Category CLINICAL CASES FOR ANESTHESIA PROFESSIONALS

Clinical Cases of the Month are narrative case studies of actual cases from the author’s experience, written in a format designed to educate medial professionals. The case studies were originally written by Dr. Novak for his Deputy Chief’s Column in The Gas Pipeline, a publication of the Stanford Department of Anesthesia.
Although the case studies are written in medical parlance, lay readers will glean insights into what anesthesiologists are doing, thinking, worrying about, and acting on during intriguing and challenging surgical dilemmas.

HIGH FLOW NASAL OXYGEN: AN ANESTHESIA GAME-CHANGER

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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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT
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At the 2023 American Society of Anesthesiologists meeting in San Francisco, I walked by a booth advertising High Flow Nasal Oxygen. The product was called Optiflow. I asked the representative to educate me. She began by opening a package containing an Optiflow nasal cannula, and she strapped it around my head and into my nostrils. Within one minute she started a flow of 40 liters per minute of humidified, warmed 100% oxygen into my nose. I felt a slight sensation of moving air, but because the flow was humidified and warm, I felt no caustic insult of gas blasting through my nose and upper airway. I was—in a word—flabbergasted. The capacity to deliver this much oxygen to a non-intubated patient is a marked advance in anesthesia care.

HFNO was originally used in neonatal and pediatric ICUs to oxygenate acute hypoxemic respiratory failure patients without utilizing an endotracheal tube. Its use expanded to adult ICUs. The ability to deliver 60 to 70 liters per minute of oxygen via the nose enabled physicians to delay or avoid intubating ICU patients with hypoxemia. HFNO is delivered via nasal prongs which are larger than conventional nasal cannula prongs, and at higher flow rates than are generally applied during conventional oxygen therapy. Inspired oxygen/air is heated to 37 °C, and is humidified to 100% relative humidity.

A typical nasal oxygen cannula is limited to supplying 6 liters per minute of oxygen, which is approximately equivalent to delivering 45% oxygen. Using a typical nasal oxygen cannula at a flow higher than 6 liters will cause a patient significant irritation and drying of the nasal mucosa.  By humidifying and heating the oxygen inflow, HFNO can deliver 100% oxygen at a flow rate of up to 60 liters per minute via heated tubing and wide-bore nasal prongs.

 

 

Optiflow Airvo 2 high-flow nasal oxygen device: (1) wire-heated circuit tubing; (2) hot plate-heated humidification chamber system; (3) nasal cannula; (4) oxygen inlet port; (5) sterile water supply.

 

One day after attending the ASA meeting in San Francisco, I heard an in-person lecture in Palo Alto, California by Professor Anil Patel from the Royal National Throat, Nose and Ear Hospital in London. Dr. Patel has been a pioneer in bringing HFNO/THRIVE from the ICU into the operating room. Dr. Patel is the author of a seminal THRIVE (Transnasal Humidified Rapid-Insufflation Ventilatory Exchange ) study, in which he wrote that THRIVE “has the potential to transform the practice of anesthesia by changing the nature of securing a definitive airway in emergency and difficult intubations from a pressured stop–start process to a smooth and unhurried undertaking.”

Patel’s landmark 2015 publication “Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnea time in patients with difficult airways” demonstrated that High Flow Nasal Oxygen (HFNO), or THRIVE, “combines the benefits of ‘classical’ apneic oxygenation with continuous positive airway pressure and gaseous exchange through flow-dependent dead space flushing. We extended the apnea times of 25 patients with difficult airways who were undergoing general anesthesia for hypopharyngeal or laryngotracheal surgery. This was achieved through continuous delivery of transnasal high-flow humidified oxygen, initially to provide pre-oxygenation, and continuing as post-oxygenation during intravenous induction of anesthesia and neuromuscular blockade until a definitive airway was secured. Apnea time commenced at administration of neuromuscular blockade and ended with commencement of jet ventilation, positive-pressure ventilation or recommencement of spontaneous ventilation. During this time, upper airway patency was maintained with jaw-thrust. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) was used in 15 males and 10 females. Mean (SD [range]) age at treatment was 49 (15 [25–81]) years. The median (IQR [range]) Mallampati grade was 3 (2–3 [2–4]), and direct laryngoscopy grade was 3 (3–3 [2–4]). There were 12 obese patients and nine patients were stridulous. The median apnea time was 14 (9–19 [5–65]) minutes. No patient experienced arterial desaturation < 90%.” (bold emphasis added by me.)

Figure 2 from this study shows the stability of O2 saturation during the prolonged apnea:

Figure 3 from this study shows the stability of end-tidal CO2 levels during the prolonged apnea, with an average rate of carbon dioxide rise of only 1.1 mm Hg per minute.

HFNO can generate a low level of positive pressure in the upper airway, directly proportional to the high gas flow delivered, probably improving oxygenation by PEEP (positive end-expiratory pressure). This PEEP effect improves alveolar recruitment, and might also improve gas exchange.

Widespread adoption of HFNO as routine therapy in the operating room is still lacking. The main textbook in our specialty, Miller’s Anesthesia, 9th Edition, describes the use of THRIVE for difficult intubations, but their coverage is limited to one paragraph in a chapter on Adult Airway Management, in a section describing Apneic Oxygenation, out of the 3112 pages in the publication.

Many clinicians are simply not aware the technology exists or that it is available.  I believe many smaller hospitals and outpatient facilities such as ambulatory surgery centers do not own the required equipment. The cost of using HFNO exceeds the cost of standard nasal cannulae, but  the cost is not prohibitive. One Optiflow oxygenation+humidification unit made by F & P Healthcare sells for about $1500. The disposable nasal tubing apparatus for one patient sells for about $35.

Important uses of HFNO in perioperative medicine will include : a) keeping a difficult airway patient oxygenated while the anesthesia provider is performing intubation or airway procedures; and b) keeping morbidly obese patients or patients with hypoxemic cardiopulmonary disease oxygenated for brief procedures without needing to place an endotracheal tube or a laryngeal mask airway (LMA).

Let’s look at two demonstrative examples:

High Flow Nasal Oxygen utilized during difficult intubation

 

  • A 53-year-old patient with a difficult airway presents for general anesthesia for bariatric surgery. The patient weighs 350 pounds, stands 5 feet 8 inches tall, and has a Body Mass Index of 53, classifying him as super morbidly obese. His airway exam shows a thick neck (circumference 42 cm, or 16.5 inches), a small mouth, a Mallampati 4 classification, and limited neck extension. You apply HFNO with 100% oxygen at 60 liters per minute, and continue this for 10 minutes prior to inducing anesthesia with propofol and rocuronium. Once the patient is unconscious, you attempt intubation with a Glidescope, and have difficulty visualizing the vocal cords. A colleague assists you by advancing an endotracheal tube threaded over a fiberoptic laryngoscope, while you hold the Glidescope in place. After 14 minutes of apnea time, your colleague is able to advance the fiberoptic scope into the trachea and slide the endotracheal tube past the vocal cords. During all this time the patient was apneic but remained well oxygenated with a saturation nadir of 97% because of the HFNO.
  • A 40-year-old patient presents for an upper GI endoscopy under intravenous sedation. The patient weighs 275 pounds and stands 5 feet 5 inches tall, for a BMI = 45. His airway exam is Mallampati 2. His abdomen is protuberant, and you’re concerned this morbidly obese patient will become hypoxemic under propofol sedation. You connect the patient to HFNO with 100% oxygen at 60 liters per minute for 5 minutes, and then position the patient in the lateral position, left side down. His oxygen saturation is 100%, and you begin a propofol infusion. The patient’s breathing becomes shallower as he loses consciousness, but his oxygen saturation remains 100% as the GI doctor inserts the endoscope into her mouth and completes the procedure. Once the gastroenterologist is finished, you turn off the propofol, the patient awakens, and you bring him to the Post Anesthesia Care Unit where he is stable until discharge.

Upper GI Endoscopy with Optiflow High Flow Nasal Oxygen

 

Currently the American Society of Anesthesiologists (ASA) Difficult Airway Algorithm states, “Recommend supplemental oxygen administration before initiating and throughout difficult airway management, including the extubation process.” There is no specific mention of High Flow Nasal Oxygen (HFNO) or Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE), but the most effective way to administer supplemental oxygen during difficult airway management, without interfering with efforts to manage the airway, is High Flow Nasal Oxygen (HFNO) or Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE).

I believe a statement that High Flow Nasal Oxygen (HFNO) or Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) is a standard of care in perioperative airway management is, in all likelihood, coming in the very near future. The benefit/risk ration of utilizing High Flow Nasal Oxygen (HFNO) or Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) is very high.

I’d suggest you contact a manufacturer of High Flow Nasal Oxygen (HFNO) equipment such as the Optiflow unit,  and look into obtaining this useful adjunct for your facilities.

Disclaimer: I have no financial ties to the manufacturers of Optiflow, nor do I have any financial incentive for recommending their product. I simply want safer care for patients everywhere.

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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 = 170/99? Advice For Passing the Anesthesia Oral Board Exams What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM

CONTINUOUS FINGER-CUFF BLOOD PRESSURE MONITORING

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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.
emailrjnov@yahoo.com
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EDWARDS CLEARSIGHT FINGER-CUFF BLOOD PRESSURE MONITOR

 

Picture this: prior to surgery you place a blood pressure cuff around the middle phalanx of your patient’s right middle finger, instead of a standard cuff on the upper arm, to measure blood pressure. Is this the future? After decades of watching intermittent readings from oscillometric (standard) blood pressure cuffs, will we be monitoring data from a continuous finger-cuff instead?

Perhaps.

A study in the September 2023 issue of Anesthesiology showed that continuous finger-cuff arterial pressure monitoring helped anesthesia professionals a) reduce hypotension during the 15 minutes following induction of general anesthesia, and b) reduce hypotension during the duration of noncardiac surgery, compared to traditional intermittent oscillometric arterial pressure monitoring.

The study was done in a single medical center, the University Medical Center Hamburg–Eppendorf in Hamburg, Germany. A total of 242 patients aged 45 and older who were scheduled for noncardiac surgery were randomized to continuous finger-cuff arterial pressure monitoring or to intermittent traditional oscillometric arterial pressure monitoring. The continuous finger-cuff arterial pressure monitor used was the ClearSight system manufactured by Edwards Lifesciences, USA.

Edwards ClearSight Monitoring System

 

An appropriately sized finger-cuff (small, medium, or large) was positioned on the middle phalanx of the third or fourth finger of every patient, along with a standard intermittent oscillometric arterial pressure monitor on the opposite arm. Traditional oscillometric arterial pressures were measured at 2.5 minute intervals. The clinical monitoring for each patient was randomized to be either 1) unblinded continuous finger-cuff arterial pressure monitoring, or 2) intermittent standard oscillometric arterial pressure monitoring with the finger-cuff data blinded. The Hamburg medical center’s institutional routine was to maintain MAP (mean arterial pressure) above 65 mmHg, and intraoperative hypotension was treated with intravenous norepinephrine, which was given at the discretion of each attending anesthesiologist.

The Anesthesiology study had two primary endpoints. The first was the amount of hypotension during the 15 minutes following the induction of anesthesia, and the second was the time-weighted average MAP less than 65 mmHg during the entire surgery. Results showed that continuous finger-cuff arterial pressure monitoring helped anesthesia providers a) reduce hypotension within the first 15 minutes after starting induction of anesthesia, and b) reduce hypotension during the entire noncardiac surgery. Patients assigned to continuous finger-cuff monitoring received more than twice as much norepinephrine both within 15 minutes after starting induction of anesthesia and during the entire surgery, when compared with patients assigned to intermittent oscillometric monitoring. This presumably explains why there was significantly less hypotension in the continuous finger-cuff monitoring group.

Intraoperative hypotension carries risks of major postoperative complications, including acute kidney injury, myocardial injury, and death. Previous studies have validated that both the severity and the duration of intraoperative hypotension are associated with postoperative complications and mortality.  Two previous trials validated the efficacy of continuous finger-cuff arterial pressure monitoring during surgery. In a study of 160 patients undergoing orthopedic surgery, continuous finger-cuff monitoring resulted in less than half the number of hypotensive events, defined as a MAP less than 60 mmHg (19 vs. 51 events).  A second study of 316 patients undergoing noncardiac surgery showed that continuous finger-cuff arterial pressure monitoring nearly halved the amount of intraoperative hypotension, defined as the time-weighted average MAP less than 65 mmHg.

The Edwards Lifesciences website describes the ClearSight continuous finger-cuff monitoring system.   In addition to continuous blood pressure monitoring, the ClearSight system records advanced hemodynamic parameters from the noninvasive finger cuff, including graphic trend displays on the Edwards Lifesciences HemoSphere monitor of:
• Cardiac output (CO)
• Stroke volume (SV)
• Stroke volume variation (SVV), and
• Systemic vascular resistance (SVR).

These parameters provide additional information which, if validated, can expand the information an anesthesia provider can monitor routinely. The parameters of continuous blood pressure (ART), continuous Mean Arterial Pressure (MAP), Cardiac output (CO) and Stroke volume (SV) are shown on the HemoSphere monitor below.


The technology behind the ClearSight continuous finger-cuff monitor involves a principle called the volume clamp method. Per the Edwards Lifesciences website, this “involves clamping the artery in the finger to a constant volume, by dynamically providing equal pressure on either side of the arterial wall. The volume is measured by a photo-plethysmograph built into the cuff. The counter pressure is applied by an inflatable bladder inside the cuff and is adjusted 1000 times per second to keep the arterial volume constant. Continuous recording of the cuff pressure results in real-time finger pressure waveform.”

Volume clamp cross section

 

Interior of the Edwards finger-cuff

 

Dr. Daniel Sessler, one of the world’s most respected and prolific anesthesia researchers, is a co-author of the recent Anesthesiology study. To me this validates the notion that continuous finger-cuff technology may eventually gain widespread adoption in operating room monitoring. (Note also that Dr. Sessler is a consultant for Edwards Lifesciences, and has received research funding from the company, as have some of the other authors of the Anesthesiology study.)

Unanswered questions regarding continuous finger-cuff blood pressure monitoring include:

  • Would data show that more frequent utilization of oscillometric (standard) blood pressure readings, recordedwith our existing equipment every one minute instead of every 2.5 minutes, give as much information as a continuous finger-cuff?
  • If a patient’s hand or fingers are jiggled or moved during monitoring, would the continuous finger-cuff give significant artifacts?
  • Would clinicians use both traditional blood pressure cuff monitoring and continuous finger-cuff monitoring on the same patient, and make physiologic conclusions from both sources of input?
  • Will other models of finger-cuff monitoring, different from the Edwards Lifesciences ClearSight model, vary in accuracy? Will clinicians trust new finger-cuff monitoring devices and their data?
  • What will be the price of this technology?

The benefit/risk ratio of continuous finger-cuff monitoring appears to be high. The technology is noninvasive and unlikely to harm our patients in any way, as long as the data is accurate. The dollar cost of this new technology will influence its rate of adoption. Existing intermittent oscillometric (traditional) blood pressure monitoring devices are already present in every operating room as standard equipment on today’s budgets. If continuous finger-cuff blood pressure monitoring is both accurate and inexpensive, the new technology may be universally adopted. But because a majority of anesthetics are administered to reasonably healthy ASA 1 or ASA 2 patients, many of them in outpatient surgery centers, one could argue that measuring intermittent blood pressures every 2.5 to 3 minutes with oscillometric (traditional) blood pressure monitoring devices is an adequate monitoring interval for these patients. If the added cost of continuous finger-cuff monitoring is excessive, this technology may be limited to hospitals, where sicker patients are anesthetized for bigger and more invasive surgical procedures, and which present increased risk for patients with hypotension.

The Food and Drug Administration recently approved an additional monitoring system based on finger-cuff technology from Edwards Lifesciences, the Acumen Hypotension Prediction Index (HPI) software system. This system uses machine learning to alert clinicians of the likelihood a patient is trending toward hypotension, or low blood pressure.

Keep your eyes open for further studies on the ClearSight system, the Acumen system, and other continuous finger-cuff monitoring equipment. This technology may become part of our operating room life in the near future.

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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 = 170/99? Advice For Passing the Anesthesia Oral Board Exams What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM

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THE TOP 10 ANESTHESIA JOURNALS

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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.
emailrjnov@yahoo.com
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This column will help you find the top 10 anesthesia journals. Prior to the internet, hard copies of medical journals were bound into volumes and stored at hospital or medical school libraries. To find a specific article required a dive into the archives of the library, with the eventual reward of finding the specific article and then photocopying it to use for your pending lecture, paper, or patient care. In the internet age, all journals are catalogued in the virtual library of the search engine PubMed.  Once you find your desired article, the abstract or sometimes the full text article is available for you to read and/or copy into your personal computer.

With this virtual library model, it makes little sense for individual clinicians to subscribe to monthly journals. Your search for journal references is done via Google or PubMed. Which journals are accessed most often? Traditional academic rankings of journals rely on the “impact factor” of each journal.

Impact factor is defined as the “scientometric index which reflects the yearly mean number of citations of the articles published in the last two years in that journal.” One such impact factor ranking list is located here.  The impact factor/rate of citations is different from the number of clicks an article receives on internet searches. How many people actually read an article? There is currently no ranking system to quantitate the important metric of internet clicks, which would document the degree of interest readers have with a specific article or journal.

Clinical anesthesia providers such as myself want to read information which impacts patient care, rather than to read basic science studies such as this one:  Pholcodine exposure increases the risk of perioperative anaphylaxis to neuromuscular blocking agents: the ALPHO case-control study. Which journals/publications contain the most valuable clinical information? There are multiple fine journals in our specialty, but in my opinion the top 10 periodical anesthesia publications for clinical information follow below. Note that 2 of the top 4 publications did not even exist when I began my anesthesia training in 1984.

THE 2023 ANESTHESIACONSULTANT.COM LIST OF THE TOP 10 ANESTHESIA PUBLICATIONS:

TEN: Journal of Clinical Anesthesia.  Per their website, this journal “addresses all aspects of anesthesia practice, including anesthetic administration, pharmacokinetics, preoperative and postoperative considerations, coexisting disease and other complicating factors, cost issues, and similar concerns anesthesiologists contend with daily. . . . JCA is affiliated with three societies that make it their official journal: the American Association of Clinical Directors (AACD); the Society for Airway Management (SAM); and the Orthopedic Anesthesia Pain Rehabilitation Society (OAPRS).” This publication launched in 1988. Comment: The Journal of Clinical Anesthesia is best known for presenting clinical data regarding relevant questions in the practice of anesthesiology.

NINE: European Journal of Anaesthesiology. Per their website, “The European Journal of Anaesthesiology is the official journal of the European Society of Anaesthesiology and Intensive Care (ESAIC), and all members receive the journal as a benefit of membership.” This publication launched in 1983. Comment: As the flagship publication for the European Society, this journal is a reliable source of recent relevant anesthesia studies.

EIGHT: Regional Anesthesia & Pain Medicine.  Regional Anesthesia & Pain Medicine. Per their website, this journal is “the official publication of the American Society of Regional Anesthesia and Pain Medicine(ASRA), a monthly scientific journal dedicated to mitigating the global burden of pain. Coverage includes all aspects of acute, perioperative, transitional, and chronic pain medicine. . . . this respected journal also serves as the official publication of the European Society of Regional Anaesthesia and Pain Therapy (ESRA), the Asian and Oceanic Society of Regional Anesthesia (AOSRA), the Latin American Society of Regional Anesthesia (LASRA), and the African Society for Regional Anesthesia (AFSRA).” This journal launched in 1976. Comment: The diagnosis and treatment of pain is the greatest frontier in the specialty of anesthesiology in the 21st century. Look to Regional Anesthesia & Pain Medicine as the leading journal in this vital subspecialty of anesthesiology.

 

SEVEN: Journal of Cardiothoracic and Vascular Anesthesia.  Per their website, this journal “is primarily aimed at anesthesiologists who deal with patients undergoing cardiac, thoracic or vascular surgical procedures. JCVA features a multidisciplinary approach, with contributions from cardiac, vascular and thoracic surgeons, cardiologists, and other related specialists.” This journal launched in 1987. Comment: The practices of cardiac, thoracic, and vascular anesthesia are the most demanding in our profession, and the Journal of Cardiothoracic and Vascular Anesthesia is the leader in reporting advances in these challenging subspecialties.

SIX: British Journal of Anaesthesia.  Per their website, this journal “publishes high-impact original work in all branches of anaesthesia, critical care medicine, pain medicine and perioperative medicine. . . . The journal is proudly affiliated with The Royal College of Anaesthetists, The College of Anaesthesiologists of Ireland, and The Hong Kong College of Anaesthesiologists.” This publication launched in 1923. Comment: This British journal is the second longest running publication of the ten in this list, and is a very well-known and well-respected journal in our profession.

FIVE: Anaesthesia.  Per their website, this journal “is the official journal of the Association of Anaesthetists and is international in scope and comprehensive in coverage. It publishes original, peer-reviewed articles on all aspects of general and regional anaesthesia, intensive care and pain therapy.” This publication launched in 1930. Comment: This British journal is the third longest running publication of the ten in this list, and is a well-known and well-respected journal in our profession.

FOUR: The ASA Monitor.  Per their website, this is “the official news publication of the American Society of Anesthesiologists. The ASA Monitor delivers the latest specialty and industry news, and practice-changing clinical information to the perioperative health care community.” This publication launched in 2004. Comment: The ASA Monitor byline is “The Leading Source for Perioperative Health Care News.”  The ASA Monitor is essentially a monthly newspaper which reports on pertinent topics regarding anesthesiology in the United States. It’s delivered to all members of the American Society of Anesthesiologists.

 

THREE: The Anesthesia Patient Safety Foundation (APSF) Newsletter.  Per their website, this publication’s  mission is “to improve the safety of patients during anesthesia care by: Identifying safety initiatives and creating recommendations to implement directly and with partner organizations, being a leading voice for anesthesia patient safety worldwide, and supporting and advancing anesthesia patient safety culture, knowledge, and learning. The APSF Vision Statement is ‘That no one shall be harmed by anesthesia care.’” This publication launched in 1986. Comment: The Anesthesia Patient Safety Foundation Newsletter is the Quality Improvement/Quality Assurance publication for our profession. The editors ferret out current problems in anesthesiology and provide solutions in an attempt to lessen or eliminate complications in the future. The APSF Newsletter should be required reading for all anesthesia professionals in order to best protect our patients.

TWO: ANESTHESIA & ANALGESIA.   Per their website, “ANESTHESIA & ANALGESIA is the ‘The Global Standard in Anesthesiology,’ and provides the practice-oriented, clinical research you need to keep current and provide optimal care to your patients. Each monthly issue brings you peer reviewed articles on the latest advances in drugs, preoperative preparation, patient monitoring, pain management, pathophysiology, and many other timely topics. . . . ANESTHESIA & ANALGESIA is the official journal of the International Anesthesia Research Society and all members receive the journal as a benefit of membership.” This publication launched in 1922. Comment: A & A (as this journal is referred to in our profession) is an outstanding publication, second only to Anesthesiology.

ONE: ANESTHESIOLOGY. Per their website, “ANESTHESIOLOGY leads the world in publishing and disseminating the highest quality work to inform daily clinical practice and transform the practice of medicine in the specialty. . . . Founded in 1940, ANESTHESIOLOGY is the official journal of the American Society of Anesthesiologists but operates with complete editorial autonomy, with an independent and internationally recognized Editorial Board.” Comment: Anesthesiology is the blueprint for what a 21st century journal should  be, mixing breakthrough science and clinical studies with the all-important American Society of Anesthesiologist standards, guidelines, and practice parameters which define our profession.

My advice? Be intellectually curious about all things related to anesthesiology. Use PubMed and Google to look up questions you want answered. You’ll be directed to many of the publications above, and you’ll be a smarter clinician as a result.

In addition:  There are dozens of anesthesia textbooks. I’ve ranked the Top 11 Anesthesia Textbooks in a previous column.

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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 = 170/99? Advice For Passing the Anesthesia Oral Board Exams What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM

CHATGPT AND ANESTHESIA

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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.
emailrjnov@yahoo.com
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In 1997 the IBM computer Deep Blue beat world chess champion Gary Kasparov head to head.  Is it feasible that CHATGPT, this decades artificial intelligence wunderkind, can equal or better a physician anesthesiologist? I entered three anesthesia consultations into CHATGPT, one preoperative, one intraoperative, and one postoperative. Is CHATGPT as good as an MD? Let’s look at what the computer answered:

PREOPERATIVE QUESTION

An 80-year-old woman with congestive heart failure gets short of breath walking up one flight of stairs. She needs to have her gallbladder removed. What sort of preoperative tests or therapies should this patient have before surgery?

 

CHATGPT: For an 80-year-old woman with congestive heart failure (CHF) who needs to undergo gallbladder removal surgery, it is essential to conduct a thorough preoperative evaluation to assess her overall health status and identify any potential risks. The specific evaluation required may vary depending on the patient’s medical history, the severity of the CHF, and the recommendations of the healthcare team involved. However, here are some general aspects that may be considered:

  1. Cardiac Evaluation: Given the patient’s CHF and symptoms of shortness of breath, it’s important to assess her cardiac function comprehensively. This may involve an electrocardiogram (ECG) to evaluate heart rhythm, an echocardiogram to assess heart structure and function, and possibly additional tests such as stress testing or cardiac catheterization, depending on the severity of her symptoms and the presence of any known cardiac conditions.
  2. Pulmonary Evaluation: Since the patient experiences shortness of breath, it may be necessary to evaluate her lung function. Pulmonary function tests, such as spirometry, may be conducted to assess lung capacity and function.
  3. Lab Tests: Routine blood tests may be performed to assess the patient’s overall health and check for any abnormalities that could impact surgery. This may include a complete blood count (CBC), comprehensive metabolic panel (CMP), coagulation profile, and other specific tests as deemed necessary.
  4. Imaging Studies: Depending on the patient’s medical history and symptoms, imaging studies like an abdominal ultrasound or a computed tomography (CT) scan may be ordered to confirm the diagnosis of gallbladder disease and assess its severity.
  5. Medication Review: A review of the patient’s current medications, including those used to manage her CHF, is crucial to ensure they are optimized for the surgery. Medications may need to be adjusted or temporarily stopped to minimize potential risks during the procedure.
  6. Anesthesia Evaluation: An evaluation by an anesthesiologist is important to assess the patient’s readiness for anesthesia and determine the most appropriate anesthesia plan for her, taking into account her cardiac condition and any other medical considerations.

It’s important to note that this is a general outline, and the specific preoperative evaluation for the patient should be determined by her healthcare team, including her primary care physician, surgeon, cardiologist, and anesthesiologist. They will consider her individual medical history and unique circumstances to ensure a safe and successful surgery.

 

INTRAOPERATIVE DECISION

A 60-year-old man with a history of hypertension is having a knee arthroscopy surgery under general anesthesia. In the middle of the anesthetic, his heart rate drops to 20 beats per minute, his blood pressure drops to unmeasurable, and he no longer has peripheral pulses. What do you think is going wrong, and what should be done do to save this man?

CHATGPT: I’m not a doctor, but the symptoms you described during the anesthetic suggest a severe and potentially life-threatening condition. This could indicate a cardiac event or a complication related to the anesthesia. One possible explanation for the sudden drop in heart rate, blood pressure, and loss of peripheral pulses is a condition called “bradycardia with hypotension” or “bradycardia-induced hypotension.”

In this situation, it’s crucial for the medical professionals involved to take immediate action. Here are some general steps that might be considered:

  1. Alert the medical team: The anesthesiologist or healthcare providers in the operating room need to be notified immediately about the patient’s deteriorating condition. The surgeon and additional medical personnel may also be called upon for assistance.
  2. Assess the airway, breathing, and circulation (ABCs): Ensure that the patient’s airway is clear and breathing is supported. Provide supplemental oxygen if necessary. Assess circulation and check for the presence of a pulse. If the patient is unresponsive or there is no pulse, initiate cardiopulmonary resuscitation (CPR) immediately.
  3. Notify the code team: If the patient remains unresponsive and pulseless, it may be necessary to activate a “code blue” or similar emergency response to involve a specialized team experienced in resuscitation procedures.
  4. Perform advanced cardiac life support (ACLS): Healthcare providers trained in ACLS protocols will initiate resuscitation measures, including chest compressions, defibrillation (if indicated for certain types of cardiac rhythms), and administration of medications such as epinephrine to help restore circulation.
  5. Identify and address potential causes: Once the patient’s vital signs have stabilized or as the resuscitation efforts continue, the medical team will work to identify the underlying cause of the cardiac event. This may involve evaluating the patient’s medical history, reviewing medications, and conducting further diagnostic tests such as an electrocardiogram (ECG) or blood tests.

It’s important to note that the above steps are general guidelines and the specific actions taken may vary depending on the patient’s condition, the resources available, and the expertise of the medical team on-site. In such a critical situation, the immediate focus will be on stabilizing the patient and providing appropriate resuscitation efforts to restore circulation and address any life-threatening issues.

 

POST ANESTHESIA EMERGENCY

In the recovery room after a tonsillectomy, a 5-year-old child coughs up blood, becomes short of breath, and becomes unconscious. What is probably going on, and what should be done to save this child?

CHATGPT: I’m not a doctor, but the symptoms you described following a tonsillectomy can be indicative of a serious complication known as postoperative hemorrhage. In this situation, it’s crucial to seek immediate medical attention. Here are some general steps that might be considered:

  1. Activate the emergency response: Alert the medical staff immediately about the child’s deteriorating condition. Nurses and physicians in the recovery room should be notified, and additional assistance may be needed, such as calling a code or emergency response team.
  2. Ensure a patent airway and support breathing: Assess the child’s airway and breathing. If the child is experiencing difficulty breathing or is unresponsive, the healthcare providers should take steps to establish and maintain a clear airway. They may administer oxygen and provide respiratory support if necessary.
  3. Control bleeding: Postoperative hemorrhage can cause significant blood loss, leading to the symptoms you described. The doctors should perform a thorough examination to identify the source of bleeding and take appropriate measures to control it. This may involve suctioning the blood from the child’s mouth, using medications to constrict blood vessels (such as topical epinephrine), or applying direct pressure to the bleeding site.
  4. Administer fluids and blood products: If the child is experiencing significant blood loss, intravenous fluids and blood products may be necessary to stabilize their condition and restore blood volume.
  5. Provide immediate resuscitation measures: If the child becomes unconscious or experiences cardiac arrest, cardiopulmonary resuscitation (CPR) should be initiated immediately. Healthcare providers trained in pediatric resuscitation will perform chest compressions, provide assisted ventilation, and administer medications as required.
  6. Prepare for surgical intervention: Depending on the severity of the bleeding and the child’s condition, emergency surgical intervention may be necessary to control the bleeding. The surgical team will be assembled, and the child will be transferred to the operating room for further assessment and management.

It’s important to note that the above steps are general guidelines, and the specific actions taken may vary depending on the child’s condition, the resources available, and the expertise of the medical team on-site. In such a critical situation, the immediate focus will be on stabilizing the child, controlling the bleeding, and providing any necessary resuscitation efforts.

 

ANALYSIS: 

Note that CHATGPT preceded two of its three answers with the words, “I’m not a doctor, but,” which likely removes the possibility that CHATGPT creator OpenAI will be sued for medical malpractice. From the answers above, I’ll attest that if you’re an inexperienced anesthesiologist or certified registered nurse anesthetist (CRNA) working alone, there is value having a resource like CHATGPT immediately available. Are there any notable errors in the CHATGPT answers? No, not really. As a written reply to the questions posed, the artificial intelligence of CHATGPT gives a reasonable outline regarding how to proceed.

Anesthesia is an acute care specialty, and often there will be no time to consult CHATGPT regarding what to do next because the patient is trying to die right in front of you, for example in the second and third scenarios above. Expect artificial intelligence in medicine to be most applicable in specialties like radiology, pathology, and dermatology, where digital images are analyzed. In radiology, this would be the evaluation of digital X-rays, MRIs, or CT scans. In pathology, this would be the evaluations of digital images of microscopic biopsies, and in dermatology, this would be the evaluation of digital images of skin lesion photographs. The model for the machine learning of digital images will be similar to the process in which a human child learns. When a child sees an animal, 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.

CHATGPT relays information developed by algorithms. Is the practice of medicine destined to be directed by computer algorithms? Yes. We’re already guided by algorithms/cognitive aides such as the decision trees of Advanced Cardiac Life Support (ACLS) or the Stanford Emergency Manual. These flow charts are useful to direct acute care, and to assure no aspect of emergency treatment is overlooked. Expanded use of algorithms is inevitable as more data is accumulated on the management of large populations of medical patients. Current electronic medical records (EMR) systems exist in every hospital, and the EMRs are generating the sort of Big Data that algorithms will be built on.

I’ve had an interest in AI and robots in medicine for years. All Things That Matter Press published my novel Doctor Vita in 2019, several years before CHAPGPT became reality. Doctor Vita described the introduction of artificial intelligence in medicine machines in a Silicon Valley university hospital. A significant and anticipated advance in Doctor Vita is the ability to interact with patients and doctors by voice input and auditory output. In short, the artificial intelligence in medicine of the future will converse with us, just as Alexa and Siri already do.

The World Health Organization projects there will be a shortage of ten million healthcare workers worldwide by the year 2030. Contemplate the following:

  1. All medical knowledge is available on the Internet. Doctors don’t know everything or remember everything, so we routinely look up facts, evidence, and data on the Internet. A computer can recall all of these facts.
  2. Most every medical diagnosis and treatment can eventually be written as a decision tree algorithm;
  3. Voice interaction software is excellent and improving every year;
  4. The physical exam is of less diagnostic importance than scans and lab tests which can be digitalized; and
  5. A computer is far cheaper than the seven-year post-college education required to train a physician.

Will artificial intelligence assist MDs or replace MDs?Replacement of medical personnel with computers will not be welcomed by patients, doctors, or nurses, but there’s a need for cheaper healthcare, and the concept of automating physician tasks is no longer the domain of science fiction. It’s inevitable that AI will change current medical practice. A bold prediction: AI will change medicine more than any development since the invention of anesthesia in 1849.

 

Will the evolution of artificial intelligence in medicine lead to improved healthcare outcomes? In 2018 and 2019 autopilots drove two Boeing 737 Max airplanes to crashes despite the best efforts of human pilots to correct their course. Eleven people were killed in crashes involving vehicles using automated driving systems in the United States during a four-month period in 2022. Will we see improved outcomes or worsening outcomes when AI intersects with medicine, and machines are directing medical care? We don’t know yet. 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, will be the coming of artificial intelligence in medicine.

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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 = 170/99? Advice For Passing the Anesthesia Oral Board Exams What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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INCREASED DOLLAR COSTS ASSOCIATED WITH DIFFICULT INTUBATION

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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.
emailrjnov@yahoo.com
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The safe management of a difficult airway is the most important single skill for an anesthesiologist. Every critically ill patient is managed by the priority of A – B – C, or Airway – Breathing – Circulation. Just as the initial most important factors in real estate are location, location, location, the three initial important factors in a critically ill patient are airway, airway, airway. I’ve written previously on the American Society of Anesthesiologists 2022 modifications to their Difficult Airway Algorithm, on the importance of expert airway management, and on advice for avoiding lost airway lawsuits, but I haven’t discussed the economic consequences of each difficult airway patient.

A 2021 publication, “Factors and Economic Outcomes Associated with Documented Difficult Intubation in the United States,”  by Moucharite et al, studied the economic cost of a difficult intubation in hospitalized patients. Using data from the Premier Healthcare Database, the study looked at adult patients with inpatient surgical admissions during 2016, 2017, and 2018. Patients in the difficult intubation group had average inpatient costs $14,468 higher than patients without difficult intubations. Patients in the difficult intubation group had average ICU (intensive care unit) costs $4,029 higher than patients without difficult intubations. For difficult intubation patients the mean hospital length of stay was 3.8 days longer and ICU length of stay was 2.0 days longer. All data were significant to a p value of < 0.0001.

In California where I practice, these numbers would be significantly higher. The mean cost of a single hospital day in California is $4181, and the mean cost of an ICU day is significantly higher.

The Moucharite study was a large retrospective review of 2,233,751 cases from hospitals in all parts of the United States. With 609 cases in the difficult intubation group and 2,233,142 cases in the non-difficult intubation group, the incidence of difficult intubation was only 0.027%. Difficult intubation patients were more likely be male, black, less than 65 years old, and have urgent or emergent admissions, obesity, cancer, congestive heart failure, COPD, renal disease, and had been treated in a teaching hospital or a hospital of 500 beds or more.

Moucharite wrote, “Difficult intubation has been associated with a variety of complications including oxygen desaturation, hypertension, dental damage, admission to the intensive care unit, and complications at extubation, as well as arrhythmias, bronchospasm, airway trauma, CICV (can’t intubate, can’t ventilate), and sequela of hypoxia (cardiac arrest, brain damage, and death). This was consistent with a 2011 study of difficult airways from the British Journal of Anesthesia which stated, “Obesity markedly increases risk of airway complications. Pulmonary aspiration remains the leading cause of airway-related anesthetic deaths. . . . Unrecognized esophageal intubation is not of only historical interest and is entirely avoidable. . . . prediction scores are rather poor, so many failures are unanticipated . . . the first-pass success rate of intubation in the operating room ranges from only 63% to 85% . . . and up to 93% of difficult intubations are unanticipated.”

The Moucharite study has limitations. It’s a retrospective study of economic Big Data, and there is no direct evidence for a cause-and-effect relationship between a difficult intubation and a more costly hospitalization. The study does not include data from electronic medical records, so we have no knowledge on all the comorbidities and complications of the difficult intubation patients. The study included only hospitalized patients, even though seventy percent of surgical procedures in the United States take place in ambulatory surgery centers and offices outside of hospitals. The reported incidence of difficult intubation  is estimated to be 1.5–8.5% of the general population, but in  the Moucharite study only 0.027% of patients were found to have difficult intubation. This discrepancy implies some patients in the Moucharite study were difficult intubations but may have been assigned to the non-difficult intubation cohort.

Note that all three authors of the Moucharite study are employees of Medtronic, a medical device company which manufactures the McGrath videolaryngoscope.

McGRATH VIDEOLARYNGOSCOPE

I expect Medtronic could cite the Moucharite study as evidence that a videolaryngoscope (such as a McGrath) is a crucial piece of equipment for avoiding expensive difficult intubation outcomes. Moucharite wrote that there is, “a need for clinicians who perform tracheal intubations to carefully consider options . . . several studies demonstrated the benefits of videolaryngoscopy [emphasis added] including a shorter time required for tracheal intubation, a higher rate of successful intubations.”

For the first look when intubating a patient, most anesthesia providers still use a traditional direct laryngoscope:

MAC 3 DIRECT LARYNGOSCOPE

 

If the direct laryngoscope does not enable a successful intubation, a reasonable second step is to switch to a videolaryngoscope such as the GlideScope, manufactured by Verathon:

GLIDESCOPE

or the C-MAC, manufactured by Karl Storz:

C-MAC

 

or the McGrath, manufactured by Medtronic:

McGRATH VIDEOLARYNGOSCOPE

 

In my experience the larger 6.4-inch screen on a GlideScope or the 5.9-inch screen on a C-MAC makes them superior videolaryngoscopes to the McGrath with its diminutive 2.5-inch screen.

Why use a direct laryngoscope in the initial intubation attempt rather than use a videolaryngoscope? A direct laryngoscope costs less than a videolaryngoscope. Most direct laryngoscopes blades are washed and reused. Videolaryngoscopes require a new disposable sleeve or blade for every case. In facilities with budget concerns, replacing all traditional laryngoscopes with videolaryngoscopes would be expensive. A McGrath costs about $2500 on eBay, and each new nonreusable blade cover costs about $10. A new GlideScope was $12,745 in 2017. A reconditioned GlideScope costs between $1000 and $10,000 on eBay, and each new nonreusable blade costs $38.

A 2022 study comparing direct laryngoscopy to videolaryngoscopy concluded that “videolaryngoscopy likely provides a safer risk profile compared to direct laryngoscopy for all adults undergoing tracheal intubation.” A recent review  stated that, “Though videolaryngoscopes have been recommended for use at first attempt of intubation by most international airway guidelines, the universal use of videolaryngoscopes is still facing hurdles because of limited training opportunities, availability and high cost.”

Should a videolaryngoscope replace a direct laryngoscope for all initial intubation attempts? I don’t think so. The majority of intubations are straightforward and are successful with a Miller 2 or a Mac 3 direct laryngoscope. Should a videolaryngoscope be available as a back-up piece of equipment for every intubation? Absolutely. The ASA Difficult Airway Algorithm includes the possible use of a videoscope, and states,
“Consider the relative merits and feasibility of basic management choices:  (consider) video-assisted laryngoscopy as an initial approach to intubation.” An anesthesia provider who initiates general anesthesia and intubation without an immediately available videolaryngoscope is in danger of not being able to follow the algorithm. The hospital I work in is stocked with either the GlideScope and the C-MAC both readily available for difficult intubations. The availability of a videolaryngoscope for either a first attempt or for backup attempts to intubate a difficult airway patient is vital.

Difficult airway cases can lead to malpractice claims. A 2009 study published in Anesthesiology showed that 2.3% of 2,211 anesthesia-related deaths in the United States from 1999-2005 were attributable to difficult intubation and failed intubation.  A 2019 study from the Anesthesia Closed Claims Project database showed that the 102 difficult intubation closed malpractice claims from 2000 to 2012 included sicker patients (n = 78 of 102), emergency procedures (n = 37 of 102), and non-perioperative locations (n = 23 of 102).  Preoperative predictors of difficult tracheal intubation were present in only 76% of the patients. Inappropriate airway management occurred in 71 patients. A “can’t intubate, can’t oxygenate” emergency occurred in 80 of the 102 claims, with a delayed surgical airway occurring in 39% of those cases. The authors wrote, “outcomes remained poor in recent malpractice claims related to difficult tracheal intubation. Inadequate airway planning and judgment errors were contributors to patient harm.”

In conclusion: Difficult intubations are a major anesthesia problem, because of: 1) the difficulty in identifying difficult intubation patients prospectively, 2) the medical comorbidities that occur with difficult airway patients, 3) the medical complications that can occur if difficult airways are mismanaged, 4) the dollar cost of increased healthcare utilization as reported in the Moucharite study, and 5) the potential medical-legal liability risk with each difficult intubation.

SuperMorbidly Obese Patient with a Difficult Airway

 

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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 = 170/99? Advice For Passing the Anesthesia Oral Board Exams What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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THE ANESTHESIA CONTROL TOWER: BIG BROTHER OR FRIEND?

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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.
emailrjnov@yahoo.com
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The Barnes Jewish Hospital, Washington University, St. Louis

Imagine this: You’re an anesthesiologist in the operating room at a busy hospital. Your patient is in mid-surgery, and you receive a call from the Anesthesia Control Tower that the patient’s blood pressure is too low, your blood transfusion replacement is inadequate, and that the patient is in danger. What do you do? How do you feel about all this?

Anesthesiologists at Barnes Jewish Hospital at Washington University in St. Louis, Missouri are studying a novel system they call the Anesthesia Control Tower (ACT). The ACT is a telemedicine-based intraoperative clinical support system.  A team led by an attending anesthesiologist uses remote monitoring to provide evidence-based support to anesthesia colleagues in all the operating rooms. The ACT is similar in concept to an air traffic control tower. The clinicians in the Anesthesiology Control Tower, called ACTors, monitor operating rooms (ORs) in real time by following the electronic health records. Just as an air traffic control tower monitors aircraft and delivers information and alerts to the pilots, the ACT communicates with anesthesia providers to assist them in providing safe care.

A press article describing the ACT states: “Surgery is a big insult to the human body. A lot can go wrong. In fact, it does. An estimated 10 to 20 percent of patients who undergo major inpatient surgery experience major complications such as heart attacks, unremitting pain, infections, and blood clots in the weeks to months following their procedures; about two percent are dead within 30 days of surgery. Some of this morbidity and mortality may be preventable through early identification of risk factors and better communication to mitigate risks during the surgery. . . . Air traffic control concepts can predict high risks for healthcare complications and improve decision making.”

The Washington University ACT provides a watchful eye over 60 operating rooms at Barnes-Jewish Hospital, watching over nearly 1,000 patients per week.  

A software program used in the ACT is called AlertWatch®. The ACT anesthesiologist (ACTor) watches a monitor displaying the Tower Mode census view (Figure 1 below), which shows an overview of all the patients in the ORs. Alerts or abnormal vital signs and laboratory results are represented by squares and triangles, respectively. Checkmarks indicate alerts that must be addressed by the ACT. The Tower Mode view looks like this (Figure 1):

 

Figure 1   Census View, Anesthesia Tower

 

The Tower Mode includes a display for each individual patient (Figure 2 below). The organ systems are labeled with relevant physiologic variables and values. Colors outline each organ, and include normal (green), marginal (yellow), or abnormal function (red). The left side of the display shows patient case information. Information regarding the patient’s medical problems can be accessed by selecting the organ system or laboratory study of interest. The black checkmark at the bottom of the left panel indicates that there is an active alert for the ACT clinicians to address (Figure 2 below):

Figure 2 Individual Patient Display, Anesthesia Tower 

 

Clicking on the checkmark opens the case review dialogue, which looks like this (Figure 3):

Figure 3, Case Review Dialogue, Anesthesia Tower

The Anesthesia Control Tower is physically located within the hospital complex, but is remote from the operating rooms. Washington University has expanded the ACT to include the Recovery Control Tower, which provides similar surveillance over patients in the Post Anesthesia Care Unit (PACU).

This photograph below depicts the Anesthesia Control Tower manpower at work at Barnes Jewish Hospital at Washington University in St. Louis:

Monitoring surgeries from the Anesthesiology Control Tower (left to right): Omokhaye M. Higo, MD, vice chair for innovation, Thaddeus Budelier, MD, program manager for the Perioperative Innovation Center, and Bradley A. Fritz, MD, assistant professor of anesthesiology, Washington University Medical School.

 

Some anesthesiologists were initially skeptical about the ACT idea. But Washington University Anesthesia Chairman Dr. Michael Avidan stated, “Most of the skepticism has evaporated over time as clinicians have perceived that innovation and technology are not threats, but rather enhancements. The conceptualization of our Perioperative Innovation Center is more akin to ‘phone a friend’ than it is to a sinister ‘big brother.’”

Current staffing levels of anesthesia professionals in the United States are inadequate. The shortage of anesthesia professionals, particularly in rural areas, may someday be remedied by a telemedicine system which resembles the ACT.  We may someday see anesthesia managed by less highly trained persons in the OR, with an ACTor backing them up by watching from on high.

Anesthesiologists who supervise Certified Registered Nurse Anesthetists (CRNAs) or Anesthesia Assistants (AAs) in an anesthesia care team model often have to provide care for multiple patients simultaneously. These attending anesthesiologists cannot physically be present in multiple operating rooms at all times. These anesthesiologists may be aided by Anesthesia Control Tower technology, which continually assesses patients for signs of deterioration and alerts the attending anesthesiologist when an adverse event is brewing.

If the Anesthesia Control Tower is to become a standard in hospital care, we need to know if the ACT changes medical outcomes. Washington University is conducting a study randomizing thousands of adult surgical patients in their operating rooms to an intervention group (ACT) or to a control group without ACT. An estimated 10,000 patients will be enrolled per year, and over four years  approximately 40,000 total patients will be enrolled. Data from this study are as yet unavailable.

The goals of this clinical trial are 1) to develop machine-learning algorithms for forecasting perioperative adverse events; 2) to develop a clinical decision support system that suggests interventions based on the algorithms, and 3) to change the paradigm of perioperative care.

Will physicians and patients see the ACT model in the near future? Significant issues regarding the adoption of Anesthesia Control Tower technology include:

  1. Documenting that ACT provides an improvement. A critical barrier for anesthesiologists, hospitals, and policy makers nationwide will be documenting that the ACT demonstrates an improvement in costs, patient outcomes, or patient experience. None of these things are apparent at this time.
  2. Paying for the ACT equipment and the ACTor on duty will be an issue. Additional hardware and software would be required at each hospital. An in-person anesthesiologist is already being paid to do each case, and the ACTor is another level of anesthesia staffing someone is going to have to pay for.
  3. Anesthesiologist opposition. A challenging barriers will be how anesthesiologists perceive systems like the ACT. Anesthesiologists are trained to be vigilant and manage their patients themselves. Having the ACT peering into the operating room, perhaps with a video camera watching the operating room, will likely be unpopular with the anesthesiologists being observed. There may also be concern that data from the ACT could be used against physicians in the event of a malpractice lawsuit. When the topic of the Anesthesia Control Tower was breached, one of my physician anesthesiologist colleagues remarked, “If that system becomes standard, I’m quitting.”
  4. Lack of need for an ACT in ambulatory settings. According to a 2017 study by the Centers for Medicare and Medicaid Services, the majority of surgical procedures in the United States, fully 70 percent, occur in ambulatory surgery centers or offices outside of hospitals. These outpatient procedures are predominantly smaller surgeries conducted on healthier patients. These smaller ambulatory facilities would have no use for the ACT, both because patients are healthier and because the surgical procedures incur less risk and fewer complications. The costs of an ACT in these smaller settings would be unlikely bring any benefit.
  5. Flawed analogy. Air traffic controllers exist to coordinate takeoffs and landings, so planes do not collide with each other in the air or on the runways. In anesthesiology, operating room patients will not collide with each other and do not have traffic issues with each other. Instead, the Anesthesia Control Tower will scrutinize each patient’s data for abnormalities that will predict a pending complication.
  6. The ACT and the algorithms developed through the ACT will likely be a transitional technology. Having one anesthesiologist (the ACTor) overseeing multiple operating rooms will likely be a steppingstone to Artificial Intelligence technology in which a computer oversees the data from each operating room, with the aim to detect and prevent adverse outcomes from developing. The arrival of ChatGPT foreshadows the AI technology about to bloom in healthcare. In the future the anesthesia provider in each operating room will likely be backed up by AI technology enforcing algorithms, rather than being backed up by a human in a control tower. I described this healthcare evolution in my 2019 book Doctor Vita, in which Artificial Intelligence in the form of inexpensive, internet-connected computers took over a California medical center and changed the face of medicine forever.

Improving vigilance and improving outcomes is the ultimate goal of ACT technology. Further data on the Anesthesia Control Tower will be forthcoming. We’ll await the prospective controlled studies, and then we’ll all learn whether or not this technology is an advance to help patients and physicians.

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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 = 170/99? Advice For Passing the Anesthesia Oral Board Exams What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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ANESTHESIA IN OUTER SPACE 

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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.
emailrjnov@yahoo.com
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An astronaut en route to Mars develops severe abdominal pain, nausea, and vomiting. A fellow crew member examines him and finds significant tenderness and guarding in the right lower quadrant of his abdomen. The crew members teleconference with physicians on Earth, with a 20-minute communication delay because of the 140-million mile distance between them. The physicians confirm a probable diagnosis of appendicitis. Because the spaceship is more than 200 days away from Earth, the physicians instruct the crew to proceed with surgery and anesthesia in outer space.

Outer space medical care will certainly not resemble Dr. Leonard “Bones” McCoy on the original Star Trek, who waved his fictional handheld “tricorder” tool over a patient to diagnose and treat the patient’s illness.

How will astronauts conduct general anesthesia and surgery in outer space? Is an anesthesiologist required on board? Is a surgeon required on board? If the flight crew doesn’t include any physicians, how will the crew proceed to save the astronaut’s life?

Full disclosure: I’ve never given an anesthetic in outer space. But to date, no one else has given an anesthetic to a human in outer space either. Protocols regarding how to accomplish anesthesia in outer space exist in the medical literature.

For comprehensive reading I’d refer you to three papers by expert Matthieu Komorowski MD, an anesthesiologist, intensive care physician, and biomedical engineer at Imperial College London, and a former Research Fellow at the European Space Agency. Three of Komorowski’s key articles are: “Anaesthesia in outer space, the ultimate ambulatory setting?” in Current Opinion in Anaesthesiology; “Fundamentals of Anesthesiology for Spaceflight,” Journal of Cardiothoracic Vascular Anesthesia, and “Potential Anesthesia Protocols for Space Exploration Missions” in Aviation Space Environmental Medicine.

Distant space missions, known as exploration class missions (e.g. missions to the Moon and Mars) are planned in the coming decades. Staffing an astronaut/physician as one of the crew members on a mission to Mars is possible, but I have no information that the National Aeronautics and Space Administration (NASA) is grooming a combination astronaut/anesthesiologist at this time.  In 2017, NASA created an Integrated Medical Model (IMM) as an evidence-based decision support tool to assess risks and design medical systems for extended space travel. The IMM includes 100 medical conditions that might commonly occur during space flight. Twenty-seven of these 100 conditions would require surgical treatment.

The most significant medical risks for space exploration missions are trauma, hemorrhagic shock, and infections. The risk of a medical emergency in space travel is estimated at one event per 68 person months. For a crew of six on a 900-day mission to Mars and back, at least one medical emergency would be expected. On a mission to Mars, the option of a stat return to Earth is impossible. Telemedicine can provide remote communication for medical consultation. While telecommunication between the Moon and Earth would have delays of only 2 seconds in each direction, for a Mars mission the delay in communications could reach up to 20 minutes in each direction, making real-time telemedicine impractical. The communications delay on a Mars mission would also mean that a surgical robot on board could not be controlled by a surgeon on Earth. The crew must be self-reliant.

Only physically and mentally fit candidates who are able to withstand the stresses of space travel are selected as astronauts. Physically and mentally fit candidates are at low risk for medical or surgical emergencies. But with the recent trend of privately funded space programs (e.g. SpaceX), some members of the general public may be offered the opportunity to experience space travel. Privately funded programs may push boundaries regarding the undesirable health status of candidates traveling into space.

PHYSIOLOGIC CHANGES IN SPACE

To devise safe anesthetic care for outer space, one must first understand the changes in an astronaut’s body during microgravity. The void of outer space provides a lack of barometric pressure, a lack of oxygen, severe extremes of temperature, and dangerous levels of radiation. Spacecraft are equipped with Environmental Control and Life Support Systems (ECLSS) to ensure livable conditions within the space capsule.  Weightlessness and microgravity cause marked changes in human physiology, described by systems as follows:

Cardiovascular system 

Microgravity causes fluid to redistribute toward the upper half of the body, resulting in facial and airway edema (swelling), and diuresis (increased urination) which leads to an intravascular volume decrease of 10-15%. The systemic vascular resistance in the arterial system decreases about 14% because of dilatation of the blood vessels, but the left ventricular systolic function of the heart is maintained near normal.

Physiology changes in outer space https://www.dailymail.co.uk/news/article-2385501/Mark-Kelly-astronaut-twin-brother-Scott-guinea-pigs-NASA-experiment-space-travel-affects-genetics.html

 

Gastrointestinal system

Weightlessness causes a combination of decreased gastric motility and increased gastric acidity. If an astronaut requires general anesthesia, one must assume the patient has a full stomach and is at risk for aspiration.

Respiratory system

Microgravity leads to an increase in respiratory rate and a decrease in tidal volume, resulting in near normal ventilation.

Neurologic system

Microgravity interferes with inner ear function, and causes disturbances in balance and vestibular function. Constant exposure to artificial lighting alters sleep rhythms, and predisposes the crew to impaired mental acuity and depression.

Musculoskeletal system

Weightlessness and inactivity cause an increase in bone resorption. Bone density decreases by about 1% per month, which predisposes astronauts to long bone fractures and kidney stones secondary to increased calcium excretion. Prolonged microgravity leads to deconditioning of the muscular system with skeletal muscle atrophy. This is most marked in the lower body, as the legs become “effectively redundant.” 

 

 

REGIONAL ANESTHESIA VERSUS GENERAL ANESTHESIA

IV fluids

Every anesthetic, regional or general, will require the patient to have an intravenous line, usually in their arm. Astronauts will be trained in the insertion of IV cannulae, and the sampling of blood for diagnostic tests. Storage of prepackaged intravenous fluids can occupy a large volume of precious cargo space. An exploration class mission may require up to 100 liters of IV fluids in case of severe burn injuries. Scientists have developed a system named IVGEN (Intravenous Fluid Generation) to prepare sterile IV normal saline from space station drinking water.

Bubbles in the IV fluids are dangerous, and are filtered out by the system, because bubbles could form air emboli and cause a stroke or a heart attack if they entered the body. Transfusable blood products have a limited shelf life, which makes an onboard blood bank impractical for prolonged space travel. Medical checklists will aim to ensure patient safety and help the astronauts gain familiarity with medical equipment and drugs. Medical kits on board will include a basic vital signs monitor, a mechanical ventilator, an ultrasound machine, suction, airway equipment, and a limited range of drugs with protocols regarding how to use them.

Monitors

Standard patient monitoring would include ECG, non-invasive blood pressure cuff, oxygen saturation, end-tidal CO2, and temperature. Preoperative ultrasound examination can be applied for diagnostic use, the assessment of cardiac function and fluid status, and assistance in visualizing blood vessels for peripheral or central line placement.

REGIONAL ANESTHESIA

A regional technique offers simplicity over general anesthesia, but a successful regional anesthetic requires skill, experience, training, and regular use of such skills. Studies on Earth show that an average of 20 procedures are required to reach a learning curve plateau. A practitioner must be schooled in regional anesthesia techniques on Earth prior to the space flight. The three suggested regional blocks to treat the majority of conditions expected to be encountered in space include femoral, sciatic, and brachial plexus nerve blocks. The blocks would be ultrasound-guided, and there is hope that AI-imbedded ultrasound technology will be available in the future to localize relevant structures such as nerves and blood vessels. The injection of a local anesthetic such as ropivacaine for a regional techniques carries the inherent risk of local anesthetic toxicity. The antidote for local anesthetic toxicity is lipid emulsion, which could occupy valuable space on board, and has a shelf life of only 24 months. Spinal blocks are impractical, as the use of typical hyperbaric local anesthesia such as 0.75% bupivicaine has not been investigated in microgravity to date.

GENERAL ANESTHESIA

General anesthesia has the advantages of a quick and reliable onset. The physiologic changes during microgravity predispose a general anesthesia patient to both aspiration of stomach contents and hypotension due to low intravascular volume. Each general anesthetic would require a preinduction loading with intravenous fluid replacement, followed by a rapid sequence induction and endotracheal intubation. In the absence of gravity, restraints will be required to keep the patient immobile for intubation.

Ketamine

Potent anesthetic gases such as sevoflurane cannot be used in outer space, as vaporizers will not function properly in microgravity. General anesthesia will include intravenous medications only. Ketamine will be the preferred drug of choice for induction of general anesthesia, as spontaneous respiration and cardiovascular stability are maintained. Ketamine induces both a dissociative state and analgesia, and has an extended shelf life of around 20 years in powder form. It’s currently used in remote locations on Earth where there is limited equipment and monitoring (e.g. combat anesthesia in low-income countries). The unpleasant psychomimetic side effects of ketamine are negated by the co-administration of an IV benzodiazepine such as midazolam or Valium. Intravenous atropine will also be administered to minimize the increased oral secretions produced by ketamine.

A muscle relaxant/paralytic drug is recommended to facilitate endotracheal intubation. Succinylcholine will not be used because of its ability to cause hyperkalemia. Rocuronium at a modified rapid sequence dose of 1mg/kg is recommended. A checklist and a PowerPoint presentation on the sequence of drugs and procedures needed to initiate general anesthesia will be available for the astronauts to read prior to and during the administration of general anesthesia. A video laryngoscope will be available, as it is recognized as an easier technique for inexperienced practitioners to complete successful endotracheal intubation. A publication by Komorowski and Fleming, “Intubation after rapid sequence induction performed by non-medical personnel during space exploration missions: a simulation pilot study in a Mars analogue environment,” demonstrated that intubation can be done by non-medical staff with little or no training via instructions from PowerPoint slides.

An intravenous infusion of ketamine is recommended for the maintenance of general anesthesia. Opioids are unlikely to be carried on a spacecraft. It’s likely the analgesic effects of ketamine will be used for acute pain relief. Sugammadex will be available to reverse the neuromuscular blockade from rocuronium, and neuromuscular monitoring will be utilized prior to extubation.

SURGERY IN SPACE

Restraining the surgeon, the patient, and the surgical tools against floating around the room in zero gravity are challenges to overcome in outer space. Magnetizing the surgical tools so they stick to the operating room table, and restraining the astronaut/surgeon and the patient are important adjustments. Surgery involving anesthesia was successfully performed on rodents for the first time in 1990 on the STS-90 Neurolab Space Shuttle. Astronauts repaired rat tails and performed laparoscopy on rodents in microgravity. It’s possible that insufflation of the human abdomen with carbon dioxide gas during laparoscopy in microgravity may cause changes in cardiac or respiratory function. During open abdominal surgery in microgravity, a patient’s intestines would float around and could obscure the view of the surgical field. Because of the large array of surgical equipment necessary for any specific surgery, a 3D printer on the spacecraft may be the solution to create tools as needed.

Bleeding in microgravity causes domes to form around the bleeding site. The domes are held in that shape because of surface tension. Enclosed surgical chambers have been developed to protect the sterile surgical field and the cabin environment during open surgeries in zero gravity. A hermetically sealed expandable surgical chamber for microgravity is called a “surgical overhead canopy” (SOC). The surgical repair can be performed within the canopy, and the canopy prevents organs or blood from floating about the cabin.

Surgical Overhead Canopy (SOC) SpringerLink Image

 

 

Anesthesia in Outer Space – Conclusion

For the appendicitis case introduced in paragraph one, the anesthetic would include the IV loading of 500 ml of normal saline; a rapid sequence intravenous induction of general anesthesia using ketamine, midazolam, atropine, and rocuronium; placement of an endotracheal tube into the patient; and an IV ketamine infusion for the maintenance of anesthesia. Once the patient is anesthetized, the surgery could either proceed as an open abdomen under a sterile surgical canopy, or a laparoscopy with the abdomen remaining closed, depending on the skillset and the surgical equipment available to the surgeon/astronaut on board.

One day an astronaut will perform the first anesthetic on a human in outer space. The astronaut will most likely not be a board-certified anesthesiologist, and he or she will likely follow a PowerPoint slide show demonstrating the sequence of procedures and pharmacology for successful anesthesia. Expect the first anesthetic in space to be a tense, exciting, and dramatic event in the history of medicine.

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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 = 170/99? Advice For Passing the Anesthesia Oral Board Exams What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM

 

 

 

 

 

ANESTHESIA PODCASTS

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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.
emailrjnov@yahoo.com
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Dr. Jed Wolpaw, the host of ACCRAC

 

An anesthesia education success story:

I was administering a mock oral board exam to a Stanford first-year anesthesia resident in November 2022, and the young man aced the test. He exceeded the knowledge base and judgement of his peers by a significant margin. After the exam, my co-examiner and I asked him how much medical training he’d had to date. He answered that he’d graduated from medical school, completed a one-year internship, and had been an anesthesia resident for (only) 4 months.

“How do you know so much about anesthesia already?” I asked.

“Almost everything you asked me I knew from keeping up with ACCRAC,” he said.

“What’s ACCRAC?” I asked.

He answered, “I was at Johns Hopkins for an anesthesia rotation, and I met Dr. Jed Wolpaw, one of the Critical Care faculty, who has a website called ACCRAC, which is a collection of anesthesia podcasts.”

ACCRAC stands for “Anesthesia and Critical Care Reviews And Commentary.” Our Stanford resident had listened to the podcasts on Dr. Wolpaw’s website for over one year, and as a result he was wise beyond his age concerning anesthesia information and decision making.

I accessed the ACCRAC website and found a wealth of information, with more than 240 podcasts pertaining to anesthesia. The majority of the podcasts were Dr. Wolpaw interviewing experts from different aspects of anesthesia or critical care. The podcasts varied from #1 (June 14, 2016)  “Properties and laws of volatile anesthetics”  . . .  to #247 (January 30, 2023) “Kali Dayton discussing her work helping ICUs around the country learn how to get their intubated patients awake, up and walking, by implementing the ABCDEF bundle.”  The podcasts are audio only. Continuing Medical Education (CME) credit is available from the website. I found ACCRAC to be the most extensive and comprehensive array of anesthesia podcasts on the internet.

I contacted Dr. Wolpaw and told him the Stanford resident’s success story. I queried him about his website and his podcasts. These were his answers to my questions:

  1. What was your impetus for initially starting ACCRAC? What void in anesthesia education did you identify?

“When I was an intern in Emergency Medicine, I listened to EMRAP (Emergency Medicine Reviews And Perspectives) as did every resident I knew, and many attendings as well.  It was a fabulous source of information and learning.  When I switched into Anesthesiology, I looked for the equivalent podcast but it didn’t exist.  I always had in the back of my mind that someday I might try to start one.  When I became an attending and heard our residents asking for audio resources, I knew it was time.”

  1. Why did you choose podcasts rather than a website of written words?

“I wanted something that people could listen to while commuting or working out, something that wouldn’t add a burden to their already busy day.  Audio only podcasts are really the only way to do that.” 

  1. How do you select your guests?

“I look for interesting articles, or approach people who give talks I find intriguing.  I also get lots of proposals from people who are doing interesting things and are interested in coming on the show.  And I get tons of emails from listeners requesting certain topics.  I can’t do them all, but I try to get to as many as possible.”

  1. What percentage of your guests are from Johns Hopkins? 

“I’m not sure of the exact number but certainly a fair amount, I’d guess maybe 70% or so.” 

  1. Is your target market residents and fellows? How about university professors, or community anesthesiologists?

“I certainly think we have a lot of content that is useful to trainees, but we also have a large number of practicing anesthesiologists, both academic and private practice, who listen (and some use it for CME) as well as nurses, CRNAs, AAs, medical students and others.”

  1. Is any aspect of ACCRAC directed toward laypeople?

“Not really, but I have done some episodes that are accessible to the lay public like a review of the book The Obesity Code, and an interview with Dr. Richard Harris who helped rescue the Thai Boys Soccer Team from a flooded cave in 2018.” 

  1. You trained at UCSF, arguably the nation’s finest anesthesia program. How does Hopkins compare to UCSF? Is there a West Coast-East Coast difference? 

“I think they are both fabulous programs.  I honestly find more similarities than differences and apart from the weather haven’t noticed much of a coastal difference.” 

  1. What are 5 or 6 of your favorite podcasts, to direct my readers to?

“I really enjoyed my conversation with Dr. Harris about the rescue of the soccer team.  The interview with Dr. Bobbie Sweitzer was also great because she pokes holes in so many assumptions we have.  I think the episode with Christian Meyhoff is also a great one since we talk about his surprising findings and why they might have come out that way.  And the same is true of my talk with Mark Neuman  about his New England Journal of Medicine (NEJM) paper.   And my conversation with Wes Ely about his book Every Deep Drawn Breath was really compelling.”

  1. How labor-intensive is it to maintain and add to ACCRAC? I notice six other individuals on your home page who assist you. 

“It’s a fair amount of work, but I really enjoy it.  I’m lucky to have volunteers who handle the social media accounts and help with the website.  For now the preparation, interviews, recording, and editing is all me but it’s manageable.” 

  1. I see that you published “Podcasting as a Learning Tool in Medical Education: Prior to and During the Pandemic Period,” a reference regarding podcasting. To what extent do you see podcasting growing in medical anesthesia?

“I think we’ll see significant growth.  Emergency Medicine is a great example where there are podcasts covering all sorts of sub-specialty topics and niche interests.  We’re already starting to see some growth in Anesthesiology with great podcasts like Depth of Anesthesia and I think we’ll continue to see more.”

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Googling the topic of “anesthesia podcasts” reveals Dr. Wolpaw’s website on the first page. Other leading sources of anesthesia podcasts include:

The American Society of Anesthesiology (ASA) presents four categories of podcasts, including (1) ASA’s Central Line, which “features leaders in our field discussing a wide variety of challenges and opportunities vital to our practice and our profession.” (2) Residents in a Room, “a podcast series for residents, by residents, featuring anesthesiologists-in-training from across the country, putting it all out there, discussing their hopes, fears and expectations for residency and beyond.” (3) ANESTHESIOLOGY featuring the “Editor-in-Chief of Anesthesiology and his monthly overview of new journal content (translated in multiple languages) and featured author podcasts that highlight research through author and editorialist interviews; (4) Summaries of Emerging Evidence (SEE), featuring “a sneak peek of the most interesting studies covered the latest edition of the popular continuing education program.”

The International Anesthesia Research Society/OpenAnesthesia presents a link to hundreds of podcasts, including interviews from anesthesia experts from 2009 – present.

Great Britain’s Association of Anesthetists, and their journal Anaesthesia, have a website which includes 38 podcasts to date.

Harvard’s Massachusetts General Hospital presents Depth of Anesthesia, a collection of 38 podcasts to date.

Feedspot ranks the top anesthesia podcasts at this link.

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Podcasts present a significant means of communication, information, and entertainment in the United States. Per The Infinite Dial report by Edison Research and Triton Digital, “As of 2021, 41% of Americans ages 12 or older have listened to a podcast in the past month, . . . up from 37% in 2020 and just 9% in 2008. Additionally, 28% of those 12 and older said they have listened to a podcast in the last week, up from 24% in 2020 and 7% when this was first measured in 2013.” Per Pew Research Center, “About a quarter of U.S. adults (23%) say they get news at least sometimes from podcasts.

Dr. Wolpaw’s 2022 publication, “Podcasting as a Learning Tool in Medical Education: Prior to and During the Pandemic Period,” makes the following important points about medical podcasts:

  1. “By entering a query for the term “podcast” in PubMed, a year-by-year breakdown of the number of publications with this term in the title shows an increasing trend from 2006 to 2022.”
  2. “For the creator, podcasting is a relatively low-cost endeavor, allowing for a low bar for entry into the podcasting space.A feasibility study conducted for the creation of an ophthalmology podcast revealed that start-up costs were just $212.18 with $29 monthly expenses.”
  3. “One review found that listeners find learning from podcasts to either be equivalent to, or better than, classroom learning.”
  4. “Multiple studies have found that listeners of medical education podcasts felt more motivated to learn.”
  5. “Rather than waiting on peer-reviewed literature, which could take several months to begin to show up, the rapidly evolving nature of the early pandemic required a faster means of propagating information to clinicians. Podcasts were a way by which-as early as February and March of 2020-anecdotal experiences from physicians across the world could be shared before peer-reviewed literature could be published.”

I find the primary advantage of podcasts is that one can listen to them while multitasking. I find a disadvantage in that, unlike a written article, one cannot skim over the content looking for the most pertinent sentences or paragraphs. If a podcast lasts 20 minutes, you’re committed to listening to every word, or to utilizing an available fast forward button for a 30 second leap to a later time. Another disadvantage is the inability to visually display internet links to references. With a written article, one can click on links to other published articles mentioned in the text. Dr. Wolpaw’s publication states that “many podcasts in medical education also utilize show notes-summary documents that accompany podcast episodes. These documents outline the episode’s main points and contain references to resources discussed in each episode.”

Podcasts are mainstays of 21st century media. The freedom to educate yourself while driving a car, doing chores, or exercising is a terrific opportunity for medical professionals. Until I discovered ACCRAC, I was not a podcast listener. Now I am, and I recommend the same to you. Podcasts won’t replace the written words of anesthesia textbooks or journals, but podcasts can be enjoyable and informative, and they have a definite role in supplementing medical education.

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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 = 170/99? Advice For Passing the Anesthesia Oral Board Exams What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM

THE NEW 2023 ASA GUIDELINES FOR QUANTITATIVE NEUROMUSCULAR MONITORING. NOW WHAT?

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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.
emailrjnov@yahoo.com
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The 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade were published last month.The paper is backed by strong science, and references an exhaustive list of no less than 277 previous publications on the topic, including this review. The paper concludes that quantitative neuromuscular (NM) monitoring is the most accurate and clinically useful technology for detecting residual neuromuscular block.

The problem? Very few anesthesia professionals have access to a quantitative NM monitoring device at present.

Currently a large number of anesthesia practitioners don’t monitor neuromuscular blockade level at all. A 2010 survey documented that 9.4% of American anesthesiologists didn’t use a peripheral nerve stimulator, and most survey respondents felt that neither conventional nerve stimulators nor quantitative neuromuscular monitors should be part of minimum monitoring standards. An editorial accompanying the 2023 ASA Guidelines states, “it is impossible to accurately predict the depth of neuromuscular block or the adequacy of reversal by using clinical tests such as tidal volume, negative inspiratory force, ability to sustain head lift, or grip strength. Similarly, qualitative assessment of responses to peripheral nerve stimulators cannot be relied upon in deciding the appropriate time for tracheal extubation.”

The most important recommendations from these ASA Practice Guidelines, each backed by Strong Strength of Recommendation (bold text by me) are:

  1. When neuromuscular blocking drugs are administered, we recommend against clinical assessment alone to avoid residual neuromuscular blockade, due to the insensitivity of the assessment.

  2. We recommend quantitative monitoring over qualitative assessment to avoid residual neuromuscular blockade. When using quantitative monitoring, we recommend confirming a train-of-four ratio greater than or equal to 0.9 before extubation.

  3. We recommend using the adductor pollicis muscle for neuromuscular monitoring.

  4. We recommend against using eye muscles for neuromuscular monitoring.

  5. We recommend sugammadex over neostigmine at deep, moderate, and shallow depths of neuromuscular blockade induced by rocuronium or vecuronium, to avoid residual neuro- muscular blockade.

Recommendation #2 will be the most challenging to follow, because, as an October 2021 study published in Anesthesiology states, “The paucity of easy-to-use, reliable objective neuromuscular monitors is an obstacle to universal adoption of routine neuromuscular monitoring.” In 2016 there were more than 224,000 operating rooms in the United States, so tens of thousands of devices could be needed.

What type of quantitative NM monitoring device should we aim to acquire? There are three types of quantitative monitors of neuromuscular blockade discussed in a 2021 Anesthesiology editorial. I quote from this reference:

1. Acceleromyography. Depolarization of the ulnar nerve results in contraction of the adductor pollicis, which flexes the thumb, producing an acceleration detected by the sensor. . . . the thumb must be entirely free to move, which precludes monitoring the hand that has been tucked at the patient’s side during surgery. The second problem is that the baseline, unparalyzed train-of-four ratio (the ratio of the fourth to the first twitch of a train-of-four), which should theoretically be equal to 1, is often greater than 1.

Acceleromyography monitoring

2. A mechanomyograph is an instrument that directly measures the isometric force of contraction of the thumb, using a force transducer. . . . A mechanomyograph is a somewhat cumbersome instrument that has been used primarily for research, and very seldom for routine clinical practice. Currently, mechanomyography is not commercially available.

3. Electromyography directly measures the compound action potential of the adductor pollicis muscle. . . No movement is required for this measurement to be made. The hand can be tucked at the patient’s side without any significant effect on the electromyogram. . . . A baseline, unparalyzed train-of-four ratio is not required. 

electromyography (EMG)

Electromyography (EMG) is the most promising of the three devices. The Nemes et al study, performed in Hungary, established that EMG compares favorably to acceleromyography, stating, “The EMG-based device is a better indicator of adequate recovery from neuromuscular block and readiness for safe tracheal extubation than the acceleromyography monitor.” The Nemes study utilized an EMG called a TetraGraph.

Where can you buy a TetraGraph? A Google search for this device leads us to a website for a company called Senzime.

TetraGraph and TetraSens EMG unit

The TetraGraph received FDA 510 clearance in 2019. Dr. Sorin J. Brull, the author of the Anesthesiology editorial on the 2023 NM Practice Guidelines, is a principal, shareholder, and the Chief Medical Officer in Senzime, as well as a Professor Emeritus of Anesthesiology and Perioperative Medicine at the Mayo Clinic.

I contacted a representative of Senzime, who demonstrated the device to me. I learned the following:

  • Senzime’s TetraGraph is manufactured in Sweden. The device has been improved and modified over the past 3 years.
  • The TetraGraph NM monitoring device clamps to an IV pole, and is slightly larger than an iPhone.  A disposable TetraSens sticker of sensing electrodes attaches to the patient’s wrist over the ulnar nerve, and extends distally to adhere to the skin over either the pinky or the thumb. The hand can be tucked out of sight and the EMG technology will still reveal accurate data.
  • The Tetragraph attaches to the TetraSens via a cable.
  • The Tetragraph screen displays a button labelled “AUTO,” which will activate serial trains-of-four at a preselected interval, for example, every 20 seconds.
  • The screen on the device is usually set to display four bars in a bar graph, representing  the measured EMG amplitude of the train of four. At control the quantitative NM score will be 100%, as all four twitches are equivalent. Once a muscle relaxant is administered to the patient, the bar graph will change, showing decreased heights of the bars dependent on the dose and time of the muscle relaxant.

TetraGraph bar graph screen depicting Train-of-Four

 

  • The anesthesiologist should wait until the quantitative NM score is 90% or greater, prior to extubation.
  • The hardware retails for $2000 – $2500 per unit. The disposable stickers that adhere to the patient’s hand are $20 each. The unit can be annexed to certain patient monitoring systems, and data can be input into an Electronic Medical Record system. Senzime’s website https://senzime.com/about-us/ceo-statement/  outlines the company’s intention to combine TetraGraph with Masimo’s patient monitoring system, stating “Our ambition is to submit the module developed to connect TetraGraph® with Masimo’s patient monitoring system Root® for approval at the end of 2023, and to launch at the beginning of 2024.”
  • To date Senzime has sold 300+ units in the United States. Several large hospital systems, including the University of Arizona, Duke, University of North Carolina, and the Medical College of Wisconsin have purchased the devices for their operating rooms. Multiple other large hospital systems are on the verge of completing purchases of 100-200 units as of January 2023. Senzime has an inventory to accommodate such purchases, and a clinical team positioned to help medical centers or surgery centers try out and/or adopt the technology.

 

Will Senzime have a monopoly or near-monopoly on this new technology? Time will tell. A Google search for “quantitative neuromuscular monitoring device” yields only a few companies competing with Senzime, including: TwitchView by Blink, Xavant, and GE Healthcare.

STANDARD OF CARE?

Are the 2023 ASA Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade now a standard of care for practicing anesthesiology?

No. Guidelines are not Standards.

In these 2023 Practice Guidelines, the ASA states, “Practice guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. . . . practice guidelines developed by the American Society of Anesthesiologists are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome.”

Expect quantitative NM monitors to become available where you work. Expect most hospitals to purchase these devices. What will you do until quantitative NM monitors become available where you work?

1. Since clinical assessment alone to avoid residual neuromuscular blockade is inaccurate, I believe a qualitative NM monitor is better than no NM monitor.

Qualitative Twitch Monitor

2. Monitoring twitch at the adductor pollicis at the wrist is more accurate than monitoring the periocular muscles, so apply your qualitative twitch monitor to the wrist.

3. Have sugammadex available when using non-depolarizing muscle relaxants such as rocuronium or vecuronium. If a patient shows signs of residual NM blockade at the end of an anesthetic, 2 mg/kg of IV sugammadex will usually resolve the NM blockade within a minute or two. Sugammadex, for the reversal of rocuronium-induced NM blockade, is one of the biggest advances in the field of anesthesiology in the past 10 years.

4. Following a general anesthetic, don’t leave your patient’s side in the PACU until you are certain that their airway is open and they are breathing adequately without any sign of residual respiratory difficulty.

Until your hospital and your surgery centers supply you with quantitative neuromuscular EMG monitors, be aware of the recommendations of the 2023 ASA Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade, and comply with them as best as you can. When quantitative NM units arrive, I encourage you to use them. The device I tested was quick to apply, easy to use, and provided valuable information to assure patient wellbeing.

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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 = 170/99? Advice For Passing the Anesthesia Oral Board Exams What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM

CIPROFOL VS  PROPOFOL

THE ANESTHESIA CONSULTANT Leave a comment
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.
emailrjnov@yahoo.com
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Ciprofol is a new intravenous (IV) anesthetic agent which is undergoing early clinical trials in China, and may become a significant tool in our anesthesia armamentarium if and when the drug is approved by the Food and Drug Administration (FDA) in the United States. Ciprofol has a chemical structure similar to propofol. Because of its rapid onset and rapid offset profile, propofol is currently the most used IV anesthetic drug in the world. Propofol is used for surgical anesthesia, procedural sedation, and intensive care unit (ICU) sedation. Propofol was FDA-approved in the United States in 1986 and is now off patent. Generic propofol is inexpensive, averaging about $2.27 for a 20 ml vial. Limitations of propofol include (a) respiratory depression, such that it can only be used by physicians who are expert in airway management (e.g. anesthesiologists, CRNAs, and emergency room doctors); (b) hemodynamic depression in some elderly or sick patients; (c) pain on injection; and (d) the propofol infusion syndrome (PIS) which can lead to hyperkalemia and cardiac arrest in ICU patients after prolonged exposure to propofol infusions.

The chemical formula of ciprofol is similar to propofol, but with single R-configured diastereoisomers.

Ciprofol is about 5 times more potent than propofol. Like propofol, ciprofol is formulated in a lipid emulsion with a drug concentration of 10 mg/mL. Let’s review the published literature on ciprofol to date. All of the following studies were done in China:

Phase 1 trials (small groups of subjects are given a single dose of the drug, and are observed and tested for a period of time to confirm safety):

Teng et al. (2021) conducted a phase I trial which demonstrated that a ciprofol dosing regimen of 0.4-0.9 mg/kg was well-tolerated and exhibited rapid onset and recovery properties. Peak plasma concentration occurred 2 minutes after injection, and all subjects recovered fully after ciprofol administration, with the shortest time being 9.2 minutes in the 0.4 mg/kg group.

Hu et al. (2021) also conducted a phase I trial in which subjects received continuous ciprofol or propofol infusions for up to 12 hours. The safety and tolerability of both drugs were comparable.

Phase II trials (performed on larger groups, e.g. 50–300 patients, to evaluate whether the drug has any biological activity or effect):

Teng et al. (2021) conducted a study on 1000 patients, which showed that ciprofol 0.4-0.5 mg/kg induced equivalent sedation/anesthesia to propofol 2.0 mg/kg during colonoscopy, and had a similar safety profile without producing serious adverse effects. No apnea was observed in any patients in the ciprofol group, but 5 patients in the propofol 2.0 mg/kg group experienced apnea. The incidence of injection pain was higher in the propofol group than in the ciprofol group (55% vs 6.8%). There were no significant dose-dependent changes in blood pressure in either the ciprofol or propofol groups.

Liu et al. (2021) conducted a phase II trial which involved 36 ICU patients who were on mechanical ventilation.  A remifentanil infusion of 0.02–0.15 μg·kg−1·min−1  plus either ciprofol or propofol were used for analgesia and sedation. The ciprofol loading dose was 0.1–0.2 mg/kg with a maintenance infusion rate of 0.3 mg/kg/h. The propofol loading was at 0.5–1.0 mg/kg, with a maintenance infusion rate of 1.5 mg/kg/h. The tolerability, sedation characteristics, and adverse events such as hypotension were comparable between both groups. The authors concluded that “ciprofol is comparable to propofol with good tolerance and efficacy for sedation of Chinese intensive care unit patients undergoing mechanical ventilation in the present study setting.”

The propofol infusion syndrome (PIS) is a potentially lethal syndrome that occurs due to prolonged infusion described in adults and pediatric ICU patients who are on mechanical ventilation. To date, published studies have not administered multi-day infusions of ciprofol to mechanically ventilated ICU patients to determine whether there is anything similar to PIS with ciprofol.

Wu et al. (2022) published a single-center trial on 92 patients titled “Efficacy and safety of ciprofol-remifentanil versus propofol-remifentanil during fiberoptic bronchoscopy.” Fentanyl (50 μg) was given to all patient 2 minutes before the intravenous administration of either 0.3 mg/kg of ciprofol or 1.2 mg/kg of propofol, followed by a remifentanil infusion in both groups. Top-up doses of one-third to one-fourth of the initial dose of ciprofol or propofol were repeated at 2-minute intervals as needed. The two drugs were comparable. The authors concluded that “ciprofol-remifentanil was non-inferior to propofol-remifentanil with regard to successful sedation for flexible bronchoscopy.” Systolic, diastolic, and mean blood pressures declined significantly less in the ciprofol-remifentanil group (p < 0.05). There was no difference in respiratory depression between the two groups, and the only statistical difference in adverse effects was a decrease in pain on injection for ciprofol over propofol (p=.001).

Chen et al. (2022) compared ciprofol and propofol in 120 women for the induction of anesthesia in gynecologic surgery. Intravenous midazolam (0.03 mg/kg) and sufentanil (0.3 μg/kg) were administered initially, followed by ciprofol (0.4 mg/kg) or propofol (2 mg/kg). After the loss of consciousness, rocuronium (0.6 mg/kg) was administered and endotracheal intubation was performed. Within the initial 10 minutes following study drug administration, blood pressure declined significantly less in the ciprofol group than in the propofol group. The authors concluded that “ciprofol was associated with slightly less pronounced effects on the cardiovascular system.” The incidence of injection pain was higher in the propofol group than in the ciprofol group (58% vs 16%, p < 0.001).

Chen et al. (2022) studied adverse reactions of ciprofol and propofol in 96 patients for gastroenteroscopy. Neither ciprofol nor propofol caused statistically significant differences in vital signs. The authors concluded that “in painless gastroenteroscopy, compared with propofol, ciprofol is equally safe and effective for patients.”

Lan et al. (2022) randomized 150 patients to ciprofol or propofol for hysteroscopy. All patients received intravenous sufentanil 0.1 μg/kg IV initially. Ciprofol patients then received an induction dose of 0.4 mg/kg and a maintenance dosage of 1.0 mg/kg/h. Propofol patients received an induction dose of  2.0 mg/kg and a maintenance dosage of 5.0 mg/kg/h. After the sedative administration, the systolic, diastolic, and mean pressures all  dropped significantly lower in the propofol group than in the ciprofol group. During the procedure, 2/75 ciprofol patients vs 17/75 propofol patients required an airway intervention such as a chin-lift or jaw-thrust maneuver (p< 0.05). The authors concluded that “the lower level of respiratory depression seen with ciprofol makes this drug more suitable and safer than propofol for hysteroscopic procedures.”

Phase III trials (randomized controlled multicenter trials on larger patient groups, aimed at determining how effective the drug is in comparison with the current “gold standard” treatment, i.e. propofol):

Li et al. (2022) conducted a phase III study at ten teaching hospitals, comparing ciprofol and propofol for deep sedation for colonoscopy or gastroscopy. A total of 289 patients were studied. Each patient received 50 μg fentanyl 1 minute before the intravenous infusion of either ciprofol (0.4 mg/kg) or propofol (1.5 mg/kg). Up to five top-up doses of 1/2 the initial dose were given upon signs of inadequate sedation, and repeated at 2-minute intervals as required. The mean time for a patient to become fully alert after the procedure was 3.3 minutes in the ciprofol group vs. 2.0 minutes for the propofol group (P < 0.001). The time to discharge was 7.4 minutes for the ciprofol group vs. 6.0 minutes for the propofol group (P < 0.001). Nine patients (6.3%) in the ciprofol group and 15 patients (10.3%) in the propofol group had respiratory events (respiratory depression, apnea, or hypoxemia), all of which were mild or moderate in severity. The authors concluded that “at a dose of 0.4 mg/kg for deep sedation, ciprofol was non-inferior to 1.5 mg/kg propofol in the success rate of gastroscopy and colonoscopy and exhibited a good safety profile.”

Wang et al. (2022) published a multi-center, double-blind phase III trial in which 186 surgery patients were randomly assigned to either ciprofol 0.4 mg/kg or propofol 2.0 mg/kg for the induction of general anesthesia. Ciprofol was “non-inferior” to propofol. Once again, the incidence of injection pain was significantly lower in the ciprofol patients compared to the propofol patients (6.8% vs. 20.5%, p < 0.05).

MY TAKE: WILL CIPROFOL BE A SUCCESSFUL ADDITION TO OUR IV ANESTHESIA DRUG ARSENAL?

It depends.

  • If ciprofol and propofol were cost-equivalent, ciprofol would gain some market share, and might prove to be a superior drug to propofol. However, when and if it is FDA-approved in the United States, ciprofol will cost significantly more than propofol because ciprofol will be on patent. Hospitals and surgery centers will be reluctant to pay more for the drug unless there are proven advantages. Ciprofol appears to have significantly less pain on injection when compared to propofol, but pain on injection with propofol is not a major issue. Pain on injection does not lead to any long term adverse outcomes, and the pain can be blocked by injecting IV lidocaine immediately prior the initial dose of IV propofol. 
  • The data that ciprofol leads to less blood pressure decreases than propofol shows only a mild difference—too small an advantage to mandate replacing propofol with ciprofol for that reason alone.
  • So far there are no data to confirm or deny that there is any equivalent to propofol infusion syndrome with ciprofol. If there is no prolonged infusion syndrome, then ciprofol may find a market for ICU sedation of mechanically ventilated patients.
  • Overall, I believe ciprofol must promise a lack of respiratory depression if the new drug is to capture any of propofol’s market share for procedural sedation/surgical anesthesia. The most bothersome issue with propofol is the risk of respiratory depression, which requires an anesthesia professional or airway expert administer the drug. If a patient is oversedated with propofol, that patient may stop breathing or have upper airway obstructed breathing, which can lead to hypoxia, cardiac arrest, and anoxic brain damage. The FDA warnings for propofol include:

For general anesthesia or monitored anesthesia care (MAC) sedation, DIPRIVAN Injectable Emulsion should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure. Sedated patients should be continuously monitored, and facilities for maintenance of a patent airway, providing artificial ventilation, administering supplemental oxygen, and instituting cardiovascular resuscitation must be immediately available. Patients should be continuously monitored for early signs of hypotension, apnea, airway obstruction, and/or oxygen desaturation. These cardiorespiratory effects are more likely to occur following rapid bolus administration, especially in the elderly, debilitated, or ASA-PS III or IV patients.

In the Li study above, 6.3% of the ciprofol patients had mild to moderate respiratory adverse events when sedated for GI endoscopy. While the 6.3% rate is lower than the 10.3% rate for the propofol patients, the non-zero incidence of respiratory events with ciprofol in this one study points to an anesthesia professional still needing to be present if ciprofol is administered for endoscopy.

In the Lan study above, during IV sedation only 2/75 ciprofol patients, compared with 17/75 propofol patients, required airway intervention such as with a chin-lift or a jaw-thrust maneuver during hysteroscopy (p< 0.05). This lower incidence of required airway intervention is encouraging, but the incidence is still not zero, and we’ll need more data to document the respiratory risks of ciprofol.

If ciprofol sedation is found to NOT produce any significant respiratory depression, apnea, or upper airway obstruction (therefore less risk of hypoxia and anoxic brain damage), this would be a profound advance over propofol. Then ciprofol could be administered for procedural sedation, e.g. for gastroenteroscopy, without an anesthesia airway expert attending to the patient. There is insufficient studies to date to know whether this will be true or not.

My guess? After all the data is in, ciprofol will cause a non-zero incidence of respiratory depression, and therefore a non-zero risk of hypoxia and anoxic brain damage, so an anesthesia airway expert will be necessary to administer the drug. The advantage of ciprofol’s lower but non-zero incidence of required airway intervention will not be a major advance in the hands of anesthesia professionals. The higher cost of ciprofol will preclude the decision of hospitals and surgery centers to switch to ciprofol until the new drug is off patent.

We’ll have to wait for more data on ciprofol, but don’t be surprised if propofol remains on top of the intravenous sedative/hypnotic anesthesia drug pedestal after the studies are concluded.

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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 = 170/99? Advice For Passing the Anesthesia Oral Board Exams What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM  

 

 

MOCK ORAL BOARD EXAMS

THE ANESTHESIA CONSULTANT Leave a comment
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.
emailrjnov@yahoo.com
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The Department of Anesthesiology, Perioperative and Pain Medicine at Stanford has administered Mock Oral Board Exams to its residents twice yearly since the 1980s. The Mock Oral is designed to mimic the conditions of the American Board of Anesthesiology (ABA) Standardized Oral Exam (SOE), which candidates must pass to become board-certified. The reference article The American Board of Anesthesiology’s Standardized Oral Examination for Initial Board Certification provides an extensive summary of the oral board examination process. 

In a previous column I advised examinees how to best prepare for the Standardized Oral Exam, and how to best perform on the exam. In this column I’ll outline how to set up a Mock Oral Exam program.

The pass rate for the Standardized Oral Exam is approximately 88%.  By subtraction, about 12% of candidates fail the SOE. 

SOE (Standardized Oral Exam) pass rates for the American Board of Anesthesiology 2017 – 2021

I believe all candidates can benefit from taking Mock Oral Exams before they take the ABA test. I took my initial Mock Oral as a first-year resident in 1984 and I failed, botching the management of a difficult airway by performing a tracheostomy too soon. I took two Mock Orals each year after that and passed the ABA Oral Exam on my first attempt. I can attest that Mock Orals are an effective simulation to prepare for the ABA exam. One can search online and find books and prep classes to prepare for the Standardized Oral Board Exam, but the only way to rehearse verbal skills for an oral exam is take practice oral exams. It’s within the resources of every anesthesia residency program to provide Mock Oral Exams for their trainees. As an examiner I’ve administered Mock Oral Exams to over 100 residents since 1989. The recipe on how to set up such a program follows below:

SCHEDULING MOCK ORAL EXAMS

Assume a residency program has 10 residents in each year, for a total number of 30 residents. On three separate evenings in November, set up Mock Oral Exams for the first year, second year, and third year residents. Provide an equal number of examiners as you have examinees. Group the examiners in pairs and send each pair to a separate office room in your hospital headquarters. For example:

November 28th. First year resident exams from 1700 hours – 1735 hours, and from 1745 hours – 1820 hours. At 1700 hours the team of Faculty Member A and Faculty Member B will examine Resident Alpha. At the same time, in four adjoining rooms four other pairs of faculty members will examine four additional residents. At 1745 hours Faculty Member A and Faculty Member B will examine Resident Beta with the same exam question. The same format is followed in the four adjoining rooms, testing a total of ten first year residents. 

November 29th. Second Year Resident exams from 1700 hours – 1735 hours, and from 1745 hours – 1820 hours. The same staffing as November 28th is repeated. The examiners may be different. The exam questions are more difficult, given that the residents are one year further in their training.

November 30th. Third Year Resident exams from 1700 hours – 1735 hours, and from 1745 hours – 1820 hours. The same staffing as November 28th is repeated. The examiners may be different. The exam questions are more difficult than on November 28th or 29th, given that the residents are in the last year of their residency training.

In May of the same academic year the exam sequence as above is repeated, giving each resident their second Mock Oral in the same training year. Each Mock Oral Exam lasts 35 minutes. The first 25 minutes will be questions about a hypothetical patient. The first examiner (e.g. Faculty Member A) begins by asking 10 minutes of questions dealing with preoperative anesthesia issues, followed by 15 minutes of questions about intraoperative issues by the second examiner (e.g. Faculty Member B), and in the final 10 minutes Faculty Member A asks questions about three completely different patients with assorted anesthesia dilemmas. 

SAMPLE MOCK ORAL TEST STEM:

An example of a Second Year Resident Mock Oral Board stem follows:

A 50-year-old man with hypertension, diabetes, obesity, and obstructive sleep apnea presents for an emergency surgery for a small bowel obstruction. He has been vomiting and unable to eat or pass gas for 12 hours. He has 8/10 pain in the abdomen. His medications are hydrochlorothiazide for hypertension, last taken 24 hours prior to admission, and a continuous insulin pump which he stopped 10 hours ago. He is 5 feet 6 inches tall and weighs 100 kg for a BMI=35. His pulse=120 beats per minute, blood pressure=170/105, oxygen saturation on room air=96%, respiratory rate=24 breaths per minute, and temperature=98.6. 

Physical exam: He is doubled over in abdominal pain and looks exhausted. His airway shows a thick neck circumference of 18 inches and a full beard. Except for tachycardia he has normal cardiac and lung exams. His abdomen is distended, and he has rebound abdominal tenderness and hyperactive bowel sounds. His labs are normal except for a glucose = 455 mg/dL and a potassium = 3.0 mEq/L. His ECG shows normal sinus rhythm. His chest X-ray is normal.

The script given to Faculty Member A reads as follows:

10 MINUTES – INTRAOPERATIVE MANAGEMENT 

  1. Blood glucose. How would you manage his blood glucose level? What would be your target glucose concentration? How would you administer insulin? How do you administer U-100 insulin? How would hypoglycemia present during general anesthesia? 
  2. Monitoring. Does this patient require invasive monitoring? Would you place an arterial line prior to induction? Why?  Is a CVP necessary? Why or why not? Would you use a pulmonary artery catheter? What about TE echo?
  3. Airway management. How would you manage the airway? Would you do an awake intubation? How would you do this? Would you do a rapid sequence induction? Which muscle relaxant would you use? Why? Assume you do a rapid sequence induction and you cannot see the vocal cords. What do you do? What if  you cannot intubate the patient and you cannot ventilate the patient with a mask?
  4. Potassium management. Will you administer potassium? Why? How fast would you give potassium? What are the risks of a low potassium during anesthesia? What are the risks of a high potassium concentration during replacement?
  5. Choice of anesthetic. What will be your plan for anesthetic maintenance? What are the advantages of inhaled anesthesia? Of total intravenous anesthesia? Which would you choose and why? Is there a role for regional anesthesia for this case? Why or why not?

The script given to Faculty Member B reads as follows:

15 MINUTES – POSTOPERATIVE MANAGEMENT 

  1. Extubation. Would you extubate the patient following the surgery? What would be your criteria for extubation? You decide to extubate the patient in the operating room. Immediately following extubation, his oxygen saturation falls to 80%. What is your differential diagnosis? How would you manage the situation?
  2. Arrythmia. On arrival to the ICU the patient’s heart rate increases to 150. How would you evaluate? Assume the blood pressure is 110/70. What therapeutic measures would you take? Assume blood pressure is 70/40. What therapeutic measures would you take?
  3. Oliguria. Assume the cardiac status is stabilized. The patient makes 80 ml of urine over the first two hours postoperatively. What is your differential diagnosis? What tests could you order? Why? Would you give a fluid bolus? Would you give a diuretic? Why? 
  4. Chest pain. Assume the patient is extubated on arrival to the ICU. He complains of upper abdominal/mid chest pain. How would you evaluate? What is your differential diagnosis? What tests would you order? How would you manage the situation?
  5. Postoperative pain. Assume no heart abnormalities are found. The patient is complaining of abdominal pain after surgery. How would you manage pain control? 

The final script for Faculty Member A reads as follows:

10 MINUTES – ADDITIONAL TOPICS 

  1. Pediatric open eye, full stomach. A 5-year-old child presents with an open eye injury due to a fall against a sharp table corner. She needs emergency surgery to save her eyesight. She ate a McDonalds Happy Meal two hours ago, but the ophthalmologist says the surgical repair cannot wait. The child will not let you start an IV while she is awake. How would you induce anesthesia? Would you consider a mask induction? Would you consider an intramuscular induction? How would you deal with the full stomach? How would you proceed? The child vomits during induction. How would you manage this?
  2. Morbidly obese patient for C-section. A 30-year-old woman presents in labor at 39 weeks. She is morbidly obese with a BMI=42. Her obstetrician decides the patient needs an urgent Cesarean section because of late decelerations on the fetal heart monitor. Would you choose regional anesthesia or general? Why? You attempt to place an epidural but get a wet tap. What would you do? If you had to administer a general anesthetic, how would you proceed?
  3. Family history of malignant hyperthermia. A 17-year-old boy with a tonsillar abscess presents for tonsillectomy. His uncle had a history of dying from malignant hyperthermia after tonsillectomy. Is this case appropriate for a freestanding outpatient surgery center? Would you delay the case? Would you order any preoperative tests? The surgeon says the case is urgent. What is your anesthetic plan?

At the conclusion of the 35-minute Mock Oral exam, the two examiners will stop. At this time the examiners discuss the performance with the resident examinee. This conversation includes:

  1. Asking the resident how they felt they did. 
  2. Discussing whether the resident made any anesthetic decisions that were unsafe, i.e. made the patient’s condition worse, or that led to a poor outcome.
  3. Discussing whether the resident answered the questions by describing what he or she would do. (This is the key to succeeding in oral examinations.)
  4. Discussing the resident’s communication and presentation skills, i.e. did they have effective eye contact, a confident speaking tone, and acceptable body language?
  5. Discussing whether the resident projected a fund of knowledge acceptable for their level of training.

Advice to Faculty Examiners on how to best perform a Mock Oral Exam:

  1. If you know the examinee personally, conduct the exam as if this was the first time you’d met them, i.e. they are “Dr. Examinee,” not “Justin,” or “Jennifer.”
  2. Read each question within the stem to the examinee, and listen to how they answer. Your job is to assess the examinee’s expertise in managing challenging anesthesia circumstances. If their answer is correct, quickly move on to the next question so you can test them on a new aspect of the patient care.
  3. Anytime an examinee introduces a new drug or a new test or a new fact into their answer, consider digging deeper by asking, “What is _____? What do you know about ____?”
  4. Don’t give immediate feedback after an answer by saying “OK.” Don’t reveal correct answers to the examinee during the exam.
  5. The examinee should not be asking you questions. If you are asked a question, deflect it by re-asking your previous question.
  6. Interject unexpected complications into each patient management, e.g. the blood pressure rises markedly or falls markedly, the pulse rate rises markedly or falls markedly, the oxygen saturation falls markedly. Find out what the examinee’s answer is in terms of differential diagnosis of the cause, and what their action(s) would be to correct the complication.
  7. Evaluate whether the examinee manages anesthesia and complications safely.
  8. Include a management of a difficult airway situation. The quickest way for an examinee to fail an oral exam is to lose an airway. 
  9. The purpose of the three extra cases in the last 10 minutes of the exam is to assess the examinee’s performance in areas that weren’t covered by the stem question, i.e. to round out the examination of pediatric, neuro, obstetric, cardiothoracic, pain, or regional anesthesia knowledge.
  10. Pay attention to the examinee’s body language, their eye contact, the confidence of their verbal answers, and their fund of medical knowledge. Does the candidate speak and answer like a consultant in anesthesiology would?

The University of North Carolina Department of Anesthesiology also administers twice yearly Mock Oral Board Exams. They videotape each exam so that each resident’s performance can be reviewed at a later date. 

Image from a videotape of Mock Oral Exams at the University of North Carolina Department of Anesthesiology

Writing Mock Oral Questions is not difficult. Performing the role of an examiner is not difficult. Prior to the exam, faculty examiners can look up the answers after reading through the questions, if they don’t know that specific area of anesthesia knowledge. 

Beyond the role of faculty members providing a Mock Oral Exam program, it’s also possible for examinees to prepare and give Mock Oral Exams to each other on their own time, as an opportunity for practicing and honing their verbal answering skills.

I recommend a Mock Oral Exam program as a key step toward passing the ABA Standardized Oral Exam, and toward becoming a board-certified consultant.

 in our field. As stated above, the only way to rehearse the verbal skills necessary for an oral exam is take practice oral exams. Good luck! 

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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 = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM

AUDIT TRAILS = THE BIG BROTHER OF MEDICAL CARE  

THE ANESTHESIA CONSULTANT Leave a comment
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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT
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The Audit Trail in the Electronic Medical Record

A spy lurks within every Electronic Medical Record (EMR), and most doctors have no idea that sentry exists. Every time a healthcare provider clicks his or her mouse on an EMR, that click is recorded by the Orwellian Big Brother of Medical Care, the audit trail. An audit trail can be defined as a “record that shows who has accessed a computer system, when it was accessed, and what operations were performed.” Virtually all EMRs in the United States now track at least four pieces of information about every instance a healthcare provider accesses a patient: 

  1. Who accessed, 
  2. Which patient record,
  3. At what time, and 
  4. The action they performed. 

The audit trail is NOT part of the EMR printout, and it’s not visible on the EMR patient care screen that we healthcare providers see. Lawyers can subpoena the audit trail in malpractice legislation, and the hospital must provide the audit trail if the court decides that the audit trail is relevant. An audit trail will look like an Excel document, with the provider’s name in one column and the information about each click listed in other columns:

In any malpractice legislation, an attorney will most likely have to hire an expert to interpret this audit trail for the judge and jury to understand what the document illustrates.

The audit trail was mandated by the 2005 Security Rule of the Health Insurance Portability and Accountability Act (HIPAA), which required all healthcare organizations to “implement hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use electronic protected health information.”  Any organization that works with electronic protected health information—which includes patient names, addresses, social security numbers, and other pieces of sensitive personal information—must use audit trails. The purpose of the audit trail was to detect inappropriate viewing of the EMR by someone who was not directly caring for the patient. For example, preventing a healthcare provider from clicking on the EMR of someone else’s patient who is a neighbor, a previous girlfriend, a celebrity athlete, politician, or entertainer. But an audit trail is a roadmap to a physician’s EMR use, and in the case of a malpractice lawsuit, the audit trail can be either redeeming or damning.

Back in the era of handwritten medical records, Samuel Shem described “buffing the chart” in his medical satire novel “The House of God.” 

“Buffing the chart” was a dishonest means of writing medical notes in a patient’s chart to make the patient look well-treated, without the doctor providing that treatment. Buffing the chart, or any other dishonesty, is impossible with EMRs. The audit trail will document whether you provided standard medical care in real time or not. If your patient has a significant complication or an adverse outcome, a lawyer can subpoena the audit trail and hire an expert to interpret it. 

Indeed, the most common use of audit trails is in medical malpractice actions. Let’s look at some hypothetical examples:

  • A 36-year-old woman is scheduled for emergency surgery at 3 a.m. for an ectopic pregnancy. The patient weighs 250 pounds and is 5 feet tall, for a Body Mass Index (BMI) = 48.8. On induction of general anesthesia, the anesthesiologist working alone is unable to successfully place an endotracheal breathing tube and is unable to ventilate oxygen into the patient. The patient develops anoxic brain damage. The family sues the anesthesiologist, and the plaintiff attorney orders an audit trail. The audit trail documents that the anesthesiologist never clicked on an available old anesthetic record which documented that this patient had a difficult airway, in which it took two anesthesiologists twenty minutes to successfully insert an endotracheal breathing tube using both a GlideScope and a fiberoptic laryngoscope. The audit trail also documents that one day after the surgery, the anesthesiologist added a paragraph to his preoperative note claiming that he was aware of the previous difficult airway diagnosis. Once the audit trail results were revealed, the anesthesiologist and his defense lawyer realize that they cannot win, and they pay a malpractice settlement out of court.  
  • A 55-year-old man is scheduled for a left hip replacement. His past medical history is significant only for hyperlipidemia. The EMR shows standard of care anesthetic management for the surgery, but in the Post Anesthesia Care Unit (PACU) the patient develops shortness of breath, chest pain, and needs to be reintubated and sent to the Intensive Care Unit. Cardiologists diagnose an acute myocardial infarction (MI) and congestive heart failure. The patient survives, but the MI leaves the patient with reduced cardiac output and chronic heart failure. The patient sues, and the plaintiff attorney orders an audit trail. The audit trail reveals that the anesthesiologist never looked at the preoperative ECG which showed ischemic changes. The standard of care following this abnormal ECG required a cardiology consult prior to the elective surgery. The plaintiff wins the case as the anesthesiologist and the primary care doctor failed to make the required referral to a cardiologist prior to the hip surgery.
  • A 55-year-old patient on chronic dialysis is scheduled for revision of a left forearm dialysis fistula. The patient receives general anesthesia for the case and has a cardiac arrest mid-surgery. The patient’s family sues, and the plaintiff attorney orders an audit trail. The audit trail shows that the patient’s potassium level prior to surgery was markedly elevated at 8.1, and this lab value was available on the chart 30 minutes prior to the induction of anesthesia, and the anesthesiologist never clicked on the laboratory value to check what the result was prior to the surgery. The plaintiff wins the malpractice lawsuit.

The following are quotations from a legal review article titled “A Pandora’s Box: The EMR’s Audit Trail.”

  1. A subpoena for audit trail information must be for legitimate reasons.  
  2. There is no clear precedent currently on the issue of whether a defendant health care provider must produce an audit trail as a matter of standard course as if it were the medical record itself. Courts surprisingly are deciding the issue primarily on relevance grounds.
  3. Once the audit trail is produced and counsel has had a chance to review it to the care rendered, plaintiff’s counsel may seek to make an issue regarding the truthfulness of the information contained in the EMR at trial including allegations of alteration or wrongdoing.
  4. Simple conjecture or inferences that an EMR record was altered based on a review of the audit trail is not enough, and expert testimony to support that position may be required. Absent expert testimony, a plaintiff patient was not permitted to present evidence to the jury.

The following are quotations from a legal publication “The Utility of Audit Trails Analysis in Medical Malpractice Actions” :

  1. Each time a patient’s EMR is opened, regardless of the reason, the audit trail documents this detail. The audit trail cannot be erased, and all events related to the access of a patient’s EHR are permanently documented in the audit trail. Providers cannot hide anything they do with the medical record. No one can escape the audit trail. It’s easy to see how and why an audit trail could serve as an important piece of evidence in a medical malpractice action. 
  2. In printed form, [audit trails] can look like gibberish to the untrained eye. Fortunately, there’s a simple solution to these problems: the use of an expert trained in understanding and navigating EMR systems and interpreting and explaining audit trails.

The take-home message: the era of “buffing the chart” is over. Whenever we healthcare providers click on any item on the EMR, or whenever we don’t click on an item on the EMR, a Big Brother Audit Trail is watching and permanently recording who accessed the EMR, which patient item was accessed, at what time, and what action was performed.

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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 = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM

THE RISK OF ANESTHESIA PATIENT TRANSPORT 

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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.
emailrjnov@yahoo.com
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Imagine this scenario: You’ve just finished anesthetizing a patient in a hospital setting, and the patient now requires transport from the operating room (OR) to the post-anesthesia care unit (PACU). During surgery your patient monitors included: a pulse oximeter, an ECG, a blood pressure cuff, a temperature monitor, and a monitor of the oxygen, carbon dioxide, and anesthetic concentration of every breath inhaled and exhaled. During the transport to the PACU, a trip which can be as short as 1 minute or as long as 5 minutes, there are no specific standards regarding monitoring. It’s common for zero monitoring equipment to be attached to the patient. It’s also not uncommon for the patient to be breathing room air during transport. When you arrive at the PACU, a nurse reattaches your patient to the vital sign monitors, and discovers that the patient’s oxygen saturation has dropped from 100% in the OR to a severely low value of 80% in the PACU. 

Patients can have inadequate breathing on arrival at the PACU for multiple reasons, including oversedation from narcotics, oversedation from propofol or general anesthetic gases, residual paralysis from muscle paralysis drugs, upper airway obstruction, laryngospasm, obesity, sleep apnea, or pulmonary disease. An anesthesiologist can easily make a diagnosis of inadequate breathing if a patient is connected to a pulse oximeter. Should we routinely monitor a patient’s oxygen saturation level during transport to the PACU?  Let’s examine current standards and policies regarding anesthesia patient transport and review the published incidence of inadequate oxygenation following OR to PACU transport.

The American Society of Anesthesiologists (ASA) Standards for Post-Anesthesia Care state: 

“A PATIENT TRANSPORTED TO THE PACU SHALL BE ACCOMPANIED BY A MEMBER OF THE ANESTHESIA CARE TEAM WHO IS KNOWLEDGEABLE ABOUT THE PATIENT’S CONDITION.  THE PATIENT SHALL BE CONTINUALLY EVALUATED AND TREATED DURING TRANSPORT WITH MONITORING AND SUPPORT APPROPRIATE TO THE PATIENT’S CONDITION.”

This sounds like a reasonable standard, but it’s non-specific and leaves the decision regarding oxygen therapy and monitoring up to the individual member of the anesthesia care team’s judgment.

One the Harvard hospitals, Beth Israel Deaconess Medical Center, published the following policy regarding anesthesia transport:

Post Anesthesia Transport Monitoring 

After an anesthetic, the patient is usually transferred to the PACU or an ICU. This guideline sets out to clarify the type of patients who will need monitoring during transportation, and the nature of monitoring required. 

Monitoring during transport is mandatory for the following patients 

·  Any patient designated as needing ICU care, irrespective of whether the patient actually goes to the PACU or an ICU. 

·  Patients who are receiving vasopressors, vasodilators, or inotropes. 

·  Any patient who has a pulmonary artery catheter in situ.

·  All intubated patients. 

·  Any patient who has had an unstable course during the anesthetic. 

·  Any patient who needs to be transported for longer than 5 minutes to the recovery area.

The above list is not exhaustive and monitoring for transportation may be instituted for any patient at the discretion of the anesthesiologist. 

This is a reasonable policy, but what if anesthesia patient transport to the PACU lasts 4 minutes and 59 seconds (i.e. a long transport, but less than 5 minutes to the recovery area)?

The most common complications for in-hospital transported patients are respiratory, meaning that a patient has inadequate breathing and/or inadequate oxygen therapy during transport. The following five studies document that unmonitored patients frequently have low oxygen levels following transport to the recovery room.

In the 2012 study Does the transportation of patients from the operating room to the post-anesthetic care unit require supplemental oxygen? the authors prospectively looked at 50 patients transported from the OR to the PACU. They measured the oxygen saturation when each patient left the OR and when the patient arrived in the PACU. Moderate hypoxemia (oxygen saturation 86% to 90%) and severe hypoxemia (oxygen saturation less than 85%) occurred in 8% and 4% of patients, respectively. Seventy-five percent of the patients with moderate or severe hypoxemia were obese, and 42% were smokers. 

In the 2012 prospective study Hypoxemia after general anesthesia, 

959 patients underwent elective surgery under general anesthesia in a university hospital. All were transported to the PACU on room air without oxygen supplementation. The oxygen saturation level was measured at the end of the transfer to the PACU. Seventeen percent of patients had a pulse oximetry reading < 90%, and 6.6% had a pulse oximetry reading < 85%. The authors concluded that “transportation of patients breathing room air from the OR to the PACU directly after GA without use of PO or supplemental oxygen seems to be questionable in terms of patient safety.”

In the 2015 study, Impact of medical training clinical experience on the assessment of oxygenation and hypoxemia after general anesthesia: an observational study, anesthetists, nurses, and medical students estimated the oxygen saturation level in their patients at the end of transfer to the PACU, after the patients had been breathing room air during the transfer following surgery under general anesthesia. The estimated oxygen saturation level was compared to the actual oxygen saturation level measured by pulse oximetry. Low oxygen saturation (oxygen saturation < 90 %) occurred in 154 out of 1,138 patients (13.5 %). Anesthetists, nurses, and medical students accurately identified only 25, 23, and 21 of the 154 patients as being hypoxemic, respectively. The authors concluded that “considering the uncertainty about deleterious effects of transient, short-lasting hypoxemia, routine use of pulse oximetry is advocated for patient transfer to the PACU.”

In the 2016 study Predictors of desaturation during patient transport to the postoperative anesthesia care unit: an observational study, 13% of 505 patients had hypoxemia during transfer to the PACU. The three risk factors for low oxygen saturation were a Richmond agitation-sedation (RASS) score lower than -2, an oxygen saturation <96% before exiting the operating room, and a body mass index >30. Seventy-two percent of the patients were transferred without oxygen, and most of the hypoxemia appeared in these patients. The authors concluded that the development of hypoxemia during transfer from the OR to the PACU was greater in patients who were more sedated, obese, or had lower oxygen saturations when they left the OR. The authors also concluded that “supplemental oxygen should be considered in higher risk patients.”

In the 2020 study Complications associated with the anesthesia transport of pediatric patients, the authors looked at a database of 2971 events pediatric adverse events, and 5% (148 events) were related to patient transport. The adverse events were primarily respiratory. Nearly 40% of the reported adverse events occurred in infants of an age less than or equal to 6 months. Seventy-five percent of the adverse respiratory events occurred postoperatively during transport from the OR to the PACU or the OR to the intensive care unit (ICU).

The distance from the OR to the PACU in the hospital I work at can be as much as 120 yards, and require anesthesia patient transport times of up to 5 minutes. The hospital supplies oxygen tanks on every gurney used to transport surgical patients from the OR to the PACU. The anesthesiologist administers nasal or mask oxygen to patients during transport.

Regarding respiratory monitoring during transport, a non-electronic monitor formerly utilized by anesthesiologists during patient transport was to pull a patient’s jaw toward the ceiling, with the palm of our hand of spanning across the patient’s mouth. In this manner we could feel each exhaled breath, documenting that the patient was breathing and ventilating themselves.

Since the arrival of COVID and the high risk of the spread of infection, anesthesiologists are wearing gloves whenever they are managing airways, and sensing a patient’s breathing through the thickness of the glove is ineffective. We need pulse oximetry monitoring.

to document adequate breathing and oxygenation. 

Every hospital owns portable vital sign monitors that look something like this:

portable vital sign monitor

These devices show real-time numeric values for the oxygen saturation, heart rate, ECG rhythm, and blood pressure, the same vital signs that are followed in the operating room. The acquisition cost for this monitor is currently $1300 per unit. If a hospital has 12 operating rooms, the total cost of 12 X $1300 = $15,600 is a reasonable investment to avoid patient complications of unstable vital signs during transport. 

What about a less expensive alternative? What about the inexpensive battery-powered pulse oximeters that clip over a fingertip are readily available at drug stores or on the internet. This product

$22.80 fingertip battery-powered pulse oximeter

is available on Amazon for $22.80, and has been reviewed by over 200,000 individuals to date. I bought one for my home and use it whenever a family member has respiratory viral symptoms. If a hospital stocked inexpensive oximeters like this one, doctors and nurses could diagnose low oxygen saturation in their patient(s) within seconds. Would these small portable devices begin to disappear or get lost? Perhaps. A possible solution would be to assign a fingertip pulse oximeter to each physician or nurse who has a need for one, and to expect them not to lose their own personal device. Could continuous fingertip pulse oximetry prevent hypoxic events during in-hospital transports? Yes. A prospective study testing this practice would be easy to do. The connection of fingertip monitors to a hospital’s electronic medical record (EMR) would not be practical, but the purpose of the monitor is to keep patients safe. Whether the monitor readings are recorded in a vital sign readout of the EMR is a less important factor. 

In conclusion, the post-surgical transport of a patient from the operating room to the PACU is a period of patient risk. The routine use of supplemental oxygen and the routine use of pulse oximetry can help anesthesiologists decrease this risk of inadequate breathing and low oxygen saturation during transport. 

CODA: The transport of post-operative patients from the OR to the ICU is a more complex undertaking than transport of patients from the OR to the PACU. The distances between the OR and the ICU are greater than the distance between the OR and the PACU. The ICU may be on a different floor and necessitate an elevator ride. A patient bound for the ICU may be asleep and intubated, which requires the anesthesiologist to ventilate the lungs with an Ambu bag attached to the endotracheal tube during the transfer. The patient may be requiring infusions of vasoactive drugs to maintain blood pressure within safe limits. The anesthesiologist may be supervising the transfusion of blood, platelets, or plasma. Managing all these factors while vigilantly watching the monitor screen while riding in an elevator with a sick patient is a challenging experience. Indeed, the post-surgical transport of a patient from the OR to the ICU requires an anesthesiologist to manage a rolling intensive care unit experience.

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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 = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM

ANESTHESIOLOGY VS. DERMATOLOGY

THE ANESTHESIA CONSULTANT 2 Comments
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.
emailrjnov@yahoo.com
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Dermatology and anesthesiology are two medical specialties which offer lifestyle balance. Dermatology is consistently one of the most competitive residencies for graduating medical students. In a ranking of the most competitive medical specialties, dermatology ranked second, trailing only plastic surgery.  Dermatology was also ranked as the number-one specialty in terms of work-lifestyle balance. Dermatology is a high-paying medical specialty with almost no emergencies, weekend duties, or night call. Dermatologists can take weeks off work without losing their entire practice. Dermatologists perform procedures with their hands, including biopsies or the resection of lesions. Dermatologists have important roles treating common problems such as chronic acne or diagnosing life-threatening melanomas. Dermatology clinic is known for short visits and long lists of patients. If a patient has multiple medical comorbidities such as hypertension, heart problems, obesity, or sleep apnea, these issues are usually unrelated to the dermatology consultation. Hypertension, heart problems, obesity, and sleep apnea are problems for the patient’s internal medicine doctor, not for the dermatologist. A career in anesthesiology seems markedly different than a career in dermatology, because anesthesiologists frequently deal with acutely ill patients, middle of the night emergency surgeries, and complex anesthetics for open heart, brain, or neonatal surgeries. But one large subset of anesthesia work closely mimics the lifestyle of dermatology practice. Before you sign up for a lifetime as a dermatologist, consider the subspecialty of ambulatory anesthesiology.

Ambulatory anesthesiology is defined as the administration of anesthetics for outpatient surgical procedures, which are minor procedures which don’t require hospitalization. Most anesthetics in the United States are for ambulatory surgeries. In 2014 there were 11 million outpatient surgeries, which was 52% of the total number of surgeries. Outpatient surgeries include tonsillectomy, knee arthroscopy, shoulder arthroscopy, breast biopsy, hernia repair, rhinoplasty, hand surgery, foot surgery, nasal septoplasty, colonoscopy, and upper gastrointestinal endoscopy. These procedures are low-risk surgeries which don’t disturb a patient’s physiology in any significant way. Ambulatory surgery patients are prescreened to eliminate those with medical problems such as morbid obesity, severe sleep apnea, or unstable cardiac, respiratory, or neurologic diagnoses. An anesthesiologist practicing 100% in an ambulatory surgery center should have zero emergency anesthetics, zero weekend duty, and zero night call. 

The duration of training for an anesthesiologist and a dermatologist is identical. Both specialties require four years of college, four years of medical school, a one-year medical internship, and three years of residency training. For either specialty, if you graduate high school at age 18, you’ll be at least 30 years old when you finish training and are ready to begin your career. A significant amount of deferred gratification is required for both specialties. Your friends who went to work straight out of college will be at least eight years ahead of you in the game of life, and may have already accumulated a mortgage and 1.93 children during the years you’ve been working as a resident physician and memorizing massive quantities of medical knowledge. Anesthesia will never be as safe or predictable as dermatology.  Anesthesia residents are required to manage all forms of cases, including open-heart surgeries, neurosurgeries, trauma surgeries, Cesarean sections, and emergent chest or abdominal surgeries. Major complications are rare in outpatient anesthesia, but if one is inducing general anesthesia, then unexpected complications of airway, breathing, or circulation (the ABCs) can occur.

Both dermatology and anesthesiology are high-paying specialties. See the list below. The average salary for a dermatologist is $438,000 (7thhighest of all specialties), and the average salary for an anesthesiologist is 405,000 (11th highest of all specialties). 

Samuel Shem’s classic medical satire “The House of God,” followed a cadre of burned-out internal medicine residents through their internship year. At the end of the book, the residents reached the conclusion that their best futures were in the NPC—Non-Patient Care—specialties, which numbered six and only six: Rays, Gas, Path, Derm, Eyes, and Psych, that is: radiology, anesthesiology, pathology, dermatology, ophthalmology, and psychiatry. The main character in “The House of God” switched his specialty from internal medicine to psychiatry. In my career I switched from internal medicine to anesthesiology. Anesthesiology is not truly a “Non-Patient Care” specialty. Anesthesiologists very much care for patients every day. A key difference is that anesthesiologists care for each patient for a short and finite time. We don’t have to deal with a patient’s chronic problems over many years, as their internal medicine doctor must do. 

An experienced anesthesiologist may eventually land a fulltime job at an ambulatory surgery center (ASC), and at that point he or she may confine his or her career to a stable weekday life of outpatient surgeries, but this ascension to ambulatory-only anesthesiologist is not common. Most career anesthesiologists who practice in ambulatory surgery centers also continue to practice at a hospital. Most general anesthesiologists need to master both inpatient and outpatient surgeries.

Is it possible to jump directly from the completion of an anesthesia residency to a solely ambulatory practice, thus mimicking the lifestyle of dermatology? In the past, I’d say the answer was no. In recent years the lack of an adequate number of anesthesiologists has created a supply-demand situation in which outpatient surgery centers have insufficient numbers of anesthesiology staff. In some geographic markets, outpatient surgery centers may choose to hire young residents right out of training. I direct you to the recent employment ad below, which promises a salary of $385,000 to $4000,000 per year for an ambulatory anesthesiology job with “No nights, weekends, holidays, trauma, hearts, neuro or OB.”

If you’re interested in a quality lifestyle medical career with regular hours, weekends off, and few emergencies, add the option of ambulatory anesthesiologist to your list of possible choices. But to gain entrance to the Emerald City of ambulatory anesthesiology, you’ll have to walk a Yellow Brick Road through a challenging anesthesia residency first. In all probability, you’ll spend your early career doing some inpatient emergency anesthesia as well. But an eventual career in ambulatory anesthesiology is an outstanding option in which you can anesthetize patients on a  weekday schedule, spend weekends and evenings with your family, and turn the ringer off on your cell phone when you go to sleep at night.

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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 = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM

THE TOP 11 ANESTHESIA BOOKS

THE ANESTHESIA CONSULTANT 1 Comment
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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT
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There are hundreds of anesthesia textbooks, but which current books are the gold standards for anesthesia knowledge? Should you buy these books, or should you advocate that your hospital purchase them for the medical library? When I was in residency training, I bought earlier editions of many of these textbooks so I could underline and highlight pertinent pages. If you purchased all 11 books in a print version today it would cost $1,643.49. The twenty-first century is a digital age, and if you purchased all 11 books in an ebook version today it would cost slightly less, at $1453.00. I currently have access to these ebooks through Stanford University’s Lane Medical Library, and I read them remotely through the Lane Library’s online website. I’ve come to prefer to read a digital copy over a hardcover book. A digital copy of a textbook is easy to access, easy to search keywords, and it’s convenient to print out excerpts or chapters. A digital textbook collection is portable, and can travel with you in your laptop, your phone, or your tablet. Digital access to all this written expertise can be at your fingertips anywhere, including in the operating room suite. 

The Anesthesia Consultant’s 2022 List of the Top Anesthesia Books includes:

Miller’s Anesthesia, 9th edition, 2019, Editor-in-Chief Michael Gropper. Miller’s has been the comprehensive textbook in our specialty since the first edition in 1981, and it touches on every facet of anesthesiology. All anesthesia providers should have access to the current two-volume 3112-page edition. (ebook $299.99, hardcover $327.16) 

Anesthesiologist’s Manual of Surgical Procedures, 6th edition, 2019, Editor-in-Chief Richard Jaffe. This textbook is organized by surgical subspecialties, and contains a catalog of almost every common surgical procedure in a fashion analogous to an academic “cookbook.” Both surgeons and anesthesiologists analyze each procedure, and include the pertinent details of might be described as an “anesthesia recipe” for each type of case. (ebook $165.29, hardcover $126.17)

The Stanford Emergency Manual. This is a free laminated guide with algorithms describing the diagnosis and treatment of the 26 most common ACLS and non-ACLS perioperative anesthesia emergencies. This is an essential cognitive aide for every operating room, code cart, and anesthetizing location in the world. (Free download) 

Kaplan’s Cardiac Anesthesia: In Cardiac and Noncardiac Surgery, 7th edition, 2016, Editor Joel Kaplan. For decades Dr. Joel Kaplan has been the go-to author regarding cardiac anesthesia as well as the management of cardiac disease in noncardiac surgery. This textbook combines both topics into a single volume. (ebook $201.99, hardcover $270.49)  

A Practical Approach to Regional Anesthesiology and Acute Pain Medicine, 5th edition, 2017, Editors Joseph Neal, De Tran, and Francis Salinas. From its beginning at Seattle’s Virginia Mason Clinic nearly 30 years ago, this textbook remains the top resource in the burgeoning fields of ultrasound-guided regional anesthesia and acute pain medicine. (ebook $106.99, paperback $78.07) 

Chestnut’s Obstetrics Anesthesia: Principles and Practice, 6th edition, 2014, Editor David Chestnut. First published in 1984, this is the leading textbook covering the field of obstetric anesthesiology. (ebook $152.49, hardcover $172.99) 

A Practice of Anesthesia for Infants and Children, 6th edition, 2018, Editors Charles Cote and Jerrold Lerman. Cote’s book has been the bible for pediatric anesthesiologists for nearly fifty years.  (ebook $146.49, hardcover $203.11)

Stoelting’s Anesthesia and Co-existing Disease, 8th edition, 2021, Editors Roberta Hines and Stephanie Jones. First published in 1983, Stoelting’s Anesthesia and Co-existing Disease is the leading textbook regarding co-existing and uncommon diseases, with a stated goal to “provide a concise description of the pathophysiology of disease states and their medical management that is relevant to the care of the patient in the perioperative period.” (ebook $110.49, hardcover $128.01) 

Complications in Anesthesia, 3rd edition, 2017, Editors Lee Fleisher and Stanley Rosenbaum. First published in 1999, this textbook lists 223 chapters, each detailing a specific problem/complication in perioperative medicine, and includes a step-by-step approach to understanding the pathophysiology and the treatment of each complication. (ebook $85.49, hardcover $114.65)

Miller’s Basics of Anesthesia, 8th edition, 2022, Editor Manual Pardo. (ebook $62.99, hardcover $99.99) First published in 1984, this is a condensed version of the two-volume 3112-page Miller’s Anesthesia tome listed as #1 above. In the 1990s my anesthesia chairman stated, “If a trainee knew everything written in this book, they’d be able to pass the American Board of Anesthesiology written and oral exams.” I would agree. The most important topics of anesthesia practice are well-presented in this 960-page book. 

Anesthesia Equipment: Principles and Applications, 3rd edition, 2020, Editor Jan Ehrenwerth. Every anesthesia professional should understand the machines they utilize. This textbook, was first published in 1993, answers the questions pertaining to anesthesia machines, airway equipment, monitors and other perioperative devices. (ebook $120.79, hardcover $122.85) 

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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 = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM

QUANTITATIVE NEUROMUSCULAR MONITORING –  NECESSITY OR TECHNOLOGY OVERDONE?

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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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT
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A QUANTITATIVE NEUROMUSCULAR MONITOR

How do anesthesiologists monitor the degree to which a patient’s muscles are pharmaceutically paralyzed during an anesthetic? A recent publication in our specialty’s most prestigious journal urges the use of a QUANTITATIVE neuromuscular monitoring machine to do this when general anesthetics include a paralytic drug. The article was not a prospective randomized study, but rather a retrospective (from 2016 to 2020) practice initiative from a solitary medical center. The goal of the authors (Weigel et al) was to measure the reversal of neuromuscular paralysis in all anesthetized patients at the end of their anesthetic, and to document that reversal in the patient’s chart.

Their measured goal was to document a train-of-four ratio of greater than or equal to 0.9 prior to extubation in each anesthetized patient. What is a train-of-four? A locomotive with four cars? Alas no. A train-of-four ratio is a monitor of the level of neuromuscular blockade. Four consecutive electronic stimuli are delivered along the path of a patient’s nerve. The twitch response of the muscle is measured in order to evaluate stimuli that are blocked, versus those that are delivered. Four consecutive muscle contractions of equal strength (a score = 1.0) occur if there is no neuromuscular blockade. If neuromuscular blockade is present, there will be a loss of twitch height of the final twitch compared to the first twitch, and the resulting ratio of the final twitch height/first twitch height (e.g. 4/5 = 0.8) will indicate the degree of blockade. The clinical concern is that a ratio of lower than 0.9 correlates with a weak patient who may not safely ventilate himself/herself.

The conclusion of the Weigel study boldly states, “Anesthesia providers are solely responsible for properly rescuing patients from the states of paralyses they initiate. This should occur for ALL PATIENTS as verified by QUANTITATIVE measurement and documentation of train-of-four ratios greater than or equal to 0.9.” (Capital letters added by me.) 

Should the American Society of Anesthesiologists (ASA) add QUANTITATIVE neuromuscular monitoring as a standard of care? 

Hmm. This would be a marked change because, to my observation, almost no anesthesia providers routinely use QUANTITATIVE neuromuscular monitoring at this time.

The authors’ goal of documenting a train-of-four ratio greater than or equal to 0.9 requires the purchase of QUANTITATIVE neuromuscular monitoring equipment in every anesthetizing location. The cost of each monitor was approximately $1,995, with the disposable costs of $20 to $25 per patient. An example QUANTITATIVE neuromuscular monitor is shown here:  

TwitchView QUANTITATIVE neuromuscular monitor

The article states, “The dangers of paralyzing a patient with neuromuscular blocking drugs are well recognized. Despite advances in anesthetic management, approximately half of all patients arriving to the postanesthesia care unit (PACU) suffer from residual blockade defined as a train-of-four ratio less than 0.9.” They cite a previous article from Anesthesia and Analgesia in 2018 which stated: “whenever a neuromuscular blocker is administered, neuromuscular function must be monitored by observing the evoked muscular response to peripheral nerve stimulation. Ideally, this should be done at the hand muscles (not the facial muscles) with a quantitative (objective) monitor. Objective monitoring (documentation of train-of-four ratio ≥0.90) is the only method of assuring that satisfactory recovery of neuromuscular function has taken place. (Bold emphasis added by me.) The panel also recommends that subjective evaluation of the responses to train-of-four stimulation (when using a peripheral nerve stimulator) or clinical tests of recovery from neuromuscular block (such as the 5-second head lift) should be abandoned in favor of objective monitoring.”

The American Society of Anesthesiologists (ASA) sets the standard of care for intraoperative monitoring. The ASA Standard of Anesthesia Monitoring currently does not mandate any form of neuromuscular monitoring. The ASA Standard of Anesthesia Monitoring is the gold standard for all operating room monitoring, is followed by all training programs, and is referred to in courts of law as the standard of care should an adverse anesthesia outcome occur. 

A 2010 survey of anesthesia providers documented that 19.3% of Europeans and 9.4% of Americans never use neuromuscular monitors. The majority of respondents from the US (64.1%) and Europe (52.2%) estimated the incidence of clinically significant postoperative residual neuromuscular weakness to be <1% (P<0.0001). Most respondents in this study reported that “neither conventional nerve stimulators nor quantitative train-of-four monitors should be part of minimum monitoring standards.”

I suggest three values in anesthetic care: Do the right thing, be safe, and Keep It Simple Stupid (the KISS principle). Rather than strapping a thumb monitor onto every one of my patients, I’m a disciple of qualitative neuromuscular monitoring—a less technologically complex form of monitoring. When I was serving my residency training in anesthesiology at Stanford in the 1980s, each resident was equipped with a MiniStim nerve stimulator, which is a qualitative neuromuscular monitor. 

MiniStim qualitative neuromuscular monitor

A qualitative neuromuscular monitoring device is simple to use. When the two terminals are applied to the facial nerve lateral to the eye of a sleeping patient and the green button is pushed, the orbital muscles will twitch if unparalyzed, and they will not twitch if paralyzed. With experience one can easily discern whether the patient is paralyzed or not, and one can estimate the degree of paralysis. The MiniStim also has a tetanus feature. When the two terminals are applied to the facial nerve lateral to the eye of a sleeping patient and the red button is pushed, a sustained electrical energy is emitted between the two terminals. The orbital muscles will show a sustained contraction if unparalyzed, and will not contract at all if fully paralyzed. If partially paralyzed, the muscles will contract and then the contraction will fade away in seconds. With experience, one can estimate to what degree the patient is paralyzed. The qualitative neuromuscular monitor does not give you the exact data, i.e. a decimal number between 0.0 (totally paralyzed and 1.0 (no paralysis) that a QUANTITATIVE neuromuscular monitor does. 

I still carry a MiniStim, and have used one for the entire 38 years I’ve practiced anesthesia, and for the 30,000 patients I’ve anesthetized. I would not start a case without a neuromuscular qualitative monitor. I would not want to be a patient receiving a neuromuscular paralytic drug if the anesthesiologist did not utilize a neuromuscular monitoring device similar to the MiniStim. The MiniStim is no longer manufactured, but other similar qualitative neuromuscular monitors are easily purchased, e.g. as depicted below, for $251, with no additional disposable costs.

SunStim qualitative neuromuscular monitor

Why is the topic of reversing neuromuscular blockade seeing this kind of scrutiny in 2022? Residual neuromuscular paralysis is less a problem now than at any time since the paralyzing medications were discovered. Why? Because in 2015 the United States Food and Drug Administration (FDA) approved the new intravenous drug sugammadex, a reliable, specific, and safe agent for the reversal of neuromuscular paralysis. Sugammadex can eliminate neuromuscular paralysis rapidly. A rocuronium molecule, bound within sugammadex’s lipophilic core, is rendered unavailable to bind to the acetylcholine receptor at the neuromuscular junction, and paralysis is reversed in seconds. 

Prior to 2015, the only reversal agent for pharmaceutical paralysis with a non-depolarizing neuromuscular blocker such as rocuronium was the drug neostigmine. Neostigmine can cause the side effect of severe bradycardia (slowing of the heart rate), and had to be administered intravenously in combination with glycopyrrolate (Robinul) or atropine. If a surgery was concluding and the patient had residual neuromuscular paralysis, the anesthesia provider needed to administer the combination of neostigmine/Robinul well before the wakeup-time, because the peak effect of neostigmine occurs at 10 minutes after administration.  If the patient was markedly paralyzed, e.g. the qualitative neuromuscular monitor showed no significant twitch or tetanus activity, neostigmine could not adequately reverse the neuromuscular paralysis in a short time. Sometimes it took 20-30 minutes before a deep neuromuscular paralysis could be reversed with neostigmine. If an anesthesia provider erroneously chose to awaken a patient prior to the time their neuromuscular paralysis was reversed or worn off, the patient would be too weak to breathe normally. A medical complication of hypoventilation or of awake paralysis could occur. 

Because of sugammadex, the risk of untreated residual neuromuscular paralysis has never been lower. Unreversed neuromuscular paralysis at wake-up should be a never-event now that sugammadex exists. There is virtually no circumstance in which an attending anesthesia provider should have unreversed neuromuscular paralysis at the present time. Why, in 2022, should we advocate for a QUANTITATIVE neuromuscular monitor which is bulky, expensive, and can only be strapped onto the thumb? The thumb location is a disadvantage, because many anesthetics, for example laparoscopies, require the arms to be tucked at a patient’s sides during surgery, and a thumb monitor is not practical. The qualitative neuromuscular monitors work on any peripheral nerve: e.g. the ulnar nerve at the wrist, the facial nerve lateral to the eye, or the posterior tibial nerve in the ankle, and provide a more versatile monitor than the QUANTITATIVE neuromuscular thumb monitor.

Qualitative neuromuscular monitoring is useful, easy, versatile, and inexpensive. QUANTITATIVE neuromuscular monitoring has the appeal of a score—a number between 0 and 1.0—that can be added to the already burdensome printout of the Electronic Medical Record (EMR), and may seem satisfying to those addicted to the dubious wonders of the EMR, or to those who want to see QUANTITATIVE neuromuscular monitors reported in the medical literature. But the addition of QUANTITATIVE neuromuscular monitoring to the required ASA list of monitors at this time is premature.

Where is the science? Where is the prospective, randomized trial of QUANTITATIVE neuromuscular monitoring versus qualitative neuromuscular monitoring in the age of sugammadex? Does anyone really believe that qualitative neuromuscular monitoring will be inaccurate and lead to significant anesthetic complications in an era when sugammadex is available? 

Qualitative neuromuscular monitoring was always a solid idea. I made this point twelve years ago when I wrote, “During residency or during the years afterward, a MiniStim and a stethoscope are arguably the only tools of your own you need to carry into an operating room to conduct a 21st-century general anesthetic.”

Until prospective scientific evidence demonstrates that QUANTITATIVE neuromuscular monitoring improves outcomes, mandating the extra technology of QUANTITATIVE neuromuscular monitoring as a required standard is not the correct path for the ASA to take in 2022 or at any time in the future. 

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 = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM

THE DIFFERENCE BETWEEN A PHYSICIAN ANESTHESIOLOGIST AND A NURSE ANESTHETIST

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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.
emailrjnov@yahoo.com
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What’s the difference between a physician anesthesiologist and a nurse anesthetist? After the first 3 – 4 years in the workforce, either one can master the manual skills of anesthesia. That is, either one can display excellence in intubating the trachea, performing a spinal or an epidural anesthetic, performing a nerve block, inserting an arterial line, or inserting a central venous pressure catheter. There is no fork in the career path that makes a busy Certified Registered Nurse Anesthetist (CRNA) automatically inferior to a medical doctor anesthesiologist in hands-on skills. So what really is the difference between a physician anesthesiologist and a nurse anesthetist? The answer: internal medicine.

All physician anesthesiologists graduate from medical school, where they rotate through clerkships in surgery, pediatrics, obstetrics-gynecology, internal medicine, emergency medicine and psychiatry, as well as electives in surgical or medicine subspecialties of their choice.

By contrast, CRNAs are registered nurses experienced in intensive care or emergency room nursing, who then enter a 2 – 3 year program of learning the skills to anesthetize patients. CRNAs can now administer anesthesia independent of any physician anesthesiologist supervision in the majority of the United States. 

The difference between a physician anesthesiologist and a nurse anesthetist is that the former has a depth of knowledge of 1) the physiology of the human body, 2) the pathophysiology of diseases, 3) the breadth of pharmacology, and 4) the ability to make diagnoses and prescribe treatment. In short, the physician anesthesiologist has extensive training in the internal medicine essentials of 1), 2), 3), and 4) above.

Nurse anesthetists are valuable and integral cogs in American healthcare. It’s not my intention to demean or minimize the role of CRNAs. My goal is to point out the most specific difference between a physician anesthesiologist and a nurse anesthetist.

At Stanford our department is named the Department of Anesthesiology, Perioperative and Pain Medicine. What is Perioperative Medicine? Perioperative Medicine is all the medical care before, during, and after surgery. Is Perioperative Medicine a subspecialty of internal medicine? In a way, it is. Following an internal medicine residency, graduates may subspecialize in cardiology, oncology, pulmonary medicine, kidney medicine, infectious disease, critical care, or . . . perioperative medicine. When I finished my Stanford internal medicine residency, the top four choices among my colleagues for the next step were: #1 a cardiology fellowship, #2 general internal medicine private practice, #3 an anesthesia residency, or #4 an oncology fellowship.

Stanford University now offers a combined internal medicine/anesthesiology residency, with the goal of training leaders in anesthesiology. The PGY1 year is spent entirely on medicine rotations.  The PGY2 year consists of all anesthesia rotations.  During PGY3-5 years, the resident alternates between 3 months of medicine rotations and 3 months of anesthesia rotations.

The outgoing Chairman of Anesthesiology, Perioperative and Pain Medicine at Stanford is Ronald Pearl MD PhD, an outstanding clinician and scientist who led our department for twenty-two years. In addition to board-certification in internal medicine and anesthesiology, Dr. Pearl is also board certified in critical care medicine. Dr. Pearl is one of the smartest clinicians I’ve ever met. His extensive internal medicine knowledge raises him above other anesthesia providers. 

Currently, anesthesiology residency programs are three years in duration, beginning after a resident has completed at least one year of internship. During those three years of anesthesia residency (PGY2 – PGY4) the resident rotates through: 

  • two one-month rotations in: obstetric anesthesiology, pediatric anesthesiology, neuro anesthesiology, and cardiothoracic anesthesiology
  • a minimum of one month in the adult intensive care unit during each of the three years 
  • three months of pain medicine, including one month in acute perioperative pain, one month in chronic pain, and one month of regional analgesia/peripheral nerve blocks
  • one-half month in a preoperative evaluation clinic 
  • one-half month in a post anesthesia care unit, and one-half month in out-of-OR locations.  

These rotations of an anesthesia resident develop the young doctor into a clinician comfortable in preoperative assessment and management, in the intraoperative administration of anesthesia, and in the postoperative evaluation and treatment of patients. 

Currently, internal medicine residency programs are three years in duration, including a one-year internship in internal medicine. During those three years (PGY1 -PGY3) a resident rotates through: 

  • a minimum of 4 months of critical care (medical ICU or cardiac care unit) rotations
  • a minimum of 1/3 of Internal Medicine training occurs in an ambulatory setting
  • a minimum of 1/3 of Internal Medicine training occurs in an inpatient setting
  • a longitudinal continuity clinic of 130 one-half-day sessions over the course of training, including one clinic per month. The continuity clinic includes evaluation of performance data for resident’s panel of patients.
  • exposure to each of the internal medicine subspecialties and to neurology
  • an assignment in geriatric medicine
  • an emergency medicine experience of four weeks
  • electives available in psychiatry, allergy/immunology, dermatology, medical ophthalmology, office gynecology, otorhinolaryngology, non-operative orthopedics, palliative medicine, sleep medicine, and rehabilitation medicine

These rotations of an internal medicine resident develop the young doctor into a broadly trained clinician experienced in multiple areas.

I’m not advocating that anesthesia departments be folded under the umbrella of their institution’s department of internal medicine. Instead, what I am recognizing is that the field of anesthesiology is more than putting in breathing tubes, arterial catheters, IV lines, or nerve block needles in a variety of different surgical settings. The field of anesthesiology is understanding and managing medical problems before, during, and after surgery, i.e., Perioperative Medicine. Describing our specialty with the word “Anesthesia” is an oversimplification of what we do. If our specialty was newly named today, it would be called Perioperative Medicine, period.

What about pediatric perioperative medicine? Doesn’t pediatric perioperative medicine involve the knowledge base of pediatricians, instead of the knowledge base of internal medicine? Yes. Deep knowledge of pediatric medicine instead of internal medicine (on adult patients) applies to pediatric perioperative medicine. No doubt a pediatrician who then completes an anesthesia residency will likely be an outstanding pediatric perioperative doctor, but only 5.4 % of anesthesia care in the United States is on pediatric patients less than 15 years old. The majority of the knowledge base for anesthesia care pertains to adult patients, i.e. the knowledge base for internal medicine physicians.

Several examples will illustrate why internal medicine forms the backbone of perioperative anesthesia practice. Before surgery, a patient who presents with insulin dependent diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea is an example of the kind of patient an internal medicine doctor sees regularly in his or her outpatient clinic. During surgery, a patient who develops atrial fibrillation or marked hypertension is an example of the kind of events an internal medicine doctor sees in an intensive care unit. After surgery, a patient who presents with chest pain or shortness of breath is an example of the kind of patient an internal medicine doctor sees in the emergency room or in the intensive care unit. Wait . . . you can argue that a CRNA has previous experience working as a registered nurse in an ICU or an emergency room before beginning nurse anesthetist training. But a registered nurse in an ICU or an emergency room does not independently diagnose and treat medical conditions. A registered nurse in an ICU or an emergency room follows written orders from a medical doctor. There is a world of difference between a medical doctor commanding diagnosis and treatment in an ICU/emergency room versus a registered nurse who follows orders.

Should all anesthesia residency training follow the Stanford optional model of combining internal medicine and anesthesia residencies into one program? No. Prolonging the training of every physician anesthesiologist in the United States makes little sense, but those who desire to be leaders will consider this double-residency option. 

Recent years brought an attempt to rename the territory of anesthesiologists as the “Perioperative Surgical Home.”  The Perioperative Surgical Home is defined as “a patient-centered, team-based, and coordinated perioperative care setup, composed of the head anesthesiologist-perioperativist in tandem with dedicated nurse practitioners and other PSH team doctors.” This is a move in a positive direction, with the intent of better patient care coordinated by an anesthesiologist-led team. There is an economic barrier to the Perioperative Surgical Home, in that the PSH may appear to be a coup attempt for anesthesia departments to take over jurisdictions from preoperative and postoperative internal medicine doctors. Any adoption of the PSH will likely be gradual, as the battle for patients plays out in each medical center.

Instead, a first step is that anesthesia departments redefine themselves as Departments of Perioperative Medicine, and that the academic training for these departments involve increasing time spent expanding the internal medicine knowledge base of residents in medical intensive care units, cardiac intensive care units, medicine wards, and medicine clinics. Performing month after month of repetitive intraoperative anesthesia care has a decreasing return on expanding a resident’s fund of knowledge, and can serve to make the role of a physician anesthesiologists and the role of a nurse anesthetist close to being the same.

It’s important that physician anesthesiologists create perceivable differences between themselves and CRNAs. The role of Perioperative Medical Doctors is a more broad and more specific identity when compared to what nurse anesthetists do. Let’s make our young physician anesthesiologist trainees into Perioperative Medicine Specialists, instead of confusing them with other anesthesia professionals who can also administer propofol, sevoflurane, and rocuronium.

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 = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM

WHEN INTERNS AND RESIDENTS UNIONIZE

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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.
emailrjnov@yahoo.com
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On May 2, 2022, residents and fellows (medical doctors in their first years of educational work after medical school) at Stanford University Health Care voted to unionize. In an email to medical staff, the Graduate Medical Education administration wrote: “Stanford Health Care (SHC) residents and fellows voted in favor of having The Committee of Interns and Residents (CIR), a local of Service Employees International Union (SEIU), serve as their collective bargaining representative. The votes cast in the election represent the sentiment of 1,049 residents and fellows who participated, out of the 1,478 employed by SHC. Ultimately, 835 voted ‘yes’ to unionization; 214 voted ‘no.’ . . . While we believe that the best relationship with our employees is a direct one without a union, we respect the results. . . . When the results are certified in the coming days, the first stages of the collective bargaining process will begin. . . . We will negotiate with the union in good faith to reach an agreement that reflects your priorities, while maintaining the best parts about training at Stanford.”

Stanford residents and fellows are not alone in choosing to unionize. A total of 1450 residents and fellows at UCSF (University of California San Francisco) recently voted to join the same Committee of Interns and Residents (CIR) union. The UCSF residents stated, “By joining CIR, UCSF residents will be able to negotiate their contracts for the first time, including bargaining for better salaries, benefits, time off, and other provisions that will improve resident life and well-being.” 

A total of over 20,000 residents and fellows at hospitals around the U.S. have voted to join this CIR union. What will this development mean to healthcare in the United States? I respect residents and fellows at the highest level. I spent five years as a medical resident, and I can empathize with the demands of their workload. From my current perspective as an attending physician at an academic medical center, how will this unionizing of housestaff (MDs who are residents and fellows) play out? 

First off, why form a union? The main reasons are a lack of bargaining power regarding:

  1. Burnout and staffing. Housestaff work up to 80 hours per week, a number that is twice the 40-hour workweek considered standard in the United States, and they do this for a duration of 3 to 7 years, depending on their specialty.  The rate of burnout is known to be high in medical doctors, and despite nods to wellness programs at most university hospitals, improvements have been slow in coming. An online survey of doctors finds an overall physician burnout rate of 42%, and the highest percentage of burnout occurred in these six specialties: urology: 54%, neurology: 50%, nephrology: 49%, diabetes and endocrinology: 46%, family medicine: 46%, and radiology: 46%.
  2. COVID. The long hours and risks of acquiring COVID while working with sick COVID patients from 2020 -2022 made many residents and fellows feel vulnerable and angry. While hospital administrators and many faculty returned to the safe havens of their homes each night, interns and residents staffed intensive care units, wards, and emergency rooms, caring for patients with this terrifying new contagious disease. When University of Massachusetts interns and residents joined the CIR union, they stated, “When the pandemic struck, securing better conditions became even more urgent, as the inequities in our healthcare system were laid bare — and in light of the rapid changes that left residents scrambling to keep up within traumatizing and sometimes dangerous practice conditions.”
  3. Higher pay. Residents and fellows are paid a salary. They do not earn an hourly wage. When their salary is divided by 80 hours of work per week, 50 weeks per year, most residents and fellows are making less than minimum wage. When University of Massachusetts interns and residents joined the CIR union, they stated, “UMass Memorial residents are willing to work 80 hours per week because we know exceptional care is critical to community well-being, but we are significantly underpaid for doing so.” 
  4. Better benefits. Residents and fellows will desire more vacation time, top-notch health insurance benefits, and perhaps even retirement contributions.

If residents and fellows don’t receive what they seek during negotiations with the administration, what consequence can residents and fellows turn to? Will they go on strike? In May 2019, interns and residents at UCSF staged a 15-minute “Unity Break” strike as a show of solidarity and power. The Committee of Interns and Residents, which represented 1,100 of UCSF’s resident and fellow population at that time, said that management had not properly recognized the contributions of their resident and intern members and offered a package that left them underpaid and underrepresented. “UCSF has failed to meet some of the very basic demands that we have been fighting for at the table,” said Kim Carter, director of the union. 

Can doctors strike? Is it ethically OK for doctors to strike? I think the answer is no. To leave patients without healthcare while doctors strike for better hours, wages, and benefits is a violation of the ethics of our healing profession. I don’t believe young doctors should be abused or squeezed into unacceptable hours, low wages, and/or poor benefits, but doctors staging a labor walkout would be a mistake. And if a union will never strike, will it ever have any real negotiating power? The CRONA (Committee for the Recognition of Nursing Achievement) nursing union at Stanford staged a strike beginning April 25, 2022, just days ago. Negotiations were successful after only one week of the strike, with the nurses gaining a tentative agreement for significant base wage increases of 5% on April 1, 2022, 2% on December 1, 2022, 5% on April 1 2023, and 5% on April 2024, in addition to other improvements in benefits, staffing, and scheduling. 

I have firsthand experience with strikes. I was a laborer during three United Steelworkers of America strikes in Northern Minnesota during summer employment in taconite mines while I was in college and medical school. Blue-collar strikes are not pretty. The picket lines were brutal, and no one dared cross them. Both sides lost money as the strikes wore on, and interpersonal conflicts simmered for a long time afterward. 

The idea of residents and fellows joining a union is not a new one. In 2001 The Los Angeles Times reported a story on this topic. The article stated, “Striking will disrupt the educational progression of classes, clinical practice and testing. A student wants to come in and have some certainty that his or her three-year residency will take three years. How would they feel if suddenly they were told they wouldn’t finish on time and, whether a strike is a good idea or a bad one, that they’re not going to be able to take a board exam?” One of the doctors who joined the union at that time stated, “Change won’t come overnight, but I think it will happen. We have to stop that cowboy attitude: ‘It’s always been this way, we’re tough, we don’t complain.’ Many residents want to complain, but they’re in an environment where if they do, they’re punished. Residents have to fight for all these things and, without a union, they don’t have any legs to stand on.”  

The ”cowboy attitude” refers an old-school medical education argument that sounds like this: “There’s no other way to educate doctors. It takes at least 80-100 hours per week. Even if you stay in-house every other night you miss half the good cases. When I was a resident, back in the (fill in the blank . . . 1950s, 1960s, 1970s, or 1980s), we slept in the hospital every other night and worked 120 hours per week. Now residents are complaining that 80 hours per week is too much.”

When I was an internal medicine resident in the 1980s, we stayed in the hospital on-call every third night and worked approximately 100 hours per week. My salary during my first year of residency was $16,000. On an hourly basis, this equated to $3.33 per hour. Adjusted for inflation, my 1980 salary would be $55,826, or $11.63 per hour, less than the current minimum wage. 

If medical centers shorten the workweek of interns and residents to 40 hours per week from the current limit of 80 hours per week, the medical center may need to hire twice as many interns and residents or other physician surrogates to do the workload. And if the union negotiates a 10-20% increase in annual salary, the cost for interns and resident would increase further. Where will all this money come from? Most of the salaries of residents and fellows are paid for by billions of dollars of federal tax money, as medical education is subsidized by the United States government. The publication Congressional Research Sources states, “Federal support for medical residency training (a.k.a., graduate medical education [GME]) is the largest source of federal support for the health care workforce. Although the health workforce includes a number of professions, the size of the federal investment in GME—estimated at $16 billion in 2015—makes it a policy lever often considered to alter the health care workforce and impact health care access.” 

Labor unions in the United States are organizations that represent workers in many industries. Labor unions grew afterCongress passed the National Labor Relations Act (NLRA) in 1935 to protect the rights of both employees and employers, to encourage collective bargaining, and to eliminate certain private sector labor and management practices which could harm the welfare of workers, businesses and the economy.

The Ailing Labor Rights of Medical Residents, by Sarah Geiger, published in 2006, describes the legal history of medical resident labor law and the attempts to legalize unionization among medical residents. I quote the following excerpts directly from Geiger’s paper: 

“From 1947 to 1974, hospital staff members did not have the right to unionize. . . . Congress then amended the NLRA in 1974 to include non-profit hospitals. The Committee on Labor and Public Welfare report on the amendments stated that it could find no acceptable reason why 1,427,012 employees of these non-profit, non-public hospitals, representing 56% of all hospital employees, should continue to be excluded from the coverage and protections of the Act. . . . One source of confusion involved the dubious supervisory status of professional health care providers. . . . health care professionals exercised supervisory roles and were thus excluded from the right to unionize. . . .

“In Cedars-Sinai Medical Center, the NLRB held that the residents, interns, and clinical fellows of Cedars-Sinai were not ‘employees’ within the meaning of the NLRA. Thus, they had no right to unionize. . . . The Board thus concluded that interns, residents, and clinical fellows were primarily students, noting the relationship between residents and Cedars-Sinai was primarily educational, and not an employment relationship. . . .  The decision remarked that interns ‘participate in these programs not for the purpose of earning a living; instead they are there to pursue the graduate medical education that is a requirement for the practice of medicine. This statement implies that residents do not actually ‘practice medicine,’ but merely are training to do so. . . . 

“In response to staunch legal criticism, the Board reversed Cedars- Sinai.  Boston Medical, an oft-quoted case, involved a unit of housestaff at the Boston Medical Center (BMC) that attempted to unionize. . . .  The Board overruled its precedent in Cedars-Sinai and held that medical interns and residents were both students and employees and thus were entitled to unionize. . . . The NLRB recognition of housestaff’s plight has done little to encourage unionization among medical interns and residents. . . . The residents’ dual roles, however, present extra-legal barriers to unionization which are not present in other industries. Residents spend an inordinate number of hours in the hospital and often are directly serving patients for twenty-four hours at a time. . . .  the fears of Congress (and earlier fears of the American Medical Association) that unionization may compromise the doctor-patient relationship or the quality of health care residents adds another layer of complication. . . .   

“The Association of American Medical Colleges (AAMC), the representative body of all accredited medical schools in the United States and Canada, as well as over 400 teaching hospitals, vehemently opposed all resident unionization efforts. . . . Offering more labor rights to medical residents would cost academic hospitals inordinate amounts of money. The cost of replacing one surgical resident with a “physician extender,” or other physician, is $210,000 to $315,000 a year. . . . the federal government is by no means an objective observer in the matter of medical residency funding and regulations. Currently, the federal government is the main financier of graduate medical education, ‘contributing $6.8 billion through Medicare, plus additional sums through the Departments of Defense and Veteran Affairs.’ The federal government is constantly looking to reduce the cost of medical care. Offering residents more control over their working conditions would likely lead them to demand more money, money that would have to come from the federal government or from private university hospitals. Thus, the government and academic hospitals are appropriate bedfellows in opposing resident labor rights. 

“The Boston Medical decision made it clear that little legal basis exists to deny medical residents unionization rights or any NLRA specified rights for that matter. Thus, unless Congress amends the NLRA, no legal barriers exist to housestaff unionization.  Many other internal barriers, however, hinder medical residents from acquiring labor rights. Unionization takes more effort than residents have time for and many fear unions will compromise their goals as physicians. A national survey of residents found that residents’ willingness to get involved in forming a union or serving as a member of union management was inversely proportional to the difficulty and amount of time their specialty required them to be in the hospital. Residents are accountable to their superiors for their future careers and would rather endure a few years of grueling working conditions than do anything which might compromise their careers. . . . Hospitals should give residents a real opportunity to unionize. . . . An informed, inclusive dialogue will serve to clarify legal and extra-legal barriers to accomplishing these congressional goals as well as to alleviate medical residents’ labor burdens.”

As described above, a crucial issue which complicates union negotiations for medical residents and fellows is that their jobs are part work and part education. Each intern or resident is a medical worker, a student of the specialty he or she is training in, and a teacher to the interns and residents who are junior to them in the hierarchy. Residents and fellows are learning as they are paid to work. Their learning is both valuable and necessary for progression to their eventual career. The U.S. News and World Report’s listing of the “Best Paying Jobs in America” lists specialties of Medical Doctors as 7 of the 10 highest paying jobs in the United States. 

No discussion of intern and resident salaries would be complete without a disclosure of the average debt these young doctors carry. Because of the high costs of medical school and college tuition, the average medical school graduate owes $241,600 in education debt. The average medical school graduate owes six times as much as the average college graduate. You can’t blame student doctors for wanting to maximize their income as medical interns, residents, and fellows.

If there’s a silver lining in all this, it’s best described in this anecdote from my training years: After completing a 3-year residency in internal medicine, I applied for and was accepted to a second 2-year residency in anesthesiology, a field I was passionate to learn about. In the first weeks of my anesthesia residency, a former chairman of the Stanford anesthesiology department gave us a lecture and tutorial on how to intubate the trachea of a patient with the highest level of skill and ease. I hung on every word he said. I was getting a lesson from a legend, and I was collecting a salary while I was learning this craft. Image a young golf professional getting paid while he received a lesson from Jack Nicklaus. I was earning a salary while I bettered my education and became more marketable in the medical marketplace. Could I have been paid more as a resident? Perhaps. But the primary gain I made during five residency years was the investment of my time in the labor and learning which made it possible for me to work as a board-certified anesthesiologist for the past 36 years . . . and still counting.

I’m confident Stanford Healthcare and the CIF union will negotiate a successful compromise agreeable to both sides. Until that time, stay tuned, as the intersection of physician labor unions and academic medical centers will generate headlines in the days ahead.

I offer this question to my readers: Do you think it’s acceptable for unionized doctors to strike?

The most popular posts for laypeople on The Anesthesia Consultant include:
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REMIMAZOLAM: NEW WONDER ANESTHETIC DRUG OR MEDICAL WHITE ELEPHANT?

THE ANESTHESIA CONSULTANT 9 Comments
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.
emailrjnov@yahoo.com
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In July 2020 the Food and Drug Administration (FDA) approved the intravenous benzodiazepine remimazolam (Byfavo, Acacia Pharma) for use in sedation for procedures of 30 minutes or less. Will anyone utilize this new drug, or is it an expensive addition to our arsenal with few significant advantages over current agents?

Remimazolam differs from midazolam (Versed), the current most commonly used IV benzodiazepine, in that remimazolam is rapidly converted to an inactive metabolite by tissue esterases, resulting in an ultra-short onset/offset profile. Remimazolam is marketed as a powder which must be reconstituted into a liquid within its vial prior to administration.

remimazolam
propofol

For use in procedural sedation, remimazolam will not replace Versed, but rather will aim to replace propofol. The proposed advantages of remimazolam over propofol include:

  1. Remimazolam can be completely reversed by the benzodiazepine antagonist flumazenil (Romazicon) whereas there is no reversal agent or antagonist for propofol. The only way to end the sedative effects of propofol is for an anesthesia professional to support the airway, breathing, and circulation of the patient until the drug effects of propofol wear off in time.
  2. Remimazolam has minimal cardiac or respiratory depression. Sicker ASA III and IV patients maintain their breathing and circulation status while under remimazolam sedation.
  3. There is no accumulative effect of remimazolam over time. Its elimination by an esterase does not slow during lengthy administration of remimazolam, as in the prolonged sedation of an intensive care unit (ICU) patient on a ventilator.
  4. There is no burning sensation upon injecting remimazolam into a patient’s intravenous line as there is with propofol.
  5. A non-anesthesia-professional can administer remimazolam, whereas an anesthesia professional/airway expert must administer and monitor propofol administration.

Are these advantages important? Items 1 – 5 are discussed as follows:

  1. Non-anesthesiologists can reverse the effects of remimazolam with flumazenil if they overdose a patient, but this advantage is less important for anesthesia professionals. Anesthesiologists can manage the airway of a patient over-sedated with a benzodiazepine without need to administer a reversal agent. I’ve never administered a dose of flumazenil in my entire career, nor have most of my anesthesia colleagues. 
  2. Propofol has cardiac and respiratory depression, but in most cases these effects are minimal. Per the PDR (Physician’s Digital Reference), patients with compromised myocardial function, intravascular volume depletion, or abnormally low vascular tone (e.g. septic patients) are more susceptible to hypotension. When an anesthesiologist is present these risks are routinely managed. 
  3. For a long operating room anesthesia case (e.g. of 8 – 10  hours duration), there is no clinically significant accumulation of propofol in the bloodstream. Propofol Infusion Syndrome (PRIS), which can be potentially fatal, is a risk with prolonged propofol sedation in the ICU (See ICU Sedation below).
  4. The burning sensation upon injecting propofol can be blunted by intravenous lidocaine. A 2016 meta-analysis showed that both lidocaine pretreatment and mixing lidocaine with the propofol were effective in reducing pain on propofol injection. In addition, a preanesthetic dose of Versed prevents a patient from remembering any burning sensation from a propofol injection that follows. 
  5. The most important advantage of remimazolam is that non-anesthesiologists can safely administer remimazolam. Propofol administration requires an experienced clinician, e.g. either an anesthesiologist, a certified registered nurse anesthetist (CRNA), or an emergency medicine physician. Per the American Society of Anesthesiologists: “The practitioner administering propofol for sedation/anesthesia should, at a minimum, have the education and training to identify and manage the airway and cardiovascular changes which occur in a patient who enters a state of general anesthesia.” 

The disadvantages of remimazolam compared to propofol include:

  1. Expense. The cost of a 20 ml (200 mg) vial of propofol is $9.20. The cost of a 20 mg vial of powdered remimazolam is $41.67. 
  2. Remimazolam is sold as a powder and must be reconstituted into a liquid before it can be injected intravenously.

Remimazolam is currently approved as an anesthesia drug in Japan and South Korea, for intensive care unit sedation in Belgium, but only for procedural sedation in the United States, China, and Europe. In total, there are four possible applications for remimazolam. Let’s examine the pros and cons of using remimazolam in these four applications:

  1. Preoperative sedation. Since midazolam (Versed) was approved in 1982, a standard anesthesia practice has included a 2 mg dose of  Versed prior to surgery to calm a patient’s anxiety. In the 1980s my anesthesia chairman at Stanford received a letter from a postoperative patient in which she complained of being awake and very anxious in the operating room prior to the anesthetic for her breast cancer surgery. Our chairman lectured to us, “Do you know many patients are nervous prior to their anesthesia and surgery? Every one of them. We have an excellent drug for relieving preoperative anxiety, and that drug is Versed. Use it! Give your patient a dose of Versed before they enter the operating room. There are few significant side effects of one dose of Versed. Use it!” Will remimazolam replace Versed for this application? No. There is no advantage of the new, shorter acting, more expensive remimazolam over Versed for preoperative sedation.
  2. Sedation for short procedures. This is the FDA-approved application for remimazolam in the United States. An example procedure would be a colonoscopy. Will remimazolam be widely used for colonoscopies in the near future? No, I doubt it. The cost increase is the main disadvantage. See the typical drug acquisition costs for three alternative sedation recipes for colonoscopy below:

            $18.40 for 400 mg of propofol; or 

$5.17 for fentanyl+Versed ($4.35 dollars for 6 mg of Versed  plus $0.82 for 200 micrograms of fentanyl); or

$41.67 for 20 mg of remimazolam. 

The increased cost per case is $23.27 for remimazolam over propofol. 

The increased cost per case is $36.50 for remimazolam over fentanyl+Versed.

If a busy endoscopy center does 100 colonoscopies cases per week, the cost increase is $2327 per week for remimazolam over propofol, or $3650 per week for remimazolam over fentanyl+Versed. These are a prohibitive cost increases with no clear added benefits. The only way remimazolam could result in cheaper sedation costs would be if a healthcare system was looking to eliminating the cost of paying for an anesthesia provider for these procedures. The pairing of remimazolam+gastroenterologist sedation rather than propofol+anesthesiologist sedation could afford significant cost savings for a healthcare system.

3. Total intravenous anesthesia (TIVA). TIVA could include a continuous infusion of the ultra-short-acting narcotic remifentanil plus a continuous infusion of the ultra-short-acting remimazolam. An alleged advantage of this technique could be the fast offset time of these two TIVA anesthetic agents. I doubt this technique will gain market share. It’s far easier to turn on the knob of a sevoflurane vaporizer than to load and manage two TIVA-syringe pumps. As well, the added expense of a prolonged infusion of remimazolam will be prohibitive.

4. ICU sedation. Remimazolam has the advantage of ongoing first-degree elimination, meaning that no matter how long the drug is infused, it will always have reliable elimination by esterase and will not accumulate in the plasma. Prolonged ICU sedation with propofol can lead to the Propofol Infusion Syndrome (PRIS). PRIS occurs predominantly in patients receiving high doses of propofol for a prolonged period. Risk factors for the development of PRIS include a critical illness such as sepsis, head trauma, use of vasopressors, and carbohydrate depletion (liver disease, starvation, or malnutrition). PRIS commonly presents as a high anion gap metabolic acidosis, with rhabdomyolysis, hyperkalemia, acute kidney injury, elevated liver enzymes, and decreased cardiac output. Because of the risk of PRIS,  the duration of propofol infusion administration should not exceed 48 hours and the administered dose should not be higher than 4 mg/kg/hour.

This potential advantage of remimazolam over propofol will be offset by the increased expense of hours or days of remimazolam utilization in an ICU sedation situation. ICU sedation with fentanyl and older benzodiazepines such as Ativan will have the advantage of a lower cost. 

In the hands of an anesthesiologist, propofol is an elegant and almost ideal intravenous sedative, with the advantages of rapid onset, rapid offset, inexpensive generic pricing, minimal cardiovascular/respiratory depression, and lack of nausea. Propofol administration does carry the risks of upper airway obstruction, hypoventilation, and low oxygen saturation, but when an anesthesiologist is present these risks are minimal. 

If a healthcare organization doesn’t want to employ an anesthesiologist or a CRNA for a case which requires procedural sedation, then remimazolam may be an excellent sedative choice. Will gastroenterologists prefer to sedate patients with remimazolam plus fentanyl without an anesthesiologist? Or will they prefer to have an anesthesiologist present to administer propofol? Expect gastroenterologists to prefer the latter, because they are not only off-loading the task of sedating the patient, they are also off-loading the risks of managing the patient’s medical co-morbidities, which can be significant if a patient has lung disease, cardiac disease, morbid obesity, or obstructive sleep apnea.

The remimazolam story suggests one of my favorite anecdotes: A former Stanford Chairman of Anesthesiology and friend of mine who left the university in 2006 to become a pharmaceutical company executive, first at Novartis and then at AstraZeneca. Ten years ago, when I asked him what new anesthesia drugs were in the pipeline, he answered, “None, and there probably will be very few new ones. The drugs you have now are inexpensive generic drugs, and they work very well. The research and development costs to bring a new anesthetic drug to market are prohibitively expensive, and unless that new drug is markedly better, it will not push the inexpensive generic drugs out of use.”

Remimazolam will capture a very small market in the United States. Until remimazolam becomes an inexpensive generic drug, I see it as a medical white elephant rather than a wonderful anesthetic advance.

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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 = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

THE RESCUE: UNDERWATER ANESTHETICS EXPLAINED

THE ANESTHESIA CONSULTANT 2 Comments
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.
emailrjnov@yahoo.com
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Underwater general anesthetics of 3 hours duration? See it in The Rescue, a new National Geographic Documentary Film directed by Jimmy Chin (winner of the 2018 Academy Award for Best Documentary Feature for Free Solo). The Rescue details the miraculous extraction of 12 boys and their coach from a flooded Thailand cave in June and July of 2018. The Rescue required 13 underwater general anesthetics delivered by an anesthesiologist and maintained by non-medical cave divers during their 3-hour swim to the mouth of the cave. How did this once-in-history anesthetic tour de force come about? You can watch the movie—a favorite for this year’s Oscar for Best Documentary—on Disney+ for their $7.99 monthly fee. This column explains the specifics as to how anesthesiology innovation saved thirteen lives in The Rescue.

The site of The Rescue was the Tham Luang Nang Non cave in Chiang Rai Province in northern Thailand. Twelve boys of ages 11 – 16 from the Wild Boar soccer team and their coach entered the cave for a birthday celebration. June monsoon rains hit and flooded the entrance of the cave, trapping all thirteen inside. 

The boys were trapped at the left of this diagram. The entrance to the cave is at the right.

The synopsis of The Rescue follows this timeline:

Day 1 – Trials of gas-powered generators to pump the water out of the cave fail to lower the water level.

Day 2 – The Thai Navy Seals arrive on site. They attempt scuba diving into the cave but abort their efforts because of low visibility and difficult access. They were only able to advance 200 meters into the cave. None had experience diving into dark narrow caves. John Volanthen, an information technology consultant who does cave diving as a hobby, shows them a map of the long tortuous cave route, and surmises that the boys are trapped about 2 kilometers into the cave. Richard Stanton, a retired middle-aged British firefighter who is also an expert in cave diving, is alerted to the predicament, and flies to Thailand to help. 

Day 5 – Stanton assembles a collection of his friends who are fellow cave divers. These men have real world jobs such as electricians, contractors, mechanics, and consultants, but are experienced in underwater cave exploration. At first, the Thai Navy Seals will not allow the cave divers to attempt a rescue because they deem it is too dangerous. Eventually the Thai Seals consent to let the cave divers proceed. Stanton describes their passage as scuba diving against a raging river of white water, with the added problem of poor visibility. They surface at the first air-filled chamber inside the cave, and instead of finding the boys they find four pump workers who were unknowingly trapped inside the cave. The cave divers swim the pump workers out, sharing their scuba regulators as they swim, but find the pump workers are easily panicked in the dark cold underwater conditions, and the passage out is very difficult. Their entire swim rescue of these men takes only 30 to 40 seconds, yet Stanton describes the ordeal as “an underwater wrestling match.” 

Day 7 –Rain continues and the water levels rise. Hundreds of people surround the mouth of the cave, and worldwide media coverage is ongoing.

Day 10 – The cave divers continue their attempts to explore the length of the cave. They extend a rope behind them to trace their route back to the outside world. After several hours of traversing the narrow route, including passing through several air chambers above water, they reach a chamber where the atmosphere smells pungent. They fear they have located the rotting flesh of decomposing bodies. Instead they shine a light into the chamber and see 13 people—the Thai boys and their coach—sitting on the rocky floor. They are skinny and frightened, but alive. They’ve had no food for 10 days and have existed by drinking the water from the cave. The cave divers return to the mouth of the cave and announce that the boys are alive. 

Day 12 – The divers follow the rope back to the boys and bring them power gel food and foil blankets. Their plan going forward is unclear. There appears to be no way to swim the boys out for the 3-hour underwater journey to the mouth of the cave. One option is to wait until October (four months) until the monsoon season is over, and the cave is no longer flooded. A second option is to somehow drill down to where the boys are trapped. A third option is to pump out millions of gallons of water out of the cave, but this is also deemed impossible. Another cave diver friend of Stanton’s is Dr. Richard Harris, who lives and works in Australia. Dr. Harris is an anesthesiologist. The team of cave divers telephone him and ask if the boys can be anesthetized for 3 hours to be extracted underwater. His initial answer is no, that this would be impossible.

At the same time, the divers bring an oxygen analyzer into the cave and discover that there is only 15% oxygen left in the atmosphere where the boys are trapped. Normal room air contains 21% oxygen, and 15% oxygen is considered an eminent threat to life for the boys. Immediate action is necessary.

Day 14 – Dr. Harris arrives at the cave. He and his cave diver colleagues come up with a plan to anesthetize and extract the boys, but there is a new problem: The Thai government does not want them to attempt the rescue. The government fears the boys will all die in the futile attempt. Enter Josh Morris,   a cave diver who speaks Thai. He explains the facts and the threat of the low oxygen atmosphere to the government authorities, and convinces them there is no time to waste and that there is no other workable plan. The government agrees to let the cave divers proceed.

Day 15 – The rescue plan is as follows: Divers will swim into the cave to the chamber where the boys are located. The divers will transport an extra oxygen cylinder, a full-face dive mask and regulator, and a dive suit for each boy. They will also carry three medications: 1) Xanax, an oral anti-anxiety pill in the Valium family of benzodiazepines; 2) ketamine, an injectable general anesthetic drug, carried in a syringe-and-needle setup; and 3) atropine, an injectable drug which dries up oral secretions (necessary because ketamine can cause excessive salivation significant enough to choke off breathing). When the cave divers arrive at the chamber where the boys are situated, they dress the first boy in a dive suit complete with a rubber head-covering. Dr. Harris then administers the Xanax pill and the intramuscular injections of ketamine and atropine. After the boy loses consciousness, they tie the boy’s hands behind the boy’s back and apply the full-face oxygen dive mask to keep the water out. The boy is placed in the water atop a full oxygen cylinder, and a diver guides the boy and the cylinder under the water. This diver clings to the rope as he begins the 3-hour journey back toward the cave entrance. There are multiple air chambers on the route back to the entrance. At each air chamber, the diver surfaces and assesses if the boy is still alive and breathing, and whether the boy is anesthetized deeply enough. If the boy is twitching, the diver injects more ketamine. Keep in mind this diver is not a doctor—he has been taught by Dr. Harris to inject more drug if the boy seems to need more sedation. This process is repeated for four boys the first day and is successful. All four reach the surface, alive and anesthetized, and are transported to a nearby hospital.

Day 17 – The process is repeated and four more boys are successfully extracted.

Day 18 – A heavy monsoon rainstorm is expected, so all five remaining individuals are extracted before the cave is totally flooded. The cave divers are hailed as civilian heroes as the last of the boys is rescued. The rescue effort involved more than 10,000 people, including divers, rescue workers, 900 police officers, 2,000 soldiers representatives from 100 governmental agencies, 10 police helicopters, more than 700 diving cylinders, and the pumping of more than a billion liters of water from the caves. 

In the aftermath, Richard Stanton returns to England and receives a George Medal, the second highest award for civilian gallantry, in a regal ceremony at Buckingham Palace. 

The Rescue is riveting and suspenseful, and ultimately worth the one hour 45 minutes and the $7.99 you’ll invest in it.

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Here’s the Anesthesia Consultant analysis of the medical circumstances in The Rescue:

  • In an operating room, anesthesia is typically delivered as a gas (e.g. sevoflurane), or intravenously. Neither gas anesthesia nor intravenous anesthesia is possible in an underwater cave rescue. Ketamine is the only general anesthetic drug which can be injected. Ketamine can be injected either into an IV (e.g. in an operating room by an anesthesiologist) or into a muscle (e.g. in a cave in Thailand). Ketamine has the advantages of quick onset and a lack of respiratory depression—that is, ketamine will not stop a patient’s breathing. But if a patient becomes over-sedated it’s possible they will have upper airway obstruction which can lead to inadequate ventilation, so ketamine administration typically needs to be administered by an anesthesia professional who monitors the patient’s breathing—unless you’re rescuing kids in a cave. Ketamine also has theses disadvantages: It results in a relatively slow wake up (compared to propofol and/or sevoflurane gas); it causes markedly increased saliva production (which is why we need to administer atropine, a secretion-blocking anticholinergic drug—along with ketamine); and ketamine can cause vivid bad dreams—for this reason we routinely give an IV benzodiazepine such as Versed along with ketamine. Re-dosing of ketamine was required because the drug’s half-life (the time it takes for the total amount of ketamine in the body to be reduced by 50%) is about 2.5 hours in adults. Dr. Harris couldn’t be with every boy en route, which is why he had to train the other cave divers how to inject ketamine for redosing.
  • Dr. Harris could have chosen to use an injection of intramuscular Versed instead of Xanax (the oral benzodiazepine used in The Rescue). A disadvantage with oral Xanax is its slow onset time. It’s unlikely the Xanax began to work until it was absorbed from the stomach and carried by the bloodstream to the brain, which likely took thirty minutes or more.
  • The choice of full-face dive masks (FFMs), capable of maintaining constant positive airway pressure (CPAP) during the anesthetics, was brilliant. All acute medical care, be it in an operating room, an intensive care unit, an emergency room, a battlefield, or a cave, follows the priority order of A-B-C, or Airway- Breathing-Circulation. The problems of keeping the airway open, as well as keeping oxygenation and ventilation intact, were daunting challenges underwater. There were no research articles and no textbooks to tell the cave divers how to deal with this situation. They used their best strategy and made their best guess, and it was successful. If excessive water had leaked into the mask, a boy could drown. 
full face dive mask

  • Fortunately all the boys and their coach were slender (per the video footage) and had low body-mass-indexes (BMIs). A patient with a low BMI typically has an easy airway, and would have a lower chance of obstructing their upper airway during a 3-hour underwater general anesthetic. An overweight patient would probably not have survived a 3-hour underwater general anesthetic. As well, all the boys and their coach were young and healthy with normal hearts and lungs. If they had been older, with any abnormal cardiac or respiratory function, they may not have survived the 3-hour underwater general anesthetic.
The Thai boys in the cave

  • It’s striking that the boys could survive for two weeks with only water and no food. Hydration is critical—no one can survive two weeks without water—but food was not imperative for this length of time. They survived without calories for two weeks, but humans can only survive for about three days without water.
  • Hypothermia, or low body temperature, was a risk during the underwater rescue. Anesthetized patients have no muscle movement and are unable to generate any body heat in the cold water. The scuba suits and hoods were aimed at minimizing the temperature drop while the boys were anesthetized.
  • No one monitored the vital signs of the boys during their 3-hour underwater general anesthetics. General anesthetics always require monitoring of these parameters: heart rate, oxygen saturation, blood pressure, ECG, respiratory rate, temperature, and end-tidal carbon dioxide expiration. In an underwater cave anesthetic, none of this was possible. Luckily the ketamine anesthesia as administered must have kept all the vital signs within acceptable limits.
  • The oxygen concentration in the atmosphere of the cave was only 15%, far lower than the normal room air concentration of 21% we’re all breathing right now. This oxygen concentration of 15% is roughly equivalent to the oxygen concentration atop a mountain at 10,000 feet of altitude. The boys tolerated the gradual decrease of the oxygen level within the cave from 21% to 15% over 12 days without any brain damage or any damage to a vital organ system. An acute decrease from 21% to 15% may have caused low blood oxygen—hypoxia—and organ damage. During anesthetics in an operating room, anesthesiologists commonly administer at least 40-50% oxygen—a higher concentration than in room air—as an extra margin of safety.

The film The Rescue documents a remarkable feat of emergency medicine and emergency anesthesia care. I recommend you see the movie, and I hope you’ll understand the medical care better because of the discussion presented above. 

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PRESIDENT BIDEN’S COLONOSCOPY ANESTHESIA

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THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
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Three days ago, I was giving anesthesia for six consecutive colonoscopy patients. Following my first case, I checked my phone and discovered that the President of the United States Joe Biden was having a colonoscopy at Walter Reed Medical Center that very morning. The headlines stated that for the first time, temporary acting presidential power was being turned over to a woman, Vice President Kamala Harris, during the time of President Biden’s colonoscopy anesthesia.

I mentioned this to the gastroenterologist I was working with that day, and he asked, “How long do you think he will be unable to make decisions as the President? We tell our patients not to drive the rest of the day, and not to make any important life decisions after their general anesthetic. Biden has the most difficult and most important job on Earth. When can he return to duty?”

I answered, “My guess is that he’ll have the same propofol anesthetic we’re administering today. The procedure will last thirty minutes, he’ll begin to awaken five minutes after the propofol is discontinued, and within an hour he’ll feel clear-headed.” The gastroenterologist was dubious that the leader of the free world would be alert enough to resume power only one hour after receiving propofol. Joseph Biden was one day short of his 79th birthday when the colonoscopy took place. Later that morning the news services reported that the President had transferred presidential powers to Kamala Harris at 10:10 a.m. EST and resumed his presidential powers at 11:35 a.m., a mere 1 hour and 25 minutes later. 

The evening after the colonoscopy, comedian Colin Jost of Saturday Night Live joked about Biden’s colonoscopy.  During Weekend Update, Jost reported on Biden’s resumption of all his presidential responsibilities immediately following the colonoscopy, and noted that Biden had just turned 79. “Half the country already thinks he’s senile,” Jost said. “You can’t drop all that on him the second he comes out of the gas.”

A note from an anesthesiologist to the comedy writers: No one uses “gas” for anesthesia for a colonoscopy. The anesthetic is solely from intravenous (IV) drug(s).

I have no specific knowledge of what anesthetic drug regimen the President received for his colonoscopy, but more likely than not he received propofol. Anesthesia for colonoscopy is typically administered so that patients have no awareness during this procedure, a procedure which does not involve surgical pain, but rather involves the uncomfortable entrance of a 66-inch-long flexible hose, one-half-inch in diameter, into their anus, rectum, and colon. 

For the quickest recovery after colonoscopy, one option is no anesthesia at all. Very few patients sign up for a colonoscopy without any intravenous anesthesia. The press reports about Biden’s colonoscopy stated that he had anesthesia, so let’s discount the option that he had the procedure while awake. 

Colonoscopy sedation is typically done with one of two recipes: 1) conscious sedation with a combination of intravenous Versed (generic name midazolam, a benzodiazepine in the Valium family) plus intravenous fentanyl, such that the patient has no memory of the procedure; or 2) intravenous general anesthesia with propofol by continuous infusion or by intermittent boluses so that the patient is unresponsive. The combination of Versed and fentanyl leads to a slower wakeup and recovery than with propofol. The duration of effect of Versed is approximately 30 to 45 minutes after a single dose, with a recovery time of 2 to 6 hours. The duration of effect of IV fentanyl begins within minutes and lasts for 30 to 60 minutes after a single dose. 

Propofol for colonoscopy leads to a quicker wakeup, a quicker discharge home, and less hangover. Virtually every surgical general anesthetic in the United States includes propofol, and anesthesiologists are experts at the administration and pharmaceutical properties of the drug. Propofol is an intravenous nonbarbiturate anesthetic which induces anesthesia quickly and provides a rapid emergence from anesthesia. The onset of action is within 20 – 40 seconds. The anesthesia provider for a colonoscopy will continue administering IV propofol until the procedure is over. A typical colonoscopy will last 20 – 40 minutes, depending on whether the gastroenterologist needs to take extra time to remove any colonic polyps. In Biden’s case, a single 3 mm benign-appearing polyp was identified and removed.

Propofol’s pharmacokinetics are described by two phases:

In the first phase (red curve), the plasma concentration decreases rapidly because the drug redistributes, or spreads, out of the bloodstream into other tissues of the body. The half–life of this fast redistribution is only 2 – 8 minutes, meaning the concentration of propofol in the bloodstream is halved every 2 to 8 minutes. This first phase explains the quick transition to wakefulness up after the drug is stopped. The second phase (black curve) is the elimination of propofol from the body. The half-life time of this elimination from the body is 4 – 7 hours (reference: MILLER’S ANESTHESIA, 9thedition, chapter 23 on Intravenous Anesthetics).

The graph below depicts the timeline after propofol is discontinued. After a one-hour infusion, the concentration of propofol in the blood drops to near zero within 30-40 minutes.

THE PROPOFOL CONCENTRATION APPROACHES ZERO 40 MINUTES AFTER THE END OF INFUSION

The website PDR.net affirms this, stating that “Recovery from anesthesia is rapid (8 to 19 minutes for 2 hours of anesthesia) and is associated with minimal psychomotor impairment.” The PDR also states that “The elimination half-life of 3 to 12 hours is the result of slow release of propofol from fat stores. About 70% of a single dose is excreted renally (by the kidneys) in 24 hours.”

While the President would be awake one hour after receiving 30 minutes of propofol, and the blood concentration would be minimal, it still takes 24 hours for 70% of a single dose of propofol to be excreted by the kidneys. Therefore, one hour after the propofol was discontinued, even though the blood concentration was minimal, a significant amount of the drug would still be in the President’s body.

I’ve had propofol anesthesia for a colonoscopy, and I can attest that I woke up promptly and was in an automobile heading home within 45 minutes after the end of the procedure. I felt alert, albeit a bit woozy, after 60 minutes of recovery time. Did I feel it would have been safe for me to resume my duties administering general anesthetics to patients at that time? No. Would a major American airline allow one of its pilots to fly passengers at that time? No. Would the U.S. Army allow a general to command thousands of soldiers at that time? I doubt it.

One hour after a propofol colonoscopy anesthetic, the President would be awake enough to converse and give a “thumbs up.” Would he be alert enough at that point to make decisions regarding the nuclear football, a potential attack on Taiwan by mainland China, or a terrorist attack on a major United States city? Was this nearly 79-year-old man safe to make all the acute decisions the United States President could have to make, only one hour after discontinuing propofol? 

The Mayo Clinic website states that, “After the exam (colonoscopy), it takes about an hour to begin to recover from the sedative. You’ll need someone to take you home because it can take up to a day for the full effects of the sedative to wear off. Don’t drive or make important decisions or go back to work for the rest of the day.” 

Was Biden fit to run the country 55 minutes after his colonoscopy anesthetic? 

Hmmm. The decision as to whether he was recovered enough to resume running the country . . . was a decision made by President Biden’s doctors on that day.

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THE NEW 2022 ASA DIFFICULT AIRWAY ALGORITHM

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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.
emailrjnov@yahoo.com
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The American Society of Anesthesiologists (ASA) just published a 2022 update on their ASA Difficult Airway Algorithm Guidelines. The 2022 document is a revision of the 2013 publication “Practice guidelines for management of the difficult airway: A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.” The 2022 ASA Difficult Airway Algorithm Guidelines are 51 pages in total.

The most important changes are identified by examining the 2013 and the 2022 algorithms side by side. Let’s look at the 2013 flow chart algorithm and compare it to the 2022 flow chart algorithm below:

THE 2013 ASA DIFFICULT AIRWAY ALGORITHM

THE 2022 ASA DIFFICULT AIRWAY ALGORITHM

Note these major changes from 2013 to 2022:

  1. The top third of the 2022 algorithm lists factors which direct the anesthesiologist to perform awake intubation. The reason for this change is undoubtably the wisdom of utilizing awake intubation when a significant risk of a difficulty airway exists. There are minimal airway risks when a patient is awake, and the benefit of placing the endotracheal tube in a difficult airway patient while the patient is awake is immense. When we give mock oral board examinations to anesthesia residents at Stanford, and we describe to the examinee that the patient has a difficult airway, the answer of “I’d do an awake intubation” is hard to criticize and almost never leads to a catastrophe. In contrast, inducing general anesthesia prior to intubation in these patients can lead to a “Can’t intubate-can’t oxygenate” emergency, which can lead to a cardiac arrest and possible anoxic brain damage.
  2. The text highlighted in red in the 2022 document is both new and vital. The first of these is “OPTIMIZE OXYGENATION THROUGHOUT,” under the pathway INTUBATION ATTEMPT WITH PATIENT AWAKE, with the footnote 2Low- or high-flow nasal cannula, head elevated position throughout procedure. Noninvasive ventilation during preoxygenation. The message is to keep oxygen flowing via nasal cannula throughout airway management attempts to minimize hypoxia, and to keep the head elevated to maximize the functional residual capacity (FRC), which is the reservoir of oxygen in the patient’s lungs.
  3. “LIMIT ATTEMPTS, Consider calling for help” is new and printed within a red box in the INTUBATION ATTEMPT AFTER GENERAL ANESTHESIA –> FAILED pathway. This is an effort to prevent repetitive unsuccessful intubation attempts from soaking up precious time, during which the brain is poorly oxygenated.
  4. “LIMIT ATTEMPTS AND CONSIDER AWAKENING THE PATIENT” is new and printed in red in the NON-EMERGENCY PATHWAY under the “Ventilation adequate/intubation unsuccessful” pathway. This is again an effort prevent repetitive unsuccessful intubation attempts from soaking up precious time, during which the brain is poorly oxygenated.
  5. “LIMIT ATTEMPTS AND BE AWARE OF THE PASSAGE OF TIME, CALL FOR HELP/FOR INVASIVE ACCESS” is new and printed in red in the EMERGENCY PATHWAY under the MASK VENTILATION NOT ADEQUATE, SUPRAGLOTTIC AIRWAY NOT ADEQUATE pathway. This is again an effort to prevent repetitive unsuccessful intubation attempts from soaking up precious time, during which the brain is poorly oxygenated.

These changes, printed or boxed in red, emphasize that the pace of difficult airway decisions is important. The duration of elapsed time is vital. When an anesthesia provider cannot intubate the patient and then cannot ventilate the patient, the oxygen level in the blood can plummet. There is a significant danger of anoxic brain damage within minutes. I’ve previously reviewed this topic in a 2019 Anesthesia Grand Rounds Lecture at Stanford, summarized in my article “Five Minutes to Avoid Anoxic Brain Damage.” The U.S. Library of Medicine website states that “Brain cells are very sensitive to a lack of oxygen. Some brain cells start dying less than 5 minutes after their oxygen supply disappears. As a result, brain hypoxia can rapidly cause severe brain damage or death,” and “Time is very important when an unconscious person is not breathing. Permanent brain damage begins after only 4 minutes without oxygen, and death can occur as soon as 4 to 6 minutes later.”

The sentence “Be aware of the passage of time, the number of attempts, and oxygen saturation” appears more than once in the 2022 Difficult Airway Algorithm Guidelines article, and is a key point for all anesthesia providers who encounter a difficulty airway emergency.

In my roles as an anesthesia quality assurance reviewer or a medical-legal expert consultant, I’ve seen this issue arise multiple times. Even though anesthesia providers believe they are following the Difficult Algorithm accurately, they are doing things too slowly, and they waste too much time. Once it’s clear that a “Cannot intubate-cannot oxygenate” scenario is occurring, the time clock is running, and the anesthesia provider must not only do the correct thing but he or she must do the correct thing without undue delay. The necessary procedure may be as invasive as a cricothyroidotomy/front of the neck access via the scalpel-bougie-endotracheal tube approach.  

The five points listed above are the major changes in the algorithm. In addition, the new 2022 article includes a Pediatric Difficult Airway Algorithm and an approach to Extubation of the Trachea in a Difficult Airway Patient. Other important quotes from the 2022 article include (bold emphasis added):

  1. “The consultants and members of participating organizations strongly agree with recommendations to perform awake intubation, when appropriate, if the patient is suspected to be a difficult intubation and difficult ventilation (face mask/supraglottic airway) is anticipated.”
  2. “Meta-analyses of randomized controlled trials comparing video-assisted laryngoscopy with direct laryngoscopy in patients with predicted difficult airways reported improved laryngeal views, a higher frequency of successful intubations, a higher frequency of first attempt intubations, and fewer intubation maneuvers with video-assisted laryngoscopy.”
  3. The footnote (7) for alternative difficult intubation approaches states: 7Alternative difficult intubation approaches include but are not limited to video-assisted laryngoscopy, alternative laryngoscope blades, combined techniques, intubating supraglottic airway (with or without flexible bronchoscopic guidance), flexible bronchoscopy, introducer, and lighted stylet or lightwand. 
  4. “A randomized controlled trial comparing a videolaryngoscope combined with a flexible bronchoscope reported a greater first attempt success rate with the combination technique than with a videolaryngoscope alone.”
  5. “When appropriate, refer to an algorithm and/or cognitive aid.” 

AUTHOR’S NOTE: I’d suggest that the Stanford Emergency Manual of cognitive aid algorithms for anesthesia and ACLS emergencies be onsite at all anesthetizing locations. 

I’d also recommend that the 2022 ASA Difficult Airway guideline algorithm be onsite at all anesthetizing locations.

Every anesthesia professional will encounter patients with difficult airways—this is one of the most important and most feared situations in our specialty. Commit the 2022 ASA Difficult Airway Algorithm to memory. Use awake intubation when you’re concerned about the potential of a “Cannot intubate-cannot oxygenate” scenario. And if you’re in the middle of a difficult airway emergency, call for help and be aware of the passage of time, the number of attempts, and the oxygen saturation. Don’t let an excessive number of minutes elapse without regaining oxygenation of your patient.

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The most popular posts for laypeople on The Anesthesia Consultant include:
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PHYSICIAN TRAINING: TWO FORKS IN THE ROAD

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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.
emailrjnov@yahoo.com
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You’re in the middle of your medical school years, and wondering what specialty to pursue. There are two major forks in the road when trying to choose the career that suits your emotional make-up and work ethic. The sooner you understand these two forks in the road, the better off you’ll be. 

CLINIC DOCTOR OR ACUTE CARE DOCTOR?

The first major fork in the road is whether you’re best suited for a career as a clinic doctor or as an acute care doctor. The main specialties for clinic doctors are internal medicine, family practice, pediatrics, and psychiatry. The main specialties for acute care doctors are surgery, anesthesiology, emergency medicine, and obstetrics-gynecology.

Internal medicine and pediatrics include subspecialties. The subspecialties of endocrinology, oncology, nephrology (kidney specialist), and allergy-immunology are primarily clinic doctors. Cardiologists are hybrid clinic/acute care doctors who must first complete a residency in internal medicine, and then subspecialize with 3-4 additional years of fellowship training. Pulmonologists (lung specialists) are also hybrid clinic/acute care doctors who must first complete a residency in internal medicine, and then subspecialize with 2 additional years of fellowship training.

Pursue a career as a clinic doctor if you enjoy sitting in a room, listening to patients and talking to patients. Most clinic doctors rarely place a tube or a needle into a patient after their residency training is completed. Most clinic doctors work daytime hours, but have weekend call and night call, which may include phone consultations or emergency room visits. Clinic doctors see multiple patients per day, perhaps 4-8 patients per day for psychiatrists, and up to 30 patients or more for some specialists such as allergists.

Pursue a career as an acute care doctor if you prefer adrenaline-charged arenas such as the operating room, the intensive care unit, the labor and delivery suite, or the emergency room. The pace will be much faster than in a clinic, and the stress level will be higher. You’ll perform surgeries, deliver babies, or run trauma Code Blues. If you become an anesthesiologist, you’ll routinely put your patients into pharmaceutical comas and then reverse that status.

These are some of the significant differences between the clinic path and the acute care path:

  1. Sudden risks are almost unknown in clinics. In a clinic setting, doctors make diagnoses, order tests, and prescribe oral medications. In an acute care setting, health care interventions involve scalpels, tubes, IVs, intravenous medications, breathing tubes and ventilators. Malpractice events are less likely to occur in clinic settings. It’s difficult to harm a patient in a clinic. Clinic errors may involve the failure to make the correct diagnosis or the failure to follow up on the result of an important test. Acute care errors can include failure to manage the A-B-Cs of airway, breathing, and circulation safely.
  2. Income differences. Physicians who do procedures, and who incur the risks of procedures gone wrong, earn more money. Physicians who staff clinics usually earn less. This fact may be concealed from medical students. Once students become aware of the income differences, the invisible hand of capitalism tends to drive them into the acute care specialties which are higher paying. The financial numbers are pertinent, because the median debt for an American medical school graduate was $200,000 in 2019. The average four-year cost for a public medical school education was $250,222, and the average four-year cost for a private medical school education was $330,180.  Medical school graduates need to earn a significant income to repay their student loans.
  3. Long-term relationships with patients. Primary care clinic doctors often attend to the same patients for decades, and form long-term cordial relationships with their patients. Acute care doctors typically see a patient once, for a surgery, an anesthetic, a childbirth, or an emergency room visit. Acute care doctors rarely develop lasting interactions with any of their patients. Clinic doctors may receive holiday cards or presents from their patients; acute care doctors will not.
  4. Lifestyle differences. Clinic doctors mainly work daytime hours, although they may receive afterhours phone calls regarding patient health problems. If one of their patients becomes acutely ill, a primary care doctor may see that patient in the emergency room. Some acute care specialists work as shift labor, especially emergency room doctors, anesthesiologists, or hospitalists. Acute care doctors may also have schedules in which they can take blocks of weeks or even months off at a time, giving them the option to pursue longer vacations or travel. Primary care doctors are rarely able to take long blocks of time away from their patients.

ACADEMIC DOCTOR OR COMMUNITY DOCTOR?

A second fork in the road during physician training is the choice whether to become an academic physician or a community physician. An academic physician is a faculty member at a medical school. Their job description includes teaching younger doctors and mentoring younger doctors in patient care. Academic physicians work in university hospitals, Veterans Administration (VA) hospitals, and county hospitals—any setting where medical students and resident physicians are training. Ambitious medical students often plan to become academic physicians, because they admire the academic professors who are training them. Ambitious medical students may profess that they want to become academic professors, because it may appear this career path is what the finest university training programs are looking for. The gambit seems to look like this: if you want to be admitted to a famous university residency program, tell them you want to be a famous professor just like the individual who is interviewing you for that program. I can only advise you to tell the truth about your career ambitions.

Most physicians eventually drift away from academic intentions, and become community physicians. Community physicians are individuals who work at your local clinic, your local hospital, or your local health maintenance organization. A 2017 article stated that “Although 45 percent of graduating medical students aspire to work in an academic setting, only about 16 percent will do so. Of those who do work in academic settings, up to 38 percent will leave academia within 10 years.” 

These are some of the significant differences between the between the academic path and the community path:

  1. Income. Academic physicians usually earn less money than community physicians. Academics spend part of their time teaching young doctors, instead of seeing additional patients. Academics may also spend part of their time doing laboratory science or clinical studies, instead of seeing additional patients. Academic departments also typically pay a “Dean’s tax” to the medical school dean, as part of their agreement within the medical school. 
  2. Housestaff back-up. Academic physicians have a team of housestaff physicians—interns, residents, and fellows—to do many of the mundane tasks of patient care for them. These housestaff physicians may sleep in the hospital and handle middle-of-the night issues while the academic faculty member sleeps at home. This is a significant benefit. I can attest that as you age, you’ll have less and less desire to get out of bed to handle urgent medical issues. Community physicians must function like interns. They set up call schedules to share night duty with other community physicians in the same specialty, but if there’s an issue at night when you’re on call, you will have to drive to the hospital to handle it.
  3. Tenure for professors. If academic professors have a productive career of publishing significant research, their university may award them with tenure, defined as lifetime job security at that university. Tenure guarantees a distinguished professor academic freedom and freedom of speech by protecting him or her from being fired no matter how controversial or nontraditional their research, publications, or ideas are. This benefit is usually only an option for basic science research doctors who are specifically hired to “tenure-track” appointments.

A THIRD FORK:

A small minority of medical school graduates shun either academic or community practice, and instead take their MD degree and go directly to work in industry either as a researcher at a medical company, or a consultant in a medical industry. Consider this path if you believe you’re not suited to taking care of patients.

My Journey:

I had personal experience with each of these forks in my medical education road. During medical school I was having a difficult time deciding between surgery and internal medicine. During my final summer quarter break, I returned to my hometown and joined the local general surgeon to observe him performing a gall bladder surgery. After the procedure, I questioned him about his satisfaction with his career in general surgery. He told me, “I’m very happy with general surgery, but if I had to do the 7-year residency over again, I could never do it. It was that difficult.” The look on his face told me what I needed to know, so I opted for a career in internal medicine. I matched at Stanford and began my three-year residency. During my second year, while I was spending my afternoons in the internal medicine clinic, I realized I preferred acute care to clinic care. That same year I’d spent one month in the Stanford intensive care unit (ICU) rotation. The Stanford anesthesia department ran the ICU, and I met multiple faculty and resident anesthesiologists who loved their specialty and were excellent role models. I made an appointment to meet with the ICU physician-in-chief, and told him I wanted to become an ICU specialist like him. He told me, “If you want to be an ICU doctor, I’d advise you to do an anesthesia residency first, because ICU care involves airway-breathing-circulation, and anesthesiologists are the airway experts. But once you finish your anesthesia residency, you’ll never come back to see me, because you’ll love anesthesia so much you’ll probably just do anesthesiology as a career.” I followed his advice. I applied to anesthesia residencies, and was eventually accepted to begin my anesthesia training, albeit three years into the future.

During those three years, I finished my internal medicine training. Then I hovered at the fork in the road between academic and community medicine during my one-year gap between my internal medicine and anesthesia residencies. The Stanford Department of Internal Medicine hired me for a twelve-month position as a faculty member in the emergency room. My role was to be the attending in the ER from 9 a.m. to 5 p.m. Monday through Friday, and to give a lecture to the residents each morning at 8 a.m. I was thrilled to be on the faculty at Stanford at the young age of 29. I discovered during that year that if you’re an academic doctor/clinician/educator who doesn’t do research, that you have minimal respect within your department. That same year I met many community doctors on their ER duty who were very happy with their work. My conclusion from my one-year academic appointment was that if you enjoyed clinical care, then it was better to just graduate from your training program and go out there and do clinical care in the community. If I’d had the skillset to become a tenure-track academic professor, perhaps I would have pursued a university career, but I did not.

THE BIG PICTURE:

There is tremendous competition to become a physician. Applications to medical school are at an all time high. According to the American Association of Medical Colleges (AAMC), applications increased 18% from 2020 to 2021. Stanford University School of Medicine received 11,000 applications for an admission class of 90 spots.

It’s an honorable and a wonderful career to heal and take care of sick and suffering as a medical doctor. If you’re admitted to an American medical school, you’ll have the choice whether to become a primary care doctor or an acute care doctor. You’ll have the choice to become an academic physician or a community physician. But you’ll have made the most important choice already—to become a medical doctor in the first place. 

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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 = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

EMERGENCY AT A SURGERY CENTER

THE ANESTHESIA CONSULTANT Leave a comment
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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT
Latest posts by THE ANESTHESIA CONSULTANT (see all)

You’re the anesthesiologist assigned to a freestanding ambulatory surgery center (ASC). Are you and the facility prepared for an emergency at a surgery center? Let’s examine this case study:

You meet your first patient of the morning, a 75-year-old female scheduled for lateral epicondylitis release surgery on her right elbow.  You review her medical record and interview her. You discover she had her aortic valve replaced with a small metal valve two years earlier. She is active, although she does experience mild shortness of breath on walking stairs. She is obese, weighing 200 pounds, with a BMI=35. She is on no medications. On physical exam, her vital signs are normal, her lungs are clear, and her heart exam is positive for the clicking sound of a mechanical valve and a 2/6 systolic murmur. She has a thick neck and a large tongue. The surgeon says he will only need to operate for 15 minutes. The patient refuses a regional nerve block, so she’ll need to be asleep.

You attach the standard vital sign monitors, preoxygenate the patient, and induce anesthesia with 150 mg of propofol, 50 micrograms of fentanyl, and 40 mg of rocuronium. You intubate her trachea with a 7.0 tube without difficulty, and place her on a ventilator delivering 1.5% sevoflurane and 50% nitrous oxide.

The patient’s arm is prepped and draped. The surgeon injects 2% lidocaine at the skin incision site, and the surgery begins. Vital signs remain normal with BP=110/70, P=80, and oxygen saturation=99%. The surgery concludes after 17 minutes. You discontinue the sevoflurane and reverse the paralysis with sugammadex. The patient’s blood pressure increases to 150/100 within three minutes. Three minutes later the oxygen saturation drops to 80% and thick frothy fluid bubbles into the endotracheal tube and the circle breathing hoses which connect the patient to the anesthesia machine. The blood pressure is now BP=180/120.

You call for help and attempt to suction the frothy fluid out of the breathing tubes. You listen to the lungs and hear loud rattling rales. You assess that you’re dealing with pulmonary edema (excess fluid in the lungs). The patient’s oxygen saturation drops to 70%. 

A second anesthesiologist responds to your call for help and arrives in the room. You explain what is going on, and while you do, the oxygen saturation becomes unmeasurable and the blood pressure machine fails to give any reading. Your colleague suggests you administer 20 mg of Lasix (furosemide) as a diuretic, and he injects this for you. You continue to ventilate the patient with 100% oxygen, and continue to suction copious fluid out of the patient’s lungs. The ECG monitor descends into a slow agonal rhythm, and when you check the carotid artery at the patient’s neck, there is no pulse. You call a Code Blue and begin CPR compressions on the patient’s chest. After thirty minutes of Advanced Cardiac Life Support (ACLS) drug administration, the pulses have not returned. You have no other therapies to offer, and the patient is declared dead.

Acute pulmonary edema on a chest X-ray

Did this have to happen? No, it did not. In a parallel universe with more competent clinicians, let’s look at how this patient should have been handled:

  1. First off, this case was inappropriate for a freestanding outpatient surgery center. This freestanding outpatient surgery center was located miles from the local hospital, and the hospital resources of an intensive care unit (ICU), respiratory therapists, arterial blood gas analysis, and chest X-rays were not available. The surgery was trivial enough—a brief procedure on the elbow—but the patient had a medical history which was too complex to approve a general endotracheal anesthetic at a freestanding ASC. Typically patients who have had a successful cardiac valve replacement are much improved after their surgery, and complaints of shortness of breath or extreme fatigue—symptoms of inadequate cardiac function—are absent. A 75-year-old patient who complains of shortness of breath on exertion was a poor candidate for anesthesia at an ASC. A pre-operative cardiology consult was indicated, and would likely include an echocardiogram and a stress test. In our parallel universe, the echocardiogram ordered by the cardiologist revealed a small aortic valve diameter—less that one centimeter—and a dilated left ventricle with an ejection fraction (LVEF) of 35% (a severely abnormal value, as the normal left ventricle can eject more than 50% of its volume). This patient with a low LVEF needed to have her surgery postponed until her cardiac function was improved via medications or a further surgical cardiac intervention was done. After that, when and if this elbow surgery ever does occur, it would need to be done in a hospital setting.
  2. What if the anesthesiologist did not adhere to #1 above, and the anesthetic led to pulmonary edema as described above? How could the anesthesiologist better manage the emergency? All acute medical care is managed by A-B-C, or Airway-Breathing-Circulation. In this case the Airway tube was in place. The Breathing was being done by the ventilator, but the breathing tube was occluded by pulmonary edema fluid. The treatment to improve the Breathing was both active suctioning to clear the airway of fluid and medical treatment to reverse the cause of the increased fluid. Diagnosis of the Breathing and Cardiac problems was as follows: discontinuation of anesthesia in this patient, who still had a breathing tube in her trachea as she awakened, stimulated markedly increased blood pressure –> the left ventricle could not eject against this high pressure –> this led to acute left heart failure with resulting backup of fluid into the lungs –> this caused pulmonary edema and dropping oxygen saturation. (Because of her airway anatomy, she was not a candidate for a deep extubation.) Treatment for both the Breathing problem and the Cardiac problem was an emergency afterload reducing drug such as nitroprusside. Every ASC must have a Code Blue cart with emergency drugs and equipment, and the anesthesiologist must call for the cart. He or she instructs one of the RNs to prepare a 250 ml bag of nitroprusside and to attach it to an intravenous infusion pump.
  3. We anesthesiologists are only as good as our monitoring devices. When the oximeter reports very low readings and the BP cuff stops working, we are in big trouble. Anesthesiologists cannot safely administer a potent intravenous infusion such as nitroprusside without an accurate second-to-second monitor of the patient’s blood pressure. One of the anesthesiologists quickly places an arterial line catheter in the left radial artery at the wrist. The arterial line is connected to the monitoring equipment, to reveal that the blood pressure is 240/140, for a mean blood pressure (MAP) of 173 mm Hg. The anesthesiologists connect the nitroprusside drip to the peripheral intravenous line, and infuse the drug to decrease the blood pressure to 140/80 (MAP=100) within minutes. The frothing fluid in the breathing tubes clears, and the oxygen saturation returns to 100%. 
  4. The anesthesiologists then place a central venous catheter in the right internal jugular vein and transfer the nitroprusside infusion to the central line. They titrate small doses of fentanyl and Versed into the peripheral IV line to sedate the patient because immediate extubation is not appropriate, and prepare to transfer the patient via ambulance to the nearest hospital ICU. The original anesthesiologist accompanies the patient in the ambulance to the ICU, while continuing to monitor the patient’s vital signs and manage the blood pressure, sedation, ventilation, and oxygenation.
  5. The patient’s sedation is discontinued the next morning in the hospital ICU, and she is extubated safely. She has no brain damage or cardiac damage. The anesthesiologist visits her that afternoon, and converses with her as she eats her lunch. She has questions about how this could have happened, and he answers each question honestly.

There are multiple take-home messages from this case study:

  1. The preoperative screening of patients at a freestanding ASC is crucial. No one wants to have a Code Blue or a near-Code Blue, miles away from any hospital. Surgery centers manage preoperative screening in various ways, but most community ASCs do not run an in-person preoperative anesthesia clinic. At our ASC, a preoperative caller contacts each patient two days prior to their scheduled surgery, and fills out a comprehensive history form based on the patient’s answers and any medical tests and/or consults available on that patient. If there are positive answers regarding important medical issues such as shortness of breath, chest pain, heart disease, obstructive sleep apnea, morbid obesity, chronic kidney or liver disease, cancer, or previous transplants, then the preoperative caller refers the case to the Medical Director. The Medical Director makes the decision whether the patient is appropriate for the scheduled surgery. If the patient is not appropriate, the case is cancelled two days ahead of time.
  2. If an acute respiratory or cardiac emergency occurs at an ASC, the first move is to call for help from a second anesthesiologist. Two minds and four hands are a better solution. The registered nurses bring a copy of the Stanford Emergency Manual into the room, as well as the code cart which includes the emergency drugs and monitoring equipment.
  3. In a true emergency, diagnosis and treatment must occur within minutes. No anesthesiologist wants to be the doctor who “draws a blank” when their patient is trying to die right in front of them. Stanford’s Dr. David Gaba pioneered acute anesthesia simulator training to improve anesthesiologist performance in emergency settings. You may inquire whether such simulations are available in your geographic area.  
  4. Always manage acute medical emergencies as A-B-C, or Airway-Breathing-Circulation, in that order. In this case the improvement in Breathing required suctioning and afterload reduction, and the improvement Cardiac required arterial line monitoring and afterload reduction.
  5. Realize that short simple surgeries exist, but some short simple surgeries on sick patients present significant anesthetic risks. The anesthesiologist must assess all medical risks and not be swayed by a surgeon who insists this will be “just a short simple case.” If an anesthesiology complication occurs, that surgeon will not likely be blamed, nor will he or she come to your defense. It will be “the anesthesiologist’s fault.”
  6. Every ASC must be prepared for acute unexpected emergencies. The code cart must be stocked with ACLS medications and monitoring equipment for arterial and/or central lines. The ASC should ideally have a copy of the Stanford Emergency Manual, and all drugs and equipment listed in that manual should be available, even though it is not a hospital setting.
  7. It’s important for ASCs to conduct mock-Code-Blue drills on a yearly basis so that staff is prepared when a real emergency occurs.
  8. Depending on cost, an ASC may choose to stock a nitroglycerin drip or a newer potent vasodilator medication such as Cleviprex (clevidipine) rather than nitroprusside in their code cart.
  9. Ideally, anesthesiologists who work at ASCs should also have medical staff privileges at an acute care setting in a hospital, and be performing anesthetics on sicker hospitalized patients there. If an anesthesia provider’s practice is reduced to only healthy patients for outpatient surgeries, that anesthesia provider may become less than competent if a patient develops an emergency in a surgery center.
  10. In case of an emergency at a surgery center, your goal is to stabilize the patient and transfer the patient to the nearest hospital as soon as it is safely possible. The hospital resources of an ICU, respiratory therapists, radiology, cardiology consultation, and a full laboratory service including arterial blood gas analysis are invaluable.

For those readers who are surgical patients, let me reassure you that the vast majority of patients cared for at freestanding ASCs have no anesthesia complications, and many ASCs are staffed by competent anesthesiologists and nurses prepared to save you in the rare event that something goes awry before, during, or after your outpatient surgery.

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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 = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

SMART GLASSES IN THE OPERATING ROOM

THE ANESTHESIA CONSULTANT Leave a comment
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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT
Latest posts by THE ANESTHESIA CONSULTANT (see all)
binocular Moverio BT-35E smart glasses

A South Korean group led by Dr. Y.E. Jang published a study in this month’s issue of Anesthesiology describing the use of a head-mounted smart glasses display during radial arterial line placement in patients younger than 2 years. Placing a catheter into the tiny radial artery in a child’s wrist is one of the most difficult procedures in our specialty. The average internal diameter of the radial artery is 1.2 ± 0.3 millimeter in children aged less than 2 years. Wearing smart glasses improved the anesthesiologist’s first-attempt success rate, and reduced the procedure time and complication rates. This was an important study, and important information.

In the control group of this study, each anesthesiologist would use a traditional ultrasound screen to visualize the artery. 

The anesthesiologist must look up to see the ultrasound machine, while he is working on the patient’s wrist.

In the smart glasses group, the ultrasound machine was located behind the operator, and the smart glasses were paired with the ultrasound machine. The smart glasses used were a binocular Moverio BT-35E unit,  connected to an ultrasound machine by a HDMI cable. The smart glasses displayed a simultaneous replica of the ultrasound screen image in front of the anesthesiologist’s eyes, so the operator could easily see both the procedure field (the radial artery at the wrist) and the ultrasound screen simultaneously without any head and eye movement. 

The anesthesiologist can see the ultrasound image while he is looking at the patient’s wrist

One hundred sixteen children were included in the study. The smart glasses group had a higher first-attempt success rate than the control group: 87.9% (51 of 58) vs. 72.4% (42 of 58) in the control group, with p = 0.036. The smart glasses group also had a shorter first-attempt procedure time (median 33 seconds) than the control group (median 43 seconds), with p = 0.007.

An accompanying editorial in the same issue of Anesthesiology stated, “This elegant prospective trial offers objective insight into the potential impact of head-mounted displays on the overall success and provider ergonomics in anesthetic care during technically complex procedures. Head-mounted displays and augmented reality devices have been evaluated in various settings, including placement of ultrasound-guided peripheral nerve blocks, for use in intraoperative patient monitoring and placement of central venous catheters.”

What will be the role of smart glasses in medicine? We all remember the original hype surrounding the 2013 release of Google Glass, a product which failed to capture a significant market of users. 

Google Glass

Problems with Google Glass included: “The unit overheated frequently with use and shut itself down, the battery life wasn’t long enough (less than an hour), the apps were great demos but limited in scope, and the user interface — tapping, swiping, blinking, head gestures, and the voice recognition after saying ‘Ok Glass’ — was not always smooth.” 

A 2014 study looked at using Google Glass to aid central venous catheter insertion in adults. This study failed to show any positive effects on success rate, procedure time, or number of attempts. These results most likely were due to the fact that larger central blood vessels in adults are easier to locate than the diminutive radial artery in the pediatric population.

Smart glasses are being studied in aviation. Both anesthesiologists and pilots have occupations where the slightest miscalculation or mistake can cost lives. Any step which enhances safety can be seen as a valuable change. A new product called AEROGLASS (Augmented reality aerial navigation for a safer and more effective aviation) attempts to put augmented reality in front of pilots’ eyes.

AEROGLASS in aviation

A recent review states, “The AEROGLASS turnkey smart glass solution provides general aviation pilots a true 3D, 360° view of navigation and safety features. One of the largest challenges for aviation professionals is accurately and safely navigating an aircraft. Current studies show that pilot error accounts for up to 70 % of all aviation accidents. Piloting an aircraft requires translating complex readings from the control panel displayed in 2D into a 3D environment and 360° reality. Accessing this information also requires pilots to take their eyes off the sky, thereby making them more prone to errors and increasing their stress levels. With a headset on, pilots will now be able to have digital 3D information appearing naturally in their field of vision, helping them make faster and better decisions. ‘Our product is an AR solution based on smart glasses. When pilots wear them, they will continue to see the scenery around them, but in addition to that, relevant safety and navigation information will be overlaid transparently within their field of view. . . . At first, the newly developed technology targets professional general aviation, but after some time AEROGLASS plans to utilize its technology in other transportation domains such as automotive and maritime or even for passengers.”

There are two potential uses for smart glasses in anesthesiology. The first is for performing invasive procedures which require ultrasound technology, such as the placement of peripheral nerve blocks or the placement of catheters into arteries and veins. This use makes sense, because it can make some procedures easier, as shown in the Jang study. But the placement of pediatric arterial lines, as in the Jang study, is a small marketplace (e.g. including pediatric open heart surgery, and pediatric surgery involving major blood loss). Ultrasound imaging for the placement of peripheral nerve blocks would be a bigger market, but to date there is no data supporting the use of smart glasses in the placement of peripheral nerve blocks.

Anesthesia vital signs monitor display

A second and more compelling use for smart glasses would be the display of a patient’s vital sign monitoring in real time on the smart glass screen, so that an anesthesiologist is in constant contact with the images of the vital sign electronic monitors. In 2021 a nurse anesthetist publication looked at the use of Google Glass by seven nurse anesthetists for display of the vital signs monitor, but there were no quantitative data to examine the significance of the technology. The physician medical literature has not studied the issue. 

Advantages of using smart glasses for real time patient vital signs monitoring would include:

  • The electrocardiogram, oximeter, and end-tidal CO2 waveforms would be displayed front and center in the anesthesiologist’s sight. The vital signs of heart rate, blood pressure, oxygen saturation, end-tidal gas values, and temperature would be constantly visualized no matter where the anesthesiologist was looking. 
  • This is a futuristic technology, and its use may connote that the hospital or surgery center is at the cutting edge of monitoring and safety equipment (despite the lack of any data to confirm this advantage at this time).

Disadvantages of using smart glasses for patient vital signs real time monitoring would include:

  • The cost of the head-mounted display (Moverio BT-35E, glasses in the current study) is approximately $800. This is not a large amount of money, but multiplied times every anesthetizing site, the expense rises.
  • The requirement for reliable and constant Bluetooth connection between the smart glasses and the electronic monitor.
  • The weight of the smart glasses (119 grams, or 0.43 pounds) is 4 – 8 times heavier than usual glasses (25 – 50 grams, or 0.05 – 0.1 pounds). Many individuals may object to wearing this product. 
  • If an anesthesiologist wears prescription glasses of his or her own, there would be two pairs of glasses needed.
  • The question of whether smart glasses are necessary in every routine anesthetic.

Let’s look at this last point. During most routine anesthetics the constant beep-beep-beep note and tone of the pulse oximeter gives the anesthesiologist real-time audible monitoring of both the heart rate and the ballpark oxygen saturation, without having to look at the display. The anesthesiologist still has to look up at the vital signs screen intermittently to note the blood pressure, end-tidal gas values, and temperature, but this intermittent look is part of the vigilance all anesthesiologists must do anyway. A left-to-right scanning gaze at the patient, the surgical field, the IV lines, any IV infusions, the airway tubing, the anesthesia machine, and the vital signs monitor screen is standard procedure in anesthesiology. If adopted, the use of smart glass technology for routine vital signs monitoring would indeed be a large market. Would the addition of smart glasses for routine monitoring be an overdose of technology in the operating room cockpit? Does excessive technology distract us from the actual patient?

Let me give you a historical perspective. As recently as the year 2000 there were zero computers in the anesthesia workstation. Our equipment included an anesthesia gas machine, a vital signs monitor, and carts which contained breathing tubes, airway equipment, syringes, needles, and drugs. Now we are encumbered by an electronic medical record (EMR) system screen + keyboard, and a narcotic-dispensing computerized drug cart in every hospital anesthetizing location. 

EPIC anesthesia electronic medical record (EMR) computer
Anesthesia drug cart
Anesthesia bar code reader/label printer computer

Add in some smart glasses with Bluetooth connection, and you’ve got an armada of gadgets to both aid the anesthesiologist and to distract him or her from the actual patient, who is three feet away and in need of vigilant care. Is anesthesia care any safer with all the computers: the EMR, and the narcotic-dispensing computerized drug cart? There is no data that these devices have made anesthesia any safer—it is only more complicated.

If smart glasses are ever to become a standard of care, I believe it would require data and proof that anesthesia complications were reduced and anesthesia outcomes were improved with such a device.

Technology in medicine tends to come between the patient and his or her doctor, a theme explored in my 2019 editorial, and in my novel Doctor Vita. View the future of medical technology with care. Think of that computer terminal between you and your doctor during a clinic visit. Now imagine a parallel situation with that computer terminal between you and your anesthesiologist, between you and your emergency room doctor, or between you and your ICU nurse. Will adding more electronic devices lead to safer care or more convoluted care? 

Put it another way: Do we need smart glasses, if we have smart anesthesiologists?

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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 = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

CARDIAC ARREST DURING A PEDIATRIC TONSILLECTOMY

THE ANESTHESIA CONSULTANT Leave a comment
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.
emailrjnov@yahoo.com
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A 12-year-old boy and his mother walk into a surgery center. The child is scheduled for a tonsillectomy, and is otherwise healthy. The anesthesiologist induces general anesthesia, and ten minutes later the patient has ventricular arrhythmias which descend into a cardiac arrest. Advanced Cardiac Life Support (ACLS) measures are applied, but the child cannot be resuscitated, and is declared dead. What caused this cardiac arrest during a pediatric tonsillectomy?

This is an actual closed malpractice case which I was asked to review. The anesthesiologist induced general anesthesia with propofol and a paralytic drug called succinylcholine (sux-in-ol-KOH-leen), and then inserted a breathing tube successfully into the patient’s windpipe. All vital signs were normal. Sevoflurane, nitrous oxide, and 50% oxygen were ventilated into the patient’s lungs. The surgeon began the tonsillectomy. One minute later the cardiac arrest occurred. The anesthesiologist followed ACLS guidelines, but standard ACLS treatments and hyperkalemia (elevated potassium concentration) treatments were unsuccessful.

Succinylcholine is an intravenous muscle relaxant (paralytic) drug commonly used in the United States. Succinylcholine is an old drug—available since 1951—which has the distinction of being the most rapid-acting intravenous muscle relaxant, and also the shortest-acting muscle relaxant. Succinylcholine is an important drug in an anesthesiologist’s toolkit. When an airway emergency threatens a patient’s life, such as the unexpected occurrence of laryngospasm, succinylcholine is the emergency drug of choice to paralyze the patient, relax the spasm of the vocal cords, and enable the anesthesiologist/emergency room physician/acute care physician to insert a life-saving breathing tube into the trachea.

But succinylcholine can be a dangerous drug. The Food and Drug Administration (FDA) placed a Black Box Warning on succinylcholine in 1994. The current succinylcholine warning in the PDR (Prescribers’ Digital Reference) reads:

“Succinylcholine is contraindicated in patients with a personal or familial history of malignant hyperthermia and/or skeletal muscle myopathy. Malignant hyperthermia may be precipitated by succinylcholine; concomitant use of volatile anesthetics may further increase this risk. 

In neonates, infants, children, and adolescents, reserve the use of succinylcholine for emergency intubation or instances where immediate securing of the airway is necessary (e.g., laryngospasm, difficult airway, full stomach, or lack of intravenous access). 

There have been rare reports of ventricular dysrhythmias and fatal cardiac arrest secondary to rhabdomyolysis with hyperkalemia, primarily in healthy-appearing pediatric patients who were subsequently found to have undiagnosed skeletal muscle myopathy, most frequently Duchenne’s muscular dystrophy. 

Affected pediatric patients are typically, but not exclusively, males 8 years or younger. Although some patients have no identifiable risk factors, a careful history and physical exam may identify developmental delays suggestive of myopathy, and a preoperative creatinine kinase could identify patients at risk. 

Closely monitor body temperature, expired CO2, heart rate, blood pressure, and electrocardiogram in pediatric patients to help detect early signs of malignant hyperthermia and/or hyperkalemia. 

The rhabdomyolysis syndrome often presents as peaked T-waves and sudden cardiac arrest within minutes of succinylcholine administration. If cardiac arrest occurs immediately after succinylcholine administration, institute treatment for hyperkalemia (e.g., intravenous calcium, bicarbonate, glucose with insulin, hyperventilation). If malignant hyperthermia is suspected, initiate appropriate treatment (e.g., dantrolene, supportive care) concurrently.”

Per the Black Box warning, succinylcholine has the potential for inducing life threatening hyperkalemia in children with undiagnosed skeletal muscular dystrophies. Severe hyperkalemia and ventricular arrhythmias followed by cardiac arrest may occur in apparently healthy children who have an occult muscular dystrophy (usually Duchenne’s muscular dystrophy). An occult muscular dystrophy is a rare inherited disease. The global prevalence of Duchenne’s muscular dystrophy is 7.1 cases per 100,000 males, and 2.8 cases per 100,000 in the general population. The Black Box warning on succinylcholine recommends to “reserve use in children for emergency intubation or need to immediately secure the airway.”

The Black Box warning applies to neonates, infants, children and adolescents. No parent wants their son or daughter under the age of 18 to electively receive a drug which has an FDA Black Box Warning for use in adolescents. No parent wants their neonate, infant, child, or adolescent to have a risk of sudden cardiac arrest under general anesthesia for a common elective surgery.

In 1994 the Anesthesia Patient Safety Foundation (APSF) published a sentinel article about the risks of succinylcholine in pediatric anesthesia. The article reviews the history of the succinylcholine warning: “In 1992, Drs. H. Rosenberg and G. Gronert published a letter in Anesthesiology briefly reviewing four deaths in male children under the age of eight who had received halothane and then succinylcholine. These cases were identified through the Malignant Hyperthermia (MH) Hotline. Reference was also made to ‘11 similar cases’ identified through the German MH Hotline. Their letter concluded with the statement: ‘We have notified the Food and Drug Administration of this potential problem and recommended that anesthesiologists carefully consider the indications for use of succinylcholine in young children.’ This letter was accepted for publication August 24,1992.” The article goes on to emphasize “the need for prompt and appropriate treatment should hyperkalemic arrest occur. This treatment involves the intravenous administration of calcium. With proper treatment, approximately 50% of patients have survived this catastrophic hyperkalemia.” The Black Box warning specifically states, “If cardiac arrest occurs immediately after succinylcholine administration, institute treatment for hyperkalemia (e.g., intravenous calcium, bicarbonate, glucose with insulin, hyperventilation).”

Despite the Black Box warning, how often is succinylcholine still used for non-emergency pediatric anesthetics in the United States? No one knows. I can attest that during a recent Quality Assurance review in the Northern California, I saw anesthetic records from a board-certified anesthesiologist who administered succinylcholine to a 14-year-old boy for elective ear surgery. I discussed this with the anesthesiologist, who was unaware they were doing anything dangerous.

There is an excellent alternative to the elective use of succinylcholine. For most cases, pediatric or adult, the muscle relaxant rocuronium is a superior alternative to succinylcholine. Succinylcholine is the IV muscle relaxant with the most rapid onset, but large doses (0.9 mg/kg) of rocuronium are nearly as rapid as succinylcholine, without any of succinylcholine’s risks.   Succinylcholine is also the IV muscle relaxant which wears off the fastest, but since the year 2015 FDA approval of the muscle relaxant reversal drug sugammadex (Bridion), an intubating dose of rocuronium can be rapidly reversed within 3 minutes by administering 16 mg/kg of sugammadex. 

Succinylcholine remains an important drug for the treatment of airway emergencies. I would never begin a general anesthetic if I did not have a vial of succinylcholine immediately available in case of an airway emergency. In addition, succinylcholine is important because it can be administered intramuscularly (in a patient who has no IV). For example, if a child is undergoing an inhalational induction of general anesthesia with sevoflurane vapor prior to a surgery, and the child suddenly goes into laryngospasm before any IV can be started, (this does occur, not uncommonly, and is a true emergency), the appropriate treatment is an intramuscular injection of 4 mg/kg of succinylcholine. The child will become paralyzed within minutes, and the anesthesiologist can then insert a life-saving breathing tube. (The mean onset of paralysis with 4 mg/kg intramuscular succinylcholine in children ages 1 to 10 ranges from 2.9 to 3.9 minutes.)

I’ve written about the advantages and risks of succinylcholine previously in the article, “Succinylcholine: Vital Drug or Obsolete Dinosaur?”  

I also refer you to the published article, “Is There Still a Role for Succinylcholine in Contemporary Clinical Practice?“

The take home messages from this case study of a cardiac arrest during a pediatric tonsillectomy are:

  • If you’re an anesthesia provider, do not administer succinylcholine to a neonate, infant, child, or adolescent for an elective surgery. The Black Box warning on succinylcholine recommends to “reserve use in children for emergency intubation or need to immediately secure the airway.”
  • If you’re a parent, prior to your son or daughter’s surgery, be empowered to ask your child’s anesthesiologist if they’re aware of the Black Box warning on succinylcholine. 
  • Nobody wants a death brought on by an elective anesthetic.

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The most popular posts for laypeople on The Anesthesia Consultant include:
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ARTIFICIAL INTELLIGENCE IN THE OPERATING ROOM . . . (THE PREMISE OF DOCTOR VITA) . . . DISCUSSED IN THE JOURNAL ANESTHESIOLOGY

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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.
emailrjnov@yahoo.com
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HAL from the movie 2001:A Space Odyssey

In 2004 I began writing Doctor Vita, a novel describing the encroachment of Artificial Intelligence (AI) into medical care. Fifteen years later, in 2019, Doctor Vita was published. The story described Artificial Intelligence in medicine as a perceived panacea that descended into a chaotic dystopian reality.

In recent years, engineers have developed closed-loop AI machines that can administer appropriate doses of anesthetics without human input, as described in The Washington Post article, “We Are Convinced the Machine Can Do Better Than Human Anesthesiologists.”

This month’s issue of Anesthesiology, our specialty’s leading journal, contains two studies on further incremental Artificial Intelligence in Medicine advances in the operating room. Both studies reveal machines that control a patient’s blood pressure automatically during surgery, by the administration of fluids and/or vasopressors (Joosten, et al. and Maheswari et al. ) 

Closed-loop anesthesia computer controllers for AI titration of anesthesia level

Two editorials accompany these publications. In the first editorial, titled “Computer-assisted Anesthesia Care: Avoiding the Highway to HAL,”  author Dr. David Story writes, “Among the cautionary tales of computer-assisted human activity, 2001:A Space Odyssey is a standout. On a journey to Jupiter, HAL the computer kills most of the crew, forcing the survivor to deactivate HAL. Like space travel, while computer-assisted health care has great potential it also contains the full Rumsfeld range of knowns and unknowns.” Dr. Story concludes his editorial with, “As our pilot counterparts are doing in aviation,anesthesiologists should anticipate training in crises while using computer-assisted technologies, as well as maintaining the skills to ‘fly’ manually.  . . . None of us wants to manage a deteriorating patient by trying to deactivate a malfunctioning computer-assisted anesthesia system, only to have it respond, ‘I’m sorry . . . I can’t do that.’”

The second editorial in the same issue of Anesthesiology is titled “Back to the OR of the Future: How Do We Make It a Good One?”  Author Dr. Martin London writes, “The classic 1985 science fiction film Back to the Future transports the erstwhile protagonist (Marty McFly, played by a young Michael J. Fox) 30 years backwards into the past in the eccentric ‘Doc’ Brown’s custom DeLorean time machine, to deal with a series of comedic yet moral quandaries regarding his future existence. A notable quote by Doc Brown is, ‘The future is whatever you make it, so make it a good one.’  Dr. London goes on to say, “The use of artificial intelligence–derived controllers clearly signals a new era in intraoperative hemodynamic management. . . . It does seem inevitable that software control of hemodynamics and anesthetic depth will become routine. Thus, we might ask, ‘What happens to the operator/clinician involved?’ Will it be more appropriate for a busy anesthesiologist covering multiple operating rooms to be supervising the admittedly extreme scenario of ‘information technology experts’ ensuring the machines are functioning properly or actual healthcare providers monitoring the patient and not the machine? And what happens when the “computers go down”? Who will rush in to fill the gap? Will the process be ‘good’ or will it be ‘dystopic?’”

Artificial intelligence in medicine is not the stuff of science fiction. AI in medicine is here. Will Artificial Intelligence in medicine assist doctors in compassionate care of their patients, or will AI present one more set of computers obstructing the relationships between healing professionals and those who need healing?

Medical journals like Anesthesiology reveal the future of medicine, as published data unfolds. A novel like Doctor Vita reveals a fictional future of medicine, based on the very trends that are going on today. 

Do you want a computer to care for you when your life is on the line? Do you want an algorithm, or a human, to be your doctor?  

Will you have a choice?

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The most popular posts for laypeople on The Anesthesia Consultant include:
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Should You Cancel Surgery For a Blood Pressure = 170/99?
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HOW THE INTERNET CHANGED ANESTHESIOLOGY FOREVER

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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.
emailrjnov@yahoo.com
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Anesthesia is a hands-on specialty. We use our manual skills daily to place breathing tubes, insert intravenous and intra-arterial catheters, and place needles for spinal punctures, epidural catheters, and regional nerve blocks. The Merriam-Webster dictionary defines the internet as “an electronic communications network that connects computer networks and organizational computer facilities around the world.” This definition seems to have has very little to do with inserting breathing tubes, catheters, or needles, yet the internet changed anesthesiology forever.

The internet is the biggest change in anesthesiology since the FDA approvals of propofol in 1989, the laryngeal mask airway in 1991, and sevoflurane in 2002.

Picture this: your job requires you to spend the majority of your day in a windowless room with four other people. You cannot leave the room, and if you make a serious error in your work, someone can die. There is a telephone on the wall. You’re allowed to bring along a briefcase or a backpack. 

This was the description of the anesthesiology workplace prior to the internet. Vigilance regarding a sleeping patient’s vital signs was always paramount, but the constant effort to be vigilant could be mind-numbing. No one can stare at an ECG/oximeter/blood pressure monitor for hours without interruption. Anesthesiologists could chat with the surgeons and/or nurses, make an occasional phone call, and at times read materials they brought with them into the operating room. Major adverse events seldom occur during the middle of a general anesthetic of long duration on a healthy patient. A comparison would be a commercial pilot flying an airplane from San Francisco to New York. The flight lasts 5 hours, but there would likely be only minor adjustments in course or altitude during the middle 4 hours. Anesthesia is said to be “99% boredom and 15 panic,” because 99% of the time patients are stable, yet 1% of the time, especially at the beginning and the end of anesthetics, urgent or emergency circumstances could threaten the life of the patient.

Since the development of the internet, anesthesia practice has changed forever. Every hospital operating room is equipped with a computer connected to the internet. Every anesthesia provider carries a smartphone connected to the internet. Many anesthesia providers carry a laptop or a tablet in their briefcases. These devices enable an anesthesiologist to remain connected to the outside world during surgery. Let’s look at the specific ways the internet has changed anesthesia practice:  

Electronic Medical Record anesthesia intraoperative vital signs record
  • Electronic medical records (EMRs). Love it or hate it, the EMR is here to stay. The EMR requires a computer terminal and screen in every operating room, and every hospital operating room must be connected to the internet. A patient’s EMR combines information from previous clinic visits, emergency room visits, laboratory and test results, and all data from the preoperative, intraoperative, and postoperative course on the day of surgery. Anesthesiologists type information into the EMR multiple times during each case.
AN EXAMPLE PUBMED SEARCH SCREEN
  • Immediate access to medical search engines. A major advantage of internet connectivity is the ability to immediately research any medical question or problem. Abstracts of every published medical study are available on Pubmed. For those of us on the faculty of a university hospital, hundreds of medical textbooks are immediately available online as reference sources. The entire catalog of FDA-approved drugs is listed on the PDR (Physician’s Desk Reference) website, or on the PDR app on our smartphones. These are all invaluable tools which empower a physician anesthesiologist and improve care to every patient.  
  • Connectivity to other anesthesia providers is a third important advantage of the internet. We’re now able to immediately contact a colleague by cell phone, text message, or email if we have a question or a problem. In anesthesia care team models, in which a Certified Nurse Anesthetist (CRNA) is physically present in the operating room while being supervised by an attending physician anesthesiologist, the MD anesthesiologist can be summoned to return to the operating room in seconds if a problem arises. You can also imagine a future vision of telemedicine in which an experienced physician anesthesiologist, who lives many miles or time zones away, can supervise a CRNA or an inexperienced anesthesiologist performing in-person patient care via Zoom conferencing. 

A 2010 publication in the journal Anaesthesia and Intensive Care stated, “Experienced anesthetists are skilled at multi-tasking while maintaining situational awareness, but there are limits. Noise, interruptions and emotional arousal are detrimental to the cognitive performance of anesthetists. While limited reading during periods of low task load may not reduce vigilance, computer use introduces text-based activities that are more interactive and potentially more distracting.”

From what I observe of anesthesia practice in the year 2021, intermittent use of the internet during anesthesia duty is not uncommon. The windowless confines of the operating room are now connected to the world.

Further scholarly research regarding computers, tablets, cell phones, and internet use in the operating room will no doubt be forthcoming. Stay tuned.

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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?
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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 = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

DYING UNDER GENERAL ANESTHESIA

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THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
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You’re an anesthesiologist and you’re contacted by a patient who is dying of cancer. He wants an end of life anesthetic so that he will be unconscious and die without pain and suffering. What do you do? Will you enable dying under general anesthesia?

A recent article from the United Kingdom discussed this topic of end of life anesthesia, otherwise known as “terminal anesthesia.” Terminal anesthesia refers to a situation when a patient has a terminal illness such as end-stage cancer and is suffering through their last days. They request to have a general anesthetic so they are unconscious throughout the process of dying under general anesthesia.

Is anyone doing terminal anesthesia anywhere? The Journal of Medical Ethics reported that in 2016, “France passed a law granting terminally ill patients the right to continuous deep sedation until death. This right was proposed as an alternative to euthanasia and was presented as the ‘French response’ to problems at the end of life. The law draws a distinction between continuous deep sedation and euthanasia.” 

Euthanasia, or the ending of life through pharmacologic intervention, is illegal in the United States, the United Kingdom, and most nations. In the 1980s and 1990s, Dr. Jack Kevorkian of the United States  infamously created a euthanasia machine that injected lethal doses of sodium pentothal (a hypnotic sleep drug), potassium chloride (an overdose of potassium which caused cardiac arrest), and pancuronium (a paralyzing drug) into terminal patients who requested a pharmacologic suicide. Dr. Kevorkian was convicted of second degree murder, and served 8 years of a 10-to-25-year prison sentence.

Dr. Jack Kevorkian and his euthanasia machine

Dying patients may have an interest in terminal anesthesia. In a survey of 500 individuals in the United Kingdom regarding end-of-life options, 88% of the respondents said they would like the option of a general anesthetic if they were dying.  

What would terminal anesthesia look like? Medication(s) would be administered through an intravenous line to bring on unconsciousness without hastening death. These last three words are key, because terminal anesthesia is specifically not to be euthanasia. Terminal patients are frail, and their cardiac and respiratory systems will be sensitive to oversedation. Terminal anesthesia is not to directly stop the patient from breathing, stop their hearts from beating, or put them at risk from aspirating food into their lungs. The duration of the IV sedation/anesthesia must be maintained until the patient’s heart eventually stops because of their underlying terminal medical illness. Because of the danger of food aspiration into the windpipe (trachea), tube feedings to the stomach during the time of this terminal anesthetic would not be allowed. 

What drugs could be used for terminal anesthesia? Propofol (an IV hypnotic drug) and midazolam (an IV benzodiazepine also known as Versed) are the most likely agents. The initial infusion of these drugs must be gradual, because bolus doses of these powerful agents into the bloodstream of a frail, end of life patient, could easily halt their breathing and hasten death. No pulse oximetry or other monitors would be used, and the person administering the drug would not remain in constant attendance with the patient. These two facts—the lack of monitoring and the lack of being physically present to attend to the patient—are boldly in defiance of what anesthesiologists do when they administer general anesthesia to patients. The motto of the American Society of Anesthesiologists is “Vigilance.” Terminal anesthesia implies minimal vigilance, and for this reason I cannot imagine the practice being approved in the United States.

An April 2021 publication in the journal Anaesthesia disagrees. The authors describe end of life anesthesia as “an impending development for which the specialty should prepare.” Co-author Jaideep Pandit, MD, professor of anesthesia at Oxford University, said, “Ethically, it is the right thing to do to make this offer to dying patients where it is technically feasible and the literature says it is. The desire to be unconscious in times of great adversity is understandable—it isn’t surprising or wrong to want to be unconscious in adverse situations. We as physicians are here to help, and if we have the means to help and meet the patient’s desire and it is ethical to do so, then we should strive to make this option feasible.” This article described the first use of end of life anesthesia as occurring over 25 years ago: “The first description of using general anesthesia in end‐of‐life care was in 1995 by John Moyle, a consultant anesthetist and palliative care physician. Moyle recognized the limitations of conventional approaches . . . Moyle developed a protocol for infusing the then relatively new anesthetic agent propofol and described its use in two patients, who died peacefully after 4 and 9 days of continuous infusion. . . . Moyle and others recommended very slow intravenous infusion by a pump at a carefully titrated dose (e.g. just 5 mg.h‐1 vs. the 100–200 mg typically used as a bolus) The depth of anesthesia achieved was inadequate for a surgical procedure, but was ideal for an undisturbed dying patient.” 

A study from Sweden described their experience with propofol for end of life sedation. Two indications for using propofol were identified. The first was refractory nausea and vomiting, and the second was the need for palliative sedation due to refractory anxiety or agitation, with or without intractable pain. Monitoring of the patient was as follows: “During the first hour of treatment, the patients were checked repeatedly by both the nurse and the physician caring for the patient. Then, evaluation was performed after 2, 6, and 12 hours. These assessments were preferably made by the physician, but when symptom control had been established, the evaluation was made by the nurse. Patients on continuous treatment with propofol were thereafter evaluated at least twice daily by the nurse in addition to their daily routine care. The physician visited the patient at least once daily for evaluation.” The mean dose range of propofol during treatment was between 0.90 and 2.13 mg/kg/h, (or for an average 70-kilogram patient, between 70 and 150 mg of propofol per hour). The length of treatment with propofol varied between 2 hours and 44 days. The study reported “All but three patients died at the unit, and the median survival was 38 days, compared with the usual median survival of 14 days at the unit.” 

Euthanasia is illegal, but general anesthesia is legal. Could general anesthesia really be approved so that individuals do not have to experience the suffering of dying? What if the United States passed a law, similar to the 2016 law in France, that granted terminally ill patients the right to continuous deep sedation until death? Will this type of terminal sedation/anesthesia ever happen in the United States? It’s currently common to utilize anesthesia/deep sedation for patients who are on ventilators in an intensive care unit (ICU). If such a patient has an untreatable illness, they may die while they are in the ICU under deep sedation, but the application of terminal anesthesia outside of an ICU is not seen in the United States today.

There are other ethical, medicolegal and practical implications to utilizing terminal anesthesia. Who would give the IV sedation/general anesthesia? The Hippocratic Oath states, “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan,” so it’s unlikely any American physician would administer the anesthetic. Would the medical malpractice court system litigate that cases of terminal anesthesia were indeed euthanasia, and therefore illegal? If the American Society of Anesthesiologists opposed the idea, could continuous deep sedation at end-of-life ever come to fruition? What if some medical professional with a license to administer anesthesia decided to open up a practice of administering terminal anesthetics? Could such an individual collect cash payments or insurance payments for administering general anesthesia to patients who were on hospice, and thereby earn a large quantum of money for each case? 

Everyone fears dying, and no one wants to have a painful or torturous death. Expect to hear more discussion about this topic in years to come, but don’t expect physician anesthesiologists in the United States to prescribe or administer terminal anesthesia any time soon. 

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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 = 170/99?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

WAS TIGER WOODS DRIVING UNDER THE INFLUENCE?

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THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
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Was Tiger Woods driving under the influence (DUI) on the morning of February 23rd, 2021 when he was injured in a single car accident? 

Perhaps his anesthesiologist knows. 

Tiger Woods underwent surgery at Harbor-UCLA Medical Center just hours after his single car rollover vehicle crash. Surgeons performed a pinning of a tibia (shin bone) fracture and pinning of an ankle fracture. Prior to administering an anesthetic, it would be important for the anesthesiologist to know the toxicology screen results in any patient who just survived such an accident. The anesthesiologist needs to know what other drugs, if any, were present in the patient’s system at the time of the crash, because this fact could influence anesthesia management. Drug use could mean central nervous system depressants (opioids, alcohol, sedatives, hypnotics, sleeping pills) or stimulants (cocaine, amphetamines). If sedative drugs were present, there can be a synergistic effect between the drugs and the anesthetic medications. If stimulant drugs were present, the patient may have tolerance and/or increased anesthetic dose requirements. 

A 2017 anesthesia study stated that “for optimal patient care through the perioperative period, it is critical to obtain information about patient drug use and other associated treatment in order to construct an appropriate anesthetic plan, including specific considerations during surgery, emergence, and in the post anesthesia care unit.” 

In a study from Nature, 1007 consecutive patients undergoing emergency surgery were screened for illicit drug use (IDU). Seventy-five patients (7.45%) were found to be positive for IDU, even though zero patients admitted a positive history of illicit drug use. Of the 75 patients, 50 tested positive for morphine, 22 tested positive for methamphetamine, 13 tested positive for ketamine, 6 tested positive for two drugs, and 2 tested positive for all three drugs. The study concluded, “Knowledge of illicit drug users (IDUs) is important because of the comorbidity related to drug use.”

Miller’s Anesthesia (9th edition, 2020, Chapter 31, Preoperative Evaluation, authored by Wijeysundera and Finlayson) states, “A patient with a history of current or previous alcohol or drug addiction presents special challenges for the perioperative team. . . . Addictive disease should be considered permanent even in patients who have had long periods of abstinence. . . . Substance abuse disorders are risk factors for poor outcomes in the perioperative setting.”

The 1996 Health Insurance Portability and Accountability Act (HIPAA) prohibits a patient’s doctors from divulging any private healthcare information (PHI) to anyone who is not caring for that patient. The anesthesiologists may know whether a motor vehicle accident patient was part of a DUI incident, but they will not release the results of such a tox screen to the press. 

The sheriff who arrived at the Woods crash scene stated there was no evidence that Woods was impaired or intoxicated at the time of the crash in Rolling Hills Estates, California. The police said they “did not issue a citation for Woods . . . To issue a ticket for reckless driving would require evidence that Woods had committed multiple violations before the crash, such as unsafe lane changes, or passing other cars unsafely, according to investigators. . . . Woods had no recollection of the collision, investigators said at the press conference.” 

I’m not a lawyer, but I presume that tox screen results could be subpoenaed if a crime had been committed. For example, if an automobile collides with a school bus and kills someone, then I presume the driver’s medical test results would be part of a criminal investigation. 

According to the forensic report, Tiger Woods was speeding as fast as 75 miles per hour, or more than 45 mph faster than the legal speed limit before his SUV crashed. Investigators said the accident was “the result of Woods driving in an unsafe manner for road conditions. . . . The evidence suggested the golfer didn’t brake or steer out of the emergency for nearly 400 feet after striking an eight-inch curb in the median.” 

Per Golfweek magazine: “forensic experts say the evidence suggests Woods was not conscious when he left his lane and kept going in a straight line before crashing. Instead of staying with the downhill road as it curved right, he went straight over the curb in the median to the left, hit a wooden sign and kept going in a straight line into opposing traffic lanes before leaving the road, hitting a tree and rolling over. Jonathan Cherney, an accident reconstruction expert and former police detective who walked the scene, told USA TODAY Sports it was ‘like a classic case of falling asleep behind the wheel, because the road curves and his vehicle goes straight.’ There were no skid marks on the road, Villanueva said. Instead, Woods’ Genesis SUV kept going straight for several hundred feet. Woods later told sheriff’s deputies he couldn’t remember how the crash occurred and didn’t remember even driving.” 

Per USA Today: “’The report doesn’t deal with the underlying cause of the crash,’ said Charles Schack, a former New Hampshire state police trooper who is now president of Crash Experts, which analyzes traffic accidents for law firms and insurance companies. ‘It addresses the data superficially with no apparent curiosity as to why Tiger drove for hundreds of feet without adjusting his steering, braking, or speed. Taking away the high-profile aspect of this crash and looking at the data and roadway, it appears that the driver made no attempt to follow the roadway during the moments leading to the crash. This is typical of a driver who was incapacitated due to a medical issue, falling asleep or being impaired.’” 

Can an individual take a sleep medication prescribed by a physician, such as Ambien, at nighttime and still have drowsiness from the medication which impairs their driving ability the next morning? Yes. In 2013 the Food and Drug Administration released the following Safety Communication regarding zolpidem (Ambien):

The U.S. Food and Drug Administration (FDA) is notifying the public of new information about zolpidem, a widely prescribed insomnia drug. FDA recommends that the bedtime dose be lowered because new data show that blood levels in some patients may be high enough the morning after use to impair activities that require alertness, including driving. Today’s announcement focuses on zolpidem products approved for bedtime use, which are marketed as generics and under the brand names Ambien, Ambien CR, Edluar, and Zolpimist.

FDA is also reminding the public that all drugs taken for insomnia can impair driving and activities that require alertness the morning after use. Drowsiness is already listed as a common side effect in the drug labels of all insomnia drugs, along with warnings that patients may still feel drowsy the day after taking these products. Patients who take insomnia drugs can experience impairment of mental alertness the morning after use, even if they feel fully awake. 

FDA urges health care professionals to caution all patients (men and women) who use these zolpidem products about the risks of next‐morning impairment for activities that require complete mental alertness, including driving. 

There appears to be a public safety concern that individuals who take Ambien for sleep may be impaired when driving a vehicle the following morning. 

Was Tiger Woods impaired on the morning of his single car accident? I don’t know, and it’s not my intent to accuse him in any way. I wish him a speedy and complete recovery, and hope we can all watch him play golf at a high level once again. The purpose of this column is to inform readers that: 1) anesthesiologists need to know the results of blood and/or urine toxicology screens before they are administer general anesthesia to an automobile trauma victim; 2) sleeping aids such as Ambien (zolpidem) carry an FDA warning that they can impair activities such as driving the morning after administration; and 3) HIPAA law prevents physicians from disclosing the medical records of patients to the media.

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The most popular posts for laypeople on The Anesthesia Consultant include:
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READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

A MORBIDLY OBESE PATIENT WITH MEAT STUCK IN HIS ESOPHAGUS

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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.
emailrjnov@yahoo.com
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You’re the anesthesiologist on call on a Saturday night. A patient arrives at the Emergency Room complaining that he ate piece of steak one hour ago, and the meat got stuck in his throat. He is morbidly obese patient who stands six feet tall and weighs 350 pounds, for a BMI of 47.

The attending general surgeon wants to do an upper GI endoscopy to extract the piece of meat from the patient’s esophagus or push it through into the stomach. He’s called on you to do the anesthetic. 

What do you do?

You examine the patient and find he has a short neck, a small mouth, and a large tongue. You cannot see his soft palate at all, and you rate him as a Mallampati 4.

Mallampati Class IV airway

The patient is alert, and is an excellent historian. He cannot even swallow his saliva. He has no difficulty breathing or significant chest pain. His hospital chart shows no past anesthetics, and he has no medical problems except hypertension which is treated with lisinopril. His vital signs are normal, and his oxygen saturation is 96% on room air.You are six months out of anesthesia training and new to this hospital. The surgeon—a 60-year-old male with the brash confidence of General Patton—is an iconic and respected figure at this medical center. He wants to proceed at once. It’s 8 pm on a Saturday night. He requests “just a little sedation” so he can insert the endoscope past the gag reflex and into the esophagus.

You bring the patient into the endoscopy suite, attach the standard vital signs monitors, and administer oxygen via a Procedural Oxygen Mask (POM, made by Mercury Medical).

You administer 2 mg of Versed and 100 micrograms of fentanyl IV. The surgeon sprays Cetacaine into the patient’s mouth for topical anesthesia and inserts a bite block. After five minutes time the patient is still wide awake. The surgeon looks at you and says, “I need him a little deeper than this.” You administer another 1 mg of Versed and 50 micrograms of fentanyl. After another five minutes time, the patient is still wide awake. The surgeon looks at you and repeats, “I need him a little deeper than this.” He says this in an impatient condescending tone, and you feel pressured. You administer 50 mg of propofol, and the patient’s eyes begin to drift closed. The surgeon inserts the gastroscope, after which the patient coughs, gags, and vomits into his airway. His oxygen saturation which had been 100% quickly plummets to 75%. You move to the head of the bed, suction the patient’s mouth, and attempt bag-mask ventilation without success. His oxygen saturation drops to 60%. You reach for a Miller 3 laryngoscope and attempt to intubate the trachea, but you cannot visualize his vocal cords. You are panicked. The surgeon is screaming at you to do something. You tell the surgeon he needs to do a tracheostomy. In the meantime you insert a laryngeal mask airway into the patient’s throat, but are still unable to ventilate the lungs. The ECG rhythm converts to ventricular fibrillation, and you call a Code Blue.

After thirty minutes of CPR and ACLS, the patient is declared dead.

What went wrong here? A patient who walked into the hospital is now dead. The basic problem was that the anesthesiologist proceeded to deeply sedate a patient with a full stomach (a known aspiration risk) without first controlling the airway by inserting an endotracheal tube. This morbidly obese patient with a thick neck, a small mouth, and a large tongue was always going to be difficult to intubate, but a successful intubation was most likely to occur under controlled circumstances with the patient awake prior to any endoscopy. The issue of a domineering surgeon pushing an inexperienced anesthesia provider into doing the wrong anesthetic is a key problem. This can and does happen, and once the case has concluded with a bad outcome, that same surgeon will deny any culpability, step back and say “I don’t do anesthesia. The decisions and actions of the anesthesiologist caused the problem, not me.”

How should the anesthetic have been done? 

In a parallel universe, an experienced anesthesiologist would do the following:

  • Explain to the surgeon and the patient that the meat stuck in the esophagus presents a dire risk of aspiration into the lungs and loss of airway, and explain to them that the case must be done either entirely awake without sedation (unlikely to be successful), or as a general anesthetic with an endotracheal tube placed prior to any endoscopy intervention.
  • This case is best done in an operating room, rather than in an endoscopy suite.
  • The anesthesiologist will assemble all emergency airway equipment, including a Glidescope, a fiberoptic laryngoscope, the entire difficult airway cart, and the scalpel, bougie, tube equipment for an emergency cricothyrotomy. 
  • The anesthesiologist will likely call in a second pair of experienced hands, either a second anesthesiologist or perhaps the in-house emergency room physician most experienced with intubating patients.
  • A rapid sequence intubation with propofol, succinylcholine, and cricoid pressure is a possible approach, but runs the risk that if the airway is so difficult that the endotracheal tube cannot be passed on the first attempt, the patient will be difficult to ventilate, difficult to oxygenate, and the meat and saliva from the esophagus could aspirate into the airway, leading to a hypoxic emergency.
  • A safer approach is an awake oral intubation using a fiberoptic laryngoscope. The back of the operating room table is inclined upward into a sitting position. Topical anesthesia and local nerve blocks of the airway are performed. See the footnote below (referenced from Miller’s Anesthesia) for a detailed description of the airway anesthesia.A Moderate sedation with Versed and fentanyl is administered, but the patient is kept awake. There’s still a risk that the topical anesthesia will blunt the cough reflex if the patient regurgitates the meat, so suction and a MaGill forceps are immediately available.
  • The anesthesiologist inserts the fiberoptic scope through an endotracheal tube (ET tube) and advances the scope into the mouth until he or she is able to visualize the vocal cords. This can be difficult and may take time, but there is no acute emergency, so an unhurried approach is warranted. Once the fiberoptic scope is threaded through the vocal cords, the patient will most likely cough violently and will require some restraint by two individuals, one on each side of the bed. The ET tube is threaded over the scope quickly and the balloon on the ET tube is inflated. The tube is connected to the anesthesia machine circuit and end-tidal CO2 is confirmed. At this point an IV bolus of propofol and rocuronium is administered to induce general anesthesia. 
  • Once the ET tube is taped securely in place, the surgeon can position the patient as he desires for the upper GI endoscopy. Anesthesia is maintained with sevoflurane and oxygen. When the surgeon is finished, the patient is awakened using sugammadex as necessary to reverse the muscle relaxation. When the patient opens his eyes, he can be safely extubated.

What are the lessons to be learned from this case study?

  • Don’t be intimidated or pushed into an unsafe anesthesia plan. Do what you were trained to do in residency, and stick to safe anesthesia practice. If an adverse outcome occurs, claiming the surgeon made you do something unsafe will not help you one bit. You are in charge of all anesthesia decisions.
  • In anesthesia practice and all acute medicine care, you must manage Airway-Breathing-Circulation (A-B-C) in that order. Anesthesiologists are trained as airway experts, and for this reason we are the most vital acute care physicians in a medical emergency. The airway must managed first.
  • Take great care when anesthetizing a morbidly obese patient. They are at higher risk for anesthetic complications. They are also at greater risk for surgical and perioperative medical problems. See the lay press coverage in U.S. News and World Report, and also another post from this blog.
  • Maintain your skills in awake intubation. No anesthesiologist uses awake intubation often. For nearly every patient the appropriate sequence is to induce anesthesia first and intubate the trachea afterwards. But some patients: e.g. those with ankylosing spondylitis, congenital airway deformities like Treacher Collins syndrome, or certain patients with morbidly obesity or super morbidly obesity (BMI > 50), awake intubation is indicated. One of my professional partners, a former Senior Examiner for the American Board of Anesthesiologists, told me that during national anesthesia oral board examinations, when a patient presented with severe airway abnormalities for a surgical case, it was very common for successful examinees to state they would perform an awake intubation. Why? Because an awake intubation burns no bridges. The patient is unharmed by general anesthesia until the ET tube is already in place, and thus is unlikely to have a Cannot Intubate-Cannot Ventilate situation that can lead to life-threatening hypoxia. And as well, in an oral exam the examinee doesn’t have to actually perform the procedure—they only have to state they could do it successfully.
  • How do you maintain your skill in awake intubation? This is the tough question. When I was in residency training, Dr. Phil Larson, a former Chairman of Anesthesia at Stanford and former Editor-in-Chief of the journal Anesthesiology, taught us elective awake intubation on patients with normal airways, who did not require an awake intubation, so we could hone the skill. Each patient was sedated with IV narcotics. Local lidocaine nerve blocks were done, and an injection of local anesthetic was administered through the cricothyroid membrane, all prior to us performing the awake fiberoptic intubation successfully. Did this take extra time? It did. The intubation and anesthesia induction took ten minutes instead of one minute. Did the surgeons mind? They didn’t, because they respected Dr. Larson, they were glad an excellent anesthesiologist was attending to their cases, and they realized that nine minutes of time was no big deal. Am I recommending you do this in your practice? No, but in this age of the Glidescope, many anesthesiologists have forgotten how to utilize a fiberoptic intubation. I recommend you practice fiberoptic intubation on asleep patients, and maintain the skill.

You may need it to save someone’s life one day.

Footnote:

A. (From Chapter 44, Airway Management in Adults, Miller’s Anesthesia, Ninth edition, pp 1373-1412)  “Topical application of local anesthetic to the airway should, in most cases, be the primary anesthetic for awake airway management. Lidocaine is the most commonly used local anesthetic for awake airway management because of its rapid onset, high therapeutic index, and availability in a wide variety of preparations and concentrations. Benzocaine and Cetacaine (a topical application spray containing benzocaine, tetracaine, and butamben; Cetylite Industries, Pennsauken, NJ) provide excellent topical anesthesia of the airway, but their use is limited by the risk of methemoglobinemia, which can occur with as little as 1 to 2 seconds of spraying. . . .  A mixture of lidocaine 3% and phenylephrine 0.25%, which can be made by combining lidocaine 4% and phenylephrine 1% in a 3:1 ratio, has similar anesthetic and vasoconstrictive properties as topical cocaine and can be used as a substitute. Topical application of local anesthetic should primarily be focused on the base of the tongue (pressure receptors here act as the afferent component of the gag reflex), the oropharynx, the hypopharynx, and the laryngeal structures; anesthesia of the oral cavity is unnecessary. . . . Before topical application of local anesthetic to the airway, administration of an anticholinergic agent should be considered to aid in the drying of secretions, which helps improve both the effectiveness of the topical local anesthetic and visualization during laryngoscopy. Glycopyrrolate is usually preferred because it has less vagolytic effects than atropine at doses that inhibit secretions and does not cross the blood-brain barrier. It should be administered as early as possible to maximize its effectiveness. “. . . Oropharyngeal anesthesia can be achieved by the direct application of local anesthetic or by the use of an atomizer or nebulizer. Topical application of local anesthetic to the larynx can be achieved by directed atomization of a local anesthetic or by the  spray-as-you-go (SAYGO) method, which involves intermittently injecting local anesthetic through the suction port or working channel of a flexible intubation scope (FIS) or optical stylet, as it is advanced toward the trachea.“Topical application of local anesthetic to the airway mucosa using one or more of these methods is often sufficient. If supplemental anesthesia is required, then a variety of nerve blocks may be used. Three of the most useful are the glossopharyngeal nerve block, superior laryngeal nerve block, and translaryngeal block. The glossopharyngeal nerve supplies sensory innervation to the posterior third of the tongue, vallecula, the anterior surface of the epiglottis, and the posterior and lateral walls of the pharynx, and is the afferent pathway of the gag reflex. To block this nerve, the tongue is displaced medially, forming a gutter (glossogingival groove). A 25-gauge spinal needle is inserted at the base of the anterior tonsillar pillar, just lateral to the base of the tongue, to a depth of 0.5 cm. After negative aspiration for blood or air, 2 mL of 2% lidocaine is injected. The process is then repeated on the contralateral side. The same procedure can be performed noninvasively with cotton-tipped swabs soaked in 4% lidocaine; the swabs are held in place for 5 minutes.”     

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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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READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

THE PHYSICIAN ANESTHESIOLOGIST JOB MARKET LOOKS EXCELLENT

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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.
emailrjnov@yahoo.com
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The physician anesthesiologist job market looks excellent. Medical students, college pre-med students, and academically successful high school students, are you wondering if anesthesiology is a great career for you? The current demand for anesthesiologists is high. If you’re geographically mobile and willing to relocate to where the demand for anesthesiologists is maximal, you’ll have little problem securing a solid job.

Career Explorer reports, “There are currently an estimated 33,000 anesthesiologists in the United States. The anesthesiologist job market is expected to grow by 15.5% between 2016 and 2026.” Over the next 10 years, it is expected that America will need 6,200 anesthesiologists. That number is based on 5,100 additional anesthesiologists, and the retirement of 1,100 existing anesthesiologists.

Anesthesiology News reports a shortage in the anesthesia job market, which is fueling high job demand in the field.

The American Society of Anesthesiologists surveyed the job market in 2016. Their study reported: “At the time of the survey, almost all the (anesthesia resident) respondents had received job offers, with 97 percent having confirmed jobs. Among the geographic regions, percent of residents having a confirmed job ranged from a 93 percent (Midwest) to 100 percent (Northeast and West). Nationwide, a majority (55 percent) of residents were joining anesthesiology groups with plans to become a partner, while 45 percent accepted employed positions. The mean starting salary was $299,605 with a standard deviation of $77,000, reflecting considerable regional differences. Residents were asked to rank factors most important in choosing a job. The three most important factors included geography, job description and monetary compensation.” 

In just the past 7 days, I received the following unsolicited job offers via personal email. Seeing is believing, so peruse these requests for anesthesiologists and see what you think:

Here’s my advice:

Anesthesiology is a fascinating, challenging, adrenaline-charged career choice with a burgeoning job market. If you’re a student considering a career as a physician, The Anesthesia Consultant website strongly recommends a career as a physician anesthesiologist. For further information, I recommend the following columns from this blog:

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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?

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

THE TEN MOST SIGNIFICANT ADVANCES IN ANESTHESIOLOGY IN THE PAST DECADE

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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.
emailrjnov@yahoo.com
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What were the ten most significant advances in anesthesiology in the past decade, 2010 – 2020? Here are my picks:

  • Sugammadex. Sugammadex was FDA-approved in December 2015, and the practice of chemically paralyzing surgical patients and reversing their paralysis has been forever changed. For my non-medical readers, sugammadex is an intravenous drug which reverses the paralysis of rocuronium, the most commonly used anesthetic paralytic drug, in approximately one minute. Sugammadex replaced the decades-old practice of injecting a combination of neostigmine and glycopyrrolate to reverse paralysis. Neostigmine and glycopyrrolate were slow to act (a wait of up to nine minutes), and could not reverse paralysis if zero twitches were present on a nerve stimulator monitor. In addition, 16 mg/kg of sugammadex IV can reverse an intubating dose of rocuronium, which makes rocuronium more quickly reversible than succinylcholine for rapid sequence intubation. Sugammadex is not cheap (a cost of $100 per 200 mg vial), but since the availability of sugammadex, no anesthesia practitioner should ever have an awake and still-paralyzed patient at the conclusion of an anesthetic. A terrific advance. Five stars.
  • Use of Zoom. In the era of COVID, Zoom videoconferencing made person-to-person communication involving anesthesiologists possible. During the early days of the COVID outbreak, the American Society of Anesthesiologists was able to keep its members informed and educated via Zoom conferencing. At the present time, almost all anesthesia continuing medical education (CME) is conducted effectively via Zoom. I attend the Stanford anesthesia Grand Rounds each Monday morning via Zoom, and the educational value is as high as it was when I attended in person. Expect Zoom CME to continue as a major vector in the years to come. Although Zoom may adversely affect in-person attendance at medical meetings forever, I believe widespread videoconferencing education is a tremendous advance. Five stars.
  • The Stanford Anesthesia Emergency Manual. See this link<