably an outstanding drug for physician-aided suicide.

I have no crystal ball, but the bottom line is this:

If sublingual sufentanil use is confined to acute care hospital settings, it will be useful and not dangerous. But if sublingual sufentanil reaches the streets as a drug of abuse, it will be lethal.

Time will tell which of these fates is the truth.

 

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The most popular posts for laypeople on The Anesthesia Consultant include:

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AUTISM AND ANESTHESIA

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.
email rjnov@yahoo.com
phone 650-465-5997

Anesthetizing uncooperative patients is difficult. The combination of autism and anesthesia requires careful planning.

autism and anesthesia

Children or adults with psychological, developmental, or behavioral disorders such as autism may be combative or aggressive, and may require extra measures of preanesthetic sedation or restraint. The parents/guardians and the anesthesia team need to be actively involved with forming the preoperative plan for uncooperative patients.

The incidence of autism in the United States is high—the Autism and Developmental Disabilities Monitoring (ADDM) Network of the Center for Disease Control estimates about 1 in 59 children has autism spectrum disorder (ASD).

Characteristics of autism include developmental delays of behavioral and social skills, and an inability to communicate. The symptoms of ASD stretch across a broad range from mild to incapacitating.

It’s not infrequent that autistic patients need surgery and anesthesia. Patients with autism commonly need to be sedated for routine procedures that a normal child or adult would cooperate with. Dental cases are common, and are frequently referred to a hospital because the typical care systems at an outpatient surgery center or a dental office are inadequate to complete a successful anesthetic.

The most common anesthesia induction technique in children and toddlers is an inhalation induction with sevoflurane. The routine practice of performing an inhalational sevoflurane induction on a child with autism may be impossible.

The most common anesthesia induction technique in adults involves the intravenous injection of propofol. The routine practice of starting a preoperative IV to begin anesthesia care on an adolescent or adult with autism may also be impossible.

Let’s look at an example case of an uncooperative adolescent who is adult-sized and who requires an anesthetic:

A 16-year-old, 70-kilogram male with Autistic Spectrum Disorder is scheduled for dental surgery and teeth cleaning. He is verbal with his mother, but refuses to interact with the anesthesia or nursing personnel. He refuses to change into a hospital gown, or to remove his long-sleeved sweater. He refuses to drink or swallow any premedication, he refuses an IV, and he refuses inhalation induction. The mother, who is the patient’s legal guardian, consents to surgery and anesthesia, but she is unable to convince her son to cooperate with the medical team.

What do you do?

The surgical and anesthetic team spent significant time explaining, reassuring, and coddling the patient, to no avail. They told the mother she had the choice of going home without any surgical procedure or anesthesia at all. The mother was adamant that the procedure needed to be performed. To this end, all parties agreed to the following plan:

  1. Two hospital security guards were called to the bedside in the preoperative area.
  2. The two hospital guards and the mother donned white operating room coveralls.
  3. At the mother’s consent, the guards laid the patient down on the hospital gurney, held him there, and the surgical team and the guards pushed the gurney down the hallway to the operating room (a significant distance of approximately 100 yards).
  4. Upon arrival in the operating room, one of the security guards uncovered the sweater from the patient’s arm, and the anesthesiologist injected an intramuscular mixture of 2 mg/kg ketamine, 0.2 mg/kg midazolam, and .02 mg/kg atropine into the patient’s deltoid muscle. The patient protested, and the mother reassured him.
  5. The oximeter and routine monitors were placed.
  6. Once the patient became sedated (2-4 minutes later), the mother was escorted from the room and the anesthesiologist started an IV in the patient’s arm. The patient was then preoxygenated via mask in the standard fashion, propofol 1 mg/kg and rocuronium 0.5 mg/kg were injected IV, and the trachea was intubated.
  7. The surgery proceeded as scheduled, with sevoflurane as maintenance anesthesia.
  8. At the conclusion of surgery, the patient was extubated awake and taken to the Post Anesthesia Care Unit (PACU) in stable condition. The mother was reunited with the patient there. The patient was sedate, calm, comfortable, and tolerated the PACU care well.
  9. The patient was discharged home without complications after 90 minutes in the PACU. The mother was happy with the perioperative care.

Perhaps this practice of intramuscular induction of anesthesia sounds brutal to you.

The intramuscular (IM) ketamine/midazolam/atropine induction of anesthesia as described in the case study above is effective. In our practice, the recipe is the combination of 2 mg/kg of ketamine, 0.2 mg of midazolam, and .02 mg/kg of atropine.

The ketamine concentration is 100 mg/ml. The midazolam concentration is 5 mg/ml. The total volume of the intramuscular injection in our case study patient was 140 mg ketamine (1.4 ml), 14 gm midazolam (2.8 ml), and 1.4 mg atropine (1.4 ml), for a total injectate volume of 5.6 ml. More dilute concentrations of these three drugs will necessitate too large a volume for intramuscular injection. This IM induction technique is effective in safely inducing general anesthesia without an IV within 2-4 minutes, and has been described in a previous article on dental office anesthesia.

There are more gentle approaches to an uncooperative patient—approaches which this patient would not agree to. The literature lists these options for premedication or induction of anesthesia in uncooperative patients:

  1. Intranasal premedication sedation with either 0.5 mg/kg of midazolam, or 1 microgram/kg of dexmedetomidine were found to be equally effective in sedating 20 uncooperativechildren aged 2-6 years for dental treatment visits. 0.25 mg/kg of atropine, in combination with 0.5 mg/kg of midazolam, and 1-2
  2. Oral premedication sedation with 5 mg/kg oral midazolam. Oral sedation is considered as the oldest, easiest way of administrating sedative drugs to pediatric patients. Midazolam is a well-known sedative, and we use this often in our practice if the patient will accept it. The effect initiates within 20–30 minutes of oral administration.
  3. Oral premedication with dexmedetomidine 5 mcg/kg.
  4. Oral midazolam, ibuprofen, and 6 mg/kg of ketamine. Oral ketamine of  up to 8 mg/kg has shown to effective in improving compliance during induction of anesthesia. Compared with oral midazolam, oral ketamine causes less respiratory depression. Ketamine does cause nystagmus, increased salivation, hallucinations and emergence delirium. When used alone as a premedicant ketamine has not been found to be effective. There is no significant difference between oral ketamine and oral midazolam in the postoperative recovery or hospital discharge.

Uncooperative children or adults with ASD will each have individualized needs. Patients with significant ASD may have severe objections to the doctor-patient relationship, and it can take a prolonged time to gain their trust. It’s important to discuss the perioperative anesthetic issues and the preoperative plan with a parent or guardian well in advance of the surgical date if possible. The anesthesia team can determine the simplest means of preoperative sedation/anesthesia to complete the case successfully, and the family can give input regarding previous anesthesia successes or failures. It’s optimal if the family and the MDs can agree to an appropriate approach to the anesthetic, days prior to the actual surgery.

Parents often ask about the risk of general anesthesia to the brain of their child. At present there is no documented connection between exposures to general anesthesia and the development or worsening of autistic symptoms. In a study of a birth cohort of 114,435 children from Taiwan from 2001 to 2010, 5197 children under the age of 2 years were exposed to general anesthesia and surgery. The 1 : 4 matched control group comprised 20,788 children. The results showed that neither exposure to general anesthesia and surgery before the age of 2 years age, nor the number of exposures, were associated with the development of autistic disorder. 

Do autistic patients suffer more complications from anesthesia and surgery than non-autistic patients? In a review by Arnold published in Pediatric Anesthesia in 2015, other than a significant difference in the premedication type and route (per the discussion above), children with ASD had similar perioperative experiences as non‐ASD subjects.

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The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

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How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

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Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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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:

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NERVE BLOCKS AND NERVE INJURY

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.
email rjnov@yahoo.com
phone 650-465-5997

Let’s discuss an elephant in the room of operating room anesthesia–the association between peripheral nerve blocks and nerve injury.

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The use of peripheral nerve blocks has crescendoed in anesthesia practice, stimulated by the use of ultrasound-guided visualization of nerves. There are growing economic industries in ultrasound machines, ultrasound block needles, and in anesthesia personnel who bill for this additional optional procedure on orthopedic patients.

Ultrasound allows us to visualize the nerves, but there are no data demonstrating a lower neurologic complication rate with this ultrasound technique.(Liu SS, et al. A prospective, randomized controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms. Anesth Analg. 2009;109:265-271).

The incidence of nerve injury following peripheral nerve block is low, but not zero. Per Gadsden, the mechanism of permanent nerve injury is felt to be either needle trauma, or toxicity of local anesthetics. In a review article by David Hardman MD MBA, of the University of North Carolina, the incidence of permanent injury rates, as defined by a neurologic abnormality present at or beyond 12 months after the procedure, ranges from 0.029% to 0.2%. This reviewed data came from old studies, dating from 2001 – 2012. There are no more recent published studies of large populations. Multiplying this 1/3000 to 1/500 incidence by the tens of thousands of nerve blocks performed yearly leads to a significant number of permanently damaged nerves.

This is a problem.

I would never agree to have an ultrasound-guided brachial plexus, femoral or popliteal nerve block performed on me.

Why not? Because I need my hands and upper extremities to function normally in order to earn a living as an anesthesiologist. Because I’m also active in a number of sports, and I need my legs and lower extremities to function normally in order to walk, run, and function in athletics.

For me, the acceptable incidence of permanent nerve injury to my limbs is zero. The incidence of permanent nerve injury with general anesthesia should be zero. Of course, if the surgical team is negligent and positions me in a dangerous posture during general anesthesia, there could be a compression or traction nerve injury, but this is exceedingly rare in competent hands. Of course, if an orthopedic surgeon is negligent and compresses, stretches or damages a nerve, there could be nerve injury, but again this is exceedingly rare in competent hands.

If I’m wary of having a peripheral nerve block performed on myself, then I must be wary for my patients as well. Every individual needs their upper and lower extremities to function normally to perform every day tasks, to perform their jobs, or to enjoy their leisure or athletic activities.

I contend that, as of 2018, the incidence and number of permanent nerve injuries during this era of ultrasound-guided nerve blocks looms larger than any medical literature confirms. Why is this? I believe there are several reasons for the under-reporting of nerve injury following peripheral nerve blocks:

  1. Time lag in published data. The data in the medical literature regarding peripheral nerve injury following nerve block is old. In a lecture on this topic by David Hardman MD MBA at the American Society of Anesthesiologists (ASA) national convention in San Francisco, none of the data regarding nerve injury complication was more recent that 2007. Recent data is still unreported, and remains to be analyzed.
  2. Time lag in Closed Claims data. The ASA Closed Claims data always lags behind the occurrence of complications. A typical malpractice lawsuit takes a long time (e.g. 4 – 7 years) to come to a conclusion. The ASA Closed Claim database may be 10 years or more in arrears before it is finally published.
  3. Some peripheral nerve injuries never get reported to anyone. Either the patient never informs the physician, the case never gets tallied in any database, the physician never informs any quality assurance (QA) committee, or the case meets its termination in a QA committee discussion that goes no further.
  4. No one publishes case reports of their complications. Do you think an anesthesiologist is motivated to publish a case report in which they had permanent nerve injury of the brachial plexus following an interscalene nerve block for shoulder surgery? Of course not. He or she wants that case buried deeply, with as few people as possible knowing. No one publishes their dirty laundry, hence the medical literature is lacking in adverse case reports.
  5. Academic professors specializing in regional anesthesia have little interest in publicizing data that could damn or minimize the importance of their chosen subspecialty. A physician who makes his or her living performing, teaching, and writing about a hammer has a conflict of interest when it comes to speaking out on the dangers of wielding that hammer.

In my role as a peer review physician, quality assurance committee member, expert legal witness, and simply as a physician in a busy medical system, I’m aware of more than a dozen patients who already have permanent nerve injury following an ultrasound-guided peripheral nerve block. None of their case histories has been published, and none of their cases have appeared in a published series of nerve injury complications.

Is there a cover-up ongoing regarding permanent nerve injury? There is certainly no publicizing of these complications.

Let me give you an example of another anesthesia technique that was associated with permanent nerve injury: In the 1990’s we routinely used hyperbaric 5% lidocaine for spinal anesthesia. Lidocaine had the advantage of supplying short (1 – 1 ½ hour) spinal anesthesia for simple cases such as cytoscopies, urethral surgeries, perineal surgeries, and inguinal hernias. Case reports of cauda equina syndrome emerged, in which some lidocaine spinal anesthetics were associated with inflammation of the distal spinal cord (cauda equina), which caused permanent lower extremity nerve injury. Because of this risk, the use of lidocaine spinal anesthesia disappeared. The risk of nerve injury was real, and the risk was too daunting to continue using that anesthesia technique.

Expect a similar story to evolve over the coming years regarding the current burgeoning practice of peripheral nerve blockade. “Complications of Peripheral Nerve Block,” an article published in the British Journal of Anaesthesia in 2010, stated that “complications of peripheral nerve blocks are fortunately rare, but can be devastating for both the patient and the anaesthesiologist.” Indeed, for the patients whose nerve injury does not resolve it can be a tragedy.

In his lecture on nerve injury complications of peripheral nerve block delivered at the 2018 ASA national convention in San Francisco, speaker David Hardman, MD MBA told a standing room only crowd of anesthesiologists that if your patient develops a permanent nerve injury following a peripheral nerve block, “you will be sued.” Why was there a huge crowd for this particular lecture? I believe it’s because many anesthesiologists are aware of the occurrence of nerve injury, and aren’t sure what to do about the incidence of ultrasound-guided nerve blocks in their practice.

No one wants to be sued, but per the Hippocratic Oath we must first do no harm. The real crisis is not that an anesthesia provider gets sued, but that the patient will go the rest of their lives without the normal use of their arm or leg.

General anesthesia has risks. Adding a regional anesthetic to a general anesthetic adds a second set of risks. At times regional anesthesia is indicated. I still perform peripheral nerve blocks on select patients, and I believe peripheral nerve blockade still has utility in anesthesia practice. I believe ultrasound-guided peripheral nerve blocks are indicated:

  1. If the scheduled procedure will cause significant post-operative pain, e.g. a total shoulder replacement.
  2. If parenteral narcotics are unlikely to relieve the pain satisfactorily, e.g. a total shoulder replacement, or you are doing a painful procedure on a patient who consumes chronic narcotics, and who will be tolerant to narcotic analgesia.
  3. If I explain the non-zero risk of permanent nerve injury, e.g. a risk of 1 in 3000 patients, and the patient both understands this risk and consents to proceed.

Seducing a patient into accepting a peripheral nerve block by minimizing the chance of permanent nerve injury with phases such as, “nerve injury is very, very rare,” or “nerve injury is very uncommon, and it usually resolves,” is deceptive medical practice. If that patient later develops permanent nerve injury, you can expect to be sued. A 2007 survey of academic regional anesthesiologists indicated that nearly 40% of respondents did not disclose the risks of long-term and disabling neurologic injury prior to performing peripheral nerve blocks.( Brull R, et al. Disclosure of risks associated with regional anesthesia: a survey of academic regional anesthesiologists. Reg Anesth Pain Med. 2007;32:7-11)

It’s better to tell the patient the truth, and risk the following dialogue:

Anesthesiologist: “The risk of permanent nerve injury after this nerve block is very low, but it’s not zero. A ballpark incidence of the chance of permanent nerve injury to your arm (or leg) is one patient in 3,000.”

 Patient: “A one in 3000 chance that I could have permanent nerve injury? I don’t want to take that chance. Skip the block.”

Yes, you might lose the opportunity to do the block, but that’s what informed consent is all about. It’s your duty to explain the risks, the benefits, and the alternatives. In Hardman’s article, the author states that he circles the words “nerve injury” on the anesthesia consent for peripheral nerve block, and he has the patient write their initials next to it, to document that they have read it and understand the risks.

 

REFERENCES:

  1. https://www.anesthesiologynews.com/Review-Articles/Article/07-15/Nerve-Injury-After-Peripheral-Nerve-Block-nbsp-Best-Practices-and-Medical-Legal-Protection-Strategies/32991/ses=ogst
  2. Liu SS, et al. A prospective, randomized controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms. Anesth Analg. 2009;109:265-271).
  3. Brull R, et al. Disclosure of risks associated with regional anesthesia: a survey of academic regional anesthesiologists. Reg Anesth Pain Med. 2007;32:7-11.
  4.  http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1948033
  5. https://www.nysora.com/neurologic-complications-of-peripheral-nerve-blocks
  6. https://academic.oup.com/bja/article/105/suppl_1/i97/235950   

 

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ABOUT THE ANESTHESIA CONSULTANT

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.
email rjnov@yahoo.com
phone 650-465-5997

Greetings. My name is Dr. Richard Novak, the author of About The Anesthesia Consultant. The Anesthesia Consultant exists to increase your knowledge about anesthesia and the practice of medicine before, during, and after surgery. The Anesthesia Consultant is designed to inform and entertain both laypeople and medical specialists, and provides answers not found in traditional textbooks.

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I’m a Stanford-trained physician, double-boarded in internal medicine and anesthesiology, and I’ve personally anesthetized over 25,000 patients over 34+ years. I’m currently an Adjunct Clinical Professor in the Stanford Department of Anesthesiology, Perioperative and Pain Medicine.

I’ve learned a lot over these years, and my intent is to share my knowledge with my readers, who include anesthesia professionals and lay people. This anesthesia blog contains more than 180 distinct pages and posts, all written by me. About half the columns are directed to the general public, so that they can understand anesthesia practice and the life of an anesthesia professional. The other half are detailed, well-referenced articles aimed at physician anesthesiologists, nurse anesthetists, and anesthesia assistants the world over.

I began my writing career in 2001, when I was the Deputy Chief of Anesthesia at Stanford University Hospital. Stanford is a mixed hospital, with both full time faculty and private practice faculty. I have been in the private practice of anesthesia since 1986, and my viewpoints are unique because very few private practice physician anesthesiologists have worked in a major university hospital for over thirty years.

Private practice anesthesia differs from academic anesthesia in important ways, and I began writing monthly Deputy Chief Columns in the Stanford Anesthesiology Department newsletter in 2001, to articulate these differences.

Once the total number of columns exceeded sixty, I created The Anesthesia Consultant website in 2010 to share my writing with readers outside Stanford. I continue to write 1 – 1 columns per month, in addition to maintaining a full time job as a clinical anesthesiologist.

In 2018, The Anesthesia Consultant was rated the #7 anesthesia blog in the world by Feedspot.

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The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

Click on the Pages of The Anesthesia Consultant for an overview of important topics, or browse through the 160+ Posts listed in the sidebar. If you don’t find the answer to your anesthesia questions, you can contact me at:

rjnov@yahoo.com.

 

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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Thanks, and good luck reading!

Richard Novak, MD

 

ANESTHESIA EXPERT WITNESS

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.
email rjnov@yahoo.com
phone 650-465-5997

Dr. Richard Novak, an Adjunct Clinical Professor of Anesthesiology at Stanford University Medical Center, is available for anesthesia expert witness consultation.

Dr. Novak is a clinician who administers anesthesia and directs perioperative medical care at Stanford University Hospital and multiple outpatient surgery centers in and around Palo Alto, California. Dr. Novak has personally performed more than 25,000 anesthetics since 1984, and is uniquely qualified because he works in an academic medical center but is also a community private practice anesthesiologist.  In addition to providing clinical care, Dr. Novak is available for experienced medical-legal expert witness consultation, case review, or testimony in the specialties of anesthesiology and perioperative internal medicine.

Dr. Novak is board certified by both the American Board of Anesthesiology and the American Board of Internal Medicine.

CONTACT EMAIL:  RJNOV@yahoo.com

 

CURRICULUM VITAE

OFFICE ADDRESS

Associated Anesthesiologists Medical Group

2237 Alma Street

Palo Alto, California 94601

telephone (650) 323-0617

 

Education:

1972-76                        B.A., Chemistry, Magna Cum Laude, Carleton College

1976-80                        M.D., University of Chicago Pritzker School of Medicine

 

Postgraduate Education:

1980-81                        Internship in Internal Medicine, Stanford University Hospital

1981-83                        Residency in Internal Medicine, Stanford University Hospital

1984-86                        Residency in Anesthesiology, Stanford University Hospital

 

Awards and Honors:

 Phi Beta Kappa, Carleton College

AOA, University of Chicago School of Medicine

 

Professional Experience:

1983-84  Physician Specialist, Department of Internal Medicine, Stanford Emergency Room, Stanford University School of Medicine

1986   Attending Anesthesiologist, Santa Teresa Kaiser Hospital, San Jose, CA

1986-88   Attending Anesthesiologist, Washington Hospital, Fremont, California

1989 to Present    Attending Anesthesiologist, Stanford University Hospital, Associated Anesthesiologists Medical Group, Inc., Palo Alto, California

 

Medical Licensure:  California

 

Medical Staff Privileges:

Stanford University Hospital, Palo Alto, California

Plastic Surgery Center, Palo Alto, California

Menlo Park Surgical Hospital, Menlo Park, California

Waverley Surgery Center, Palo Alto, California

California Ear Institute, Palo Alto, California

 

Board Certification:

1981       Diplomate, National Board of Medical Examiners

1983       Diplomate, American Board of Internal Medicine

1987       Diplomate, American Board of Anesthesiology

 

Academic Appointments/Presentations:

1983-84    Physician Specialist, Department of Internal Medicine, Emergency Room Attending, Stanford University School of Medicine.

1988-1993    Clinical Instructor, Stanford University Department of Anesthesiology

1993- 2000    Adjunct Clinical Assistant Professor, Stanford University Department of Anesthesiology.

2000 to August 2018    Adjunct Clinical Associate Professor, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine.

September 2018 to present   Adjunct Clinical Professor, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine.

 

Teaching Experience:

1983  Instructor, Advanced Trauma Life Support, Instructor, Advanced Cardiac Life Support

1984   Lecturer, Emergency Management of Overdose,  Stanford Hospital Pharmacy Symposium

1988 to Present  Examiner, Practice Oral Board Exams, Stanford Department of Anesthesia

1992  Lecturer, Preoperative Assessment of Internal Medicine Patients,

Internal Medicine Resident  Conference, Stanford University Hospital

1993  Lecturer, Anaphylaxis on Induction of General Anesthesia,, Stanford Anesthesia Grand Rounds

1995  Lecturer, Electrolyte Disturbance during Hysteroscopy, Stanford Anesthesia Grand Rounds

2001 Lecturer, Anaphylaxis during Liposuction, Stanford Anesthesia Grand Rounds

2001 to Present  Author, Deputy Chief Column, Anesthesia Gas Pipeline, Department of Anesthesia, Stanford, CA.

2003  Lecturer, Hypovolemic Shock in Gynecologic Laparoscopy, Stanford Anesthesia Grand Rounds

2004 Lecturer, Neurologic Complications following Total Joint Replacement, Stanford Anesthesia Grand Rounds

2005 Lecturer, Preoperative Screening at an Freestanding Ambulatory Surgery Center, Stanford Anesthesia Grand Rounds

2007 Lecturer, Awareness During General Anesthesia, Stanford Anesthesia Grand Rounds

2009 Lecturer, Medical Director Management of a Freestanding Ambulatory Surgery Center, Stanford Anesthesia Grand Rounds

2011 Lecturer, Pulmonary Edema in a 3-Year-Old Following Tonsillectomy, and 75 Cases of 10-Hour Outpatient General Anesthetics for Atresia/Microtia Pediatric Surgery, Stanford Anesthesia Grand Rounds

2015 Lecturer, Pediatric Anesthesia in a Freestanding Ambulatory Surgery Center, Stanford Anesthesia Grand Rounds

2016  Invited Lecturer, The Transition From Anesthesia Residency to Community Practice, University of New Mexico, Albuquerque, New Mexico, July 14, 2016

2016  Invited Lecturer, Pediatric Anesthesia at Freestanding Ambulatory Facilities, University of New Mexico Anesthesia Grand Rounds, Albuquerque, New Mexico, July 15, 2016

2017  Lecturer, Expert Witness Testimony in Anesthesia, Stanford Anesthesia Grand Rounds

2017  Exhibit: an audio recording of The Metronome, a poem by Richard Novak MD, at the Russell Museum of Medical History and Innovation at Massachusetts General Hospital regarding perspectives on anesthesia, at Boston City Hall Plaza as part of HUBweek, Boston’s festival of innovation, October 2017.

 

Offices Held:

1991 to Present  Vice President, Associated Anesthesiologists Medical Group, Inc.

1995 to 1998   Alternate Delegate, District 4, California Society of Anesthesiologists

1996 to 2000  Medical Advisory Board, Palo Alto Surgecenter

2001-2015  Deputy Chief of Anesthesia, Stanford University Medical Center

2002-Present  Medical Director, Waverley Surgery Center, Palo Alto, California

2005-2014  Delegate, District 4, California Society of Anesthesiologists

2006-Present Expert Reviewer, Medical Board of California

 

Medical Committees:

1997 to 2009   Care Improvement QA Committee, Stanford Univ. Hospital

1998 to Present   Quality Assurance Committee, Stanford Dept. of Anesthesia

1997 to Present   Quality Assurance Committee, Associated Anesthesiologists Medical Group

1996 to 2000    Medical Advisory Board, Palo Alto Surgecenter

2002 to 2009   Stanford University Hospital Anesthesia QA Committee

2002 to Present  Chairman, Waverley Surgery Center QA Committee

 

Publications:

Novak RJ, Gaeke R, Kirsner JB. Chronic Daily Narcotic Use in Patients with Crohn’s Disease:   Gastroenterology May 1980;  78(5): Part 2, p 1331.

Novak  RJ, Hill BB, Schubart PJ, Fogarty TJ, Zarins CK.  Endovascular Aortic Aneurysm Repair in a Patient with Prohibitive Cardiopulmonary Risk:  Anesthesiology 1999;  91:  1542 – 45.

Novak RJ, Dental Anesthesia for Autistic Children, letter to the editor:   Autism Research Review International 2000, Vol 14, No. 4, page 7.

Novak RJ, The Metronome, Anesthesiology, Mind to Mind Section 2012: 117:417.

Novak RJ, Vascular Access Made Easy, Outpatient Surgery Magazine Manager’s Guide to Ambulatory Anesthesia, July 2013, pages 10-19.

Novak RJ, Lessons in Medication Labeling, Outpatient Surgery Magazine Manager’s Guide to Ambulatory Anesthesia, October 2013, pages 22-25.

Author, Deputy Chief Columns, January 2001 – 2015, Anesthesia publication Gas Pipeline, circulated internationally by the Department of Anesthesia, Stanford, CA.

Author, The Anesthesia Consultant website, http://theanesthesiaconsultant.com

Novak RJ, The Doctor and Mr. Dylan, a novel, Pegasus Books, 2014, and Montelago Press, 2017, (second edition).

Novak, RJ, Best Practices in Drug Safety, Manager’s Guide to Staff and Patient Safety Supplement to Outpatient Surgery Magazine, October 2015, pages 34-40.

Novak RJ, Book Chapter, Disorders of Potassium Balance, in Complications in                        Anesthesia, 3rd Edition, 2017, edited by Lee Fleisher and Stanley Rosenbaum,                        Elsevier Press, Philadelphia.

Novak RJ, Book Chapter: Management of Insulin Overdose; in Advanced                         Perioperative Crisis Management, 2017, edited by Matthew McEvoy                                          and Cory Furse, Oxford Press.

Novak RJ, Book Chapter, Anesthesia Considerations in Ear Reconstruction, in Modern Microtia Reconstruction: Art, Science, and New Clinical Techniques, edited by Reinisch J and Tahiri Y, Springer Press, New York, 2019.

Novak RJ, Ideas That Work: Anesthesiologists Start Their Own IVs to                                     Build Rapport With Patients, Outpatient Surgery Magazine, April 2017.

Novak RJ, Doctor Vita, a novel, All Things That Matter Press, 2019.

 

Volunteer Activities:

 1992 to 2000    Internal Medicine Physician, RotaCare Clinic of East Palo Alto

2007 to 2009     Internal Medicine Physician, Samaritan House Clinic, Redwood City

2015 to present  Editor for SafeSpace mental health non-profit organization, Menlo Park, CA

 

Professional Societies:

American Society of Anesthesiologists

California Society of Anesthesiologists

California Medical Association

Santa Clara County Medical Association

 

All expert witness testimony follows the Guidelines For ExpertWitness Qualifications and Testimony, as set forth by American Society of Anesthesiologists:

GUIDELINES FOR EXPERT WITNESS QUALIFICATIONS AND TESTIMONY (Approved by the ASA House of Delegates on October 15, 2003, and last amended on October 22, 2008) PREAMBLE The integrity of the litigation process in the United States depends in part on the honest, unbiased, responsible testimony of expert witnesses. Such testimony serves to clarify and explain technical concepts and to articulate professional standards of care. The ASA supports the concept that such expert testimony by anesthesiologists should be readily available, objective and unbiased. To limit uninformed and possibly misleading testimony, experts should be qualified for their role and should follow a clear and consistent set of ethical guidelines. A. EXPERT WITNESS QUALIFICATIONS 1. The physician (expert witness) should have a current, valid and unrestricted license to practice medicine. 2. The physician should be board certified in anesthesiology or hold an equivalent specialist qualification. 3. The physician should have been actively involved in the clinical practice of anesthesiology at the time of the event. B. EXPERT WITNESS ETHICAL GUIDELINES 1. The physician’s review of the medical facts should be truthful, thorough and impartial and should not exclude any relevant information to create a view favoring either the plaintiff or the defendant. The ultimate test for accuracy and impartiality is a willingness to prepare testimony that could be presented unchanged for use by either the plaintiff or defendant. 2. The physician’s testimony should reflect an evaluation of performance in light of generally accepted standards, reflected in relevant literature, neither condemning performance that clearly falls within generally accepted practice standards nor endorsing or condoning performance that clearly falls outside accepted medical practice. 3. The physician should make a clear distinction between medical malpractice and adverse outcomes not necessarily related to negligent practice. 4. The physician should make every effort to assess the relationship of the alleged substandard practice to the patient’s outcome. Deviation from a practice standard is not always causally related to a poor outcome. 5. The physician’s fee for expert testimony should relate to the time spent and in no circumstances should be contingent upon outcome of the claim. 6. The physician should be willing to submit such testimony for peer review.

 

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

Coming in 2019, from All Things That Matter Press: DOCTOR VITA, Rick Novak’s second novel

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.
email rjnov@yahoo.com
phone 650-465-5997

ai-medical-1-orig

 

How do you imagine the future of medical care? Cherubic young doctors holding your hand as you tell them what ails you? Genetic advances or nanotechnology gobbling up cancerous cells and banishing heart disease? Rick Novak describes a flawed future Eden where the only doctor you’ll ever need is Doctor Vita, the world’s first artificial intelligence physician, endowed with unlimited knowledge, a capacity for machine learning, a tireless work ethic, and compassionate empathy.

artificial-intelligence-in-medicine

In this science fiction saga of man versus machine, Doctor Vita blends science, suspense, untimely deaths, and ethical dilemma as the technological revolution crashes full speed into your healthcare.

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Set on the stage of the University of Silicon Valley Medical Center, Doctor Vita is the 1984 of the medical world– a prescient tale of Orwellian medical advances.

 

LOCKER SLAMMERS

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.
email rjnov@yahoo.com
phone 650-465-5997
My friend, colleague, and President of the company I work for, the Associated Anesthesiologists Medical Group in Palo Alto, California, wrote an excellent column describing Locker Slammers for the American Society of Anesthesiologists Monitor (September 1, 2018; Volume 82, Number 9).
Read on–you won’t be disappointed.
Dr. Champeau is the current elected Treasurer of the American Society of Anesthesiologists
Michael W. Champeau, M.D., FASA, is Adjunct Clinical Professor of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California.

Michael W. Champeau, M.D., FASA, is Adjunct Clinical Professor of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California.

Not long ago, ASA CEO Paul Pomerantz and I discussed the downward pressure on exhibitor fees at the ASA annual meeting. It’s an important topic because ASA derives about 18 percent of its total annual revenue from the meeting, and more than 40 percent of that comes from our exhibitors.
The problem, more and more, is that the vendors are questioning the return on their investment in displaying their products on our exhibit floor. They suspect that our attendees, overwhelmingly practicing anesthesiologists, are no longer the decision-makers driving purchases in their health care organizations. Put simply, it appears to the exhibitors as though we’re no longer the leaders.
The conversation reminded me of the Rovenstine Lecture that Peter Pronovost, M.D., Ph.D., delivered at the annual meeting in 2010. His address, “We Need Leaders,” tackled the issues of improvements in patient safety and the multiple levels of leadership that made those advances possible.
One of the reasons I remember the speech so clearly is because of a rhetorical device Dr. Pronovost employed in its delivery. Nearing the end of his talk, he enumerated a lengthy series of patient safety goals, beginning each with “Now is the time to …” and ending with the simple declarative, “We need leaders.” The mantra drove home his message and made for an unforgettable lecture.
If I had one criticism of the address, though, it would be that Dr. Pronovost took a limited view of the innumerable roles for which we do, in fact, need leaders. We don’t need leaders just for the advancement of patient safety; right now our specialty desperately needs leaders on every front.
If the rewards and satisfaction of a career in anesthesiology were graphed on the abscissa and the passage of time on the ordinate, our current situation places us at a dangerous point of inflection on that trajectory.
With our successes in engineering, pharmacology and myriad other areas of research, anesthesia is safer than it’s ever been, despite an ever-sicker patient population. We’ve been compensated well financially over the past decades for overcoming the inherent dangers of rendering patients insensate to the pain of surgery and supporting their circulation and respiration when we’ve deprived them of the ability to do so for themselves.
But we’re now at a crossroads where anesthesia is beginning to be perceived as so safe that paying for physician leadership in its administration appears to add insufficient additional value to the health care marketplace.
We need leaders to demonstrate that anesthesiologists not only provide the best care, but do, in fact, add value to the American health care system.
We need leaders to prove that anesthesiologists, not independently practicing mid-level practitioners, will continue to expand the knowledge base of the specialty and improve the care that all of us someday, unfortunately, will require.
And we need leaders to carry these messages to the public and to the legislators who define our national priorities.
We need this leadership at every level: within our practices, on our hospital committees, in the executive suites of our hospitals, in the deans’ offices of our academic institutions, as the CEOs of our integrated health care systems, in organized medicine, in our communities and even in our government. We need physician anesthesiologists to be those leaders.
Accordingly, ASA wants to be a resource for its members as they advance to fill those positions. In 2016 we began an Executive Physician Leadership Program in coordination with Northwestern University Kellogg School of Management. It has sold out every year. Last year, the ASA Administrative Council included Health Systems Leadership as a “Strategic Pillar” in ASA’s “2020 Vision for the Future: Contract with our Community.” And in January of this year, ASA President James Grant, M.D., M.B.A., FASA, announced an exciting new collaboration between ASA and the American College of Healthcare Executives (ACHE) that will yield opportunities for our organizations to partner on physician leadership development.
ASA members currently serve as:
  • ■ CEOs of the University of California, Davis, and Dartmouth-Hitchcock Health systems.
  • ■ Executive Vice President for Health Affairs at the University of Kentucky.
  • ■ Chief Operating Officer of New York-Presbyterian/Columbia University Medical Center.
  • ■ Surgeon General of the United States.
  • ■ A member of Congress in the U.S. House of Representatives.
While ASA certainly wants to encourage and support members aspiring to these lofty heights, not all of us can or need to be engaged at this rarified level.
As Dr. Pronovost said in his Rovenstine Lecture, “You do not have to be the smartest or the strongest or the most powerful or the most influential. You also do not need to be the department chair … You simply need to have courage to think of what could be, clarity about the task at hand and commitment to convert these thoughts into a reality.” He added, “Leadership is helping people address problems that will make the world better. It means focusing on a goal and inviting everyone to help achieve it. It means serving others more than ourselves.”
So, in fact, each of us can be a leader. The anesthesiologist who encourages every member of his or her group to be a member of ASA, their state component and state medical society is a leader. The anesthesiologist who inspires others to donate to political candidates and organizations that support the medical specialty of anesthesiology is a leader. The anesthesiologist who volunteers to serve on medical staff committees is a leader. All of us, no matter where we’re pigeonholed on the organization chart, can be leaders.
Sadly, we’re currently a little short on leaders. In fact, too many anesthesiologists are instead locker slammers. What’s a locker slammer? A locker slammer is the antithesis of a leader. A locker slammer is the anesthesiologist who arrives in the morning, provides or medically directs anesthesia in the operating room for a list of surgical patients, drops the final patient of the day off in the PACU, goes straight to the changing room, changes clothes and then slams the locker door and walks out of the building.
Locker slammers add insufficient value to the medical specialty of anesthesiology. They don’t expand the knowledge base of the profession or improve care. They contribute little that a mid-level practitioner could not contribute. They don’t enhance the reputation of their anesthesia group, their health care system or the profession of anesthesiology. They deliver clinical anesthesia, period.
It’s ironic that some of us may even have chosen anesthesiology as a profession specifically because it lends itself to locker slamming.
Locker slammers might administer an excellent anesthetic. They may well be compassionate and caring physicians, loving spouses and wonderful parents.
But, right now, we need more. We need leaders.

FIVE MINUTES . . . TO AVOID ANOXIC BRAIN INJURY

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.
email rjnov@yahoo.com
phone 650-465-5997

Anoxic brain injury. These three words make any anesthesiologist cringe. In layman’s terms, anoxic brain injury, or anoxic encephalopathy, means “the brain is deprived of oxygen.”

Five minutes stopwatch

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In an anesthetic disaster the brain can be deprived of oxygen. Without oxygen, brain cells die, and once they die they do not regenerate. If something dire goes wrong during anesthesia and surgery and the flow of oxygen to the brain is cut off, an anesthesia practitioner has about five minutes to diagnose the cause of the problem and treat it. Some brain cells start dying within five minutes after the oxygen supply disappears, and brain hypoxia can rapidly cause severe brain damage or death. (1,2)

In malpractice cases I’ve consulted on, a five-minute window is an accepted duration for low blood oxygen levels to cause permanent brain damage.

The good news is that catastrophic events causing sudden drops in oxygen levels are very rare during anesthesia. I’ve reviewed the risks of anesthesia in the 21st Century in a previous column, which I refer you to.

Miller’s Anesthesia is the premier textbook in anesthesiology. I respect Miller’s Anesthesia as an outstanding reference, but a keyword search for “anoxic encephalopathy” in Miller’s Anesthesia only links to two chapters: one on temperature regulation, and second on pediatric intensive care. The topic of anoxic encephalopathy as related to anesthesia disasters and brain death—a issue that can ruin both a patient’s life and an anesthesiologist’s career—is not specifically covered in Miller’s Anesthesia.

Anesthesiologists are human, and human error is known to seep into anesthesia care. Miller’s Anesthesia, Chapter 7 on Human Performance and Patient Safety,3 makes several statements pertinent to human error:

“. . . anesthesia professionals themselves, both as a profession and as individuals, have strengths and vulnerabilities pertaining to their work environment. The performance of human beings is incredibly flexible and powerful in some aspects but very limited in others. Humans are vulnerable to distractions, biases, and errors.”  

“The stakes are high because even for elective surgery in healthy patients, there is an ever-present and very real risk of injury, brain damage, or even death. A catastrophe is often the end result of many pathways that begin with seemingly innocuous triggering events. . . .”

“Because more than 70% of all errors in medicine can be attributed to problems with human factors rather than problems with knowledge or practical skills, the impact of human factors cannot be overestimated.

My impression, based on 34 years in an anesthesia career, is that some anesthesia practitioners perform better under pressure. Just like Joe Montana had the knack for doing the right thing on a football field when the pressure was on, and just like Sully (Chesley Sullenberger) made correct decisions when the jet engines of US Airways Flight 1549 were knocked out by collisions with birds shortly after takeoff, some anesthesia practitioners perform well under intense pressure . . . and some don’t.

Let me present two examples, inspired by real cases, of relatively healthy young patients who had unexpected hypoxic (low oxygen) episodes. These patients had drastically different outcomes due to different anesthetic care:

CASE 1.

A 40-year-old male presented for outpatient septoplasty surgery. His past medical history was positive for obesity (weight=100 kg with a BMI=32) and hypertension. His preoperative vital signs were normal with an oxygen saturation of 98%.

Anesthesia was induced with propofol 250 mg, fentanyl 100 micrograms, and rocuronium 50 mg IV. An endotracheal tube was easily placed, and breath sounds were equal bilaterally. Anesthesia was maintained with oxygen, nitrous oxide, and sevoflurane 1.5%, and incremental doses of 50 micrograms of fentanyl.

The surgery concluded 2 hours later, and the nitrous oxide and sevoflurane were discontinued. The patient began to cough, and reached up to try to pull out his endotracheal tube. The anesthesiologist decided to extubate the trachea. After extubation the patient was making respiratory efforts, but no airflow was noted. A jaw thrust attempt to break suspected laryngospasm was ineffective. The oxygen saturation dropped to 78%.

  • Succinylcholine 40 mg was administered. There was no improvement in the oxygenation or airway.
  • Two minutes later a second dose of succinylcholine 60 mg was administered. There was continued inability to move oxygen.
  • Two minutes later, a #4 LMA was placed, with continued inability to move oxygen.
  • Two minutes later the anesthesiologist attempted to reintubate the trachea. The first attempt was unsuccessful due to poor visibility. The oxygen saturation dropped to 50%.
  • Seven minutes after the initial oxygen desaturation to 78%, a second laryngoscopy using a GlideScope was successful, and a 7.0 ET tube was placed. Copious secretions were suctioned out of the ET tube. Ventilation remained difficult and peak inspiration pressures were high. The patient continued to be hypoxic. The patient’s ECG deteriorated into pulseless electrical activity (PEA), and chest compressions were initiated. Epinephrine 1 mg was administered IV twice, the peripheral pulses returned, and chest compressions were stopped.
  • Twenty minutes after the oxygen desaturation to 78%, the oxygen saturation finally rose to 94%. A chest x-ray showed pulmonary edema. The diagnosis was laryngospasm leading to negative pressure pulmonary edema. Furosemide 20 mg was administered IV. The patient remained on a ventilator in the ICU for seven days, at which time he was declared brain dead.

 

CASE 2.

A 30-year-old male was scheduled for maxillary and mandibular osteotomies for obstructive sleep apnea. He was otherwise healthy. He weighed 80 kg and had a BMI=26. His preoperative vital signs were normal.

Anesthesia was induced with propofol 250 mg and rocuronium 50 IV, and a right cuffed nasal endotracheal tube was placed. Breath sounds were bilateral and equal. Anesthesia was maintained with sevoflurane 1.5%, nitrous oxide 50%, propofol 50 mcg/kg/hr, and incremental doses of 50 mcg fentanyl. The surgery concluded 4 hours later. The surgeons wired the upper and lower teeth together. The propofol, sevoflurane, and nitrous oxide were discontinued.

The patient opened his eyes ten minutes later, and responded appropriately to conversation. The endotracheal tube was removed, and the patient’s airway was patent. He was moved to the gurney, the back of the gurney was elevated 30 degrees, and a non-rebreather mask with a 10 liters/minute flow rate of oxygen was strapped over his face. The anesthesiologist then transported the patient down the hallway to the PACU. En route the patient became more somnolent and developed upper airway obstruction resistant to jaw thrust maneuvers.

  • On arrival at the PACU the patient was nonresponsive, and his initial oxygen saturation was 75%. The anesthesiologist began mask ventilation via an Ambu bag, and the oxygen saturation rose to 90%. The patient was making ventilatory efforts without significant air movement.
  • The wires fixating the maxilla and mandible together were severed with a wire cutter.
  • The anesthesiologist attempted laryngoscopy with a Miller 2 blade, and was unable to visualize the larynx because of frothing fluid bubbling in the oropharynx. A presumptive diagnosis of negative pressure pulmonary edema was made, and a GlideScope was called for. The oxygen saturation was 88%.
  • After suctioning the frothy fluid which filled the oropharynx, a second laryngoscopy attempt with the GlideScope yielded successful placement of a 7.0 oral endotracheal tube. Pulmonary edema fluid was suctioned from the lumen of the endotracheal tube, and furosemide 20 mg was injected IV. The oxygen saturation rose to 98% on 100% oxygen.

The duration of time from when the patient’s oxygen level was discovered to be 75% until his oxygen level rose above 90% was two minutes. The duration of time from when the patient’s oxygen level was discovered to be 75% until the trachea was successfully reintubated was four minutes.

The patient remained intubated in the ICU for two nights, with diagnoses of upper airway edema post maxillary-mandibular osteotomies and negative pressure pulmonary edema. He was extubated on post-op day #3, when he successfully passed a cuff-leak test. His oxygen saturations were normal and his brain was undamaged. He walked out the hospital alive and well.

Case #1 and Case #2 were similar in that both patients were young relatively healthy men having head and neck surgery. The expected risk of serious complication for each procedure was low. The expected risk of death, or of brain death, was extremely small. Yet one man died and the other survived.

Why?

In Case #1, a case study based on a closed claim malpractice settlement, the delays in anesthesia care led to prolonged low oxygen levels, and these prolonged low oxygen levels caused anoxic brain damage. The deviations from the standard of care included:

  1. The patient was extubated too early, at a time when he was still partially anesthetized, in a transitional phase of anesthesia, and not yet awake. The safest technique for extubation is awake extubation, when the patient is an awake state of eye opening and obeying commands. Per the Difficult Airway Society Guidelines for the Management of Tracheal Extubation, an awake intubation is when “the patient’s eyes are open and the patient is responsive to commands.”4 This patient had head and neck surgery, and was at risk for post-operative airway problems. Extubating before the patient opened his eyes and obeyed verbal commands was a deviation from the standard of care.
  2. Once the patient developed post-extubation laryngospasm, the standard of care was for the anesthesiologist to act immediately to relieve airway obstruction and correct hypoxemia. Laryngospasm can lead to hypoxia, as it did in this case. The order of treatment is A-B-C, or Airway–Breathing–Circulation. When the immediate application of jaw thrust and continuous positive airway pressure via facemask was unsuccessful, and the oxygen saturation dropped into the 70’s, the standard of care was to immediately paralyze the patient with an intubating dose of succinylcholine (1 mg/kg IV) and to reinsert an endotracheal tube. Per Difficult Airway Society Guidelines for the Management of Tracheal Extubation, “If laryngospasm persists and/or oxygen saturation is falling: (administer) succinylcholine 1 mg/kg intravenously. Worsening hypoxia in the face of continuing severe laryngospasm with total cord closure . . . requires immediate treatment with intravenous succinylcholine. The rational for 1 mg/kg is to provide cord relaxation, permitting ventilation, re-oxygenation and intubation should it be necessary.”4 The entire time from the onset of laryngospasm to the successful control of the airway and ventilation of the lungs in Case #1 exceeded 20 minutes.

When a bad outcome like this occurs in a hospital or surgery center, a facility’s Quality Assurance Committee examines the details of the case—not to assign blame—but to identify flaws in patient care systems which must be improved in the future.

When a patient’s family hires a lawyer to investigate a bad outcome, the same analysis of the medical record and the medical details occurs, but the stakes are different. Physicians and facilities carry malpractice insurance with limits in the millions of dollars. If a physician or a facility is found to have performed below the standard of care, and if that negligent performance is found to have caused patient damage, they may well lose a malpractice settlement. The minute-by-minute pulse oximetry data will be scrutinized during any ensuing malpractice trial or deposition, with an aim to document how many minutes the oxygen saturation was critically low. A time frame of five minutes or greater of hypoxia in the medical record can be damning for the anesthesiologist’s case.

In the Miller’s Anesthesia chapter titled Human Performance and Patient Safety, Drs. Rall and Gaba describe 15 Key Points of Crisis Resource Management (CRM).3 Highlights of the Key Points include:

  • CRM Key Point 2. Anticipate and Plan. “Anesthesia professionals must consider the requirements of a case in advance and plan for the key milestone. They must imagine what could go wrong and plan ahead for each possible difficulty. Savvy anesthesia professionals expect the unexpected, and when it does strike, they then anticipate what could happen next and prepare for the worst.”
  • CRM Key Point 3. Call for Help Early.
  • CRM Key Point 4. Exercise Leadership and Followership With Assertiveness. “A team needs a leader. Someone has to take command, distribute tasks, collect information, and make key decisions. . . . Followers are key members of the team who listen to what the team leader says and do what is needed.”
  • CRM Key Point 8. Use All Available Information. “Information sources include those immediately at hand (the patient, monitors, the anesthesia record), secondary sources such as the patient’s chart, and external sources such as cognitive aids (see later) or even the Internet.”
  • CRM Key Point 11. Use Cognitive Aids. “Cognitive aids—such as checklists, handbooks, calculators, and advice hotlines—come in different forms but serve similar functions. They make knowledge “explicit” and “in the world” rather than only being implicit, in someone’s brain.” An example cognitive aid is the Stanford Emergency Manual, which I recommend.5

Dr. David Gaba, one of the authors of this chapter, is a longtime friend of mine and a pioneer in the fields of anesthesia simulator design and crisis management. I respect this list of 15 CRM Key Points, but I also know that when the clock is ticking on those five minutes of patient hypoxia, there is no time to think through 15 items. There is no time for any wasted effort or motions. The anesthesia provider must captain the ship and restore oxygenation without delay. The anesthesia provider needs a plan embedded in his or her brainstem that allows them to keep the patient safe.

Based on my experience as both a practicing anesthesiologist for over 30 years and an expert witness for over 15 years, when your patient’s oxygen level drops acutely, these are the things you need to DO:

  1. First off, turn your oxygen supply to 100% oxygen. Turn off all nitrous oxide or air input.
  2. Call for help.
  3. Think A-B-C, or Airway-Breathing-Circulation, in that order.
  4. Examine the patient, particularly their airway and lungs.
  5. If the patient is not already intubated, and you cannot mask ventilate the patient to a safe oxygen level, intubate the trachea immediately to deliver 100% oxygen via controlled ventilation. Use succinylcholine, the fastest emergency paralytic drug.
  6. If you cannot intubate the patient with a traditional Miller 2 or Mac 3 blade, request a GlideScope videoscope ASAP. (Have the American Society of Anesthesiologists Difficult Airway Algorithm committed to memory.)
  7. Have the Stanford Emergency Manual5 in your operating room suite, and ask a registered nurse to recite the Cognitive Aid Checklist for HYPOXEMIA to you, to make sure you haven’t missed something.
  8. If the patient is still not improving, reaffirm your assessments of A-B-C. Fix the Airway, fix the B, then fix the Circulation.
  9. Remember: ACLS (Acute Cardiac Life Support) is important, but ACLS is C, and if A and B are faulty, the cardiac care of ACLS will not save the brain.

Other advice to anesthesiologists:

  • Before a hypoxic emergency occurs in your practice, do yourself and your patients a favor by passing the American Board of Anesthesiologists oral board examination. The time spent studying for the oral boards will make you a safer and smarter anesthesiologist who is better prepared to handle emergency situations. A study in the journal Anesthesiology showed rates for death and failure to rescue from crises were greater when anesthesia care was delivered by non-board certified midcareer anesthesiologists.6 In the Stanford Department of Anesthesiology, Perioperative and Pain Medicine, we administer mock oral board examinations to the residents and fellows twice a year. Presenting an examinee with a sudden hypoxic episode is a common occurrence during the exam. If you can think well in a room in front of two examiners, you are more likely to think well in a true hypoxemic emergency when your patient’s life is at stake.
  • A second tip: If you have access to anesthesia simulator sessions, enroll yourself.

What if you’re a patient reading this? What if you’re contemplating surgery? How can you optimize your chances to avoid an anesthetic disaster?

I offer these suggestions:

  • Choose to have your surgery at a facility that is staffed with American Board of Anesthesiology board-certified physician anesthesiologists.
  • Ask a knowledgeable medical professional to recommend a specific anesthesiologist at your facility, and request that specific anesthesiologist for your care.
  • Inquire about who would manage your crisis if you have one during or after your surgery. Will your anesthesia professional be a physician anesthesiologist, a Certified Registered Nurse Anesthetist (CRNA), or an anesthesia care team made up of both? If an anesthesia care team is attending to you, how many rooms is each physician anesthesiologist supervising? How far away or how many minutes away will your physician anesthesiologist be while you are asleep?
  • In the future, quality of care data will be available on facilities and physicians, including anesthesiologists. These metrics will allow patients to compare facilities and physicians. Do your homework with whatever data is publicized. Research the facility you are about to be anesthetized in.
  • If you’re a higher risk patient, i.e. you have: significant obesity, obstructive sleep apnea, heart problems, breathing problems, age > 65, or you’re having regular dialysis, emergency surgery, abdominal surgery, chest surgery, major vascular surgery, cardiac surgery, brain surgery, regular dialysis, total joint replacement, or a surgery with a risk of high blood loss . . . be aware you’re at a higher risk, and ask more questions of your surgeon and your anesthesia provider.
  • If yours is an elective surgery, realize you have time to heed the advice in this column. Take your time to choose your surgeon, your facility, and your anesthesia provider if you can.

None of us, anesthesia providers or the families of patients, want to be sitting in a courtroom for a malpractice trial because there were five bad minutes without oxygen.

References:

  1. https://medlineplus.gov/ency/article/001435.htm
  2. https://medlineplus.gov/ency/article/000013.htm
  3. Rall M, Gaba D, et al. Human Performance and Patient Safety. Miller’s Anesthesia, Chapter 7, Eighth Edition, p 106-166.
  4. Popat M, Mitchell V, et al. Difficult Airway Society Guidelines for the management of tracheal extubation, Anaesthesia 2012, 67, 318-340.
  5. Stanford Anesthesia Cognitive Aid Group. Emergency Manual: Cognitive aids for perioperative clinical events. *Core contributors in random order: Howard SK, Chu LK, Goldhaber-Fiebert SN, Gaba DM, Harrison TK http://emergencymanual.stanford.edu/
  6. Silber JH et al. Anesthesiologist Board Certification and Patient Outcomes. Anesthesiology.2002 May;96(5):1044-52.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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LETHAL EXECUTION USING FENTANYL . . . AN ANESTHESIOLOGIST’S OPINION

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.
email rjnov@yahoo.com
phone 650-465-5997

Lethal injection using fentanyl occurred for the first time in the death penalty execution of Carey Dean Moore in Nebraska August 14th, 2018.

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Per CBS News, “The Nebraska drug protocol called for an initial IV dose of diazepam, commonly known as Valium, to render the inmate unconscious, followed by the powerful synthetic opioid fentanyl, then cisatracurium besylate to induce paralysis and stop the inmate from breathing and potassium chloride to stop the heart.

Diazepam and cisatracurium also had never been used in executions before.”

From an anesthesiologist’s point of view:

  1. Valium (diazepam), an antianxiety drug, is seldom used in current surgical anesthesia practice, as it has been replaced by Versed (midazolam), which has a faster onset and causes less stinging on intravenous injection.
  2. Fentanyl, a powerful morphine-type narcotic, given in very high doses, brings on sedation, respiratory depression, and unconsciousness. The combination of Valium and high doses of fentanyl (typically 100 micrograms per kilogram) was the standard anesthetic used for open heart surgery in the 1980s. High doses of fentanyl can cause chest wall rigidity, which would add to any agonal respiratory efforts during a lethal injection, hence the necessity of a muscle relaxant (see below).
  3. Cisatracurium, a muscle relaxant or paralyzing drug, blocks all muscle movement and breathing. The paralyzing drug is used to both stop respiration and to eliminated any writhing and agonal movements during the dying movements.
  4. Potassium chloride, in high concentrations, causes the heart to fibrillate and cease beating.

Beginning in the 1970s, initial lethal injection recipes in the United States included 1) sodium thiopental (a barbiturate) to induce sleep, 2) pancuronium (a muscle relaxant) to paralyze the individual, and 3) potassium chloride to fibrillate the heart. In the 1970s-1990s, thiopental and pancuronium were commonly used anesthetic drugs. (In recent decades, propofol has replaced thiopental as the hypnotic of choice for general anesthesia for surgery, and the drugs rocuronium and vecuronium have replaced pancuronium as muscle relaxants for surgery.)

The European Union banned the export of thiopental for lethal injection in 2011, and a search for available alternate sedatives and intravenous anesthetics ensued. By 2016, more than twenty American and European pharmaceutical manufacturers had blocked the sale of their drugs for use in lethal injections, effectively making most FDA-approved unavailable for any potential lethal execution drug.1

This use of fentanyl, diazepam, and cisatracurium in Nebraska is the latest chapter in the recipe for lethal injection story. Stay tuned to see whether the manufacturers of these drugs choose to ban their sale for use in capital punishment.

For previous columns regarding lethal injection procedures, see

JANUARY 2014 LETHAL INJECTION WITH MIDAZOLAM AND HYDROMORPHONE . . AN ANESTHESIOLOGIST’S OPINION, and

APRIL 2014 LETHAL INJECTION IN OKLAHOMA . . . AN ANESTHESIOLOGIST’S VIEW.

Note: As a physician who took the Hippocratic Oath to never harm patients, I neither approve of nor would assist in any way in the lethal injection of a prisoner.

 

References:

  1. Eckholm, Erik “Pfizer Blocks the Use of Its Drugs in Executions”The New York Times. May 16, 2016.

 

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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WILL ATUL GAWANDE CHANGE THE FUTURE FOR ANESTHESIOLOGISTS?

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.
email rjnov@yahoo.com
phone 650-465-5997

Dr. Atul Gawande was named CEO of the new Amazon-Berkshire-JPMorgan Chase healthcare partnership. Dr. Robert Pearl wrote an original article in Forbes (June 25, 2018) titled, “Why Atul Gawande Will Soon Be the Most Feared CEO in Healthcare.” Dr. Gawande is a Professor of Surgery at Harvard/ Brigham and Women’s Hospital, and is the bestselling author of multiple nonfiction books directed at healthcare topics. Gawande also has a Masters Degree in Public Health, and with his background as a clinician, he is well poised to interpret the problems of our current healthcare system. Per Dr. Pearl, Gawande was hired by the new Amazon-Berkshire-JPMorgan Chase healthcare partnership to “disrupt the industry, to make traditional health plans obsolete, and to create a bold new future for American healthcare.” Will Gawande change the future for anesthesiologists?

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I’ve read Dr. Gawande’s books and I’ve heard him speak at Stanford. I have the highest respect for his intellect, clinical acumen, and insight. I’m intrigued and excited by what changes he might envision and enact for American healthcare. Surgical care comprises $500 billion, or 40% of healthcare dollars spent spent in America, so we can expect changes in our surgical world to be a likely source of healthcare savings.

Author Dr. Robert Pearl is the former CEO of Kaiser’s Permanente Medical Group, and brother to my Stanford University Department of Anesthesiology Chairman Ronald Pearl MD PhD. In his Forbes article, Robert Pearl lists three major reforms he anticipates Gawande will advocate for. Each reform is aimed to radically improve how care is paid for and provided—and each reform is aimed to radically alter how healthcare providers must function to survive in the future. Let’s look at these three proposed Gawande changes, and how they affect the future for anesthesiologists:

 

  1. Taking out the trash. Pearl writes, “It’s estimated that 25 percent of all U.S. healthcare spending (about $765 billion each year) is wasted. From arthroscopic knee surgeries for chronic cartilaginous injuries to chemotherapy administered in the last month of life, insurers have long reimbursed unnecessary claims and perpetuated a fee-for-service model that rewards doctors for providing more (not better) care. Dr. Gawande has witnessed the excesses of modern medical treatment first-hand, cataloging in his essays the toll wasteful care takes on patients, including his own friends and family. I believe one of his first operational goals will be to root out wasteful spending and services, not as way to ration care, but as a tool to improve clinical outcomes.”

         EFFECT ON ANESTHESIOLOGY AND PERIOPERATIVE MEDICINE: Each “unnecessary claim” that needed an anesthesiologist and every “fee-for-service” procedure that involved anesthesia care would disappear, decreasing the need for anesthesiologists and anesthesia services. This proposed elimination of wasteful spending would decrease the demand for anesthesia professionals.

 

  1. Creating a checklist. Pearl writes, “Gawande earned national acclaim with his 2009 bestseller, The Checklist Manifesto, inspiring an entire industry to double down on evidence-based medicine. From the exam room to the operating room, doctors today follow a clear set of protocols that Dr. Gawande helped establish. He’s currently focused on extending these successes to other areas, including maternity care and the treatment of patients with complex and chronic diseases. For example, the doctor has observed how the best healthcare providers can help 90 percent or more of their patients control high blood pressure. And yet the national control rate is just 55 percent. Left to their own devices, physicians prefer to follow their guts when diagnosing and treating patients. Dr. Gawande knows that, most of the time, science (not intuition) saves more lives, raises the quality of care and lowers costs.”

EFFECT ON ANESTHESIOLOGY AND PERIOPERATIVE MEDICINE: In the future, specific evidence-based protocols and algorithms could dictate anesthesia “recipes.” In the past, every anesthesia provider has had the freedom to design and carry out the pharmacology, monitoring, and perioperative care for each patient as he or she saw fit. These individual decisions were based on each physician’s training and experience. But in recent years, for example, protocols have been introduced to standardize perioperative care for total knee replacement, so that anesthetics include a spinal anesthetic, an adductor canal nerve block, and sedation or a light general anesthetic as well as multimodal analgesia with oral analgesic supplements. These total knee protocols have become standardized and accepted. What about future protocols? Can an insurer dictate what they will or will not pay for, based on their assessment of scientific evidence? This could occur if the insurer has data that the non-protocol care does nothing to improve quality, and it costs more. Let’s look at an example: There are a variety of pharmaceutical choices for the anesthesia care of a shoulder arthroscopy. An ultrasound-directed nerve block is optional. Is there evidence that the block provides safer or cheaper outcomes? If an evidence-based analysis is conducted and it shows that complications, costs, room time, and ancillary staff support are most economical with general anesthesia sans a nerve block, then that interscalene nerve block could be deemed an extraneous charge—an extraneous procedure that will not be paid for. If an anesthesiologist wanted to use the nerve block, the insurer would not reimburse those costs. Only the drug costs, procedures, and protocols approved by the insurance company would be approved. In the current fee-for-service practice, the anesthesiologist may be reimbursed $1000 for an ultrasound-directed nerve block that takes 5 minutes to perform. In the future the anesthesiologist may be doing that block without any reimbursement, yet still be responsible for any costs of that block and any risks or complications of that block. Having Amazon/Gawande dictate evidence-based protocols for postoperative care may produce cost-cutting economics, and anesthesiologists might find their hands tied to a recipe dictated from on high.

 

  1. Being human. Pearl writes, “In Being Mortal, Dr. Gawande shines an unflattering light on end-of-life care in America, revealing that treatment for our nation’s elderly is often expensive, ineffective and inhumane. He has long been an advocate for the model of clinician as counselor, not as technician, and for the power of palliative care to make end-of-life treatment more compassionate and personal. His stories about his own father and mother are moving, and underscore the emotions driving his desire to improve care for our nation’s sickest patients.”

EFFECT ON ANESTHESIOLOGY AND PERIOPERATIVE MEDICINE: All physicians have witnessed expensive and often futile end-of-life intensive care management for elderly patients. If physicians and hospitals are offered an open checkbook, they may choose to administer expensive high-tech interventions to elderly patients during their last weeks of life, including ventilator care, pressors, multiple antibiotics, blood product transfusions, and surgeries. In America we value every life as a precious resource. We value saving every life. It’s probable true that we can no longer afford to spend millions of dollars on the last weeks of each sick elderly patient’s life. It’s probably true that we need some conscience, some compassion, some judgment, and some empathy to choose who to attempt to save. Currently physicians cannot police these decisions themselves, and the government cannot set any rationing policies regarding end-of-life care. It may very well be insurance companies like Amazon/Gawande who set the incentives and disincentives directing payment or non-payment for such care. If surgeons and medical centers lose incentives to perform end-of-life surgical procedures, there will be decreased caseloads for anesthesiologists.

 

The expense of the current American healthcare system is unsustainable. Healthcare costs are 17% of the Gross National Product, and this percentage is growing every year. The cost of insuring employees is a large share of the wage and benefit expenses of every American CEO. The cost of insuring loved ones with current high-deductible insurance plans is a large share of the expense budget for every American family.

Something has to change. The driver of change may very well be the combined economic clout and intellect of: Amazon, the company that delivers UPS packages to our door 36 hours after placing an order; Warren Buffett, the world’s third richest man; J P Morgan Chase, a multi-national investment bank; and d) a talented physician/author/visionary named Atul Gawande.

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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ANESTHETIC RISKS IN CHILDREN

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.
email rjnov@yahoo.com
phone 650-465-5997

What are the anesthetic risks for children? What should you do if your 2-year-old son or daughter requires surgery and anesthesia? Should you consent to proceed? Should you wait until he or she is 3 years old?

The answer to all these questions is: “It depends.”

am_150605_child_anesthesia_800x600

Let’s look at recommendations as they exist in 2018.

On December 14, 2016, the United States Food and Drug Administration (FDA) issued a Drug Safety Communication Drug Safety Communication Warning that general anesthesia and sedation drugs used in children less than 3 years of age who were undergoing anesthesia for more than 3 hours, or repeated use of anesthetics, “may affect the development of children’s brains.”

The text of this December 2016 FDA statement reads:

The U.S. Food and Drug Administration (FDA) is warning that repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children’s brains. . . . Consistent with animal studies, recent human studies suggest that a single, relatively short exposure to general anesthetic and sedation drugs in infants or toddlers is unlikely to have negative effects on behavior or learning. However, further research is needed to fully characterize how early life anesthetic exposure affects children’s brain development. . . . Health care professionals should balance the benefits of appropriate anesthesia in young children and pregnant women against the potential risks, especially for procedures that may last longer than 3 hours or if multiple procedures are required in children under 3 years. Discuss with parents, caregivers, and pregnant women the benefits, risks, and appropriate timing of surgery or procedures requiring anesthetic and sedation drugs.”

This FDA warning resulted in a labeling change for these 11 common general anesthetics drugs and sedative agents:

  • Propofol
  • Sevoflurane
  • Midazolam
  • Isoflurane
  • Desflurane
  • Halothane
  • Pentobarbital
  • Etomidate
  • Ketamine
  • Lorazepam
  • Methohexital

Of these, sevoflurane and propofol are mainstay drugs used in pediatric anesthetics. Anesthesia for infants and children is most frequently initiated with an inhalation induction of sevoflurane vapor, because most infants and children do not have an IV line prior to induction. The primary intravenous hypnotic drug for children is propofol.

Because of this FDA statement, the propofol package insert warning label now reads:

Pediatric Use; ANIMAL TOXICOLOGY AND/OR PHARMACOLOGY). Some published studies in children suggest that similar deficits may occur after repeated or prolonged exposures to anesthetic agents early in life and may result in adverse cognitive or behavioral effects. These studies have substantial limitations, and it is not clear if the observed effects are due to the anesthetic/sedation drug administration or other factors such as the surgery or underlying illness. Anesthetic and sedation drugs are a necessary part of the care of children needing surgery, other procedures, or tests that cannot be delayed, and no specific medications have been shown to be safer than any other. Decisions regarding the timing of any elective procedures requiring anesthesia should take into consideration the benefits of the procedure weighed against the potential risks.”

For sevoflurane, the package insert warning label now reads:

Repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in neonates, infants, and children younger than 3 years, including in utero exposure during the third trimester, may have negative effects on brain development. Consider the benefits of appropriate anesthesia in young children against the potential risks, especially for procedures that may last more than 3 hours or if multiple procedures are required during the first 3 years of life. It may be appropriate to delay certain procedures if doing so will not jeopardize the health of the child. No specific anesthetic or sedation drug has been shown to be safer than another. Human studies suggest that a single short exposure to a general anesthetic in young pediatric patients is unlikely to have negative effects on behavior and learning; however, further research is needed to fully characterize how anesthetic exposure affects brain development.

There are no real alternatives to these 11 general anesthetic drugs regarding pediatric anesthesia. Dexmedetomidine and narcotics are not on the FDA list, but dexmedetomidine and narcotics are not sufficient to provide general anesthesia by themselves.

What does this mean to physicians and parents regarding anesthetics on children under the age of 3 years?

The most common indications for infants and toddlers to be placed under general anesthesia are for short procedures such as ear tubes for chronic ear infections, hernia repair, or removal of the adenoids. At times infants or toddlers require general anesthesia or sedation so they will stay still during a procedure, such as when they need an MRI or a CT scan.

There are an estimated 1.5 -2 million children under 3 years of age who undergo anesthesia annually in the United States. Prior to the FDA statement, Texas Children’s Hospital performed more than 43,000 cases each year. Approximately 13,000 of these cases involved patients under 3 years of age, and more than 11,000 of these anesthetics lasted more than 3 hours. Nearly all of the prolonged anesthetics were for serious congenital conditions for which treatment could not be delayed until the patient reached 3 years of age. Because of the FDA warning, the hospital adopted the warning’s recommendation that a discussion occur among parents, surgeons and other physicians, and anesthesiologists regarding the duration of anesthesia, any plan for multiple general anesthetics for multiple procedures, and the possibility that the procedure could be delayed until after 3 years of age.1

Dr. Constance Houck, chair of the American Academy of Pediatrics’ Surgical Advisory Panel and an Associate Professor of Anesthesia at Harvard Medical School said, “two recently published studies examining short-term anesthesia exposure for hernia repair did not show neurobehavioral differences between those who had received a general anesthetic and those who had not. . . . Most surgeries are less than one hour, but some infants and children with significant congenital defects require more prolonged surgery. . . Examples would include such defects as cleft lip and palate and malformations of the urinary or gastrointestinal tract.” Postponing major reconstructive surgery until children are older is generally not an option. “There is no evidence to suggest that short procedures should be postponed, but parents should always discuss with their child’s pediatrician and surgeon the risks and benefits of timing of procedures.2

The American Society of Anesthesiologists response to the FDA statement read: “the accumulated human data suggest that one brief anesthetic is not associated with cognitive or behavioral abnormalities in children. Most but not all studies in children do however suggest an association between repeated and or prolonged exposure and subsequent difficulties with learning or behavior.”3

In addition to the FDA drug recommendations, there are well documented surgical concerns with operating on children under age 3. For example, the recommendations for pediatric tonsillectomy are to delay until age 3, based on a high degree of evidence for increased respiratory complications at ages younger than 3.4

An overriding important consideration regarding pediatric anesthetics is: Who will be doing the anesthesia? It’s important to inquire regarding the experience and training of the physician anesthesiologist who is about to anesthetize your child. (See my related column Pediatric Anesthesia: Who is Anesthetizing Your Child?)

Some anesthesiologists do specialty fellowship education for one or two years in pediatric anesthesia, usually at an academic pediatric hospital, and are therefore well-trained to attend to your child. In community hospitals, experienced physician anesthesiologists who have attended to children since their residency training commonly do pediatric anesthetics. My practice fits this model: I am not a fellowship-trained pediatric anesthesiologist, but I have anesthetized thousands of children safely over 33+ years since my Stanford residency.

Let’s return to the question of whether your 2-year-old should have anesthesia and surgery.

My family had a personal experience with this question. My oldest son fell and cracked his upper right incisor when he was 1½ years old. He had three general anesthetics in the following nine months for dental surgeries: the first surgery to place a cap on the fractured tooth, the second surgery to extract the tooth because it died, and a third surgery to place a prosthetic incisor to replace the lost tooth. These three surgeries were performed in 1998 and 1999 when my son was between 1½ and 3 years of age. He suffered no apparent developmental delays secondary to anesthesia, but in the present day, following the FDA statement, both the physicians and the parents would be unlikely to proceed with three repeated anesthetics on such a young child.

The answer for you depends on whether your child’s surgery is elective and can wait until he or she is 3 years old, whether it is a one-time surgery, whether the surgery is brief, whether it is an emergency or whether it is to remedy a congenital deformity and can not be delayed. You’ll need to have an informed consent discussion with the surgeon, the physician anesthesiologist, and perhaps your pediatrician. If your child’s surgery is a one-time anesthetic for a common short procedure such as ear ventilation tubes or an inguinal hernia repair, it’s likely that proceeding with anesthesia and surgery will be the correct answer. If the surgery is urgent or if delaying surgery will cause an adverse outcome, then proceeding with anesthesia and surgery will be the correct answer. Trust your surgeon and physician anesthesiologist as consultants, and you’ll make the correct choice.

Be reassured. The Society for Pediatric Anesthesiology states that “complications are extremely rare. In the United States, the chance (risk) of a healthy child dying or sustaining a severe injury as a result of anesthesia is less than the risk of traveling in a car.”5

 

References:

  1. Andropoulos DB, Greene MF. Anesthesia and Developing Brains — Implications of the FDA Warning. N Engl J Med 2017; 376:905-907
  2. https://www.forbes.com/sites/ritarubin/2016/12/17/fda-has-ordered-new-label-warnings-but-its-not-clear-that-anesthesia-is-risky-in-pregnancy-kids/#45afde9138c9
  3. https://www.asahq.org/advocacy/fda-and-washington-alerts/washington-alerts/2016/12/asa-response-to-the-fda-med-watch
  4. Lescanne E, et al. Pediatric tonsillectomy: clinical practice guidelines. Eur Ann Otorhinolaryngol Head Neck Dis. 2012 Oct;129(5):264-71.
  5. http://www2.pedsanesthesia.org/patiented/risks.iphtml

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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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:

41wlRoWITkL

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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The anesthesiaconsultant.com, copyright 2010, Palo Alto, California

For questions, contact:  rjnov@yahoo.com

 

 

 

 

 

 

 

 

 

HOW NEW IS “MODERN ANESTHESIA?”

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.
email rjnov@yahoo.com
phone 650-465-5997

Point/Counterpoint: How new is modern anesthesia? Are modern anesthesia techniques radically different from the methods of twenty years ago? True or false?

1990s-moodboard

 

POINT: False. Twenty-first century general anesthetics are nearly identical to the anesthetic techniques of the late 1990s. Consider this list of the most commonly administered anesthetic drugs in the United States in the present day (2018):

Medication                        Year introduced

Propofol                              1989

Sevoflurane                        1995

Nitrous oxide                     1846

Fentanyl                               1959

Versed                                   1985

Rocuronium                        1994

Succinylcholine                  1952

Zofran                                  1991

Bupivicaine                          1957

 

I review hundreds of anesthesia records each year from California and multiple other regions of America. I can attest that these nine medications are still the mainstays of most anesthetics. A typical standard general anesthetic includes Versed as an anti-anxiety premed, propofol as the hypnotic, sevoflurane +/- nitrous oxide as the maintenance vapor(s), fentanyl as the narcotic, Zofran for nausea prophylaxis, rocuronium or succinylcholine for muscle paralysis, and bupivicaine injected (usually by the surgeon) for long-lasting pain relief.

How can it be that general anesthesia has ceased to evolve? In this brave new world of the Internet, iPhones, iPads, and personal computers, how could anesthesiology have stalled out with 20th-century pharmacology? My colleague Donald Stanski, MD PhD, former Chairman of Anesthesiology at Stanford and now an executive in pharmacology business, explained it to me this way: The existing anesthesia drugs are cheap and work well. The cost of research and development for each new anesthesia drug is prohibitively expensive, and for pharmaceutical companies there is no certainty that any new anesthesia drug would control a sufficient market share to make a profit.

I believe we would benefit from a new narcotic drug that would promise less side effects than the fentanyl/morphine analogues, i.e. less respiratory depression, nausea, and sedation. I believe we would benefit from a new ultra-short onset paralyzing drug without the side effects of succinylcholine, i.e. without the risks of muscle pain, hyperkalemic arrests, triggering of malignant hyperthermia, increased intracranial and intraocular pressure, or bradycardia. Someone may discover these products someday, but for the present time the older drugs enjoy the market share.

What about regional anesthesia? When a patient needs a spinal anesthetic, the recipe of bupivicaine +/- morphine is unchanged from the 1990s. When a patient needs an epidural for surgery, the recipe of bupivicaine or lidocaine +/- narcotic is unchanged from the 1990s.

What about monitors of vital signs? The standard monitoring devices of pulse oximetry, end-tidal CO2 monitoring, and other essential anesthesia vital sign monitors were developed and in use by the 1990s. I can think of no specific reason why a general anesthetic administered in 2018 would be safer than a general anesthetic administered in the 1990s.

 

COUNTERPOINT: True. Anesthesia in 2018 is markedly different from anesthesia in the 1990s. Most of the drugs in use haven’t changed, but current-day anesthesia providers practice in a cockpit surrounded by computers. Each operating room anesthesia location is the epicenter of computerized medical record-keeping machines, computerized Pyxis-style drug storage systems, computerized labeling machines, and bar-code reading billing machines. If you don’t understand how to command these high-tech devices, you’ll be unable to initiate an anesthetic at a university hospital. The adage that “the patient comes first” is sometimes lost in an array of LED displays, passwords, and keyboards.

There have been other significant changes in anesthesia practice since the year 2000:

  • The most significant advance is the video laryngoscope, a vital tool for intubating difficult airways, which has facilitated endotracheal intubation in thousands of patients where 20th-century rigid laryngoscope blades were not effective.
  • Ropivicaine was released in the year 2000, and has the distinct advantage of long-lasting local anesthetic nerve blockade with less motor block than bupivicaine.
  • Sugammadex is a remarkable advance, allowing for the reliable reversal of neuromuscular paralysis in only seconds. Sugammadex is the single most important new medication in the toolbox of the 21st-century anesthesiologist.
  • Ultrasound-guided regional anesthesia was developed in 1994, but became popular in the past ten years. Administering local anesthetic injections adjacent to major nerves grants non-narcotic pain relief to thousands of patients following orthopedic surgeries.
  • Acute pain services utilize nerve blocks and other adjuncts to relieve post-operative discomfort. Pain service teams were available only in primitive forms in the 1990s. In fact, at Stanford we changed our name from the “Department of Anesthesiology” to the “Department of Anesthesiology, Perioperative and Pain Medicine” since the turn of the millennium.

 

In closing:

At a wedding a bride is advised to wear something old, something new, something borrowed, and something blue.

In the world of anesthesia we use some things old, some things new, nothing borrowed, and . . . we make sure our patients never turn blue.   🙂

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

*
*
*
*

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:

41wlRoWITkL

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

The anesthesiaconsultant.com, copyright 2010, Palo Alto, California

For questions, contact:  rjnov@yahoo.com

 

 

 

 

 

 

 

 

 

THE JOY OF BEING A DOCTOR

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.
email rjnov@yahoo.com
phone 650-465-5997

My greatest joy of being a doctor comes immediately after the conclusion of a pediatric anesthetic.

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I stay with the child until the anesthetic depth has dissipated, the breathing tube is removed, and the child is awake and safe with the recovery room nurse in the Post Anesthesia Care Unit. At that point I walk out to the waiting room to find the parents so I bring them back to see their child. I invariably have a bounce to my step, and I’m a bit choked up with anticipation. I’ve done this enough times to know what to expect. The mother and father are waiting with wide eyes and worried looks on their faces. I give them a reassuring smile and my first words are, “Everything went perfectly. Your son (or daughter) is safe. Follow me.” The three of us return to the bedside in the recovery room, where the mother and child reunion occurs (cue up the Paul Simon soundtrack). The parents fawn over their child, the child reaches out his or her arms, the relief is palpable, and I’m proud to have contributed to the positive outcome.

Why go to medical school? Bright, hard-working college students have choices to make. Many ambitious young people wonder if they should apply to medical school. It’s difficult to get into med school, the journey is long (four years of medical school followed by three to seven years of residency), and the tuition can be high.

Why go to medical school? The daughter of one of my friends is an undergraduate business school student, and her last summer internship was with Proctor and Gamble working in the sales and marketing force selling Clorox. Selling bleach is a career choice radically different from going to medical school.

Do you want to sell bleach, or do you want to help people? The answer to “Why do you want to go to medical school?” is almost that simple. So many jobs in America are related to selling some product, some service, or some commodity. Becoming a physician is about helping people, and it’s also about making your own life have a greater purpose.

“Why do you want to be a doctor?” is the first question asked at most medical school interviews. Answers vary. Why do young men and women choose to become doctors nowadays? One guiding factor might be economics. The average salary for a physician in the United States is in excess of $250,000. To a 22-year-old, that high salary is alluring. Non-medical students who pursue careers in teaching, engineering, or business will start at lower annual salaries, but the future income of a physician is balanced against the deferred gratification of the years involved in their education. The student must pay for four years of medical school tuition and living expenses, and then work for meager wages for 3-7 years afterwards as a resident. The medical student delays the onset of their “real world” employment until age 30-32.

Non-medical students who go to work straight out of college at age 22 may already have families, mortgages, multiple cars, and perhaps a vacation home, while the 32-year-old physician has an 80-hour-a-week job, $250,000 of student loans, and the obligation to take care of sick patients at 3 a.m. It’s not an easy life, it’s not all fun, and most doctors wonder at one time or another whether they made the right choice. Making a lot of money is not the right answer to the question of why you want to go to medical school.

So why do we go to medical school? Young men and women who have a physician parent are in the best position to reply from the heart—they’re aware that their parent works long hours, reads incessantly to stay well informed, and gets out of bed in the middle of the night to handle emergencies. A doctor’s son or daughter has heard all the good and bad stories that describe a physician’s lifestyle. But most college students don’t have a doctor for a parent, and most college students have a little idea what the lifestyle of a physician would feel like. My father was a welder. I had no family experience to guide my career choice. For students like me, without a physician parent, it’s important to work medical volunteer jobs and/or research jobs to test the waters before applying to medical school, to decide whether the life of a doctor would appeal to them.

Why go to medical school? Each new patient I meet treats me with respect—a respect I don’t get if I’m outside of the hospital walking down the street or shopping at a grocery store. Years ago I shared this impression with my wife, and she said, “Of course your patients treat you with respect. You’re about to take their lives into your hands. They’re nervous, they’re scared, and the last thing they want to do is to get you in a bad mood!” This may be true, but the respect your patients give you is bona fide, and it’s a feeling few other jobs can offer.

Why go to medical school? I don’t think you’ll ever get equivalent joy out of selling bleach (or some other commodity) that you’ll gain helping other human beings with their health problems. Medicine is a profession. A career in medicine is an opportunity to entwine your work life with other people’s lives in a meaningful and remarkable way. You might make more money as a CEO or a venture capitalist, but few other jobs bring the potential to change lives for the better to the degree that being a physician does.

When you go to your medical school interview and the professor asks you “Why do you want to be a doctor,” the answer from your heart must be five words long:

“I want to help people.”

Your reward for becoming a doctor will arrive years later, when you feel what I feel when I reunite parents with their child after surgery. You’ll feel the joy and satisfaction of a purposeful life.

 

P.S. In 2012 the journal Anesthesiology published my poem “The Metronome,” which describes a scene from my life as a pediatric anesthesiologist:

 

The Metronome

 

To Jacob’s mother I say,

“The risk of anything serious going wrong…”

She shakes her head, a metronome ticking without sound.

“with Jacob’s heart, lungs, or brain…”

Her lips pucker, proving me wrong.

“isn’t zero, but it’s very, very close to zero…”

Her eyes dart past me, to a future of ice cream and laughter.

“but I’ll be right there with him every second.”

The metronome stops, replaced by a single nod of assent.

She hands her only son to me.

 

An hour later, she stands alone,

Pacing like a Palace guard.

Her pupils wild. Lower lip dancing.

The surgery is over.

Her eyebrows ascend in a hopeful plea.

I touch her hand. Five icicles.

I say, “Everything went perfectly. You can see Jacob now.”

The storm lifts. She is ten years younger.

Her joy contagious as a smile.

The metronome beat true.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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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:

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FENTANYL AND THE OPIOID CRISIS: AN ANESTHESIOLOGIST’S PERSPECTIVE

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.
email rjnov@yahoo.com
phone 650-465-5997

The United States is in the midst of an opioid epidemic. The crisis consists of two separate threats. One is the increased presence of powerful illicit street drugs such as fentanyl. The second threat is the increasing use of oral prescription painkillers like Oxycontin, Percocet, and Vicodin. This column addresses fentanyl—its medical aspects and the on-the-street abuses of this powerful narcotic.

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MEDICAL USE OF FENTANYL

I’ve administered fentanyl to over 20,000 patients in my career, and can vouch for the medical utility and import of this drug. Fentanyl is the most commonly administered narcotic during surgery in the United States. If you’ve had a surgical anesthetic, or even a colonoscopy, you’ve likely received fentanyl with few ill effects. Fentanyl is an essential ingredient in the pharmaceutical armamentarium of acute care medicine in hospitals, surgery centers, intensive care units, and emergency rooms throughout the United States. On the streets, fentanyl is killing people. In our hospitals and surgery centers, fentanyl is a useful adjunct as omnipresent as Tylenol.

Fentanyl was first synthesized by Dr. Paul Janssen of Janssen Pharmaceuticals in the 1960s, and was then introduced into anesthetic practice under the brand name Sublimaze.1 Fentanyl is a rapid-onset narcotic drug usually administered by intravenous injection. Compared to morphine, fentanyl is more lipid (fat) soluble, which means the drug crosses into the central nervous system more quickly and works faster than morphine. The termination of the effect of low doses of fentanyl results from decreased concentration, as the drug redistributes from the bloodstream to other organ tissues.

The elimination of higher doses of fentanyl from the body depends on elimination by the liver. Morphine, Demerol, and Dilaudid are other common intravenous medical narcotics, which have slower onset and longer duration of action. When injected into an intravenous line, fentanyl reaches its peak analgesic effect in minutes, significantly faster than morphine. This quicker onset makes fentanyl an easier drug for anesthesiologists to titrate to a desired effect., which makes fentanyl superior when timing for a patient’s awakening from anesthesia. As outpatient and ambulatory surgery blossomed, a short-acting narcotic such as fentanyl, which wore off promptly, became the narcotic of choice.

The most daunting feature of fentanyl is its potency. Most drugs used by anesthesiologists are in doses of milligrams (mgs) or grams (gms). Fentanyl is approximately 100 times more potent than morphine, so a typical 5 mg (5 mg = 5000 microgram) dose of morphine is equivalent to a mere 50 microgram dose of fentanyl. A typical intravenous incremental dose of fentanyl to an adult patient is a mere 50-100 micrograms. The drug is marketed as one milliliter = 50 micrograms for this reason, so 1 – 2 milliliters is an appropriate dose. This potency and the need to be packaged in micrograms is unique to fentanyl and its analogues sufentanil and remifentanil, and requires medical personnel to become comfortable with the low ranges of the appropriate microgram doses.2

Medical fentanyl can be administered in several ways:

  • Intravenous fentanyl, as described above, is the most common medical usage of the drug.
  • Rarely, fentanyl is added to the spinal fluid as part of a spinal anesthetic block prior to surgery, or to the epidural space as part of an epidural block prior to surgery or prior to labor for childbirth.
  • Transdermal drug delivery of fentanyl via an adhesive skin patch is also possible, because of the drug’s high solubility in both water and oil, low molecular weight, high potency, and its lack of skin irritation. Fentanyl transdermal patches (Durogesic or Duragesic) are useful in chronic pain management. The patches work by slowly releasing fentanyl through the skin into the bloodstream over 48 to 72 hours, allowing for long-lasting pain management. Dosage is based on the size of the patch.
  • Oral transmucosal fentanyl citrate (OTFC) is a solid dosage form of fentanyl that consists of fentanyl incorporated into a sweetened lozenge on a stick. A commercially available fentanyl product for oral administration, the fentanyl lollipop Actiq, is an application of this technology. The lollipop provides a means by which the drug can dissolve slowly in the mouth. The lollipop is only FDA approved for providing analgesia to patients with chronic pain or cancer pain, and the fentanyl lollipop is not FDA-approved for analgesia after surgery.

Narcotics suppress pain by their action in the brain and spinal cord, but they cause their adverse side effects in multiple organ systems, including the respiratory and cardiovascular systems. The principal danger from narcotics is respiratory depression. The respiratory rate is usually markedly slowed in narcotic overdose, as excessive doses of narcotics make people stop breathing. If there’s an anesthesiologist present to support a person’s breathing, respiratory depression is not a problem. On the streets, with no medical personnel present, respiratory depression from a narcotic overdose can be fatal.

The anesthesia world is well aware of the risks of fentanyl addiction. Narcotic addiction has struck down many anesthesia providers who found themselves vulnerable to sampling the potent euphoria-inducing fentanyl doses they were administering to their patients. Stanford authors described fentanyl addiction in anesthesiologists in 1980.3 More than a dozen of my personal friends and colleagues died anesthetic drug-related addiction deaths in the 1980s and 1990s.

For some of these physicians the first sign of their addiction was death by overdose. In others the addiction was uncovered, they were sent to rehabilitation programs, and they are still alive today. Anesthesiologists graduating from narcotic rehab programs are still known to have a risk to relapse. The relapse rate for anesthesiologists after drug abuse treatment is greatest in the first 5 years and decreases as time in recovery increases. The positive news is that 89% of anesthesiologists who complete treatment and commit to aftercare remain abstinent for longer than 2 years. However, death is still the primary presenting sign of relapse in opiate-addicted anesthesiologists.

 

FENTANYL AS A STREET DRUG

The current battle against fentanyl as a street drug has little or nothing to do with American medical practice. Most of the fentanyl found on the streets is not diverted from hospitals, but rather is sourced from China and Mexico. Dealers sought a narcotic product cheaper and even stronger than heroin, and that product is fentanyl. In 2016 there were more than 60,000 fatal overdoses in America. More than half were due to opioids, and the newest and most potent street narcotic was fentanyl.

Fentanyl-related overdose deaths increased nearly 600 percent from 2014 to 2016. “If anything can be likened to a weapon of mass destruction in what it can do to a community, it’s fentanyl,” said Michael Ferguson, a special agent in charge of the Drug Enforcement Administration’s New England division. “It’s manufactured death.” Illicit fentanyl is imported directly from China or Mexico, where the drug is manufactured. Dealers then mix the powder into other drugs, making for imprecise potency in sometimes-lethal doses.4 The IV street drug fentanyl is believed to be manufactured in China or Mexico, and is smuggled across the borders. Highly organized drug cartels are spreading the drug throughout the country. Its street nickname is “China White” or “China Girl,” referring at where most of the drug is thought to be coming from. The DEA estimates that drug traffickers can buy a kilogram of fentanyl powder for $3,300 and sell it on the streets for more than 300 times that, generating nearly a million dollars.5

As a street drug, fentanyl can be injected intravenously, taken orally, or snorted nasally. Each of these routes poses a threat:

  • Intravenous fentanyl as a street drug – Prior to fentanyl, heroin was the injectable street drug of choice. Because of the extremely high strength and potency of pure fentanyl powder, it’s difficult to dilute appropriately. The diluted mixture may be far too strong and, may cause respiratory depression and death. Some heroin dealers mix fentanyl powder with heroin to increase potency or compensate for low-quality heroin. Because fentanyl is more potent than heroin, the presence of even small quantities of fentanyl in injected heroin can result in respiratory depression. The fentanyl sold on the streets is likely made in a non-pharmaceutical lab, and is less pure than the medical version anesthesiologists administer. Its effect on the body can be hard to predict. Heroin and fentanyl look identical, and with drugs purchased on the street, addicts don’t know what they’re taking. An intravenous fentanyl overdose can cause a person to cease in breathing within minutes of injection, and result in death. Narcan, or naloxone, is a specific antagonist of narcotic overdose. Administration of Narcan as a fentanyl overdose antidote is a potential acute rescue remedy. 
  • Oral fentanyl as a street drug – Fentanyl is also sold as an oral street drug. Ten people died in just twelve days from fentanyl-laced pills in Sacramento County, California in March of 2016. In San Francisco, fentanyl showed up in pills labeled as Xanax, which turned out to be pure fentanyl. After 26 years in a Orange County crime lab south of Los Angeles, forensic scientist Terry Baisz said, “I was shocked the first time I tested this stuff and it came back as fentanyl. We hadn’t seen it before 2015.” Dealers were describing their pills as Xanax or Oxycodone. The tablets looked nearly identical to products manufactured by commercial pharmaceutical companies, although the pills sold on the streets contained fentanyl.6 The singer Prince’s death in 2016 was due in part to an overdose of fentanyl, likely in a pill form of counterfeit hydrocodone-acetaminophen (Vicodin) tablets.7
  • Intranasal fentanyl as a street drug – If fentanyl is supplied to the addict in powder form, and the powder is confused with cocaine and is snorted intranasallly, the addict may die. A hospital in New Haven, Connecticut treated twelve overdoses, three of them fatal, in just an eight-hour period in June 2016 among addicts who were snorting a white powder they purchased on the city’s streets. 8The powder they believed was cocaine turned out to be fentanyl. The absorption of a nasal dose of fentanyl can lead to immediate respiratory depression and death.

U.S. Surgeon General Jerome Adams, an anesthesiologist, has suggested distributing the narcotic antagonist Narcan freely, so that onlookers can quickly treat fentanyl-overdosed individuals.9 I respect Dr. Adams at the highest level, but I’m skeptical of this approach. An addict injecting fentanyl while he or she is alone is still at high risk of dying, and I’m not aware of any statistics documenting whether addicts reliably have company present while they are injecting themselves.

First response Emergency Medical Technicians should carry Narcan. Treatment of patients who are discovered comatose for unknown reasons has long included an empiric injection of Narcan to reverse possible narcotic overdose. The public needs to be aware of the existence of fentanyl powder, its ultra-high potency, and the danger of a fatal overdose immediately after the intravenous injection, oral ingestion, or intranasal inhalation of any street drug. There’s a real threat that any dose of street fentanyl can be lethal.

In our operating rooms, hospitals, surgery centers, and intensive care units, fentanyl is used safely. On the streets, fentanyl poses nothing but problems. Education, prevention, and DEA enforcement will have key roles in addressing the crisis of fentanyl in non-medical settings.

 

References:

  1. Fentanyl, Chemical and Engineering News, https://pubs.acs.org/cen/coverstory/83/8325/8325fentanyl.html
  2. Kazuhiko F, Opioid Analgesics, Miller’s Anesthesia, 8th Edition, Chapter 31, 864-914.
  3. Spiegelman WG, Saunders L, Mazze Ri, Addiction and anesthesiology, Anesthesiology 1984 Apr;60(4):335-41.
  4. Lewis N et al. Fentanyl linked to thousands of urban overdose deaths, Washington Post, August 15, 2017.
  5. https://www.washingtonpost.com/graphics/2017/national/fentanyl-overdoses/?utm_term=.8c722ada39be Nazarenus C. The opioid fentanyl: the new heroin, but deadlier. Medical Marijuana 411, May 11, 2016.
  6. https://medicalmarijuana411.com/opiod-fentanyl-new-heroin-deadlier/Sidner S. The opioid fentanyl: the new heroin, but deadlier. ClickonDetroit.com, May 10, 2016. https://www.clickondetroit.com/health/fentanyl-the-new-heroin-but-deadlier
  7. Kroll D, Prince’s Death From Fentanyl May Have Been Due To Counterfeit Generic Drugs, Pharma and Healthcare, Aug 22, 2016. https://www.forbes.com/sites/davidkroll/2016/08/22/princes-death-from-fentanyl-may-have-been-due-to-counterfeit-generic-drugs/#52096f902b17
  8. Bebinger M, Fentanyl-laced cocaine becoming a deadly problem among drug users, Health News from NPR, March 29, 2018. https://www.npr.org/sections/health-shots/2018/03/29/597717402/fentanyl-laced-cocaine-becoming-a-deadly-problem-among-drug-users
  9. Surgeon General Urges More Americans To Carry Opioid Antidote, NPR Public Health, April 5, 2018. https://www.npr.org/sections/health-shots/2018/04/05/599538089/surgeon-general-urges-more-americans-to-carry-opioid-antidote

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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INTRAVENOUS ACETAMINOPHEN: AN IMPORTANT NON-OPIOID THERAPY, OR AN EXORBITANTLY PRICED VERSION OF AN OVER-THE-COUNTER MEDICATION?

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.
email rjnov@yahoo.com
phone 650-465-5997

Intravenous acetaminophen was introduced in Europe in 2002. The United States Food and Drug Administration approved IV acetaminophen (Ofirmev, Cadence Pharmaceuticals) in 2010 for management of mild to moderate pain, moderate to severe pain with adjunctive opioid analgesics, and reduction of fever.

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IV acetaminophen (Ofirmev)

 

 

Acetaminophen (Tylenol) has been available in oral and rectal forms for decades. 

tylenol-tylenol-extra-strength-500-mg-150-units

Oral acetaminophen

 

Healthcare costs continue to skyrocket in the United States. In 2016 Americans spent $435 billion on prescription drugs.1 This month the Trump administration released a 44-page blueprint for executive action on drug pricing entitled “American Patients First.” Their goal is to drive prescription drug costs down by increasing competition. At this time it’s too early to tell how effective these efforts will be.

Anesthesiologists are the only physicians who prescribe and then directly administer medications themselves. CRNAs are the only nursing professionals who prescribe and then directly administer medications themselves. Because anesthesiologists and CRNAs typically don’t pay for the medications, there can be a disconnect regarding costs and value.

If you were in charge of pharmaceutical purchasing at a hospital or an ambulatory surgery center, and you had an identical acetaminophen molecule available for either 5 cents per dose or $42 per dose, which would you choose? The answer is obvious, but as an administrator you are not prescribing the drug.

A 2014 study showed that patients who received IV acetaminophen reported superior satisfaction with pain control compared to patients who received placebo.2 In inpatient and postoperative settings, intravenous acetaminophen became a route of choice for rapid analgesia, and appeared to reduce the need for other analgesics such as opioids. Disadvantages of IV acetaminophen included the time and equipment needed for IV drug administration, as well as increased costs.

In a publication from the Canadian Journal of Hospital Pharmacy, Jibril wrote, “The study drug (acetaminophen, either oral or IV) was given when patients first awakened after surgery, and additional doses were given every 6 h until 0900 the next morning. . . . The use of opioids was significantly lower in the group receiving acetaminophen by the IV route than in the group receiving acetaminophen by the oral route (p < 0.05). However, this difference did not translate into a significant difference in rates of postoperative nausea and vomiting or any significant difference in pain scores on a 100-mm visual analogue scale (VAS) at any time. . . . A major finding of this review was the absence of strong evidence suggesting superiority of IV acetaminophen administration over oral routes. . . . IV acetaminophen may be useful for opioid-sparing in postoperative pain. To date, no strong evidence exists that IV acetaminophen should replace any form of standard care. At most, the evidence indicates that this formulation could function as an adjunctive agent in patients unable to take oral forms. . . . . In the United States, there has been great debate regarding use of this formulation, which has led many hospitals to adopt policies and procedures that restrict use for a limited period or for patients not able to take medications by mouth. These restrictions are required because of the cost of the product, in addition to other administration-related inconveniences. Canadian hospitals and formulary committees should be aware of the available efficacy and safety data if the formulation is marketed in Canada and its use becomes widespread. Given the high cost and the lack of superiority over oral forms, Canadian hospitals may need to restrict use of the IV formulation, as their US counterparts have already done.”3

In a study of IV acetaminophen use in neurosurgical ICU patients at Virginia Commonwealth University, Gretchen Brophy, PharmD, of the departments of pharmacy and neurosurgery wrote, “We and every institution I’ve spoken to have restricted its use, because we don’t have data saying it’s more effective. At $33 a dose” – recently up from $10 – “it’s harder to justify. At least in the 0-3 hour window, it didn’t have any additional benefit over oral. It might still be better at 1 hour; kinetically, that would make sense, but there’s nothing yet to say from what we did that it’s better.”4 VCU restricted intravenous acetaminophen use to one dose per patient.

Mallinckrodt purchased Cadence Pharmaceuticals in 2014, and increased the price of Ofirmev from $17.70 to $42.48 per vial. (A full case of Ofirmev includes 24 vials.) Sales increased to $71 million during their fiscal first quarter, double the amount for the same period the previous year. Hospitals noted the rise in expenses and sought alternatives such as oral acetaminophen, and the volume of sales dropped. Robert Press, chief of hospital operations at NYU Langone, which anticipated $1 million in additional costs because of Ofirmev, was quoted to say, “We found out a lot of the use was really not necessary and we found we could give alternative products.”5

Some hospitals removed Ofirmev from their formularies after the price went up. Others simply switched to alternatives such as oral acetaminophen. Others increased their budgets to cover the cost of the drug, but the net effect of Mallinckrodt’s price hike was to reduce the doses of Ofirmev prescribed. Mallinckrodt’s U.S. headquarters are located in Missouri. Senator Claire McCaskill (D-Missouri) wrote a letter to Mallinckrodt CEO Mark Trudeau demanding information about pricing and revenue numbers. In the letter she also suggested that Ofirmev, expensive as it was, might actually be saving hospitals money because of opioid-sparing. Senator McCaskill wrote, “Any obstacle to prescribing non-opioid alternatives, even those used solely in a hospital setting, is cause for concern.” It should be noted that McCaskill received $2,500 in campaign financing from Mallinckrodt during the 2016 election cycle.6

Mallinckrodt released a statement that read, “One recent analysis of health economic data on the use of Ofirmev coupled with a one-level reduction in opioid use was linked to decreasing hospital stays, potential opioid-related complications and related costs for the treatment of acute surgical pain. . . . The study showed a potential of $4.7 million in annual savings for a typical, medium-sized hospital.”6

The clinical benefit of reduced opioid consumption with Ofirmev has not been evaluated nor demonstrated in prospective, randomized controlled trials. In a review in the journal Pharmacotherapeutics, Yeh wrote, “Although use of intravenous acetaminophen has reduced other postoperative resource utilization (e.g., hospital length of stay) in some studies outside the United States in patients undergoing abdominal surgery, a full economic evaluation in the United States has yet to be undertaken.”7

The research study anesthesiologists would like to read is a prospective, randomized, double-blind trial of 1000 mg of preoperative oral acetaminophen, versus 1000 mg of IV acetaminophen administered just prior to the end of surgery. Will this research ever be performed? I hope so, but you can bet Mallinckrodt is never going to fund that study.

I repeat Jibril’s conclusion to sum up the answer to our initial question above:“An absence of strong evidence suggesting superiority of IV acetaminophen administration over oral routes. . . . To date, no strong evidence exists that IV acetaminophen should replace any form of standard care. At most, the evidence indicates that this formulation could function as an adjunctive agent in patients unable to take oral forms. . . . Therefore, on the basis of current evidence, if a patient has a functioning gastrointestinal tract and is able to take oral formulations, IV formulations are not indicated.”3

And what is the solution regarding anesthesia providers who frequently choose to prescribe IV acetaminophen despite these recommendations? The hospital I work at, Stanford University Hospital, restricts Ofirmev usage to patients who are NPO (nothing by mouth), and each Ofirmev order has a hard stop after 24 hours, eliminating further usage. The owners of the surgery center I medically direct have an even more decisive solution: Ofirmev is not on the facility formulary at all.

 

References:

  1.  Cortez J. Prescription Drug Spending Hits Record $425 Billion in U.S. Bloomberg, April 13, 2016.                                                https://www.bloomberg.com/news/articles/2016-04-14/prescription-drug-spending-hits-record-425-billion-in-u-s
  2. Apfel CC et al. Patient satisfaction with intravenous acetaminophen: a pooled analysis of five randomized, placebo-controlled studies in the acute postoperative setting. J Healthc Qual. 2014 Jan 16.
  3. Jibril F, et al. Intravenous versus Oral Acetaminophen for Pain: Systematic Review of Current Evidence to Support Clinical Decision-Making, Can J Hosp Pharm. 2015 May-Jun; 68(3): 238–247.
  4. Otto MA et al. No pain benefit found for IV acetaminophen vs. oral in the neuro ICU. Clinical Neurology News. January 30, 2015.
  5. Staton T. Price hikes aren’t always sustainable: Just ask Mallinckrodt about Ofirmev. Fierce Pharma. Oct 12, 2015. https://www.fiercepharma.com/pharma/prie-hikes-aren-t-always-sustainable-just-ask-mallinckrodt-about-ofirmev
  6. Staton T. Mallinckrodt’s pain med Ofirmev gets scrutiny in Senate—but this pricing probe has a twist. Fierce Pharma. May 30, 2017. https://www.fiercepharma.com/pharma/mallinckrodt-s-pain-med-ofirmev-gets-scrutiny-senate-but-pricing-probe-has-a-twist
  7. Yeh Y et al. Reviews of Therapeutics: Clinical and Economic Evidence for Intravenous Acetaminophen. Pharmacotherapeutics. 08 May 2012.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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LEARJET ANESTHESIA – THE EARLY DAYS OF HEART TRANSPLANTATION

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.
email rjnov@yahoo.com
phone 650-465-5997

Learjet anesthesia? Yes, anesthesia can be a glamorous specialty. During my Stanford training in 1984-1986 I flew on Learjets more times than I can count, during missions to harvest donor hearts from throughout the western United States.

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Norman Shumway MD PhD, a Stanford surgical professor and legend, invented the heart transplantation procedure and performed the first heart transplant in the USA on January 6, 1968 in operating room 13 of Stanford University Hospital. Survival rates for heart transplantation patients increased markedly in 1983 with the adoption of cyclosporine as an effective anti-rejection drug. During the 1980’s Stanford was the only prominent heart transplantation program in the western United States, and the quantity of brain dead heart donors was modest. In order to expand their volume of transplants, Stanford created a fixed-wing aircraft harvesting and transportation program to bring donor hearts to Palo Alto from distant locations.

One registered nurse had a fulltime job locating appropriate brain dead heart donors within a 60-90 minute Learjet trip from Stanford. A separate team of physicians and nurses was responsible for assembling a waitlist of prospective heart transplant recipients, and for arranging housing for them within the San Francisco Bay Area.

When Stanford learned of a brain dead donor with a normal heart at a distant location, the following choreography occurred: 1) a matching donor was identified and told to come to Stanford Medical Center immediately; 2) a team of surgeons, anesthesiologists, nurses, and a heart-lung perfusionist was paged to Stanford Medical Center immediately to prepare the recipient patient for his or her transplant surgery; and 3) a transport team of two surgeons (a chief resident in cardiac surgery and a second surgical resident), one anesthesia fellow or resident, one scrub nurse, one circulating nurse, and the nurse in charge of the transport team were all paged to the Stanford Medical Center immediately.

Note that the anesthesia transport team member was only an anesthesia fellow or a resident. The eligible residents were second-year residents (anesthesia residency training was only two years in duration during the 1980’s). As a second-year resident, I was a partially trained anesthesiologist who had done only 800-1000 anesthetics at that time, and was not yet eligible to sit for the American Board of Anesthesia exam.

An ambulance transported our team to the Moffett Field Air Force Base, 10 miles southeast of the Stanford campus, where we boarded a Learjet for the flight to the donor hospital. The donor harvesting catchment area was as far north as Seattle, as far south as Las Vegas, and as far east as Boise. We had no medical tasks to do in flight, and we spent our time looking out the windows and small talking. Upon arrival at the airport in the donor city, an ambulance transported us to the hospital.

At the hospital we proceeded to the intensive care unit where we found the donor’s brain dead body connected to a ventilator and ICU monitors. At this point my work began. Even though the patient was brain dead, it was imperative to maintain his or her vital signs and oxygenation at optimal levels to preserve the cardiac function for the eventual recipient. My first tasks were to insert an arterial line in the radial artery to monitor blood pressure, and to insert a central venous pressure catheter in the internal jugular vein to administer medication infusions as needed to decrease or increase the blood pressure during the upcoming surgery. We would then transport the patient through the hallways of this foreign hospital, accompanied by the surgeons, and directed by staff of that hospital who knew the floor plan. I’d be squeezing an Ambu bag full of oxygen to ventilate the patient, all the while vigilant of the vital signs displayed on a portable monitor during the transport.

We’d arrive in the operating room—a room we’d never seen or worked in before—and prepare the patient for surgery. My job was to connect the patient to the operating room ventilator and the standard cardiac surgery monitors: ECG, oximeter, arterial line, and central venous pressure. The manufacturers of the monitoring equipment varied from hospital to hospital, and it was not unusual for the equipment to be different than machines I’d worked with before. My next task was to prepare vasoactive drips such as nitroprusside and connect them to the central venous pressure IV line. No anesthetic drugs were used, because the donor was brain dead, but surgical stimulus always caused increases in blood pressure and heart rate. It was critical that pumping against a high resistance or pumping at a high rate not tax the donor heart. I also had to fill out a written anesthesia medical record to document what I was doing to the patient.

The scrub tech, nurse, and the two surgeons prepped and draped the patient for surgery, and the initial incision was made over the sternum. A power saw was used to cut the breastbone down the midline to enter the chest. A rib-spreader was used to widen the cavity and improve visualization. The surgeons inspected the heart in terms of its general appearance, size, contractility, and the state of the coronary arteries. Once they’d determined the heart was indeed normal, the transplant nursing coordinator made a phone call to the Stanford operating room in California to inform them it was a green light to anesthetize the heart recipient there.

In our operating room, the two surgeons clamped off the aorta and all other blood vessels leading into and out of the heart, and injected a cardioplegic solution into the coronary arteries via the root of the aorta. This solution preserved the heart function during the upcoming trip when the heart would no longer be beating. The surgeons then cut the heart out of the body, placed it in a sterile bag, and placed the bag into an Igloo chest full of ice. I turned off the ventilator, the surgeons removed their gloves and gowns, and our whole cast scurried out of the operating room with the Igloo and its precious cargo in hand.

It was always a bizarre sight to see that human carcass with an empty thorax lying on an operating room table when we left the operating room. In the later months of my Learjet experiences, a second transplant team was sometimes present to harvest the kidneys or corneas after we departed.

The original ambulance met us at the Emergency Room entrance, and we sped back to the airport Code 3 with alarms blaring. We drove onto the tarmac next to the Learjet and climbed inside. The doors closed, engines flared, and wheels up . . . we were on our way back to Palo Alto.

The flight home was relaxing. We’d spent an intense period of time at the hospital, and we had no work to do except to ride and look out the windows. Beverages and food were always supplied for the trip home. The mood was jubilant—the feeling you get with medical jobs when you realize you’ve accomplished something. We were helping the recipient patient in their journey back to health, and experiencing private jet travel at 35,000 feet at the same time.

On arrival to Moffett Field, an ambulance awaited us on the tarmac. We’d climb in and ride at top speed back to Stanford. We stopped in front of the Emergency Room, and the surgeons and the nurse coordinator ran through the doorway and up the stairs to operating room 13, where the anesthetized recipient patient lay, his or her chest open, ready to receive the new heart at once.

At this point I went home. An anesthesia resident colleague and an anesthesia faculty member were upstairs attending to the recipient. Caring for the recipient patient was their job for today—mine was finished.

How stressful was the entire journey to harvest the new heart? Pretty stressful, to be honest. At that point, I’d done less than two years of anesthesia training, and I was relatively inexperienced. During my training, a faculty member always stood right next to me during every anesthesia induction and a faculty member was immediately available at all times. On the Learjet trips I was without faculty backup for the first time. The setting at the destination hospital was always unfamiliar. The equipment on hand at the destination hospital was often unfamiliar. The cardiac chief resident surgeon was typically an intense 39-year-old who’d been training for decades and who had little interest in waiting any longer than possible while an anesthesia resident-in-training toiled to insert an arterial line and a central venous catheter. Even though the patient was brain dead, there was no tolerance for errors in ventilation or medical management, it was imperative to keep the vital signs stable throughout the donor surgical procedure, and there was time pressure to keep the process moving.

Prior to my anesthesia residency I’d completed three years as an internal medicine resident at Stanford and one year as an attending in the Emergency Room at Stanford. All my experience in internal medicine and emergency medicine was useful on those heart-harvesting trips—but I knew how lucky I was. Internal medicine residents don’t get to ride Learjets, and ER attendings don’t get to ride Learjets either.

An added motivation: We were paid $35/hour for our time, a princely sum in 1986.

Alas, none of this would happen nowadays. Currently there are hundreds of cardiac transplantation programs in the United States, and each program procures their donor hearts from close geographic proximity.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

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The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

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Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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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:

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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THE #7 ANESTHESIA BLOG IN THE WORLD

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.
email rjnov@yahoo.com
phone 650-465-5997

Today theanesthesiaconsultant.com was named the #7 anesthesia blog in the world by Feedspot.

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I’m grateful to Feedspot for this honor, and to my readers for making this possible.

See the link here to view the complete list of the world’s top anesthesia blogs.

Theanesthesiaconsultant.com was ranked #7, behind such high-powered professional websites such as Anesthesiology News, the Journal of the Association of Anaesthetists of Great Britain and Ireland, and Reddit Anesthesiology,

I write theanesthesiaconsultant from the unique point of view of a busy attending anesthesiologist who works in both private practice and also in an academic setting at Stanford University. After 35+ years and 25,000+ anesthetics, I’m still learning. And as I learn, I write about it.

Keep reading, and I’ll keep writing!

 

Thanks,

Richard Novak, MD

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

ARE SURGERY CENTERS SAFE?

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.
email rjnov@yahoo.com
phone 650-465-5997

Are surgery centers safe? This column is in response the Kaiser Health News story “How a push to cut costs and boost profits at surgery centers led to a trail of deaths” published on USAToday.com this week. The article set off a firestorm of controversy in the surgery center industry. The Kaiser article cites anecdotal information and allegations from ongoing litigation cases of patients seemingly harmed by their care at outpatient ambulatory surgery centers.

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The quantity of ambulatory surgery centers has greatly increased over the past forty years for three primary reasons: Technologic advances made surgery easier, anesthetic care is safer, and healthcare payment policies encourage ambulatory surgery. I’ve been the Medical Director at a busy freestanding ambulatory surgery center in Northern California for a decade and a half. I’m a Stanford University-trained anesthesiologist and internist, and I’m uniquely qualified to answer the question: Are American surgery centers safe?

Yes, they are safe.

A review of the medical literature on Pubmed shows no peer-reviewed studies or data that surgery centers provide less safe care than hospitals.

Surgery and anesthesia are never 100% safe, no matter where procedures are done. There are always risks. The roles of anesthesiologists and surgeons at surgery centers are to minimize the risks.

There are four key questions regarding safe patient care at surgery centers:

  1. Is the scheduled procedure appropriate for an outpatient surgery center?
  2. Is the patient healthy enough to tolerate the scheduled procedure as an outpatient?
  3. Are the healthcare professionals at that center practicing at the standard of care?
  4. Is the surgery center accredited by an organization such as the Accreditation Association for Ambulatory Health Care (AAAHC)?

 

Question #1.

The most important screening question for a surgery center is, “What is the scheduled procedure?” Knee arthroscopies, tonsillectomies, inguinal hernia repairs, and colonoscopies are standard surgery center procedures. You cannot do large cases such as craniotomies, open heart surgeries, or an aortic vascular surgeries at a surgery center. The necessary backups of an intensive care unit, a blood bank, respiratory therapy, and a clinical laboratory are lacking. The job of a Medical Director is to survey the schedule each week, and decide if any planned cases are outside the usual comfort zone for that center. If there is any question, the Medical Director must gather more information on the procedure and the patient, usually by talking directly to the surgeon, and decide whether or not to give the case a green light. If the verdict is a red light, the surgeon needs to do the case in a hospital.

In recent years, some surgery centers have expanded their scope. Procedures such spine surgeries, total joint replacements, and bariatric surgeries are performed as ambulatory or short stay procedures at some outpatient centers. As the USAToday.com article points out, one motivation is money. A surgery center can extract well-insured cases from hospitals in order to increase profits for the surgery center. Is it better for a patient to have these procedures in a freestanding facility detached from a hospital? There is a paucity of research in peer-reviewed medical literature regarding the performance of these cases outside of hospitals. The USAToday.com article lists multiple spine surgery patients who died after surgery at an ambulatory surgery center. Medicare has only approved payment for spinal surgery at ambulatory centers since 2015. To my knowledge, no one has published the overall statistics regarding complications from spinal surgery in surgery centers and compared this to the complications from similar procedures in hospital settings.

What about the claim from the USAToday.com article that 911 calls from a surgery center are a problem? If a patient unexpectedly becomes acutely ill at a surgery center, calling 911 and transferring the patient to a hospital is routine policy and appropriate medical care.

 

Question #2.

How does a facility decide whether a patient is fit enough to undergo a given surgery at an outpatient center? At a surgery center, it’s the Medical Director’s job to screen every patient prior to scheduling. It’s the Medical Director’s job to prevent patients who are too sick from having a procedure at a surgery center. Different systems exist for preoperative assessment. Large university hospitals staff preoperative anesthesia clinics for their patients, and patients are required to physically visit the clinic to be examined and assessed prior to inpatient surgery. This system is not always practical in outpatient community medicine. Patients are usually assessed by their primary care physicians as indicated before surgery. A typical preoperative screening protocol at a surgery center is as follows: a preoperative assessment professional from the surgery center will telephone each patient several days before surgery, ask a series of pertinent screening medical questions, and fill out a standardized form. Any outlying answers are referred to the Medical Director, who decides if the patient is fit for the surgery. If the patient is too sick, the Medical Director will cancel the case, and tell the surgeon that the surgery needs to be done in a hospital.

 

Question #3.

When a complication occurs, anesthesiologists and surgeons in the operating room have a responsibility to correctly diagnose the problem and apply the correct therapy. The legal term for this is that physicians must adhere to the “standard of care.” The standard of care is defined as “what a reasonably trained physician would do in the same circumstance.” Deviating from the standard care is called negligence, and is part and parcel to medical malpractice lawsuits. If a bad outcome occurs in a surgery center because of negligence, i.e. malpractice, this is not a fault of the surgery center system. This concept is a central flaw in the USAToday.com article. The article cites multiple bad outcomes from surgery center cases, and in many of these cases the central issue seems to be negligent, below the standard of care decisions and actions by the health care professionals involved. Negligence is not specific to surgery centers.

 

Question #4.

Most surgery centers provide care to Medicare patients, and must meet standards approved by the federal government. To obtain Medicare certification, a surgery center must have an inspection conducted by a representative of an organization that the government has authorized to conduct that inspection, such as the Accreditation Association for Ambulatory Health Care (AAAHC). Inspectors will physically visit the surgery center to verify that the center meets established standards. Most surgery centers have passed such an inspection. The surgery center I work at is recertified every three years. If you’re uncertain whether your local surgery center is safe, request documentation that the facility has been certified by an organization such as AAAHC.

Nearly 60% of all surgical procedures in the United States are performed as outpatient surgery. Tens of millions of Americans receive care in ambulatory surgery centers each year. I’ve personally had two arthroscopic surgeries and three colonoscopies, and I chose to have all five procedures at a freestanding outpatient surgery center. The USAToday.com article cited anecdotal adverse outcomes from patients who were cared for at outpatient ambulatory surgery centers. Adverse outcomes will occur, but the frequency of these events (adverse events vs. total number of cases) is extraordinarily small. America’s surgery centers are by and large very safe. I reaffirm that no peer-reviewed data documents that ambulatory surgery centers are unsafe.

The key issues regarding surgery center safety will always be the four questions posed above. Is a given procedure safe and appropriate for an outpatient surgery center? Is a given patient fit enough to have their particular procedure in an outpatient surgery center? Are the healthcare professionals at that center practicing at the standard of care? And is the surgery center accredited by an organization such as the AAAHC?

In the overwhelming majority of America’s surgery centers, the answers to these three questions will be “Yes, yes, yes, and yes.”

 

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HANGOVER AFTER GENERAL ANESTHESIA

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.
email rjnov@yahoo.com
phone 650-465-5997

Prior to surgery your patient tells you, “I always get a hangover after general anesthesia. I sleep for hours and I’m nauseated. All my life I’ve been very sensitive to medications. I never drink alcohol, and even a ½ dose of Nyquil or cold medicine knocks me out all night.”

What do you do with this information?

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I’ve been a full time anesthesiologist for 34 years, and I’ve heard this monologue from patients countless times. My impression? The patient is always right. They’ve had the same body all their lives, and they know their reaction to central nervous system depressants. Listen to them and adjust your care.

Hangover after general anesthesia (HAGA) describes a patient who has a safe general anesthetic, but who then feels hungover, sedated, and wasted for a time period exceeding two hours afterwards. There is significant overlap between HAGA and postoperative nausea and vomiting (PONV).

The four established risk factors for PONV are: 1) the use of postoperative narcotic pain relievers, 2) female sex, 3) a non-cigarette smoker, and 4) a previous history of PONV.1 In my experience, these same four characteristics are risk factors for HAGA. Painful surgeries require more narcotics, which can lead to more nauseated patients. If the surgery isn’t painful, an anesthesia provider can work to eliminate postoperative narcotics, and minimize both PONV and HAGA.

With modern pharmacology and anesthetic techniques, HAGA should be uncommon. Propofol and sevoflurane are the mainstays of 21st century general anesthesia. Both are ultra-short acting medications that enable anesthesiologists to produce alert, awake patients within an hour of most general anesthetics.

Propofol has a quick onset and quick offset clinical effect, because the drug is highly lipid soluble and is rapidly distributed out of the bloodstream to other tissues of the body. When administration of propofol is discontinued, the initial fall in the plasma concentration is 50% due to this redistribution and 50% due to liver metabolism. The time to awakening after a 2-hour anesthetic is rapid (8-19 minutes).2 The elimination (hepatic) half-life is 3 to 12 hours, but propofol is not known to cause nausea. Hangover symptoms from propofol are rare. Sleepiness is the most common side effect, and this clears quickly.

Sevoflurane also has a quick onset and quick offset. Sevoflurane vapor is primarily eliminated via ventilation from the lungs. Because the drug has low solubility in the bloodstream, the pulmonary elimination is rapid, and only 5% of sevoflurane remains in the body to be metabolized by the liver and excreted via the kidneys. Pertinent mild side effects of sevoflurane include nausea/early 25%, vomiting/early 18%, dizziness/early 4%.3 These incidences of nausea and vomiting are higher than for propofol, so utilization of propofol over sevoflurane seems prudent for patients with a history of HAGA or PONV. However, because propofol is a sedative/hypnotic and does little to provide surgical analgesia, the addition of either a potent vapor such as sevoflurane or a narcotic is often necessary.

Over the years I’ve examined previous anesthetic records for many patients with a history of HAGA. The most common findings in these old records are relative overdoses of narcotics, be it fentanyl, Dilaudid, morphine, or any another narcotic. My impression is that some anesthesia providers rely on a set recipe for their narcotic dosing, and that they do not adequately alter or adjust this recipe for patients who are small, petite, elderly, or teetotalers. Narcotics are often indicated during surgery when surgical stimulus peaks, or near the conclusion of surgery to insure a patient has an adequate systemic narcotic effect and won’t wake up in agony. When a patient has a history of HAGA or PONV, I recommend minimizing the amount of intraoperative IV narcotics. Additional IV narcotics can be added post-extubation if the patient complains of significant pain.

Anesthesia providers typically judge anesthetic dosing depending on: a) patient weight, b) patient age, and c) the patient’s vital signs (i.e. high blood pressure and/or heart rates are treated by increasing doses of drugs, and low blood pressures are treated with decreasing drug administration).

A patient’s weight can be misleading. Multiple studies support that drug doses should be based on lean body weight (LBW) rather than their total weight.4,5 A 5-foot-6-inch obese patient may weight 200 pounds but have an estimated LBW of 150 pounds. Injected drug doses need to reduced by a factor of 150/200, or ¾.

Patients at extremes of age, e.g. geriatric or neonatal patients, can have significantly reduced requirements for injected anesthetic drugs. I refer the reader to textbook chapters on pediatric and geriatric anesthesia for evidence.

Utilizing increased anesthesia depth to treat hypertension or tachycardia is appropriate if the diagnosis is inadequate depth of anesthesia. If in your clinical assessment you’re administering an adequate level of anesthesia, then it’s appropriate to treat hypertension or tachycardia with antihypertensive agents or beta blockers rather than adding extraneous anesthetic depth or narcotics.

Is there science to confirm the existence of excessive anesthesia dosing? In a February 2018 Stanford Grand Rounds lecture, Dr. Daniel Sessler of the Cleveland Clinic presented data that hypotension is a risk factor for perioperative myocardial injury. Per Dr. Sessler’s unpublished data gleaned from electronic medical records on thousands of patients, one-third of intraoperative hypotension occurs during the time period between the induction of anesthesia and the surgical incision. During this time period, general anesthesia doses are unopposed by surgical stimulus. An inference from this data is that lesser amounts of general anesthetic drugs are required between induction and incision. Options to lower the anesthetic doses pre-incision include: a) less or no narcotic until the time of incision, b) utilizing 60% nitrous oxide without sevoflurane until incision, or c) utilizing sevoflurane without any nitrous oxide until incision. My preference is a combination of options a) and c), i.e. minimizing or avoiding narcotics until incision, and avoiding nitrous oxide until incision.

Conflicting data exist regarding redheaded patients and general anesthesia. A 2004 study of 10 redheads and 10 controls showed the inhaled desflurane requirement in redheads was significantly greater than in dark-haired women.6 This conclusion was refuted in a 2010 prospective study of 468 patients which showed no significant difference in recovery times, pain scores or quality of recovery scores in patients with red hair.7

Whenever possible it’s advisable for the surgeon to inject local anesthesia near the surgical site, or the anesthesiologist to use local anesthetic via a nerve block or a neuroaxial block to minimize postoperative pain.

Should we use intraoperative BIS monitors to guide minimalization of intraoperative anesthetics and narcotics? Although the idea is intriguing, I’m not aware of any data to support that BIS monitors provide a significant solution to the problem of intraoperative overmedication.

When a patient has a past history of HAGA or PONV, prior to surgery I discuss a metaphorical postoperative teeter-totter. On one end of the teeter-totter, the patient will have minimal postoperative pain but will be at risk for the systemic side effects of IV narcotics, namely sedation and nausea. On the opposite end of the teeter-totter, the patient will have some postoperative pain but will also benefit from lower systemic side effects of IV narcotics, namely lower levels of sedation and nausea. I tell the patient that after the surgery, in the Post Anesthesia Care Unit, they will be awake and able to make their own decisions whether they desire additional doses of intravenous narcotics or not, with the full knowledge that extra doses of narcotics may bring extra risk of sedation and nausea.

Can anything be done to predict the risk of HAGA? I attempt to identify teetotalers preoperatively. I routinely ask every patient, “Do you drink alcohol at times?” Their answers vary from, “No, I do not drink at all,” to “Yes, once or twice a month,” to “Yes, two glasses of wine every day.” It’s been my experience that patients who never drink alcohol (the most prevalent central nervous system depressant in the world) are more sensitive to anesthetic medications. It’s easy to postulate that a teetotaler’s brain is more sensitive to CNS depressants, and that their hepatic metabolism is less efficient clearing CNS depressants than a patient who ingests alcohol or other CNS depressants daily.

This column conveys what I’ve learned based on my clinical experiences over decades. When you attend to patients with a past history of hangover after general anesthesia, try the suggestions discussed above:

  1. Take a history and correctly identify patients with a past history of hangover after general anesthesia.
  2. Utilize propofol > sevoflurane for patients who are petite, who never drink alcohol, or give a history of being sensitive to CNS depressants.
  3. Administer significantly less IV narcotics to patients who are petite, who are elderly, who never drink alcohol, or give a history of being sensitive to CNS depressants.
  4. Administer intravenous doses based on lean body weight, not the actual weight, on obese patients.
  5. Administer lower doses of narcotics to patients at extremes of age, e.g. geriatric patients and the very young.
  6. Regarding intraoperative hypertension and/or tachycardia, if the anesthetic depth is already adequate, consider treating with antihypertensive medications or beta blockers rather than adding additional anesthetic.
  7. Decrease the amount of anesthesia you administer between the induction of anesthesia and surgical incision.
  8. Utilize local anesthetic/regional blocks to minimize postoperative pain as appropriate.
  9. Ask patients “Do you drink alcohol at times?” For teetotalers, utilize decreased doses, particularly decreased doses of narcotics.

These patients will likely fare better in your hands than what they’ve experienced after previous surgeries, and they will rank you above the historical control of anesthetists who’ve overdosed them in the past.

References:

  1. Apfel CC et al. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 1999 Sep;91(3):693-700.
  2. http://www.pdr.net/drug-summary/diprivan?druglabelid=1719#11
  3. http://www.pdr.net/drug-summary/Ultane-sevoflurane-32
  4. Lemmens HJ . Perioperative pharmacology in morbid obesity. Curr Opin Anaesthesiol.2010 Aug;23(4):485-91.
  5. Chassard D et al. Influence of bodycompartments on propofol induction dose in female patients. Acta Anaesthesiol Scand. 1996 Sep;40(8 Pt 1):889-91.
  6. Liem EB et al. Anesthetic requirement is increased in redheads. 2004 Aug;101(2):279-83.
  7. Myles PSBuchanan FFBain CR. The effect of hair colour on anaesthetic requirements and recovery time after surgery. Anaesth Intensive Care.2012 Jul;40(4):683-9

 

 

 

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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:

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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THE MOST SIGNIFICANT ANESTHESIOLOGIST OF THE 20TH CENTURY

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.
email rjnov@yahoo.com
phone 650-465-5997

The most significant anesthesiologist of the 20th century died just weeks ago, on December 21, 2017. His name was William New, MD, PhD. Many of you have never heard of Dr. New, and don’t know what he was famous for, but in my opinion he was the Most Valuable Player of the anesthesia ranks in the last one hundred years.

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The original Nellcor N100 pulse oximeter

 

William New was a Stanford anesthesiologist and electrical engineer. In 1978 Bill New invented the prototype of the modern pulse oximeter. In 1981 Dr. New founded and became Chairman of the Nellcor company, the manufacturer of the first commercially available pulse oximeter.

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Nellcor pulse oximeter finger probe

For my non-medical readers, a pulse oximeter is a medical device that indirectly monitors the oxygen saturation of blood by assessing the red color of pulsatile blood, usually in the patient’s fingertip. The original pulse oximeter was a stand-alone monitor, about the size of a cigar box, that was both portable and easy to use. The monitor displayed two numbers, the pulse rate and the oxygen saturation, as well as a vertical array of LEDs that mimicked the rise and fall of each pulse. The monitor emitted an audible beep, with high tones representing adequate oxygen levels and low tones representing unsafe oxygen levels. Without looking at the monitor, a clinician knew whether the patient was in danger, simply by listening to the pitch of the beep tone from the oximeter.

Steve Jobs changed our way of life with the introduction of the iPhone. In parallel, Bill New changed the world with the introduction of the pulse oximeter. No single device in the 20th century changed medical care more than the oximeter. Nellcor’s successful production, marketing, and sales efforts of their pulse oximeter changed not just anesthesia practice, but medical practice, forever.

Prior to the pulse oximeter, anesthesiologists had only unreliable measures of tissue oxygenation, such as observing how red the blood seemed when the surgeon made the initial incision into the patient. Undetected hypoxia could present as a sudden cardiac arrest. Anesthesia was a more dangerous undertaking without true second-to-second knowledge of the patient’s oxygenation.

In July 1984 during the first week of my Stanford anesthesia residency at the Santa Clara County Hospital, the entire medical center owned only three Nellcor pulse oximeters. Each morning the attending anesthesiologists would huddle and decide which three had the greatest need for the new technology. The remaining operating rooms would proceed without oximetry. The situation was better at Stanford University Hospital, where each operating room included a pulse oximeter—but there were no oximeters in the PACUs, preoperative units, or intensive care units.

It may be difficult for you to imagine the increased stress level when administering anesthesia without knowing what the patient’s arterial oxygen saturation is. The reassuring audible “beep-beep-beep” treble notes from the Nellcor were reassuring, and the descending bass notes of an acute desaturation struck terror into every one of us.

The market for the Nellcor pulse oximeter exploded between 1984 and 1986, and eventually all ICUs and acute care areas had oximeter monitoring. The oxygen saturation became recognized as “the fifth vital sign,” joining heart rate, blood pressure, respiratory rate, and temperature. On October 21, 1986, the American Society of Anesthesiologists made pulse oximetry a required standard monitor for all anesthetic care. The new standard read: “During all anesthetics, a quantitative method of assessing oxygenation such as pulse oximetry shall be employed. When the pulse oximeter is utilized, the variable pitch pulse tone and the low threshold alarm shall be audible to the anesthesiologist or the anesthesia care team personnel.”

In 1990 an American Society of Anesthesiology Closed Claims Study examined 1541 malpractice settlements, and showed that adverse respiratory events constituted the single largest class of injury (522 of 1541 cases; 34%).  Death or brain damage occurred in 85% of these cases. Three-fourths of the adverse respiratory events were due to inadequate ventilation (196 cases; 38%), esophageal intubation (94 cases; 18%), and difficult tracheal intubation (87 cases; 17%). Most of the adverse respiratory outcomes (72%) were considered preventable with better monitoring (i.e. pulse oximetry plus capnography).

After the adoption of pulse oximetry and end-tidal carbon dioxide monitoring as standards, unexpected cardiac arrests from hypoxia or esophageal intubation became rare. Malpractice cases from respiratory events decreased, and malpractice insurance for anesthesiologists decreased in cost. In its landmark 1999 publication To Err is Human, the Institute of Medicine cited anesthesiology as the specialty that had made the most significant advances in patient safety.

Over the ensuing years, multiple companies produced pulse oximeters to mimic and compete with Nellcor. At the present time oximeters are ubiquitous, and are found in all clinics, emergency rooms, ICUs, PACUs, operating rooms, ambulances, critical care transport aircraft, and even in many homes. Today you can purchase a tiny finger oximeter from Walmart for $11.95

How big is the business of selling oximeters? The global pulse oximeter market was valued at $1.5 billion in 2015, and is projected to grow with a CAGR (Compound Annual Growth Rate) of 6.15%. Escalating healthcare costs are driving the market toward more home care, boosting the demand for remote patient monitoring devices, and increasing the demand for pulse oximeters.

I didn’t know Dr. New personally, although he and I attended the same alumni gatherings many times. He was congenial, humble, smart, and shunned the spotlight. He didn’t even have a Wikipedia page. He was nonetheless a celebrity among us. All Stanford anesthesia alumni knew the importance of his contribution to medical history. Dr. New continued his work as an engineer, entrepreneur and educator, and volunteered as an advisor for the Stanford Anesthesia Innovation Lab (SAIL), a medical device incubator focused on accelerating the development of anesthesia-related medical devices.

We anesthesiologists keep our patients alive, one at a time, aided by Dr. New’s discovery, and in total his discovery has kept millions of patients safe. The Stanford anesthesia department emailed out this brief note that Bill New wrote some years ago, which captured his thoughts regarding the future of our specialty:

As I ponder the future of ‘anesthesiology’ in a world where human physiology is unchanged but technology expands exponentially, the challenges and opportunities loom large. Moore’s Law and corollaries Rock’s Law + Edholm’s Law are driving us toward a technology singularity in anesthesia and critical life support, converting our human role to empathy and advocacy and no longer direct administration of agents/agonists, pills or potions, biochemical or otherwise.

I think back on academic departments and even entire schools/institutes of study at Stanford some fifty years ago that no longer exist or have morphed to fit the present world order.  I see anesthesiology morphing over the next fifty in a comparable way, with technology (as in many fields) becoming the dominant paradigm.

Stanford needs to lead us into this new unknown vortex — and one of the best ways is how we train/acculturate our residents/fellows to embrace the 21st century, which is unlikely to become simply the elongation of the 20th century shadow.  The past generation in academia blossomed to maturity with NIH grants, Medicare funding, peer review, publish or perish, tenure, big labs, hierarchical seniority, hospital hubs, risk-adverse regulation and a plethora of other customs and traditions.  The accoutrements of academia yesterday will vanish.  Anesthesia can — and must — join the new paradigm that technology now offers.

– Bill 

 

In a future column I’ll discuss the implications of Dr. New’s vision for the future of anesthesiology.

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William New MD PhD

 

The most popular posts for laypeople on The Anesthesia Consultant include:

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Will I Be Nauseated After General Anesthesia?

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MERITS OF PHYSICIAN ANESTHESIOLOGY

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.
email rjnov@yahoo.com
phone 650-465-5997

Some people have difficulty seeing the outstanding merits of physician anesthesiology. I understand where these opinions come from, but the phenomenon still bothers me.

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Today I read a thoughtful and well-written essay in Anesthesiology News titled, Anesthesiologists-The Utility Players of the Medical Field written by anesthesiologist David Stinson MD from my native state of Minnesota. His thesis is that, like utility players on a baseball team, we are valuable but suffer an identity crisis. He writes, “Our specialty, anesthesia, has suffered an identity crisis for decades. Are we the ‘captain of the ship’ or is the surgeon? . . . It is never quite clear and the answer changes with location and context. Are we physicians or are we glorified advanced practice nurses?”

To me, the appropriate headline should read, “Anesthesiologists—the Most Valuable Players of the Medical Team.” I’d like to see an anesthesiologist saying, “I’m going to Disney World” at the end of the Super Bowl before picking up his (or her) MVP trophy.

Why would I say this? Two anecdotes will illustrate why I understand the problem. In the late 1970’s I was a third-year medical student at a prominent Midwestern medical school, where an unspoken rank system existed in the operating room. The surgical attendings were the kings, the students were the peasants, the nurses and techs were serfs, and the anesthesiologists were the whipping boys for the surgeons. I witnessed consistent verbal abuse, bullying, condescending barking commands, and lack of respect directed from surgeons toward anesthesiologists. One day I was scrubbed in as a retractor-holding medical student on a 12-hour esophagectomy, and at the conclusion of the procedure the attending surgeon removed his gloves and gown and left the room to talk to the family. Five minutes later, the patient had a cardiac arrest. The resuscitation was not successful, and the patient died. Afterward the surgeon bellowed his disapproval regarding how the anesthesia team had failed to keep the patient alive after he had spent all day “curing” the patient. It was an unforgettable experience to me, and one of the take-home messages was that I never wanted to be an anesthesiologist.

Fast-forward three years into the future, when I was an internal medicine resident at Stanford serving my medical intensive care unit rotation. The anesthesiology department ran the ICUs at Stanford during the 1980’s. The ICU attendings were charismatic, smart, decisive, impressive role models. The ICU attendings had respectful peer relationships with all the surgeons, including the private-practice cardiac surgeons whose post-operative patients were housed in the ICU. Morning rounds, evening rounds, and the eight hours in between were filled with action, procedures, upbeat emotions, and encouraging talk about the specialties of anesthesiology and critical care medicine. The Stanford anesthesia residents boasted of weekdays off after their nights on call, Learjet trips to harvest donor hearts for Dr. Norm Shumway’s cardiac transplant patients, weeklong trips to third-world countries to perform anesthetics on cleft lip and palate patients, and best of all, the excitement of inserting endotracheal tubes, arterial lines, central lines, Swan Ganz catheters, spinal and epidural needles into patients of all sizes and surgical needs. This was alluring to internal medicine residents. Each year a significant number of internal medicine residents applied for admittance to anesthesiology residencies, which is what I did. Were surgeons hollering at the anesthesiologists at Stanford? In a word . . . no. The department had the respect of the surgeons. This was the environment I grew up in, and the professional spirit we all should aspire to.

Here are 10 reasons why anesthesiologists should hold their heads high and never have a molecule of low self esteem around their medical center:

  1. All of acute care medicine is based on A-B-C, or Airway-Breathing-Circulation. Operating room medicine, intensive care medicine, emergency room medicine, trauma helicopter medicine, and battlefield medicine are all based on A-B-C, or Airway-Breathing-Circulation. Who are the experts of the A, or Airway? Anesthesiologists are the experts. There can be no acute care resuscitation without someone managing the airway, usually with an endotracheal tube. It’s true that other medical professionals have abilities to place endotracheal tubes, but none of them have the breadth of skills, techniques, and volume of attempts as anesthesiologists do. Hold your heads high. Read my column on bullying in the operating room. Don’t put up with condescending behavior from a surgeon. Surgeons know how to wield a scalpel. You know how to wield the most valuable tool of all medical equipment, the laryngoscope.78432-7985650
  2. It’s true that surgeons bring the patients to the operating room for surgery. It’s just as true that none of those patients would agree to the operations without having an anesthetic. The anesthesiologist’s role is vital.
  3. Clinic doctors are important. They manage primary care as well as outpatient specialty care. They make diagnoses and prescribe therapeutic medicines. Anesthesiologists also partake in clinic care in preoperative clinics and pain clinics. An anesthesiologist’s knowledge of internal medicine isn’t as comprehensive as a board-certified internist, but the consider the flip side: None of the internists can administer general anesthesia, regional anesthesia, or manage the A of the A-B-Cs like an anesthesiologist can. I was an internal medicine doctor who lacked these skills and then acquired them during anesthesia residency. Trust me—internists envy the skills of anesthesiologists.
  4. Anesthesiologists deal with life and death situations on a regular basis. Clinic doctors, including surgeons on their days in clinic, listen to and talk to patients. There is no peril in outpatient clinic medicine. On any given day at your job as an anesthesiologist you could be attending to a morbidly obese adult, a tiny child, a frail geriatric patient, or an emergency thoracic case. Your heart rate will climb as high as the patient’s, and you’ll manage the circumstances. Anesthesiologists are goalies at the Pearly Gates, and we should be proud of it.
  5. Physician anesthesiologists have a fascinating job. Anesthesiologists administer anesthetics to virtually every specialty: general surgery, cardiac surgery, neurosurgery, obstetrics, gynecology, otolaryngology, orthopedic surgery, podiatry, ophthalmology, plastic surgery, psychiatry for electroshock therapy, invasive radiologists, cardiologists, oral surgeons, dentists, and pediatric surgeons. The breadth of knowledge across specialties is unrivaled by any other physician.
  6. Who is the captain of the ship in the operating room? Is it the surgeon or is it the anesthesiologist? My advice is: don’t concede the role to your surgical colleague alone. He or she knows how to do the operation. You know how to do the anesthetic. It is a symbiotic relationship. Do not lay yourself down on the ground in reverence. In the words of the Eagles song “Peaceful Easy Feeling,” “she can’t take you anywhere you don’t already know how to go.” If you see and feel yourself as the servant, second in command, that’s where you’ll find yourself . . . as the servant, second in command. Step up. Be an equal. Be in control of your domain, a critical domain.
  7. Physician anesthesiologists are well paid. Per U. S. News and World Report, an anesthesiologist is the highest paying job in America. Think about that. There are 325 million people in our country, and there are thousands of different job descriptions. Your profession is the highest paid. Be proud of that.
  8. Physician anesthesiologists are in demand. As I write this in 2018, I receive multiple emails per day seeking attending anesthesiologists for jobs around the USA. If you’re willing to relocate and be mobile, you’ll find numerous suitors competing for your services as an attending anesthesiologist. Per U.S. News and World Report, the unemployment rate for anesthesiologists is a paltry 0.5%.
  9. Physician anesthesiologists help people every day. You could be selling Coca Cola or cell phones or cell phone data networks or stocks. Would you be serving humanity as well if you were working in some business job? You have the opportunity to change lives for hundreds of patients per year.
  10. Maybe you’re worried that nurse anesthetists will take your job away. I have no crystal ball to foretell the future, but consider these things: (a) Most CRNAs work in anesthesia care team models with our physician anesthesiologist colleagues, and this MD-CRNA relationship is a well accepted model of patient care that will persist into the future; (b) Physician anesthesiologists are needed for leadership roles in clinical care, administration, committees, and quality assurance; and (c) Remember that you are a physician and CRNAs are not. Keep up your skills. The large medical systems of the future will tier their anesthesia coverage. Complex cases will always require MD anesthesiologists. It’s likely that simple cases such as cataracts, lymph node biopsies, and knee arthroscopies can be safely done with CRNA anesthesia. Continue to seek out and perform difficult anesthetic cases only an MD would feel comfortable doing. If you find yourself attending to only ASA I an ASA II patients for straightforward surgeries, you may indeed find your job taken by someone with less training. Instead, step up. Be proud of your training, your unique skills, the heritage of your profession, and the esteem of your standing among your fellow physicians.

 

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IS YOUR GRANDFATHER TOO FRAIL FOR ANESTHESIA?

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.
email rjnov@yahoo.com
phone 650-465-5997

Is your grandfather too frail for surgery? There are iPad apps to help you answer the question regarding frailty and anesthesia.

Webster’s Dictionary defines frailty as “the condition of being weak and delicate.” Frailty is also a medical term with an accepted definition of “a multisystem loss of physiologic reserve that makes a person more vulnerable to disability during and after stress.”1

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The majority of frail patients are elderly. My training was in both internal medicine and anesthesiology, and the intersection of these two fields is geriatric anesthesia. Metrics of frailty exist, and the evaluation of a patient’s frailty index will become an important part of geriatric anesthesia care.

The geriatric population is increasing in size, and the number of elderly patients undergoing surgery is increasing as well. More than half of all operations in the United States are performed on patients of ages ≥65 years, and this proportion will continue to increase.2

In the past a physician’s assessment of a patient’s frailty was an “eyeball” judgment, dependent on how robust versus how frail a patient looked, and dependent on an interpretation of the patient’s active medical problems. Medical researchers began to seek a quantitative metric for frailty, and they proposed frailty evaluation tools.

Dr. Linda Fried developed one of the first frailty indexes in 2001. She studied 5317 men and women 65 years of age or older, and tabulated their answers to questions regarding these five criteria of the Fried Frailty Index: 1,3

  1. Unintentional weight loss. The patient is asked the question, “In the last year, have you lost more than 10 lb unintentionally (i.e., not as a result of dieting or exercise)?” Patients answering “Yes” are categorized as frail by the weight loss criterion.
  2. The patient is read the following two statements: (1) I felt that everything I did was an effort; (2) I could not get going. The question is asked, “How often in the last week did you feel this way?” The patient’s response is rated as follows: 0 = rarely or none of the time (<1 day); 1 = some or little of the time (1 to 2 days); 2 = a moderate amount of the time (3 to 4 days); or 3 = most of the time.
  3. Muscle weakness. The patient is asked about weekly physical activity. Patients with low physical activity are categorized as frail by the physical activity criterion.
  4. Slowness while walking. The patient is asked to walk a short distance and timed. Patients who are slow walkers are categorized as frail by the walk time criterion.
  5. Grip strength. The patient’s grip strength is measured. Patients with decreased grip strength are categorized as frail by the grip strength criterion.

Frailty was defined as a clinical syndrome in which three or more of these five criteria were present. The overall prevalence of frailty in this age>65 patient population was 6.9%. The frailty phenotype was predictive of falls, worsening mobility or disability.

Other researchers, using a variety of frailty scales, have found that increasing frailty correlates with poorer outcomes after surgery. Korean researchers enrolled 275 consecutive elderly patients (aged ≥65 years) who were undergoing intermediate-risk or high-risk elective operations.4 A comprehensive geriatric assessment (CGA) was performed before surgery. The CGA included 6 areas: the number of medical problems, the number of medications taken, physical function, psychological status, nutrition, and risk of postoperative delirium. This CGA frailty score predicted all-cause mortality rates after surgery.

McMaster University professors authored the Fit-Frailty App (available at Apple or Google App Store), a smartphone/iPad app based on the 30-item Canadian Multicentre Osteoporosis Study Frailty Index.5 It takes only minutes to answer the questions on the app, and the app generates a frailty score, which ranges from 0 to 1.0.

The Edmonton Frail Scale (available at Apple or Google App Store) is a 9-criteria iPad app survey which quantifies a frailty score from 0-17. It’s easy to use, and takes about 2–3 minutes to complete.

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In the future you’ll see patients filling out frailty apps such as these on iPads in the future, with anesthesiologists and other doctors using the frailty score as part of the pre-surgery evaluation. You can also expect research on whether intervention into or modification of these frailty criteria prior to surgery results in lower postoperative complication rates.

Fire up your iPads, download these frailty apps, and see how fit or frail your grandfather is right now.

References:

  1. Sieber F, Pauldine R, Geriatric Anesthesia, Miller’s Anesthesia, Chapter 80, 5th edition, 2407-2422.
  2. Etzioni  DA, et al. The aging population and its impact on the surgery workforce. Ann Surg. 2003;238(2):170-177.
  3. Fried LP et al. Frailty in Older Adults: Evidence for a Phenotype, The Journals of Gerontology: Series A, Volume 56, Issue 3, 1 March 2001, Pages M146–M157.
  4. Kim S-W et al, Multidimensional Frailty Score for the Prediction of Postoperative Mortality Risk, JAMA Surg. 2014;149(7):633-640.
  5. Kennedy CC et al, A Frailty Index predicts 10-year fracture risk in adults age 25 years and older: results from the Canadian Multicentre Osteoporosis Study (CaMos) Osteoporosis International, December 2014, Volume 25, Issue 12, pp 2825-2832.

 

 

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The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

PHYSICIAN ANESTHESIOLOGIST LISTED AS THE #1 BEST PAYING JOB BY U.S. NEWS AND WORLD REPORT

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.
email rjnov@yahoo.com
phone 650-465-5997

For years I’ve extolled the intellectual and emotional virtues of a career in anesthesiology. This week U.S. News and World Report credited anesthesiologist with another honor: the highest paying job in their 2018 Best Paying Jobs survey.

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Regarding the #1 job, physician anesthesiologist, the article states, “the breadth of the profession has dramatically expanded in the last decade. Anesthesiologists still work in hospital operating rooms, but their expertise is also needed in other places, including invasive radiology, gastrointestinal endoscopy, electrophysiology and more. In fact, the profession is expected to grow by 18 percent through 2026, with 5,900 new jobs.” The median salary for a physician anesthesiologist was listed as $208,000, and the unemployment rate as 0.5%.

The article also states, “The journey to becoming an anesthesiologist is a long one. After obtaining an undergraduate degree, hopefuls need to take the Medical College Admission Test (MCAT) and attend medical school. After graduation, they will then have to pass the United States Medical Licensing Examination (USMLE) to undergo a one-year internship followed by a three-year residency in anesthesiology. Most anesthesiology residents go on to do a one- to two-year fellowship program to learn a subspecialty, such as critical care or obstetric anesthesia. After completing residency and taking an exam, anesthesiologists may also receive their board certification through the American Board of Anesthesiology. It’s not required, but it does demonstrate advanced skill and knowledge and many help with getting more professional opportunities or a higher salary. However, all anesthesiologists have to obtain state licensure, the requirements for which vary by state. By the time an anesthesiologist is through residency and a fellowship, he or she will have completed anywhere from 12,000 to 16,000 hours of clinical training, according to the American Society of Anesthesiologists.”

The job of a certified nurse anesthetist was listed as #11 on the Best Paying Jobs list. The article states, “health care reform and the aging baby boom population are precipitating the demand for more health care providers. And indeed, the BLS (Bureau of Labor Statistics) predicts that the profession is poised to grow by about 16 percent by the year 2026, which translates into 6,700 new job openings.” The median salary of nurse anesthetists was listed as $160,270, and the unemployment rate as 2.7%.

Careers in anesthesia are intellectually stimulating, emotionally gratifying, and have high median salaries and ultra-low unemployment. Expect the demand for acceptance into physician anesthesiologist and nurse anesthetist training programs to remain high. I see both careers to remaining attractive and secure for the foreseeable future.

 

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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THE MINI-COG: COGNITIVE IMPAIRMENT AND SURGICAL OUTCOME

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.
email rjnov@yahoo.com
phone 650-465-5997

What is a Mini-Cog? Most anesthesia professionals have never heard of the Mini-Cog test, but recent evidence shows it can provide important prognostic information on our geriatric patients prior to surgery.

 

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The Mini-Cog™ (© S. Borson, All rights reserved) is a 3-minute screening test for cognitive impairment. The test consists of three steps: Step 1 is Three Word Registration, Step 2 is Clock Drawing, and Step 3 is Three Word Recall Scoring.

STEP 1 (Three Word Registration): To administer the test, you look directly at a patient and say, “Please listen carefully. I am going to say three words that I want you to repeat back to me now and try to remember. The three words are [select one of the list of three words from the versions below]. Please say them for me now.”

If the patient is unable to repeat the words after three attempts, you move on to Step 2.

Version 1: Banana Sunrise Chair

Version 2: Leader Season Table

Version 3: Village Kitchen Baby

Version 4: River Nation Finger

Version 5: Captain Garden Picture

Version 6: Daughter Heaven Mountain

STEP 2 (Clock Drawing): You say: “Next, I want you to draw a clock for me. First, put in all of the numbers where they go.” When that is completed, say: “Now, set the hands to 10 past 11.” You utilize a preprinted circle on a blank page for this exercise. You move to Step 3 if the clock is not complete within three minutes.

STEP 3 (Three Word Recall Scoring): You ask the person to recall the three words you stated in Step 1.

SCORING: Word Recall= ______ (0-3 points), 1 point for each word spontaneously recalled without cueing. Clock Draw= ______ (0 or 2 points). Normal clock = 2 points. A normal clock will have all numbers placed in the correct sequence and approximately correct position (12, 3, 6 and 9 are in anchor positions) with no missing or duplicate numbers. The clock hands are pointing to the 11 and 2 (11:10) positions. Hand length is not scored. Inability or refusal to draw a clock = 0 points.

TOTAL SCORE = Word Recall score + Clock Draw score. Some studies consider a score of 3 or less diagnostic of cognitive impairment, other studies require a score of 2 or less.

 

In the November 2017 issue of Anesthesiology, Culley et al of Harvard utilized the Mini-Cog as a preoperative screening test on 211 patients without a diagnosis of dementia, 65 years of age or older, who were scheduled for an elective total hip or knee replacement. Fifty of 211 (24%) of the patients screened positive for probable cognitive impairment (CI) by a Mini-Cog score of 2 or less. Compared to patients with a score of 3 or greater, the low Mini-Cog scorers were more likely to be discharged to a place other than home (67% vs. 34%), develop postoperative delirium (21% vs. 7%), and have a longer hospital length of stay. Culley concluded that many older elective orthopedic surgical patients have probable cognitive impairment preoperatively, and that this impairment is associated with the development of postoperative complications. The authors suggest that identifying these patients who are at greater risk may allow for the design of interventions to lower complications in this population.

Cognitive impairment (CI) is not dementia, but in all likelihood is a precursor. How common is CI, or the related diagnosis “cognitive impairment, not dementia” (CIND) in America? The incidence of both is higher than you might guess. Plassman et al evaluated for CI in participants in the Aging, Demographic, and Memory Study using a comprehensive in-home assessment. A total of 456 individuals aged 72 years and older who were not demented at baseline were followed for 8 years. An expert panel assigned the diagnosis of normal cognition, CIND, or dementia. The incidence of dementia was 33.3 per 1,000 person-years. The incidence of CIND was 60.4 per 1,000 person-years. An estimated 120.3 individuals per 1,000 person-years progressed from CIND to dementia. Over a 5.9-year period, 3.4 million individuals aged 72 and older in the United States developed dementia, and over this same period almost 4.8 million individuals developed incident CIND. Their conclusions: the incidence of CIND is greater than the incidence of dementia, and that patients with CIND are at a high risk of progressing to dementia.

The value of the Mini-Cog test has been studied in other populations of geriatric patients. Robinson et al studied the preoperative Mini-Cog test in subjects 65 years of age and older, prior to a planned elective operation requiring a postoperative ICU admission. In this study, CI was defined as a Mini-Cog score of 3 or less. Eighty-two out of 186 subjects (44%) had baseline impaired cognition. Compared to those who scored 4 or greater, the CI group had a higher incidence of postoperative complications (41% vs. 24%), a higher incidence of delirium (78% vs. 37%), longer hospital stays (15 ± 14 vs. 9 ± 9 days), higher rate of discharge to an institution (42% vs. 18%), and a higher 6-month mortality rate (13% vs. 5%).

Patel et al studied the Mini-Cog test on 720 consecutive patients prior to discharge during hospitalization for heart failure. A Mini-Cog score of 2 or less was considered abnormal. The prevalence of CI was high (23%). In the 6 months following hospitalization, 342 of the 72 patients (48%) were readmitted, and 24 (3%) died. A poor Mini-Cog performance was identified as the most important predictor of readmission or death among 55 variables studied.

At Stanford our department is titled the Department of Anesthesiology, Perioperative and Pain Medicine. Perioperative medicine includes preoperative evaluation. The concept of a Preoperative Anesthesia Clinic originated with Dr. Steve Fischer at Stanford. As a double-boarded anesthesiologist and internal medicine doctor, I’ve honed my skills in the preoperative evaluation of the geriatric patient. Up to the present I have not utilized the Mini-Cog test in my preoperative evaluation.

Should the future preoperative evaluation of geriatric surgical patients include a Mini-Cog test?

Perhaps.

The American College of Surgeons and the American Geriatrics Society recently published guidelines recommending the preoperative screening of older surgical patients with a tool such as the Mini-Cog. These are recommendations, not mandates, and time will tell how prevalent the Mini-Cog becomes in the geriatric anesthesia preoperative workup. It’s unlikely that patients will be denied surgery for borderline or low preoperative Mini-Cog scores, but the potential for improving postoperative outcomes in the low scorers presents a challenge for the entire perioperative community of anesthesiologists, surgeons, intensivists, and nurses.

Keep your eyes open for further research regarding the value of the preoperative Mini-Cog test. And as you age, you might choose to rehearse your retention of the three-word lists above, and practice drawing clocks that read 11:10.   🙂

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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AVOIDING PREVENTABLE ERRORS IN ANESTHESIA – 14 TIPS

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.
email rjnov@yahoo.com
phone 650-465-5997

One goal of theanesthesiaconsultant.com is to make the practice of anesthesia safer. The practice of anesthesia on healthy patients is quite safe, but we want to do everything we can to avoid preventable errors.

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The safety of anesthesia on ASA I and II patients has been compared to the safety record of commercial aviation. Few passengers board an airplane and worry they will die before they land at their destination. But planes do crash, and so do anesthetized patients.

In August 2107 the journal Anesthesiology published the study “Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage,” authored by Christian M. Schulz MD et al. . This was an important study which documented what experienced anesthesiologists already know—although our specialty has never been safer, preventable deaths still occur.

The study analyzed the United States Anesthesia Closed Claims Project database of 10,546 malpractice claims between 2001-2013. A total of 266 cases of brain damage or death during anesthesia care in the operating room under the care of a solo anesthesiologist occurred. Of these 266 cases, 198 (74%) had a situational error by the solo anesthesia provider. Malpractice payments were made in 85% of these situational error cases, compared to only 46% in other cases. The total of 198 patients in 12 years averaged more than16 preventable deaths per year.

What was the definition of a situational error? The article sited three types: perception, comprehension, and projection.

PERCEPTION ERROR. A failure to gather information via history, the patient’s chart, physical exam, diagnostic tests, imaging, or monitors, including the absence of monitors.

COMPREHENSION ERROR. The information was available, but there was a failure to understand and diagnose the significance of information obtained from history, physical exam, diagnostic tests, imaging findings, or monitors.

PROJECTION ERROR. A failure to forecast future events or scenarios based on a high-level understanding of a problematic situation.

Of the 198 situational errors, perception errors were most common (42% of the cases), followed by comprehension errors (29%) and projection errors (29%).

72% of the errors occurred during general anesthetics, 23% occurred during monitored anesthesia care, and 5% occurred during regional anesthetics.

The primary damaging event differed in the 198 error cases vs. the 68 other cases. In the 198 situational error cases, respiratory events were the dominant category (p<.001), including inadequate oxygenation/ventilation (24%), difficult intubation (11%), and pulmonary aspiration (10%). In the 68 non-error cases, cardiovascular events were the dominant category. All the anesthesiologists were single practitioners, that is, they were not part of an anesthesia care team with a nurse anesthetist.

The authors of the study made the following points in their discussion of the findings:

  1. Many perception errors stemmed from lack of or lack of attention to respiratory monitoring. Key respiratory monitors were pulse oximetry and end-tidal CO2 monitors.
  2. Other common perception errors were missing preoperative information, which led to inadequate preoperative evaluation.
  3. The most common comprehension error was failure to comprehend an ongoing clinical difficulty related to respiratory problems.
  4. Many projection errors involved lack of appreciation of difficult airways.
  5. Projection errors also included procedures taking place in inappropriate environments, such as very sick patients having surgery in an office or an outpatient surgery center.

The authors made the following suggestions to decrease preventable errors:

  1. Perception errors may be prevented by regular scanning and processing of all the information available prior to and during every anesthetic.
  2. A “call for help” and the use of cognitive aides (e.g. emergency checklists or an emergency manual) may help when a patient deteriorates.
  3. Situational awareness training can be addressed in anesthesia crisis resource management education, including simulation training.

There were limitations to the Schulz study. The assembled data was retrospective and nonrandom. The Anesthesia Closed Claims Project may not reflect the true incidence of situational errors in anesthesia practice in the United States. As well, the 198 patients found in this study are only those countable via the closed malpractice claims. The true number of uncaptured cases of preventable deaths is unknown.

I have a busy practice of medical-legal consultation. I evaluate 8-10 cases per year of preventable death or brain death, and I’m just one person with one medical-legal practice. I believe there are far more cases that exceed my reach.

The Schulz study listed 11 specific patient case examples of preventable errors. Based on these 11 cases, the multiple legal cases referred to me, my 31 years of practice, and my 25,000 personally administered anesthetics for all types of surgeries and patients, I’m qualified to give advice on how to decrease preventable errors in anesthesia. My advice follows:

  1. I see uninformed preoperative workups leading to errors. Be an outstanding preoperative physician. Your preoperative assessment of each patient needs to be complete and pertinent. Pay special attention to cardiac, respiratory, neurologic, and any other significant medical issues. If you’re uncomfortable with any lack of information, you must acquire that information before you begin an anesthetic. If you need a consultant such as a cardiologist, cancel the case and get a cardiac consult before you proceed.
  2. As part of your preoperative workup, ask every patient if they can climb two flights of stairs. Be wary when administering general anesthesia to any patient who cannot walk up two flights of stairs. If a patient develops shortness of breath at this modest exertion, this is evidence of a lack of cardiac or respiratory reserve. This requires preoperative workup to determine the diagnosis and to apply treatment prior to general anesthesia. Any patient who has significant knee, hip, foot, or back pain or who has claudication that prevents him or her from walking up two flights of stairs has not proven to you that they have adequate cardiac and/or respiratory reserve. A referral to a cardiologist/pulmonologist/internist for preoperative clearance testing may be indicated prior to surgery.
  3. Don’t let surgeons talk you into anesthetizing patients you believe are inadequately worked up for anesthesia. Don’t let surgeons talk you into anesthetizing patients using anesthesia techniques or anesthesia plans you’re not comfortable with. We give mock oral board exams to residents at Stanford, and a common exam question is to try to dupe the resident into doing something unsafe because the surgeon demanded it. The surgeon is not trained in anesthesiology. The surgeon does not pay your malpractice insurance, and he or she will not have to endure your malpractice lawsuit if the anesthetic goes awry.
  4. Don’t let surgeons talk you into anesthetizing patients in inappropriate locations or settings. Be careful anesthetizing sicker patients in offices or in freestanding outpatient surgery centers. These facilities lack ICUs, clinical labs, blood gases, respiratory therapists, radiology, and backup anesthesia professionals. Be wary of performing procedures which are too invasive or too extensive in these settings. Twenty years ago one of our orthopedic surgeons attempted to schedule an 80-year-old female for a total knee replacement in a freestanding outpatient surgery facility which had overnight capabilities. I refused to staff the case, and told him, “Cases like this—that’s why we have hospitals.” He hung up on me, but there were no further requests to schedule similar patients at that facility. There are pressures to perform increasingly difficult procedures on increasingly sicker patients in non-hospital settings. Resist these pressures. There can be no surgery without an anesthetic. Be consistent with the values you learned in your university residency program. These values haven’t changed—they’re called the standards of care—and they reflect what an adequately trained physician will do in any give situation. Stay within these standards of care, and you’re unlikely to ever lose a malpractice lawsuit.
  5. The highest number of malpractice cases I review involve airway disasters. Do not screw up airway management. This includes intubation, extubation, and mask ventilation. I’ve previously written on this topic, and I can’t emphasize it enough.
  6. Because the highest number of malpractice cases I review invol