The anesthesia consultant

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

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?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

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

AIRWAY LAWSUITS

20 Jan 201529 Oct 2018THE ANESTHESIA CONSULTANT 2 Comments

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

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Latest posts by THE ANESTHESIA CONSULTANT (see all)

STANFORD EMERGENCY MANUAL POCKET VERSION - 28 Sep 2023
CALL FROM THE JAILHOUSE REVIEW: “I LOVED HOW THE BOOK WAS CRAFTED.” - 15 Sep 2023
CONTINUOUS FINGER-CUFF BLOOD PRESSURE MONITORING - 28 Aug 2023

At weddings you’ll often hear a Bible verse that reads, “And now these three remain: faith, hope and love. But the greatest of these is love.” (1 Corinthians 13:13) A parallel verse in the bible of acute care medicine would read, “Emergencies are managed by airway, breathing, and circulation. But the greatest of these is airway.” The objective of this column is to help you avoid airway lawsuits.

Every health care professional learns the mantra of airway-breathing-circulation. Anesthesiologists are the undisputed champions of airway management. This column is to alert you that avoiding even one airway disaster during your career is vital.

Following my first deposition in a medical-legal case years ago, I was descending in the elevator and a man in a suit asked me what I was doing in the building that day. I told him I’d just testified as an expert witness. He asked me what my specialty was, and I told him I was an anesthesiologist. The whistled through his teeth and smirked. “Anesthesia,” he said, “Huge settlements!”

I’ve consulted on many medical malpractice cases which involved death or brain damage, and airway mishaps were the most common etiology. It’s possible for death or brain damage to occur secondary to cardiac problems (e.g. shock due to heart attacks or hypovolemia), or breathing problems (e.g. acute bronchospasm or a tension pneumothorax), but most deaths or brain damage involved airway problems. Included are failed intubations of the trachea, cannot-intubate-cannot-ventilate situations, botched tracheostomies, inadvertent or premature extubations, aspiration of gastric contents into unprotected airways, or airways lost during sedation by non-anesthesia professionals.

Google the keywords “anesthesia malpractice settlement,” and you’ll find multiple high-profile anesthesia closed claims, most of them related to airway disasters. Examples from such a Google search include:

The Chicago Daily Law Bulletin featured a multimillion-dollar verdict secured by the family of a woman who died after being improperly anesthetized for hip surgery. The anesthesiologist settled prior to trial, resulting in the family being awarded a total of $11.475 million for medical negligence. The 61-year-old mother and wife was hospitalized in Chicago for elective hip replacement surgery. Because of a prior bad experience with the insertion of a breathing tube for general anesthesia, she requested a spinal anesthetic. Her anesthesiologist had trouble inserting a needle for the spinal anesthesia, so he went ahead with general anesthesia. The anesthesiologist was then unable, after several attempts, to insert the breathing tube. He planned to breathe for her through a mask and let her wake up to breathe on her own. A second anesthesiologist came into the room and decided to attempt the intubation. He tried but was also unsuccessful. Finally, a third anesthesiologist came into the operating room and tried inserting the breathing tube several times. He too was unsuccessful. All of the attempts at inserting the tube caused the tissues in her airway to swell shut, blocking off oxygen and causing cardiac arrest. She suffered severe brain damage and died.
$20 Million Verdict Reached in Medical Malpractice Lawsuit Against Anesthesiologist. A jury returned a $20 million verdict in an anesthesia medical malpractice lawsuit filed by the family of a woman who died during surgery when bile entered her lungs. The wrongful death lawsuit alleged that the anesthetists failed to identify that the victim had risk factors for breathing fluid into her lungs, despite the information being available in her medical record. The victim was preparing to receive exploratory surgery to determine the cause of severe stomach pains when she received the anesthesia. Once anesthetized, she began breathing bile into her lungs. She then later died. The jury awarded $20 million in favor of the plaintiff.
A $35 million medical malpractice settlement was matched by only one other as the largest settlement for a malpractice case in Illinois, and the most ever paid by the County of Cook for a settlement of a personal injury case. The client, a 28-year-old woman, suffered severe brain damage from the deprivation of oxygen resulting from the failure of an anesthesiologist to properly secure an intubation tube. The client, immediately following the occurrence, was in a persistent vegetative state from which the likelihood of recovery was virtually nil. Miraculously, she regained much of her cognitive functioning, although still suffering from significant physiological deficits requiring attendant care for the rest of her life.
Anesthesia Death Results in $2 Million Settlement: 36-Year-Old Man Dies From Anesthesia Mishap Following Elective Hernia Repair Surgery. The plaintiff’s decedent was a 36-year-old man who died secondary to respiratory complications following an elective hernia repair. During the pre-operative anesthesia evaluation, the defendant noted the patient had never been intubated and had required a tracheostomy for a previous surgery. The defendant decided to administer general endotracheal anesthesia with rapid sequence induction. The surgery itself was without incident. Following extubation, the patient began to have difficulty breathing. The patient desaturated. The surgeon was called back to the OR to perform a tracheostomy, however, there was no improvement in the patient’s oxygenation and he continued to have asystole. Subsequently, he went into respiratory arrest and coded. The code and CPR were unsuccessful, and the patient was pronounced dead.

Per Miller’s Anesthesia, failure to secure a patent airway can result in hypoxic brain injury or death in only a few minutes. Analysis of the American Society of Anesthesiologists (ASA) Closed Claims Project database shows that the development of an airway emergency increases the odds of death or brain damage by 15-fold. Although the proportion of claims attributable to airway-related complications has decreased over the past thirty years since the adoption of pulse oximetry, end-tidal-CO2 monitoring, and the ASA Difficult Airway Algorithm, airway complications are still the second-most common cause of malpractice claims. (Miller’s Anesthesia, Chapter 55, Management of the Adult Airway, 2014).

In 2005, in the ASA-published Management of the Difficult Airway: A Closed Claims Analysis (Petersen GN, et al, Anesthesiology 2005; 103:33–9), the authors examined 179 claims for difficult airway management between 1985 and 1999. The timing of the difficult airway claims was: 67% upon induction, 15% during surgery, 12% at extubation, and 5% during recovery. Death or brain damage during induction of anesthesia decreased 35% in 1993–1999 compared with 1985–1992, but death or brain damage from difficult airway management during the maintenance, emergence, and recovery periods did not decrease during this second period. There is no denominator to compare with the numerator of the number of closed claims, so the prevalence of airway disasters was unknown.

Awake intubation is touted as the best strategy for elective management of the difficult airway for surgical patients. Fiberoptic scope intubation of the trachea in an awake, spontaneously ventilating patient is the gold standard for the management of the difficult airway. (Miller’s Anesthesia, Chapter 55, Management of the Adult Airway, 2014). Awake intubation is a useful tool to avert airway disaster on the oral anesthesiology board examination. Dr. Michael Champeau, one of my partners, has been an American Board of Anesthesiology Senior Examiner for over two decades. He tells me that oral board examinees choose awake intubation for nearly every difficult airway. This is wise–it’s hard to harm a patient who is awake and breathing on their own. Is the same strategy as easily implemented outside of the examination room? In actual clinical practice, an awake intubation may be a tougher sell. Awake intubations are time-consuming, require patience and understanding from the surgical team, and can be unpleasant to a patient who will be conscious until the endotracheal tube reaches the trachea–an event which can cause marked coughing, gagging, hypertension and tachycardia in an under-anesthetized person. As anesthesia providers, we perform hundreds of asleep intubations per year, and only a very small number of awake intubations. Inertia exists pushing anesthesia providers to go ahead and inject the propofol on most patients, rather than to take the time to topically anesthetize the airway and perform an awake intubation. But if you’ve ever lost the airway on induction and wound up with a “cannot intubate-cannot ventilate” patient, you’ll understand the wisdom in opting for an awake intubation on a difficult airway patient.

I refer you to Chapter 55 of Miller’s Anesthesia for a detailed treatise on the assessment and management of airways, which is beyond the scope of this column. In addition to the reading of Chapter 55, I offer the following clinical pearls based on my 30 years of practice and my experience at reviewing malpractice cases involving airway tragedies:

Become skilled at assessing each patient’s airway prior to anesthesia induction. Pertinent information may be in the old chart or the patient’s oral history as well as in the physical examination. Red flags include: previous reports of difficulty passing a breathing tube, a previous tracheostomy scar, morbid obesity, a full beard, a receding mandible, inability to fully open the mouth, rigidity of the cervical spine, airway tumors or masses, or congenital airway deformities.
Learn the ASA Difficult Algorithm and be prepared to follow it. (asahq.org/…/ASAHQ/…/standards-guidelines/practice-guidelines-for- management-of-the-difficult-airway.pdf‎).
Become skilled with all critical airway skills, particularly mask ventilation, standard laryngoscopy, video laryngoscopy, placement of a laryngeal mask airway (LMA), fiberoptic intubation through an LMA, and awake fiberoptic laryngoscopy.
Read the airway strategy recommended in the Appendix to Richard Jaffe’s Anesthesiologist’s Manual of Surgical Procedures, an approach which utilizes a cascade of the three critical skills of (A)standard laryngoscopy, (B)video laryngoscopy, and (C)fiberoptic intubation through an LMA. For a concise summary of this approach read my column Avoiding Airway Disasters in Anesthesia (http://theanesthesiaconsultant.com/2014/03/14/avoiding-airway-disasters-in-anesthesia).
If you seriously ponder whether awake intubation is indicated, you probably should perform one. You don’t want to wind up with a hypoxic patient, anesthetized and paralyzed, who you can neither intubate nor ventilate.
If you’re concerned about a difficult intubation or a difficult mask ventilation, get help before you begin the case. Enlist a second anesthesia provider to assist you with the induction/intubation.
Take great care when you remove an airway tube on any patient with a difficult airway. Don’t extubate until vital signs are normal, the patient is awake, the patient opens their eyes, and the patient is demonstrating effective spontaneous respirations. An airway that was routine at the beginning of a surgery may be compromised at the end of surgery, due to head and neck edema, airway bleeding, or swollen airway structures, e.g. due to a long anesthetic with a prolonged time in Trendelenburg position.
If you’re a non-anesthesia professional administering conscious sedation, never administer a general anesthetic sedative such as propofol. A combination of narcotic and benzodiazepines can be easily reversed by the antagonists naloxone and flumazenil if oversedation occurs. There is no reversal for propofol. Airway compromise from oversedation due to propofol must be managed by mask ventilation by an airway expert.

In its 1999 report, To Err Is Human: Building a Safer Health System, the Institute of Medicine recognized anesthesiology as the only medical profession to reduce medical errors and increase patient safety. With the pulse oximeter, end-tidal-CO2 monitor, a myriad of airway devices, and the Difficult Airway Algorithm, the practice of anesthesia in the twenty-first century is safer than ever before. Let’s keep it that way.

Faith, hope, and love. The greatest of these is love.

Airway, breathing, and circulation. The greatest of these is airway. Your patient’s airway.

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

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

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

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?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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KIRKUS REVIEW

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

Nuanced characterization and crafty details help this debut soar.

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

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:

AVOIDING AIRWAY DISASTERS IN ANESTHESIA

14 Mar 201426 Apr 2019THE ANESTHESIA CONSULTANT 8 Comments

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

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Latest posts by THE ANESTHESIA CONSULTANT (see all)

STANFORD EMERGENCY MANUAL POCKET VERSION - 28 Sep 2023
CALL FROM THE JAILHOUSE REVIEW: “I LOVED HOW THE BOOK WAS CRAFTED.” - 15 Sep 2023
CONTINUOUS FINGER-CUFF BLOOD PRESSURE MONITORING - 28 Aug 2023

Every anesthesia practitioner dreads airway disasters. Anesthesiologists and nurse anesthetists are airway experts, but anesthesia professionals are often the only person in the operating room capable of keeping a patient alive if the patient’s airway is occluded or lost. Hypoxia from an airway disaster can lead to brain damage within minutes, so there is little time for human error.

A fundamental skill is the ability to assess a patient’s airway prior to anesthesia. One must assess whether the patient will pose: 1) difficult bag-mask ventilation, 2) difficult supraglottic/laryngeal mask airway placement, 3) difficult laryngoscopy, 4) difficult endotracheal intubation, or 5) difficult surgical airway.

Of critical importance is #1) above, that is, recognizing the patient who will present difficult mask ventilation. Conditions that make for difficult bag-mask ventilation are uncommon, and usually can be detected during physical examination. Despite the importance of expertise in endotracheal intubation, I teach residents and trainees that the most important airway skill is bag-mask ventilation. Every year I encounter several patients who present unanticipated difficult intubations. In each of these patients, I’m able to mask ventilate the patient to keep them oxygenated while I try various strategies and techniques to successfully place an endotracheal tube or a laryngeal mask airway.

Most anesthesia airway disasters aren’t merely difficult intubations, but scenarios that are classified as “can’t intubate, can’t ventilate.” In these “can’t intubate, can’t ventilate” situations, the anesthesiology professional has only minutes to restore oxygenation to the patient or else the risk of permanent brain damage is very real.

The American Society of Anesthesiologists Difficult Airway Algorithm is a guide for anesthesia practitioners regarding how proceed in airway management. The algorithm is detailed, complex, comprehensive, and defines the standard of care in any medical-legal battle concerning hypoxic brain damage due difficult airway clinical cases. The algorithm is so detailed, complex, and comprehensive that some would say it’s impossible to remember every step in the acute occurrence of an airway disaster.

A simplified approach has been touted.

Dr. C. Philip Larson, Professor Emeritus, Anesthesia and Neurosurgery, Stanford University, and Professor of Clinical Anesthesiology at UCLA, and previous Chairman of Anesthesiology at Stanford, was one of my teachers and mentors for both endotracheal intubation and fiberoptic intubation. In a Letter to the Editor of the Stanford Gas Pipeline in May, 2013, Dr. Larson wrote, “there is no scientific evidence that anesthesia is safer because of the ASA Difficult Airway Algorithm. While an interesting educational document, I question the daily clinical value of this algorithm, even in its most recent form (Anesthesiology 2013; 118:251-70). The ASA Difficult Airway Algorithm was developed by committee and has all the problems that result when done that way. It is complex, diffuse, multi-dimensional, and all-encompassing such that it is not an instrument that one can easily adopt and practice in the clinical setting.”

Dr. Larson recommends a system of Plans A-D, a system he published in Clinical Anesthesiology, editors Morgan GE, Mikhail MS, Murray MJ, Lange Medical publication, 4th edition, 2006, pp 104-5, and in Current Reviews in Clinical Anesthesiology (2009; 30:61-72), and also in the Appendix on airway management and intubation in the newest edition of Anesthesiologists Manual of Surgical Procedures by Richard Jaffe et al (Lippincott Williams and Wilkins, 5^th Edition, May 2014). An outline of the system is as follows:

A. Plan A is direct laryngoscopy an intubation using a Miller or MacIntosh blade.

B. If Plan A is unsuccessful, Plan B includes use of video laryngoscopy with a GlideScope or similar device.

C. If Plan B is unsuccessful, Plan C is placement of an LMA with intubation through that LMA using a fiberoptic bronchoscope.

D. “If Plans A-C fail,” Larson wrote in his Letter to the Editor of the Stanford Gas Pipeline in May, 2013, “one needs Plan D. The first and perhaps the most prudent option is to cancel the proposed operation, terminate the anesthetic, and wake the patient up. The operation would be rescheduled for another day, and at that time an awake fiberoptic intubation technique would be used. Alternatively, if the operation cannot be postponed, then the surgeon should be informed that a surgical airway (i.e.: tracheostomy) must be performed before the planned operation can commence. To date, utilization of Plan D because of failure of Plans A-C has not occurred.”

Dr. Larson wrote that the airway skills in Plan A – C should be practiced regularly on patients with normal airways. I agree with Dr. Larson that in managing difficult airways, a practitioner needs a short list of procedural skills that he or she is expert at rather that a large array of procedures that they rarely use (such as the alternative intubation techniques using light wands or blind nasal techniques, or invasive airway procedures such as retrograde wires passed through the cricothyroid membrane or transtracheal jet ventilation through a catheter). It’s wise for anesthesiologists to regularly hone their techniques of video laryngoscopy (Plan B) and fiberoptic intubation via an LMA (Plan C) on patients with normal airways, to remain expert with these skills.

Regarding Plan B, an important advance is the availability of portable, disposable video laryngoscopes such as the Airtraq, a guided video intubation device. In my career I sometimes work in solo operating room suites distant from hospitals. In these settings, the operating room is usually not be stocked with an expensive video scope such as the GlideScope, the C-MAC, or the McGrath 5. I carry an Airtraq in my briefcase, and if the need for Plan B arises I am prepared to utilize video laryngoscopy at any anesthetizing location. I suggest the practice of carrying an Airtraq to any anesthesiologist who gives general anesthetics in remote locations.

Regarding emergency surgical rescue airway management, Dr. Larson recently published a Letter to the Editor in the American Society of Anesthesiologists Newsletter, February 2014, entitled, Ditch the Needle – Teach the Knife. In this letter, Dr. Larson wrote:

“in life-threatening airway obstruction, … an emergency cricothyrotomy is much quicker, easier, safer and more effective than any needle-based technique. I can state with confidence that there is no place in emergency airway management for needle-based attempts to establish ventilation. It should be deleted from the ASA Difficult Airway Algorithm. I have participated in seven cricothyrotomies in emergency airway situations, and all of the patients left the hospital without any neurological injury or complications from the cricothyrotomy. The risk-benefit ratio is markedly in favor the knife technique…. With a knife, or scissors, one cuts quickly either vertically or horizontally below the thyroid cartilage and there is the cricothyroid membrane or tracheal rings. The knife is inserted into the trachea and turned 90 degrees, and an airway is established. At that point, a small tube of any type can be inserted next to the knife. The knife technique is much safer because there is virtually nothing that one can harm by making an incision within two inches or less in the midline of the neck, and it can be performed in less than 30 seconds. In contrast, the needle is fraught with complications, including identifying the trachea, making certain that the needle is entirely in the trachea and does not move ( to avoid subcutaneous emphysema when an oxygen source is established), establishing a pressurized oxygen delivery system (which will take more than five minutes even in the most experienced circumstances), and avoiding causing a tension pneumothorax… I know of multiple cases of acute airway obstruction where the needle technique was attempted, and in all cases the patients died. I know of no such cases when a cricothyrotomy was used as the primary treatment of acute airway obstruction.”

A final note on the awake intubation of patients with a difficult airway: In hindsight in any difficult airway case, one often wishes they had secured an endotracheal tube prior to the induction of general anesthesia. The difficult problem is deciding prior to a case which patient has such a difficult airway that the induction of general anesthesia should be delayed until after intubation. In anesthesia oral board examinations it may be wise to say you would perform an awake intubation on a difficult airway patient rather than risk the “can’t intubate, can’t ventilate” scenario the examiner is probably poised to skewer you with. In medical malpractice lawsuits, plaintiff expert witnesses in anesthesia airway disaster cases often testify that a brain-dead patient’s life would have been saved if only the anesthesiologist had performed awake intubation rather than inducing general anesthesia first and then losing the airway. The key question is: how does one decide which patient needs an awake intubation? As an anesthesia practitioner, if you performed awake intubations on one out of 50 cases because you were worried about a difficult airway, you would delay operating rooms and surgeons multiple times per year because of your caution. You will not be popular if you do this. In my clinical practice and in the practice of the excellent Stanford anesthesiologists I work with, the prevalence of awake intubation is very low. I estimate most anesthesiologists perform between zero and two awake intubations per year. The most common indications include patients with severe ankylosing spondylitis of the cervical spine, congenital airway anomalies, and severe morbid obesity. Dr. Larson wrote in his Letter to the Editor of the Stanford Gas Pipeline in May, 2013, “I do anesthesia for most of the patients with complex head and neck tumors, and I find fewer and fewer indications for awake fiberoptic intubation. As long as the lungs can be ventilated by bag-mask or LMA, which is true for almost all sedated patients, Plan C is easier, quicker and safer than awake fiberoptic intubation both for the patient and the anesthesia provider. In experienced hands, Plan C can be completed in less than 5 minutes, and one can become proficient by practicing in normal patients. I have done hundreds of Plan C’s, many under difficult circumstances, without a single failure or complication. Obviously, no technique will encompass every conceivable airway problem, but mastering Plans A-D and awake oral and nasal fiberoptic intubation will meet the needs of anesthesia providers in almost all circumstances.”

May you never experience the emotional trauma of an airway disaster. Become an expert in bag-mask ventilation, always have access to a video laryngoscope or an Airtraq, and consider Dr. Larson’s Plan A-D system, described in detail in the Appendix on airway management and intubation in the newest edition of Anesthesiologists Manual of Surgical Procedures by Richard Jaffe et al (Lippincott Williams and Wilkins, 5^th Edition, May 2014).

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

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

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

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?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

*
*
*
*

KIRKUS REVIEW

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

Nuanced characterization and crafty details help this debut soar.

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

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:

HOW RISKY IS A TONSILLECTOMY?

31 Dec 20131 Nov 2018THE ANESTHESIA CONSULTANT 2 Comments

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

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Latest posts by THE ANESTHESIA CONSULTANT (see all)

STANFORD EMERGENCY MANUAL POCKET VERSION - 28 Sep 2023
CALL FROM THE JAILHOUSE REVIEW: “I LOVED HOW THE BOOK WAS CRAFTED.” - 15 Sep 2023
CONTINUOUS FINGER-CUFF BLOOD PRESSURE MONITORING - 28 Aug 2023

13-year-old Jahi McMath of Oakland, California suffered sudden bleeding from her nose and mouth and cardiac arrest following a December 9^th 2013 tonsillectomy, a surgery intended to help treat her obstructive sleep apnea. After the bleeding she lapsed into a coma. Three days later she was declared brain-dead.

tonsillectomy-recovery-day-by-day-12

How could this happen?

Behind circumcision and ear tubes, tonsillectomy is the third most common surgical procedure performed on children in the United States. 530,000 tonsillectomies are performed children under the age of 15 each year. Tonsillectomy is not a minor procedure. It involves airway surgery, often in a small child, and often in a child with obstructive sleep apnea. The surgery involves a risk of bleeding into the airway. The published mortality associated with tonsillectomy ranges from 1:12,000 to 1:40,000.

Between 1915 and the 1960’s, tonsillectomy was the most common surgery in the United States, done largely to treat chronic throat infections. After the 1970’s, the incidence of tonsillectomies dropped, as pediatricians realized the procedure had limited success in treating chronic throat infections. The number of tonsillectomies has increased again in the last thirty years, as a treatment for obstructive sleep apnea (OSA). Currently 90 percent of tonsillectomies are performed to treat OSA. Only 1 – 4 % of children have OSA, but many of these children exhibit behavioral problems such as growth retardation, poor school performance, or daytime fatigue. The American Academy of Otolaryngology concluded that “a growing body of evidence indicates that tonsillectomy is an effective treatment for sleep apnea.”

Tonsillar and adenoid hypertrophy are the most common causes of sleep-disordered breathing in children. Obstructive sleep apnea is defined as a “disorder of breathing during sleep characterized by prolonged upper airway obstruction and/or intermittent complete obstruction that disrupts normal ventilation during sleep.” (Miller’s Anesthesia, 7^th edition, 2009, Chapter 82).

In OSA patients, enlarged tonsils can exacerbate loud snoring, decrease oxygen levels, and cause obstruction to breathing. Removal of the tonsils can improve the diameter of the breathing passageway. Specific diagnosis of OSA can be made with an overnight sleep study (polysomnography), but applying this test to large populations of children is a significant expense. Currently only about 10 percent of otolaryngologists request a sleep study in children with sleep-disordered breathing prior to surgery (Laryngoscope 2006;116(6):956-958). In our surgical practice in Northern California, most pediatricians and otolaryngologists forego the preoperative overnight sleep study if the patient has symptoms of obstructed sleep, confirmed by a physical exam that reveals markedly enlarged tonsils.

Every tonsillectomy requires general anesthesia, and anesthesiologists become experts in the care of tonsillectomy patients. Prior to surgery the anesthesiologist will review the chart, interview the parent(s), and examine the child’s airway. Most children under the age of 10 will be anesthetized by breathing sevoflurane via an anesthesia mask, which is held by the anesthesiologist. Following the child’s loss of consciousness, the anesthesiologist will place an intravenous (IV) catheter in the child’s arm. The anesthesiologist then inserts a breathing tube into the child’s windpipe, and turns the operating table 90 degrees away so the surgeon has access to operate on the throat. The surgeon will move the breathing tube to the left and right sides of the mouth while he or she removes the right and left tonsils. (note: children older than the age of 10 will usually accept an awake placement of an IV by the anesthesiologist, and anesthetic induction is accomplished by the IV injection of sleep drugs including midazolam and propofol, rather than by breathing sevoflurane via an anesthesia mask).

The child remains asleep until the tonsils are removed, and all bleeding from the surgical site is controlled. The anesthesiologist then discontinues general anesthetic drugs and removes the breathing tube when the child awakens. Care is taken to assure that the airway is open and that breathing is adequate. Oxygen is administered until the child is alert. Tonsillectomy is painful, and intravenous opioid drugs such as fentanyl or morphine are commonly administered to relieve pain. The opioids depress respiration, and monitoring of oxygen levels and breathing is routinely done until the child leaves the surgical facility.

Most tonsillectomy patients have surgery as an outpatient and are discharged home within hours after surgery. Prior to the 1960’s patients were hospitalized overnight routinely post-tonsillectomy. In 1968 a case series of 40,000 outpatient tonsillectomies with no deaths was reported, and performance of tonsillectomy on an outpatient basis became routine after that time. (Miller’s Anesthesia, 7^th edition, 2009, Chapter 33).

Published risk factors for postoperative complications after tonsillectomy include: (1) age younger than 3 years; (2) evidence of OSA; (3) other systemic disorders of the heart and lungs); (4) presence of airway abnormalities; (5) bleeding abnormities; and (6) living a long distance from an adequate health care facility, adverse weather conditions, or home conditions not consistent with close observation, cooperativeness, and ability to return quickly to the hospital. (Miller’s Anesthesia, 7^th edition, 2009, Chapter 82).

The incidence of post-tonsillectomy bleeding increases with age. In a national audit of more than 33,000 tonsillectomies, hemorrhage rates were 1.9% in children younger than 5 years old, 3% in children 5 to 15 years old, and 4.9% in individuals older than 16. The return to the operating room rate was 0.8% in children younger than 5 years old, 0.8% in children 5 to 15 years old, and 1.2% in individuals older than 16. (Miller’s Anesthesia, 7^th edition, 2009, Chapter 75).

Primary bleeds usually occur within 6 hours of surgery. Hemorrhage is usually from a venous or capillary bleed, rather than from an artery. Complications occur because of hypovolemia (massive blood loss), the risk of blood aspiration into the lungs, or difficulty with replacing the breathing tube should emergency resuscitation be necessary. Early blood loss can be difficult to diagnose, as the blood is swallowed and not seen. Signs suggesting hemorrhage are an unexplained increasing heart rate, excessive swallowing, pale skin color, restlessness, sweating, and swelling of the airway causing obstruction. Low blood pressure is a late feature. (Miller’s Anesthesia, 7^th edition, 2009, Chapter 75).

What happened to 13-year-old Jahi McMath in Oakland following her tonsillectomy? We have no access to her medical records, and all we know is what was reported to the press. The following text was published in the 12/21/2013 Huffington Post:

After her daughter underwent a supposedly routine tonsillectomy and was moved to a recovery room, Nailah Winkfield began to fear something was going horribly wrong.

Jahi was sitting up in bed, her hospital gown bloody, and holding a pink cup full of blood.

“Is this normal?” Winkfield repeatedly asked nurses.

With her family and hospital staff trying to help and comfort her, Jahi kept bleeding profusely for the next few hours then went into cardiac arrest, her mother said.

Despite the family’s description of the surgery as routine, the hospital said in a memorandum presented to the court Friday that the procedure was a “complicated” one.

“Ms. McMath is dead and cannot be brought back to life,” the hospital said in the memo, adding: “Children’s is under no legal obligation to provide medical or other intervention for a deceased person.”

In an interview at Children’s Hospital Oakland on Thursday night, Winkfield described the nightmarish turn of events after her daughter underwent tonsil removal surgery to help with her sleep apnea.

She said that even before the surgery, her daughter had expressed fears that she wouldn’t wake up after the operation. To everyone’s relief, she appeared alert, was talking and even ate a Popsicle afterward.

But about a half-hour later, shortly after the girl was taken to the intensive care unit, she began bleeding from her mouth and nose despite efforts by hospital staff and her family.

While the bleeding continued, Jahi wrote her mother notes. In one, the girl asked to have her nose wiped because she felt it running. Her mother said she didn’t want to scare her daughter by saying it was blood.

Family members said there were containers of Jahi’s blood in the room, and hospital staff members were providing transfusions to counteract the blood loss.

“I don’t know what a tonsillectomy is supposed to look like after you have it, but that blood was un-normal for anything,” Winkfield said.

The family said hospital officials told them in a meeting Thursday that they want to take the girl off life support quickly.

“I just looked at the doctor to his face and I told him you better not touch her,” Winkfield recalled.

Despite the family’s description of the surgery as routine, the hospital said in a memorandum presented to the court Friday that the procedure was a “complicated” one.

Despite the precaution of hospitalizing Jahi McMath post-tonsillectomy, when her bleeding developed it seems the management of her Airway-Breathing-Circulation did not go well. I’ve attended to bleeding post-tonsillectomy patients, and it can be a harrowing experience. It can be an extreme challenge to see through the blood, past the swollen throat tissues post-surgery, and locate the opening to the windpipe so that one can insert the breathing tube needed to supply oxygen to the lungs. Assistance from a second anesthesiologist is often needed. The surgeon will be unable to treat or control severe bleeding until an airway tube is in place. Difficult intubation and airway management can lead to decreased oxygen levels and ventilation, jeopardizing oxygen delivery to the brain and heart. If severe bleeding is unchecked and transfusion of blood cannot be applied swiftly, the resulting low blood pressure and shock can contribute to the lack of oxygen to a patient’s brain.

A bleeding tonsillectomy patient can be an anesthesiologist’s nightmare.

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

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KIRKUS REVIEW

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

Nuanced characterization and crafty details help this debut soar.

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

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IS YOUR GRANDMOTHER TOO OLD FOR SURGERY?

2 Oct 20132 Nov 2018THE ANESTHESIA CONSULTANT 4 Comments

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Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

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This column is for my non-medical layperson readers. Your 85-year-old grandmother had two gallstone attacks in the past 6 months. Is she too old for surgery? Is it safe for her to have her gallbladder removed?

It depends. A general surgeon would serve as the consultant as to the natural history of the gallbladder disease. He may opine that future gallstone attacks are likely, and that the severe pain and fever of acute cholelithiasis is possible.

If your grandmother was 50 years old, you’d expect the surgical team to operate on her. For an 85-year-old patient, the surgical prognosis depends on her medical condition. She needs preoperative assessment from a specialist, and that specialist would be an anesthesiologist.

At Stanford University the anesthesia department is known as the Department of Anesthesia, Perioperative and Pain Medicine. The word perioperative refers to medical practice before, during, and after surgical operations. Preoperative assessment refers to the medical work-up before a surgical procedure—the work-up which establishes that all necessary diagnostic and therapeutic measures have been taken prior to proceeding to the operating room.

Age alone should not be a deterrent to surgery. Increased life expectancy, safer anesthesia, and less invasive surgical techniques such as laparoscopy have made it possible for a greater number of geriatric patients to undergo surgical intervention. The decision to operate should not be based on age alone, but should be based on an assessment of the risk-to-benefit ratio of each individual case. Surgical risk and outcome in patients 65 years old and older depend primarily on four factors: (1) age, (2) whether the surgery is elective or urgent, (3) the type of procedure, and (4) the patient’s physiologic status and coexisting disease. (reference: Miller’s Anesthesia, Chapter 71, Geriatric Anesthesia, 7^th Edition, 2009).

Let’s look at each of these four factors:

1) Age. Data support that increasing age increases risk. Complication rates and mortality rates are higher for patients in their 80’s than for patients in their 60’s.

2) Emergency surgery. Patients presenting for emergency surgery are often sicker than patients for elective surgery, and have increased risk. There may be insufficient time for a full preoperative medical workup or tune-up prior to anesthesia.

3) Type of procedure. A trivial procedure such as finger or toe surgery carries significantly less risk than open heart surgery or intra-abdominal surgery.

4) Coexisting disease. The American Society of Anesthesiologists has a classification system for patients which categorizes how healthy or sick a patient is (see the American Society of Anesthesiologists Physical Status Class categories below). A patient with severe heart or lung disease is at higher risk than a rigorous patient who hikes, bikes or swims daily without heart or lung pathology.

Let’s examine these four factors in your 85-year-old grandmother. Regarding factor (1), she is old, and therefore she carries increased risk solely because of her advanced age. Regarding factor (2), her surgery is non-emergent, and this is in her favor. Regarding factor (3), her procedure requires intra-abdominal surgery, which is more invasive and carries more cardiac and respiratory risk than a trivial hand or foot or cataract surgery. She’ll have to cope with post-operative abdominal pain and pain on deep breathing, each of which can affect her lung function after anesthesia. Factor (4), her pre-existing medical history and physical condition, is the key element in her pre-operative consult.

The American Society of Anesthesiologists Physical Status Class categorizes patients as follows:

Class I – A normal healthy patient. Almost no one over the age of 65 is an ASA I.

Class II – A patient with mild systemic disease.

Class II – A patient with severe systemic disease.

Class IV – A patient with severe systemic disease that is a constant threat to life.

Let’s say your grandmother has well-treated hypertension, asthma, hyperlipidemia, and obesity. She is reasonably active without limiting heart or lung disease symptoms, and she can climb two flights of stairs without shortness of breath.

She is an ASA Class II.

What if your grandmother had a past heart attack which left her short of breath walking up two flights of stairs, or she has kidney failure and is on dialysis, or she has severe emphysema that leaves her short of breath walking up two flights of stairs? These problems make her an ASA Class III, and she is at higher risk than a Class II patient.

If your 85-year-old grandmother is short of breath at rest or has angina at rest, due to either heart failure or chronic lung disease, she is an ASA Class IV patient, and she is at very high risk for surgery and anesthesia.

Laypersons can access an online surgical risk calculator, sponsored by the American College of Surgeons, at www.riskcalculator.facs.org, and enter the specific data for any surgical patient, to estimate surgical risk.

If your grandmother has well-treated hypertension, asthma, hyperlipidemia, and obesity as described above, then her operative risk is moderate and most anesthesiologists will be comfortable giving her a general anesthetic. The American College of Surgeons risk calculator estimates her risk of death, pneumonia, cardiac complications, surgical site infection, or blood clots as < 1%. Her risk of serious complication is estimated at 2%.

How will the anesthesiologist proceed?

For an 85-year-old patient, most anesthesiologists will require a written consultation note from an internal medicine primary care doctor or a cardiologist prior to proceeding with anesthesia. The anesthesiologist will then confirm that all necessary diagnostic and therapeutic measures have been done prior to surgery. Routine lab testing is not be ordered because of age alone, but rather pertinent lab tests are done as indicated for the particular medical problems of each patient.

The anesthesiologist then explains the risks of anesthesia and obtains informed consent prior to the surgery. He or she will explain that an 85-year-old patient with treated hypertension, asthma, hyperlipidemia, and obesity has a higher chance of heart, lung, or brain complications than a young, healthy patient. Your grandmother will have to accept the risks as described by the anesthesiologist.

What do anesthesiologists do differently for geriatric anesthetics, in contrast to anesthesia practice on young patients?

(1) Anesthesiologists use smaller doses of drugs on elderly patients than they do on younger patients. Geriatric patients are more sensitive to anesthetic drugs, and the effect of the drugs will be more prolonged.

(2) Geriatric patients have progressive loss of functional reserve in their heart, lungs, kidney, and liver systems. The extent of these changes varies from patient to patient, and each patient’s response to surgery and anesthesia is monitored carefully. (Miller’s Anesthesia, Chapter 71, Geriatric Anesthesia, 7^th Edition, 2009). The anesthesiologist’s routine monitors will include pulse oximetry, electrocardiogram, automated blood pressure readings, temperature monitoring, and monitoring of all inspired gases and anesthetic concentrations. Because most anesthetic drugs cause decreases in blood pressure, anesthesiologists slowly titrate additional anesthetic doses as needed, and remain vigilant for blood pressure drops that are excessive or unsafe.

What about mental decline following geriatric surgery?

Postoperative short-term decrease in intellect (decrease in cognitive test performance) during the first days after surgery is well documented, and typically involves decreases in attention, memory, and fine motor coordination. Early cognitive decline after surgery is largely reversible by 3 months. The reported incidence of cognitive dysfunction after major noncardiac surgery in patients older than 65 years is 26% at 1 week and 10% at 3 months. (reference: Johnson T, Monk T, Rasmussen LS, et al: Postoperative cognitive dysfunction in middle-aged patients. Anesthesiology 2002; 96:1351-1357).

In conclusion, the decision to proceed with your grandmother’s surgery and anesthesia requires an informed assessment of the benefit of the surgery versus the risks involved. Well-trained anesthesiologists anesthetize 85-year-old patients every day, with successful outcomes. My advice is to choose a medical center with fine physician anesthesia providers, and heed their consultation regarding whether your grandmother poses any unacceptable risk for surgery and anesthesia.

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

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

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

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

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

*
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KIRKUS REVIEW

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

Nuanced characterization and crafty details help this debut soar.

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

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:

SHOULD YOU CANCEL SURGERY FOR A BLOOD PRESSURE OF 170/99?

11 May 20138 Jul 2021THE ANESTHESIA CONSULTANT 43 Comments

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

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

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Clinical Case for Discussion: This month’s question is on hypertension and anesthesia. You are scheduled to anesthetize a 71-year-old male for an arthroscopic rotator cuff repair. His blood pressure when you meet him in pre-op is 170/99 mmHg. The nurses and the surgeon are alarmed. What would you do? Should you cancel surgery for a blood pressure of 170/99?

Discussion: You assess the patient carefully. A review of his chart shows he’s been taking anti-hypertensive oral medications for ten years. His current regimen includes daily atenolol and lisinopril, with his most recent doses taken this morning with a sip of water. He was seen in his internist’s office one week ago, and at that time his blood pressure was 140/88. He has no other medical comorbidities. His cardiac, renal, and neurologic histories are negative. He does not have diabetes. His BMI (Body Mass Index) is normal at 25. He walks three miles per day. His resting EKG and his BUN and creatinine are normal.

The patient’s physical exam is unremarkable except that he appears nervous. Should you cancel the case and send him back to his internist to adjust the blood pressure medical therapy regimen? Should you lower his blood pressure acutely with intravenous antihypertensive drugs, and then proceed with the surgery?

Hypertension, defined as two or more blood pressure readings greater than 140/90 mm Hg, is a common affliction found in 25% of adults and 70% of adults over the age of 70 (Miller’s Anesthesia, 7^th Edition, Chapter 34, Preoperative Evaluation). Over time, hypertension can cause end-organ damage to the heart, arterial system, and kidneys. Hypertensive and ischemic heart disease are the most common types of organ damage associated with hypertension. Anesthesiologists are always wary of cardiac complications in hypertensive patients.

Chronic hypertension is a serious health hazard. But what about a single, markedly-elevated blood pressure value prior to elective surgery? Are there any data to guide our decision about whether to proceed with surgery? There are. A 2004 publication by Howell is a meta-analysis of 30 studies examining the relationship between hypertensive disease, elevated admission arterial pressure, and perioperative cardiac outcome. This paper found little evidence for perioperative complications in patients with admission arterial pressures of less than 180 mm Hg systolic or 110 mm Hg diastolic. This paper recommends that anesthesia and surgery not be cancelled for blood pressures lower than 180/110 mm Hg.

Based on the Howell study, Miller’s Anesthesia recommends that elective surgery be delayed for hypertension, until the blood pressure is less than 180/110 mm Hg.

In my prior career as an internal medicine doctor, I saw many hypertensive patients who’d presented for surgery with elevated blood pressures, yet whose blood pressure was adequately controlled in clinic. The anxiety and stress of anticipated surgery can elevate blood pressure acutely. If surgery is cancelled because of this hypertension and the patient is referred back to the primary care internist, the blood pressure is often well-controlled in the office setting on the same drug regimen that gave poor blood pressure control on admission to surgery. A primary care provider will be reluctant to add further medications in the office setting if the blood pressure is not elevated in clinic.

What about emergency surgery? What if a patient presents for urgent surgery for acute cholecystitis, and his blood pressure is 190/118 mm Hg? For urgent or emergent surgery, consider titrating intravenous antihypertensive drugs such as labetolol (5–10 mg q 5–10 minutes prn) or hydralazine (5–10 mg q 5–10 minutes prn) to decrease blood pressure prior to initiating anesthesia. Because the eventual induction of general anesthesia with intravenous and volatile anesthetics will lower blood pressure by vasodilation and cardiac depression, any pre-induction antihypertensives must be titrated with great care. Once doses of labetolol or hydralazine are injected, there is no way to remove the effect of that drug. For critically ill patients, consider monitoring with an arterial line and infusing a more titratable and short-acting drug such as nitroprusside for blood pressure control.

Let’s return to the anesthetic for your elective shoulder surgery patient with the blood pressure of 170/99 mmHg. You begin by administering 2 mg of midazolam IV. Three minutes later his blood pressure decreases to 160/90. You anesthetize him with 50 micrograms of fentanyl, 140 mg of propofol IV, and 30 mg of rocuronium, and intubate the trachea. In the next 20 minutes, while the patient is moved into a lateral position for the surgery, his blood pressure drops to 95/58. Because most anesthetics depress blood pressure by vasodilation or cardiac depression, it’s common for patients such as this one to require intermittent vasopressors to avoid hypotension, especially at moments when surgical stimulus is minimal. One of the recommendations of the Howell study is that intraoperative arterial pressure be maintained within 20% of the preoperative arterial pressure. This recommendation can be a challenge, especially if the preoperative blood pressure was elevated. A 20% reduction from 170/99 (mean pressure = 122 mm Hg) would be 136/79. A 20% reduction from the mean pressure of 122 mm Hg would be a mean pressure of 98 mm Hg. You choose to treat the patient’s hypotension with 10 mg of IV ephedrine, which raises the blood pressure to 140/85. Fifteen minutes later, the surgeon makes his incision, and the blood pressure escalates to 180/100. You treat this by deepening anesthesia with small, incremental doses of fentanyl and propofol. The surgery concludes, you awaken the patient without complications, and his blood pressure in the Post Anesthesia Care Unit is 150/88 mm Hg.

This pattern of perioperative blood pressure lability is common in hypertensive patients, and will require your vigilance to avoid extremes of hypotension or hypertension. Remember that based on the Howell study, Miller’s Anesthesia recommends elective surgery be delayed for hypertension until the blood pressure is less than 180/110 mm Hg. Armed with this information, you’ll cancel fewer patients for preoperative hypertension.

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

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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

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:

WILL YOU HAVE AN ANESTHESIOLOGIST FOR YOUR WISDOM TEETH EXTRACTION SURGERY?

29 Apr 201320 Sep 2022THE ANESTHESIA CONSULTANT 20 Comments

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Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

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In the United States, will you have an anesthesiologist for your wisdom teeth extraction surgery? If you are a healthy patient, the answer is: probably not.

In the United States, oral surgeons perform most wisdom teeth extraction surgeries. This is a very common surgery, with the operation performed on up to five million times in the United States each year. Most patients are healthy teenagers. Oral surgeons perform wisdom teeth surgeries in their office operating rooms, and most oral surgeons manage the intravenous sedation anesthesia themselves, without the aid of an anesthesiologist.

Oral surgeons are trained in the airway management and general anesthesia skills necessary to accomplish this safely, and a nurse assists the oral surgeon in delivering sedative medications. Oral surgeons must earn a license to perform general anesthesia in their office. To administer general anesthesia in an office, most oral surgeons complete at least three months of hospital-based anesthesia training. In most states, oral surgeons then undergo an in-office evaluation by a state dental-board-appointed examiner, who observes an actual surgical procedure during which general anesthesia is administered to a patient. It’s the examiner’s job to inspect all monitoring devices and emergency equipment, and to test the doctor and the surgical staff on anesthesia-related emergencies. If the examinee successfully completes the evaluation process, the state dental board issues the doctor a license to perform general anesthesia. Note that even though the oral surgeon has a license to direct anesthesia, the sedating drugs he or she orders are often administered by a nurse who has no license or training in anesthesia.

In an oral surgeon’s office, general anesthesia for wisdom teeth extraction typically includes intravenous sedation with several drugs: a benzodiazepine such as midazolam, a narcotic such as fentanyl or Demerol, and a hypnotic drug such as propofol, ketamine, and/or methohexital. Prior to administering these powerful drugs, the oral surgeon must be certain that he or she can manage the Airway and Breathing of the patient. After the patient is asleep, the oral surgeon injects a local anesthetic such as lidocaine to block the superior and inferior alveolar nerves. These local anesthetic injections render the mouth numb, so the surgeon can operate without inflicting pain. Typically, no breathing tube is used and no potent anesthetic vapor such as sevoflurane is used. The oral surgeon may supplement intravenous sedation with inhaled nitrous oxide.

The oral surgeon has all emergency airway equipment, breathing tubes, and emergency drugs available. The safety record for oral surgeons using these methods seems excellent. My review of the National Institutes of Health website PubMed reveals very few instances of death related to wisdom teeth extraction. Recent reports include one patient who died in Germany due to a heart attack after his surgery (Kunkel M, J Oral Maxillofac Surg. 2007 Sep;65(9):1700-6. Severe third molar complications including death-lessons from 100 cases requiring hospitalization). A second patient died in Japan because of a major bleed in his throat occluding trachea, one day after his surgery (Kawashima W, Forensic Sci Int. 2013 May 10;228(1-3):e47-9. doi: 10.1016/j.forsciint.2013.02.019. Epub 2013 Mar 26. Asphyxial death related to postextraction hematoma in an elderly man).

Most oral surgeons do not publish their mishaps or complications, so the medical literature is not the place to search for data on oral surgery deaths. Deaths that occur during or after wisdom teeth extraction are sometimes reported in the lay press. In April 2013, a 24-year-old healthy man began coughing during his wisdom teeth extraction in Southern California, and went into cardiac arrest. He was transferred to a hospital, where he died several days later.

In 2011, a Baltimore-area teen died during wisdom teeth extraction. The family’s malpractice claim was settled out of court in 2013.

Every general anesthetic carries a small risk, such as these two reported cases of death following wisdom teeth extractions. All acute medical care involves attending to the A – B – C ‘s of Airway, Breathing, and Circulation. During surgery for wisdom teeth extraction, the oral surgeon is operating in the patient’s mouth. Surgery in the mouth increases the chances that the operation will interfere with the patient’s Airway or Breathing. The surgeon’s fingers, surgical instruments, retractors, and gauze pads crowd into the airway, and may influence breathing. If the patient’s breathing becomes obstructed, altering the position of the jaw, the tongue, or the neck is more challenging than when surgery does not involve the airway.

I’ve attended to hundreds of patients for dental surgeries. For dental surgery in a hospital setting, anesthesiologists commonly insert a breathing tube into the trachea after the induction of general anesthesia. A properly positioned tracheal tube can assure the Airway and Breathing for the duration of the surgery. Because an anesthesiologist is not involved with performing the surgery, his or her attention can be 100% focused on the patient’s vital signs and medical condition. When anesthesiologists are called on to perform general anesthesia for wisdom teeth extraction in a surgeon’s office, we typically use a different anesthetic technique. Usually there is no anesthesia machine to deliver potent inhaled anesthetics, therefore intravenous sedation is the technique of choice. Usually no airway tube is inserted. When general anesthesia is induced in an office setting, the patient must have an adequate airway, i.e. and American Society of Anesthesiologists Class I or II airway. A typical technique is a combination of intravenous midazolam, fentanyl, propofol, and/or ketamine. Oxygen is administered via the patient’s nostrils throughout the surgery. The adequacy of breathing is continuously monitored by both pulse oximetry and end-tidal carbon dioxide monitoring. The current American Society of Anesthesiologist Standards for Basic Anesthetic Monitoring (July 1, 2011) state that “Every patient receiving general anesthesia shall have the adequacy of ventilation continually evaluated. … Continual monitoring for the presence of expired carbon dioxide shall be performed unless invalidated by the nature of the patient, procedure or equipment.”

The motto of the American Society of Anesthesiologists is “Vigilance.” If the patient’s oxygen saturation and/or end-tidal carbon dioxide numbers begin to decline, an anesthesiologist will act immediately to improve the A – B – C ‘s of Airway, Breathing, and Circulation.

Let’s return to our opening question: Will you have an anesthesiologist for your wisdom teeth extraction surgery? If you are a healthy patient, I cannot show you any data that an anesthesiologist provides safer care for wisdom teeth surgery than if an oral surgeon performs the anesthesia. The majority of wisdom teeth extractions in the United States are performed on healthy patients without an anesthesiologist, and reported complications are rare. If you want an anesthesiologist, you need to make this clear to your oral surgeon, and ask him to make the necessary arrangements. If you do choose to enlist a board-certified anesthesiologist for your wisdom teeth extractions, know that your anesthesia professional has completed a three or four year training program in his field, and is expert in all types of anesthesia emergencies. As a downside, you will be responsible for an extra bill for the professional fee of this anesthesiologist.

Whether an anesthesiologist or an oral surgeon attends to your anesthesia, the objectives are the same: Each will monitor the A – B – C ‘s of your Airway, Breathing, and Circulation to keep you oxygenated and ventilated, so you can wake up and leave that dental office an hour or so after your wisdom teeth extraction surgery has concluded.

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

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

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

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?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

*
*
*
*

KIRKUS REVIEW

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

Nuanced characterization and crafty details help this debut soar.

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

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:

THE OBESE PATIENT AND ANESTHESIA

7 Mar 201320 Sep 2022THE ANESTHESIA CONSULTANT 2 Comments

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Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

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Obese patients make anesthesiologists’ work more arduous. Obese patients, especially morbidly obese and super obese patients, are at increased risk when they need surgery. Perhaps you’re overweight and you wish you weren’t. Your anesthesiologist wishes the same thing. Let’s look at the reasons why.

Two hundred million Americans, or 65% of the U.S. adult population, are overweight or obese. Obesity as a disease is second only to smoking as a preventable cause of death.

The body mass index (BMI) has become the most widely applied classification tool used to assess individual weight status. BMI is defined as the patient’s weight, measured in kilograms, divided by the square of the patient’s height, measured in meters.

A normal BMI is between 18.5 and 24.9. Patients are considered to be overweight with a BMI between 25 and 29.9 obese with a BMI between 30 and 39.9, morbidly obese between 40 and 49.9, and super obese at greater than 50.

Morbid obesity is associated with far more serious health consequences than moderate obesity, and creates additional challenges for health care providers. Between 2000 and 2010, the prevalence of morbid obesity in the U.S. increased by 70%, whereas the prevalence of super obesity increased even faster. It’s estimated that in 2010, 15.5 million adult Americans, or 6.6% of the population, had an actual BMI >40, and carried the diagnosis of morbid obesity.

MEDICAL PROBLEMS ASSOCIATED WITH OBESITY

Obesity is an independent risk factor for heart disease, hypertension, stroke, hyperlipidemia, osteoarthritis, diabetes mellitus, cancer, and obstructive sleep apnea (OSA). A neck circumference > 17 inches in men or > 16 inches cm in women is associated with obstructive sleep apnea. As a result of these concomitant conditions, obesity is also associated with early death.

There is a clustering of metabolic and physical abnormalities referred to as the “metabolic syndrome.” To be diagnosed with metabolic syndrome, you must have at least three of the following: abdominal obesity, elevated fasting blood sugar, hypertension, low HDL levels, or hypertriglyceridemia. In the United States, nearly 50 million people have metabolic syndrome, for an age-adjusted prevalence of almost 24%. Of people with metabolic syndrome, more than 83% meet the criterion of obesity. Patients with metabolic syndrome have a higher risk for cardiovascular disease and are at increased risk for all-cause mortality.

Obstructive sleep apnea (OSA) is a condition characterized by recurrent episodes of upper airway obstruction occurring during sleep. Obesity is the greatest risk factor for OSA, and about 70% of patients (up to 80% of males and 50% of females) with OSA are obese. OSA is defined as complete blockage of airflow during breathing lasting 10 seconds or longer, despite maintenance of neuromuscular ventilatory effort, and occurring five or more times per hour of sleep (Apnea Hypopnea Index, or AHI, greater than or equal to five), and accompanied by a decrease of at least 4% in arterial oxygen saturation. This diagnosis can be made only in patients who undergo a sleep study. Obstructive sleep apnea is classified as mild, moderate, or severe, as follows:

Mild OSA =A HI of 5 to 15 events per hour
Moderate OSA = AHI of 15 to 30 events per hour
Severe OSA = AHI of more than 30 events per hour

Treatment is recommended for patients with moderate or severe disease, and initial treatment is the wearing of a continuous positive airway pressure (CPAP) device during sleep.

ANESTHETIC CHALLENGES

Every anesthesia task can be more difficult to perform in an obese patient. Excess adipose tissue (fat) on the upper extremities makes it harder to place an IV catheter. Excess fat surrounding the mouth, throat, and neck can make it more difficult to place an airway tube. Excess fat can make it more difficult to place a needle in the proper position for a spinal anesthetic, an epidural anesthetic, or a regional block of a specific peripheral nerve. On thick, cone-shaped upper arms, it can be difficult for a blood pressure cuff to detect the blood pressure accurately.

During surgery, an anesthesiologist’s job is to maintain the patient’s A-B-C’s of Airway, Breathing, and Circulation, in that order. All three tasks are more difficult in obese patients.

Airway procedures are often much more difficult to perform in obese patients than in patients with normal BMIs. Every general anesthetic begins with the anesthesiologist injecting intravenous medications that induce sleep. Next the anesthesiologist controls the breathing by using a mask over the patient’s face, and then he or she places an airway tube through the patient’s mouth into the windpipe.

The airway anatomy of obese patients, with or without OSA, may show a short, thick neck, large tongue, and significantly increased amounts of soft tissue surrounding the uvula, tonsils, tongue, and lateral aspects of their throats. This can contribute to the development of airway obstruction and also increase the probability that it will be more difficult to keep the airway open during mask ventilation. This can also contribute to difficulty placing an anesthesia airway tube into the windpipe at the beginning of general anesthesia.

What about breathing difficulties? The chief reason that obese patients have difficulty with breathing during anesthesia is that they have abnormally low lung volumes for their size. When lying flat on their back, a patient’s increased abdominal bulk pushes up on their lungs, and prevents the lungs from inflating fully. Once the patient is anesthetized, this mechanical situation is worsened, because breathing is impaired by the anesthetic drugs and muscle relaxation allows the abdomen to sink further into the chest. The essence of the problem is that the abdomen squashes the lungs and makes them less efficient both as a reservoir and as an exchange organ for oxygen. Because of this, the obese patient is at risk for running out of oxygen and turning blue more quickly than a lean patient.

In one study, patients undergoing general anesthesia received 100% oxygen by facemask before induction of general anesthesia. After the induction of general anesthesia, the patients were left without ventilation until their oxygen saturation fell from 100% to 90%. Patients with normal BMIs took 6 minutes for their oxygen level to fall to 90%. Obese patients reached that end point in less than 3 minutes.

What about circulation? Maintaining stable circulatory status can be difficult because obese patients have a higher prevalence of cardiovascular disease, including hypertension, arrhythmias, stroke, heart failure, and coronary artery disease. During anesthesia and surgery, unexpected high or low blood pressure events are more common in obese patients than in those with normal BMIs. Morbidly obese patients have a higher rate of heart attack postoperatively than patients with normal BMIs.

Regional anesthesia, especially epidural and spinal anesthesia, is often a safer technique than general anesthesia in obese patients. However, regional anesthesia can be technically more difficult because of the physical challenge of the anatomy being obscured by excess fat.

Operative times are often longer in obese patients, owing to technical challenges for the surgeon regarding anatomy distorted or hidden behind excessive fat. Longer surgery means a longer time under general anesthesia, which is a cause of delayed awakening from anesthesia. At the conclusion of surgery, obese patients wake more slowly than lean patients. Anesthetic drug and gas concentrations drop more slowly post-surgery, because traces of the chemicals linger in the reservoirs of excessive adipose tissue.

Common serious postoperative complications in obese patients include blood clots in the legs (deep venous thrombosis) and wound infections at the surgical incision line.

(Reference for this section: Miller’s Anesthesia, 7^th Edition, 2009, Chapter 64).

DATA ON THE RISKS OF OBESITY AND SURGERY

In one landmark study, researchers analyzed postoperative complications in 6,773 patients treated between 2001 and 2005 at the University of Michigan. Of the patients who had complications, 33% were obese and 15% were morbidly obese. Obese patients had much higher rates of postoperative complications than nonobese patients, as follows: 5 times more heart attacks, 4 times more peripheral nerve injuries, 1.7 times more wound infections, and 1.5 times more urinary tract infections. The overall death rate was no different for obese and nonobese patients, but the death rate was nearly twice as high among morbidly obese patients as compared with nonobese patients (2.2% vs. 1.2%).

CONCLUSIONS

Experienced anesthesiologists respect the risks and difficulties presented by obese, morbidly obese, and super obese patients. The ranks of overweight Americans are growing, and every week we anesthetize thousands of them for surgery. As an obese American, are you safe in the operating room? You probably are, because anesthesia professionals are well-educated in the risks of taking care of you. But you must realize that you are at higher risk for a complication than those with a normal BMI.

What can you do about all this? If you are morbidly obese and your surgery is optional, you may consider not having surgery at all. If you have time before surgery, you can try to lose weight. Before any surgery, you should consult your primary care physician to make sure that any obesity-related medical problems have been addressed. You may be placed on medication for hypertension, hyperlipidemia, or diabetes. You may have undiagnosed OSA, and may benefit from a nightly CPAP treatment for that disorder.

Bariatric surgery (e.g., gastric banding, gastric bypass) is a well-accepted and effective treatment for weight loss in super obese and morbidly obese patients. Bariatric surgery refers to surgical alteration of the small intestine or stomach with the aim of producing weight loss. More than 175,000 bariatric surgeries were performed in 2006, and more than 200,000 were performed in 2008 (Miller’s Anesthesia, 7^th Edition, 2009, Chapter 64). Weight loss after bariatric surgery is often dramatic. On the average, patients lose 60% of their extra weight. For example, a 350-pound person who is 200 pounds overweight could lose about 120 pounds. All the anesthetic considerations and risks discussed above would still apply to any patient coming to the operating room for weight loss surgery.

Obesity was considered a rarity until the middle of the 20th century. Now more than 300,000 deaths per year in the United States and more than $100 billion in annual health care spending are attributable to obesity. Obesity most frequently develops when food calorie intake exceeds energy expenditure over a long period of time.

If you’re obese, this doctor recommends you eat less, and exercise more. Stay lean if you can. Your anesthesiologist will thank you.

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

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

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

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?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:

THE TOP TEN MOST USEFUL ADVANCES AND THE FIVE MOST OVERRATED ADVANCES AFFECTING ANESTHESIA IN THE PAST 25 YEARS

6 Feb 201312 Jul 2021THE ANESTHESIA CONSULTANT 2 Comments

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

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

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In 1986 the American Society of Anesthesiologists adopted pulse oximetry and end-tidal CO2 monitoring as standards of care. These two monitors were our specialty’s major advances in the 1980’s, and made anesthesia safer for everyone. What are the most significant advances affecting anesthesia since that time? As a clinician in private practice, I’ve personally administered over 20,000 anesthetics in the past quarter century. Based on my experience and observations, I’ve assembled my list of the Top Ten Most Useful Advances Affecting Anesthesia from 1987-2012. I’ve also assembled my list of the Five Most Overrated Advances Affecting Anesthesia from 1987-2012.

THE TOP TEN MOST USEFUL ADVANCES AFFFECTING ANESTHESIA IN THE PAST 25 YEARS (1987- 2012):

#10. The cell phone (replacing the beeper). Cell phones changed the world, and they changed anesthesia practice as well. Before the cell phone, you’d get paged while driving home and have to search to find a payphone. Cell phones allow you to be in constant contact with all the nurses and doctors involved in your patient’s care at all times. No one should carry a beeper anymore.

#9. Ultrasound use in the operating room. The ultrasound machine aids peripheral nerve blockade and catheter placement, and intravascular catheterization. Nerve block procedures used to resemble “voodoo medicine,” as physicians stuck sharp needles into tissues in search of paresthesias and nerve stimulation. Now we can see what we’re doing.

#8. The video laryngoscope. Surgeons have been using video cameras for decades. We finally caught up. Although there’s no need for a video laryngoscope on routine cases, the device is an invaluable tool for seeing around corners during difficult intubations.

#7. Rocuronium. Anesthesiologists long coveted a replacement for the side-effect-ridden depolarizing muscle relaxant succinylcholine. Rocuronium is not as rapid in onset as succinylcholine, but it is the fastest non-depolarizer in our pharmaceutical drawer. If you survey charts of private practice anesthesiologists, you’ll see rocuronium used 10:1 over any other relaxant.

#6. Zofran. The introduction of ondansetron and the 5-HT3 receptor blocking drugs gave anesthesiologists our first effective therapy to combat post-operative nausea and vomiting.

#5. The ASA Difficult Airway Algorithm. Anesthesia and critical care medicine revolve around the mantra of “Airway-Breathing-Circulation.” When the ASA published the Difficult Airway Algorithm in Anesthesiology in 1991, they validated a systematic approach to airway management and to the rescue of failed airway situations. It’s an algorithm that we’ve all committed to memory, and anesthesia practice is safer as a result.

#4. The internet. The internet changed the world, and the Internet changed anesthesia practice as well. With Internet access, clinicians are connected to all known published medical knowledge at all times. Doctors have terrific memories, but no one remembers everything. Now you can research any medical topic in seconds. Some academics opine that the use of electronic devices in the operating room is dangerous, akin to texting while driving. Monitoring an anesthetized patient is significantly different to driving a car. Much of O.R. monitoring is auditory. We listen to the oximeter beep constantly, which confirms that our patient is well oxygenated. A cacophony of alarms sound whenever vital signs vary from norms. An anesthesia professional should never let any electronic device distract him or her from vigilant monitoring of the patient.

#3. Sevoflurane. Sevo is the volatile anesthetic of choice in community private practice, and is a remarkable improvement over its predecessors. Sevoflurane is as insoluble as nitrous oxide, and its effect dissipates significantly faster than isoflurane. Sevo has a pleasant smell, and it replaced halothane for mask inductions.

#2. Propofol. Propofol is wonderful hypnotic for induction and maintenance. It produces a much faster wake-up than thiopental, and causes no nausea. Propofol makes us all look good when recovery rooms are full of wide-awake, happy patients.

#1. The Laryngeal Mask Airway. What an advance the LMA was. We used to insert endotracheal tubes for almost every general anesthesia case. Endotracheal tubes necessitated laryngoscopy, muscle relaxation, and reversal of muscle relaxation. LMA’s are now used for most extremity surgeries, many head and neck surgeries, and most ambulatory anesthetics.

THE FIVE MOST OVERRATED ADVANCES AFFECTING ANESTHESIA IN THE PAST 25 YEARS (1987-2012):

#5. Office-based general anesthesia. With the advent of propofol, every surgeon with a spare closet in their office became interested in doing surgery in that closet, and they want you to give general anesthesia there. You can refuse, but if there is money to be earned, chances are some anesthesia colleague will step forward with their service. Keeping office general anesthesia safe and at the standard of care takes careful planning regarding equipment, monitors, and emergency resuscitation protocols. Another disadvantage is the lateral spread of staffing required when an anesthesia group is forced to cover solitary cases in multiple surgical offices at 7:30 a.m. A high percentage of these remote sites will have no surgery after 11 a.m.

#4. Remifentanil. Remi was touted as the ultra-short-acting narcotic that paralleled the ultra-short hypnotic propofol. The problem is that anesthesiologists want hypnotics to wear off fast, but are less interested in narcotics that wear off and don’t provide post-operative analgesia. I see remi as a solid option for neuroanesthesia, but its usefulness in routine anesthetic cases is minimal.

#3. Desflurane. Desflurane suffers from not being as versatile a drug as sevoflurane. It’s useless for mask inductions, causes airway irritation in spontaneously breathing patients, and causes tachycardia in high doses. Stick with sevo.

#2. The BIS Monitor. Data never confirmed the value of this device to anesthesiologists, and it never gained popularity as a standard for avoiding awareness during surgery.

#1. The electronic medical record. Every facet of American society uses computers to manage information, so it was inevitable that medicine would follow. Federal law is mandating the adoption of EMRs. But while you are clicking and clicking through hundreds of Epic EMR screens at Stanford just to finish one case, anesthesiologists in surgery centers just miles away are still documenting their medical records in minimal time by filling out 2 or 3 sheets of paper per case. Today’s EMRs are primitive renditions of what will follow. I’ve heard the price tag for the current EMR at our medical center approached $500 million. How long will it take to recoup that magnitude of investment? I know the EMR has never assisted me in caring for a patient’s Airway, Breathing, or Circulation in an acute care setting. Managing difficulties with the EMR can easily distract from clinical care. Is there any data that demonstrates an EMR’s value to anesthesiologists or perioperative physicians?

Your Top Ten List and Overrated Five List will differ from mine. Feel free to communicate your opinions to me at rjnov@yahoo.com.

As we read this, hundreds of companies and individuals are working on new products. Future Top Ten lists will boast a fresh generation of inventions to aid us in taking better care of our patients.

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

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

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

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?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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KIRKUS REVIEW

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

Nuanced characterization and crafty details help this debut soar.

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

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:

IS ANESTHESIA 99% BOREDOM AND 1% PANIC?

15 Jul 20122 Sep 2020THE ANESTHESIA CONSULTANT 8 Comments

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

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

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When you have surgery, do you care who administers your anesthetic? You should. An oft-repeated medical adage states:“anesthesia is 99% boredom and 1% panic.

36164768-a-depiction-of-the-pearly-gates-of-heaven-open-with-the-bright-side-of-heaven-contrasting-with-the-d

GOALIES AT THE PEARLY GATES

As an anesthesiologist who’s delivered over 50,000 hours of operating room care over 25 years, I can attest that the adage is true. Ninety-nine percent of the time, the anesthesia provider’s job requires vigilance during a patient’s stable progression of metronome heartbeats and regular breathing, but 1% of the time requires clear thinking and prompt action during moments of sheer panic. These stress-filled episodes of panic are unknown to the general public, yet represent ordeals that every anesthesia provider must rise above to protect their patients.

Webster’s Dictionary defines panic as “ an overwhelming feeling of fear and anxiety.” If you were to observe an anesthesiologist at work, you would see little or no evidence of overwhelming fear or anxiety. Even under dire emergencies, most anesthesia providers remain outwardly composed and efficient while they make the necessary diagnoses and apply the appropriate treatments. But anesthesiologists are human–no human can watch another human trying to die without feeling intense emotions. These emotions are fear and anxiety.

No field of medicine provides the stunning variety of anesthesia. Patients vary from neonates to centenarians, from laboring women to motor vehicle accident victims at three a.m., while surgeries vary from repair of a broken finger to the transplantation of a heart or a liver. Technologic advances have led surgeons to operate on older and sicker patients, and to attempt more complex surgeries than decades ago.

The operating room is an intense environment. Operating room medicine is pressure-packed for four reasons:

Anesthetic drugs change the physiology of patients in profound ways.
Surgeons do dangerous things to patients.
Surgical patients have diseases. Some of these diseases are urgent or severe.
Human beings make errors. This includes both surgeons and anesthesia providers.

Unbelievable events occur at unexpected times in operating rooms, and your anesthesia provider must keep you safe. He or she is in control of your airway, breathing, and circulation at every moment. Your anesthesia provider is your insurance policy against medical complications during surgery. Your anesthesia provider’s job is to play Goalie at the Pearly Gates, and keep you alive.

The individual administering your anesthesia can vary–your anesthesia provider may be:

a medical doctor (an anesthesiologist),
a certified registered nurse anesthetist (CRNA) or anesthesia assistant (AA) supervised by an anesthesiologist, or
a CRNA working without anesthesiologist supervision.

In the United States, anesthesiologists personally administer 35% of the anesthetics. Anesthesia care teams, in which an anesthesiologist medically directs a team of AA’s or CRNA’s, administer 55% of the anesthetics. CRNA’s, working unsupervised, administer 10% of the anesthetics.

There are people who perceive anesthesia care to be so safe that it can be taken for granted. They are wrong. Anesthesia care is safest when a physician, a board-certified anesthesiologist, directs the anesthetic care. Published data shows that:

Mortality rates after surgery are significantly lower when anesthesiologists direct anesthesia care.
Failure-to-rescue rates (the rate of death after a complication) are significantly lower when anesthesiologists direct anesthesia care.
Death rates and failure-to-rescue rates are significantly lower when board-certified anesthesiologists supervise anesthesia care, compared to when mid-career anesthesiologists who are not board-certified supervise anesthesia care.

“Failure-to-rescue” implies that the anesthesia provider wasn’t successful in preventing a 1% panic moment from turning into a death statistic. The phrase “failure-to-rescue” is a key theme of this book. Or more precisely, the phrase “successful rescue” is a key theme of this book. When unexpected events occur during surgery–the 1% panic moments–your anesthesia provider needs to make the correct diagnosis and apply the correct therapeutic intervention to successfully rescue you.

When you meet your anesthesia provider prior to surgery, you’re about to trust your life to a stranger. It matters who that stranger is. As a patient, do you have any control over who your anesthesia provider will be? If your surgery is an emergency at 2 a.m. when only one anesthesia provider is available, you will not. But for most surgeries, and all elective surgeries, this book will teach you what to expect in anesthesia care, and what you can do to receive the best in anesthesia care.

Anesthesiologists must finish a minimum of 12 years of post-high school education–four years of college, four years of medical school, and four years of anesthesia internship and residency. Nurse anesthetists must finish a minimum of 7 or 8 years of post-high school education –four years of college, a minimum of one year of critical care nursing experience, and two to three years of anesthetist training. Anesthesia assistants must finish a minimum of 6 years of post-high school education–four years of college, and a 24-month program to obtain a Master’s degree as an anesthesia assistant.

Why would an individual choose to become an anesthesia provider? It’s rare for teenagers or college students to dream of themselves as anesthetists. Most popular television, movies, and fiction portray physicians in more conventional careers as surgeons, emergency room doctors, or in clinics. Only 4% of medical school graduates choose anesthesiology.

I believe that individuals who choose anesthesia for their medical career are individuals who love the adrenaline rush of acute medical care. Operating room anesthesia is a 180-degree turn from outpatient clinics, where practitioners take histories, order lab tests, write prescriptions for pills, and make appointments to see their patient weeks into the future. Instead of experiencing clinic visits over months or years, the anesthetic encounter is immediate care with immediate results. Instead of a clinic patient returning weeks later for a recheck, the anesthetic patient wakes up from their anesthetic, and is discharged to their home or their hospital bed within hours.

I had already completed a three-year residency in internal medicine before I began my years of anesthesia training. The diagnosis and treatment of complex medical patients appealed to me during internal medicine training, but I found the glacial pace of outpatient clinic care boring. When I worked along side anesthesiologists in the intensive care unit, I was wooed by their skills in placing breathing tubes, intravenous and intra-arterial catheters, and their apparent calmness no matter how ill any patient was. The world of acute care medicine is the world of airway, breathing, and circulation. No specialty mastered all three as completely as anesthesiologists did.

The beginning of specialty training in anesthesia brings both intimidating power and overwhelming challenge. For the first time in your life, your profession is to inject powerful medications into patients and watch them lose consciousness in seconds. Administering your first anesthetic is an unforgettable experience. One minute you are chatting with a patient, telling them to picture themselves relaxing on a beach in Hawaii, and the next minute you’ve rendered them unconscious and totally dependent on you to manage their airway, breathing, and circulation.

Moving from novice anesthesiologist trainee to experienced specialist requires hard work and patience. On the first day of my anesthesia residency, I was so green I didn’t even know which hoses connected my anesthesia gas machine to the patient. While learning the anesthesia profession, trainees must learn to endure the 99% boredom factor and glean their most valuable lessons during the 1% panic time. During my first week of training, after my patient was asleep with the breathing tube inserted and the anesthesia gases flowing, my faculty member, Dr. Gregory Ingham, said to me, “This procedure will take four hours.” He stood next to me for a minute or two in silence, then he said, “I hope you’re of a contemplative nature.”

Why would he say such a thing to a first-week trainee? I believe he said it because much of operating room anesthesia care is tedious vigilance over a stable situation. The anesthetist needs to cope with this fact, and hopefully even appreciate and enjoy the stability.

One week after my first exposure to Dr. Ingham, I was on call overnight in the hospital with him again. We had four consecutive emergency cases, all young healthy men with injuries suffered in motor vehicle or motorcycle accidents. Prior to the fourth case, at 2 a.m., I evaluated the patient and proposed my anesthetic plan. “Our patient is a healthy 25-year-old male except for his open femur fracture,” I said. “I thought we could do the anesthetic the same way we did the last three.”

Dr. Ingham nodded at me and sighed, “Richard, the patients are all different, but the anesthetics are all the same.”

Is this true? Why would he make a statement like this to an impressionable young trainee? There is a great deal of cynicism and battle fatigue in his comment, but a grain of truth. Patients are all different, and many anesthetics are similar, but not every anesthetic is identical. There are always choices for the anesthetist to make–crucial, life threatening decisions–every day, and on every case. Decisions are made before the surgery, during the stable phases of the anesthetic, and during the 1% of moments when the anesthetist’s mind is reeling.

Patients see none of this. Patients typically have ten minutes or less to meet their anesthesia provider. In the internal medicine clinic, patients are awake for 100% of their face-to-face time with their doctor, but before a surgery the anesthesiologist has only a brief encounter to gain their patient’s trust. In the internal medicine clinic, a large number of patients had chronic complaints that were difficult to cure: chronic pains, high blood pressure, obesity, or diabetes. The treatments usually involved a prescription for pills. At the next office visit, the patient might feel better, but there was a significant chance that the patient would feel the same or feel no better, or perhaps they would have a new side-effect symptom from the pill you prescribed for them.

The anesthetic patient encounter is markedly different. Prior to the surgery, most patients are anxious but they treat their anesthesiologist with soaring respect. After the surgery, I find my patients are often gushing in their gratitude for the fact that I had delivered them safely back to consciousness. In contrast to my sometimes-disappointed medicine clinic patients, the anesthetic patients are so upbeat that they make me feel wonderful.

When I describe the elation of interacting with anesthesia patients, my best friend offers a simple explanation: “Of course your patients respect you before the surgery. You’re about to knock them unconscious. They’ll have no control and they’re completely dependent on you. They want you to like them. They want you to keep them alive.”

I believe that assessment is accurate. Every patient wants the same thing from their anesthesia provider. A successful, complication-free experience. And that’s what happens . . . almost every time.

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

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

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

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?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:

DO ANESTHESIOLOGISTS HAVE THE HIGHEST MALPRACTICE INSURANCE RATES?

11 Jun 201219 Nov 2018THE ANESTHESIA CONSULTANT 10 Comments

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

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

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STANFORD EMERGENCY MANUAL POCKET VERSION - 28 Sep 2023
CALL FROM THE JAILHOUSE REVIEW: “I LOVED HOW THE BOOK WAS CRAFTED.” - 15 Sep 2023
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How high are anesthesiology malpractice rates? Do Anesthesiologists pay the highest malpractice insurance rates?

In a word, “No.”

Anesthesia mishaps can lead to critical events such as death or coma, but in recent decades improvements in operating room technology and education have led to fewer such events.

Prior to 1985, anesthesia malpractice claims for death or brain death were most often due to lack of oxygen the patient’s heart or brain. Two significant breakthroughs arrived in the 1980’s to help anesthesiologists care for you: 1) the pulse oximeter, and 2) the end-tidal carbon dioxide monitor.

The pulse oximeter, developed by Nellcor and Stanford anesthesiologist William New, M.D., is a device that clips to a patient’s fingertip. A light-emitting diode shines a red light through the finger, and a sensor on the opposite side of the finger measures the degree of redness in the pulsatile blood flow within the finger. The more red the color of the blood, the more oxygen is present. A computer in the pulse oximeter calculates a score, called the oxygen saturation, which is a number from 0-100%. An oxygen saturation equal to or greater that 90% correlates with a safe amount of oxygen in the arterial blood. A score of 89% or lower correlates with a dangerously low oxygen level in the blood. The pulse oximeter monitor enables doctors to know, second-to-second, whether a patient is getting sufficient oxygen. If the oxygen saturation goes below 90%, doctors will act quickly to diagnose and treat the cause of the low oxygen level. A patient can usually sustain a short period low oxygen saturation, e.g. up to 2 or 3 minutes, without permanent damage to the brain or cardiac arrest by an oxygen-starved heart.

The end-tidal carbon dioxide (CO2) monitor is a device that measures the concentration of CO2 in the gas exhaled by a patient on every breath. During normal ventilation, every exhaled breath contains CO2. When no CO2 is measured, there is no ventilation, and the doctor must act quickly to diagnose and treat the cause of the lack of ventilation.

Prior to the invention of these two monitors, it was possible for an anesthesiologist to mistakenly place a breathing tube in a patient’s esophagus, instead of the trachea, and not know of the error until the patient sustained a cardiac arrest. With the addition of the two monitors, the lack of CO2 (there is no CO2 in the stomach or esophagus) from the end-tidal CO2 monitor immediately indicates that the tube is in the wrong place. The anesthesiologist can then remove the tube, resume mask ventilation with oxygen, and attempt to replace the tube into the windpipe. If the oxygen level to the patient’s blood dips below 90%, this is a second piece of data that indicates that the patient is in danger of brain damage or cardiac arrest.

In addition, in the early 1990’s the American Society of Anesthesiologists created the Difficult Airway Algorithm, which is a step-by-step approach for anesthesiologists to follow when the task of placing a breathing tube for an anesthetic is challenging or difficulty. This Algorithm dictates a standard of care for practitioners, and this advance in education lowered the number of mismanaged airways.

In the 1980’s, surgical anesthesia claims were 80% of closed malpractice claims against anesthesiologists (American Society of Anesthesiologists Closed Claims database). By the 2000’s, this number dropped to 65%. Brain damage represented 9% of claims, and nerve injury accounted for 22% of claims (23% were permanent and disabling, including loss of limb function, or paraplegia or quadriplegia) Less common claims were airway injury (7% of claims), emotional distress, (5% of claims), eye injuries including blindness (4% of claims), and awareness during general anesthesia (2% of claims).

Decreasing anesthesiologist malpractice premiums reflect the decrease in the number of catastrophic anesthesia claims for esophageal intubation, death, and brain death.

In 1985, the average malpractice insurance premium was $36,224 per year for a $1 Million per claim/$3 Million per year policy. By 2009, this decreased to $21,480, a striking 40% drop.(Anesthesia in the United States 2009, Anesthesia Quality Institute)

Specialties with the highest risk of facing malpractice claims are neurosurgery (19.1 percent), thoracic and cardiovascular surgery (18.9 percent) and general surgery (15.3 percent). Specialties with the lowest risks are family medicine (5.2 percent), pediatrics (3.1 percent) and psychiatry (2.6 percent). Anesthesiologists rank in the middle of the pack, at 7%. (Malpractice Risk According to Physician Specialty, Jena, et al, N Engl J Med 2011) From 1991 to 2005, this article identified 66 malpractice awards that exceeded $1 million dollars, which accounted for less than 1% of all payments. Obstetrics and gynecology accounted for the most payments (11), followed by pathology (10), anesthesiology (7), and pediatrics (7).

The take-home message is that anesthesia has serious risks, but those risks have decreased significantly in recent years because of improvements in monitoring and education. Compared to other specialties, the risk of an anesthesiologist being sued is about average among American medical specialties.

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

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

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

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:

ANAPHYLACTIC REACTION UNDER GENERAL ANESTHESIA

29 Nov 201120 Nov 2018THE ANESTHESIA CONSULTANT 1 Comment

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Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

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Clinical Case For Discussion: Anaphylaxis during anesthesia can be a difficult diagnosis. A 59-year-old male is undergoing a sigmoid colectomy. Twenty minutes after surgery begins, the peak inspiratory pressure on the ventilator rises to 50 cm H2O, and the systolic blood pressure reading on your vital signs monitor drops to 70. What do you do?

Discussion: You begin by rechecking the ABC’s of Airway, Breathing, and Circulation. You suction the endotracheal tube to be sure it is patent. It is. You squeeze the bag and listen to the lungs to make sure both lungs are ventilated. They are, but there are diffuse wheezes. You recheck the blood pressure device in the stat mode. The repeat blood pressure is unchanged. You feel for peripheral pulses, and they are not palpable. Heart tones are present, but the rate is 140 beats per minute. The oxygen saturation is 70%. There are no acute ST changes on the ECG. The exposed skin is normal.

You need a diagnosis to make the appropriate therapy. This is the acute onset of a multi-system disorder, with bronchospasm and hypotension, in a previously healthy patient. There are not many conditions that cause both acutely, and I want you to think of anaphylaxis early on. A differential diagnosis includes:

(1) an acute myocardial infarction, with left heart failure and pulmonary edema,

(2) acute septic shock, or

(3) airway occlusion or acute asthma with decreased ventilation and cardiac dysfunction.

The absence of ST changes, arrhythmias, rales, or gallop make the first unlikely, the second is very uncommon, and respiratory dysfunction is not likely to cause hypotension.

At the beginning of any surgery, multiple drugs including anesthetics, muscle relaxants, narcotics, and antibiotics are given in a short time period. The identity of which drug is causing the allergic reaction is often impossible to determine. Anaphylaxis secondary to latex exposure from surgeon’s gloves has also been reported.

Regardless of the cause of the anaphylaxis, the treatment will be the same.

Anesthetic drugs are stopped, 100% oxygen is administered, and a bolus of intravenous fluid is given. Treatment must include intravenous epinephrine. Other causes of hypotension can be treated with dopamine or phenylephrine, but anaphylaxis will not respond to these drugs. Bronchospasm can be treated with inhaled bronchodilators such as albuterol, but this will have little effect in anaphylaxis.

Prompt epinephrine therapy is crucial. The dose of epinephrine is important. The 1 mg. ampule of epinephrine needs to be diluted. Treatment is begun in 10 to 100 microgram increments, and increased as needed. The response should be immediate, with increase in systemic vascular resistance, blood pressure, and improvement in bronchospasm and oxygen saturation. An epinephrine infusion may be needed to maintain vital signs. An arterial line and central venous catheter are inserted. Adjunct drugs such as steroids, diphenhydramine, and an H-2 blocker are given intraveously.

The surgery is quickly ended. The patient is transferred to the ICU, with the trachea still intubated.

An excellent textbook reference on the treatment of anaphylaxis is the Stanford Cognitive Aid Emergency Manual, available for free download on the Internet.

In 27 years of anesthesia, I have had 4 cases of anaphylaxis. In these 4 episodes the offending drugs were (1) protamine, (2) intravenous contrast dye, (3) vecuronium, and (4) atracurium.

If you were to ask graduating anesthesia residents what is likely to be the case of their career, most would probably say some big heart/thoracic/neuro/zebra type of case. This case shows that it may be some typical case, where something bad happened when they were least expecting it.

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

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

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

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?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

Learn more about Rick Novak’s fiction writing at rick novak.com by clicking on the picture below:

INFORMED CONSENT IN ANESTHESIA: SHOULD YOU TELL PATIENTS THEY COULD DIE?

19 Jul 20112 Oct 2018THE ANESTHESIA CONSULTANT Leave a comment

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