AUTISM AND EPIDURAL ANESTHESIA FOR CHILDBIRTH

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

This month the Journal of the American Medical Association Pediatrics (JAMA Pediatrics) released an online study “Association Between Epidural Analgesia During Labor and Risk of Autism Spectrum Disorders in Offspring,” authored by Qiu et al. This study examined the issue of autism and epidural anesthesia for childbirth. The article showed a 37% increased incidence of autistic spectrum disorder (ASD) in children whose mothers received epidural anesthesia during labor. The article drew scant publicity. 

Instead the key news coverage was an October 12, 2020 press release  from the American Society of Anesthesiologists, the Society for Obstetric Anesthesia and Perinatology, the Society for Pediatric Anesthesia, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, which stated “a new retrospective database study published in JAMA Pediatrics on October 12th, 2020 does not provide credible scientific evidence that labor epidurals for pain relief cause autism. . . . In the scientific literature, the finding of an association between a treatment and an outcome does not prove the treatment caused the outcome.”


The American Society of Anesthesiologists is a very reputable professional organization. I’ve been a card-carrying member of the ASA for 36 years, and I respect the Society at the highest level. The American Society of Anesthesiologists may desire to downplay the results of the JAMA Pediatrics study, but the public deserves a chance to understand what the study accomplished. The JAMA Pediatrics study was not designed to show that labor epidurals do or do not cause autism. The study was designed to assess whether labor epidural exposure for routine vaginal delivery was associated with autistic spectrum risk in the offspring. The study did find an increased incidence of autism in children of mothers who had labor epidural anesthesia, and that’s an important story.

The Center for Disease Control (CDC) states that as of the year 2020,  1 in 54 children are identified with autism spectrum disorder.  The incidence of autism has increased markedly over the past decades, and the reason for this is unclear.  The number of reported cases of autism increased dramatically in the 1990s and early 2000s, from less than one child per 1000 in 1996 to greater than 5 children per 1000 in 2007.

As children on the autism spectrum become adolescents and young adults, they may have difficulties developing friendships, communicating with others, or understanding what behaviors are expected in school or at work. Almost everyone in America knows a family which contains an autistic child. Many families and expectant parents fear their next child will be autistic, and would like to be aware of any behaviors or choices which increase this risks. Explanations regarding the reasons for increases in autism prevalence have been split into a) the opinion that increasing diagnosis and identification of the disorder is leading to numbers, and/or b) the opinion that the increase is due to specific environmental factors which cause autism. What those environmental factors might be is unclear. Scientific American published an excellent review of this topic in 2017

There is no link between vaccines and autism.

In the United States, most laboring women are not interested in experiencing labor pain while unmedicated. Epidural anesthesia is very popular and has been shown to be safe for both the mother and for the infant.  

For readers who are not healthcare providers: in administering a labor epidural anesthetic, an anesthesiologist inserts a needle into the mother’s low back, locates the tip of the needle into the epidural space adjacent to the spinal cord, and injects local anesthetic into the epidural space. The local anesthetic is usually bupivacaine or ropivacaine.

The anesthesiologist then threads a slender hollow catheter into the epidural space, to facilitate delivery of either a continuous infusion of dilute local anesthetic or intermittent injections of local anesthetic. 

The duration of a labor epidural anesthetic exposure can be 8 hours or more. Beginning in the 1980s, labor epidural anesthesia became increasingly popular, rising to its current prevalence of use in the majority of vaginal childbirths. The JAMA Pediatrics study stated that, “widespread use of labor epidural anesthesia during the past few decades has significantly improved perinatal outcomes for mothers and their newborns; however, our findings raise the concern that the short duration of labor epidural anesthesia exposure may be associated with long-term neurodevelopmental disorders in offspring.”

The JAMA Pediatrics study was a retrospective longitudinal birth cohort study. The data were derived from Kaiser Southern California electronic medical records from a single medical system. A total of 147,895 singleton children were delivered vaginally in the eight years between January 1, 2008, and December 31, 2015. Seventy-four percent of these women received a labor epidural anesthetic. A screening checklist was administered to all of their children between the ages of 18 and 24 months of age to screen for developmental delays, including autistic spectrum disorder. A clinical diagnosis of autistic spectrum disorder was based on the evaluation of pediatric developmental specialists.

Autism spectrum disorders were diagnosed in 2039 children (1.9%) of the epidural anesthesia group and 485 children (1.3%) of the non-epidural anesthesia group. Children in the epidural group were 37 percent more likely to have autism than those in the unexposed group.

With a labor epidural anesthetic exposure of less than 4 hours, compared to the non-epidural group, the Hazard Ratio was 1.33 (95%CI, 1.17-1.53), a 33% greater incidence.  With a labor epidural anesthetic exposure of 4 to 8 hours, the Hazard Ratio was 1.35 (95%CI, 1.20-1.53), a 35% greater incidence, and with a labor epidural anesthetic exposure of more than 8 hours the Hazard Ratio was 1.46 (95%CI, 1.27-1.69), a 46% greater incidence. Thus there was a trend of increased autism risk associated with increasing duration of labor epidural anesthetic exposure.

The authors wrote, “the risk was increased with increasing duration of exposure to labor epidural anesthesia. Potential mechanisms showing an association between labor epidural anesthesia and risk of autism spectrum disorder are largely unknown and require further studies. Although labor epidural anesthesia can effectively block labor pain and pain related hormonal release and changes, we speculate that its (i.e. labor epidural anesthesia) commencement may represent the beginning of a novel maternal and fetal physiology, a new homeostasis, and a dynamic biochemical equilibrium, which encompass the principles of physiology, endocrinology, immunology, pharmacology and toxicology, epigenetics, and psychology. Some mechanisms are transient, but others may be persistent and may affect major body systems. . . . Owing to their low molecular weight, all local anesthetics given epidurally can cross the placenta and be redistributed into the maternal and fetal circulation, and thereby may subject both the mother and fetus to the risk of toxic effects.”

The JAMA Pediatrics authors concluded, “exposure to labor epidural anesthesia was associated with a 37% increased risk of autism spectrum disorder in children after adjusting for potential confounders. Longer duration of epidural exposure was associated with greater autism spectrum disorder risk. . . . This study suggests that maternal labor epidural anesthesia may be associated with increased autism spectrum disease risk in children.” 

The paper stated that, “In the United States, more than 70% of women receive some form of a neuraxial procedure (i.e. epidural or spinal anesthetic) during labor. Although the effectiveness of neuraxial anesthesia for labor pain management and the safety of neuraxial anesthesia for the fetus and newborns during the perinatal period have been well documented, the long-term effects of neuraxial anesthesia on the offspring are largely unknown. Limited toxicology and animal studies have shown that standard clinical doses of local anesthetics can produce neurotoxic effects and alter normal behavioral development in rhesus monkeys.”

In the conclusions to the JAMA Pediatrics study the authors wrote, “Our findings are intriguing and bring a concern for the safety and long-term health of offspring regarding the short term epidural use for labor pain. . . . This study suggests that exposure to epidural analgesia for vaginal delivery may be associated with increased risk of autism in children; further research is warranted to confirm the study findings and understand the potential mechanisms.” 

The JAMA Pediatrics study has certain strengths, including its large size, and a single integrated health care delivery system for both the collection of data and the standardized screening for autistic spectrum disorder. The study has the limitation of being a retrospective examination of prerecorded medical record data. The authors admit in their paper: “our findings should be interpreted with caution given the wide varieties of labor epidural anesthesia practice and cannot be interpreted as a demonstration of a causal link between labor epidural anesthesia exposure and subsequent development of autistic spectrum disorder.”

Recall that the American Society of Anesthesiologists, the Society for Obstetric Anesthesia and Perinatology, the Society for Pediatric Anesthesia, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine released their joint statement that said, “’Association Between Epidural Analgesia During Labor and Risk of Autism Spectrum Disorders in Offspring,’ a new retrospective database study published in JAMA Pediatrics on October 12th, 2020 does not provide credible scientific evidence that labor epidurals for pain relief cause autism.”

Please note: “Credible scientific evidence” of cause and effect could only come from a prospective, randomized, double-blinded, placebo-controlled trial of women treated with or without labor epidural anesthesia. That study will never be done, because it would require pregnant women to enroll in a trial in which half of the mothers would receive a local anesthetic epidural anesthetic and half of the mothers would receive placebo epidurals. Then their physicians would prospectively collect data on the two groups, followed by screening their singleton birth children for autistic spectrum disorders. Such a study could provide scientific evidence whether labor epidurals do or do not cause autism—but no one is going to be able to do that study in the United States. Going forward, the best evidence we’re likely to get are future multiple repeat retrospective studies, such as this current JAMA Pediatrics publication, to ascertain whether there is “a statistical association” between labor epidural anesthesia and the occurrence of autistic children. Repeat studies will be published. Stay tuned. In the meantime, labor pain will continue, and physician anesthesiologists will continue to place labor epidurals in the majority of laboring women to blunt the agony of childbirth pain. 

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he 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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Should You Cancel Surgery For a Blood Pressure = 178/108?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM.

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ANESTHESIA FACTS FOR NON-MEDICAL PEOPLE: ANESTHETIC TECHNIQUES

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

This column is for non-medical laypeople, and pertains to the different types of anesthetic techniques used in the 21st century. See below:

GENERAL ANESTHESIA

A general anesthetic renders the patient asleep and insensitive to pain for surgery. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. Before the anesthetic, oxygen is administered by mask to fill the patient’s lungs with 100% oxygen. Most adult patients are given general anesthesia by intravenous injection, usually of the medication propofol. This injection causes the patient to lose consciousness within 10 – 20 seconds. This is called the induction of anesthesia. The maintenance of anesthesia during surgery is done by mixing an anesthesia gas or gases with the oxygen. Typical inhaled anesthesia gases are nitrous oxide, sevoflurane, or isoflurane. Sometimes a continuous infusion of intravenous anesthetic such as propofol is given as well. The choice and dose of drugs is done by the anesthesia attending, based on the patient’s size, age, the type of surgery, and the anesthesiologist’s experience.

Many patients are given prophylactic anti-nausea medication during the anesthetic. If postoperative pain is anticipated, the anesthesiologist can also administer intravenous narcotics such a morphine, meperidine (Demerol), or fentanyl.

Depending on the patient’s medical condition and type of surgery, the anesthesiologist may protect the patient’s airway during the general anesthetic by placing a breathing tube through the mouth, either an endotracheal tube (ET Tube) into the patient’s windpipe, or a laryngeal mask airway (LMA) just above the voice box.

At the conclusion of surgery, the general anesthetic gases and/or intravenous anesthetic infusion(s) are discontinued. The patient usually regains consciousness within 5 – 15 minutes. The patient is then transferred to the recovery room.

SPINAL ANESTHESIA

Spinal anesthesia is done by the injection of local anesthetic solution into the low back into the subarachnoid space. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The word subarachnoid translates to “below the arachnoid”. The arachnoid is one of the layers of the meninges covering the nerves of the spinal column. In the subarachnoid space lies the cerebral spinal fluid (CSF) which surrounds the spinal cord and brain. In a spinal anesthetic, the subarachnoid space is located with a needle by the anesthesiologist, and the appropriate anesthetic medications are injected.

Local anesthetics, such as lidocaine or bupivicaine (brand name Marcaine), given into the subarachnoid space, bring on sensory and motor numbness. The anesthesiologist chooses the dose and type of drug depending on the patient’s age, size, height, medical condition, and the type of surgery.

Following the onset of numbness from spinal anesthesia, the patient may either stay awake for surgery, or more often intravenous anesthesia is given to achieve a light sleep. Sometimes light general anesthesia is given to supplement spinal anesthesia.

EPIDURAL ANESTHESIA

Epidural anesthesia is done by the injection of local anesthetic solution, with or without a narcotic medication, into the low back into the epidural space. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The word epidural translates to “outside the dura”. The dura is the outermost lining of the meninges covering the nerves of the spinal column. The epidural space is located with a needle by the anesthesiologist, and the appropriate anesthetic medications are injected.   Often, a tiny catheter is left in the epidural space, taped to the patient’s low back, to allow repeated doses of the medication to be given.  The catheter is removed at the end of surgery, or sometimes days later if continued epidural medications are administered for postoperative pain control.

Local anesthetics, such as lidocaine or bupivicaine (brand name Marcaine), given into the epidural space, bring on sensory and motor numbness. The anesthesiologist chooses the dose and type of drug depending on the patient’s age, size, height, medical condition, and the type of surgery.

Following the onset of numbness from epidural anesthesia, the patient may either stay awake for surgery, or more often intravenous sedation is given to achieve a light sleep. Sometimes light general anesthesia is given to supplement epidural anesthesia.

REGIONAL ANESTHESIA

Regional anesthesia is the injection of local anesthetic (either lidocaine or Marcaine) near a nerve to block that nerve’s function.  Examples of regional anesthesia include arm blocks (axillary block, interscalene block, subclavicular block), and leg blocks (femoral block, sciatic block, popliteal block, ankle block).  An advantage of regional anesthesia blocks is that the patient may remain awake for the surgery.  If desired, the anesthesia provider may administer intravenous sedation or general anesthesia in addition to the regional anesthetic, to allow the patient to sleep during the surgery–the advantage of this combined anesthetic technique is the regional anesthetic blocks all surgical pain and less sleep drugs are required.

INTRAVENOUS SEDATION ANESTHESIA

Some minor surgical procedures (for example: breast biopsies, eyelid surgery, some hernia surgeries) can be done with the combination of local anesthesia plus intravenous anesthesia sedation. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The anesthesiologist is present for the entire surgery, and administers intravenous sedatives as required for the patient’s comfort and the surgeon’s needs.  If the sedation is deep enough, the intravenous sedation will be termed general anesthesia. While the patient is sedated, the surgeon usually injects local anesthetics into the surgical site to block both surgical and post operative pain.

Vigilance by an anesthesiologist during intravenous sedation is also known as Monitored Anesthesia Care, or MAC.

PEDIATRIC ANESTHESIA

Because the separation of a young child from his or her parents can be one of the most distressing aspects of the perioperative experience, many children benefit significantly from oral preoperative sedation with midazolam. This relatively pleasant-tasting liquid is given by mouth about twenty minutes prior to the start of the anesthetic. Although the midazolam rarely causes children to fall asleep, it does reduce anxiety dramatically, allowing for a much smoother separation from parents. It also tends to cause a wonderful short term amnesia, so that the children often have no recollection of separating from their parents, or even of going to the operating room.
Although the initial anesthetic is usually administered via an intravenous infusion in adult patients, this approach requires starting an IV while the patient is still awake. This technique would be quite unpopular with younger children.  Most young children prefer to go to sleep breathing a gas, a technique known as an inhalation induction. This technique is used for almost all routine surgeries, but cannot safely be employed in certain rare situations, such as emergencies.

An inhalation induction consists of the child breathing a relatively pleasant smelling anesthetic vapor – usually sevoflurane – via a facemask for approximately 30 to 60 seconds. The child loses consciousness while breathing the gas, and the IV can then be started painlessly. Generally, the child continues to breath the gas throughout the duration of the surgery, either via the facemask or an endotracheal tube, depending on the duration and type of surgery. It is this breathing of the gas which keeps the child anesthetized. At the end of the surgery, the gas is discontinued, and the child begins to awaken.

Prior to awakening, children may be given either analgesics (pain medicines) or anti-emetics (drugs which reduce the likelihood of nausea and vomiting). The type of surgery will determine which of the many possible medications will be used for these purposes. The purpose of these medications is to make the child’s awakening as calm and pleasant as possible. Equally important in this regard is reuniting the child with his or her parents as quickly as possible.
Despite best attempts, it is important for parents to realize that children, especially those less than five years of age, often are somewhat cranky and irritable following anesthesia and surgery. We do our best to minimize this, but we cannot prevent it in all cases. Similarly, some children will experience postoperative nausea and vomiting despite receiving medications which are intended to prevent it.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

 

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited

 

 

ANESTHESIA FOR SPECIALTY SURGERIES

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

This column is specifically for my non-medical layperson readers, and is a discussion of the different types of anesthesia for specialty surgeries. See below:

 

I.  CHILDBIRTH (OBSTETRIC ANESTHESIA):

Most obstetric anesthesia is for either vaginal delivery or for Cesarean sections.

Anesthesia for Vaginal Delivery:  Anesthesia for vaginal delivery is utilized to diminish the pain of labor contractions, while leaving the mother as alert as possible, with as muscle strength as possible, to be able to push the baby out at the time of delivery.  Anesthesia for labor and vaginal delivery is usually accomplished by epidural injection of the local anesthetics bupivicaine (brand name Marcaine) or ropivicaine.

is done by the injection of local anesthetic solution, with or without a narcotic medication, into the low back into the epidural space. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood.

The word epidural translates to “outside the dura”. The dura is the outermost lining of the meninges covering the nerves of the spinal column. The epidural space is located with a needle by the anesthesiologist, and the appropriate anesthetic medications are injected.   Often, a tiny catheter is left in the epidural space, taped to the patient’s low back, to allow repeated doses of the medication to be given.  The catheter is removed after childbirth.

Anesthesia for Cesarean Section: Cesarean section is a surgical procedure in which the obstetrician makes an incision through the skin of the lower abdomen, and through the wall of the uterus, or womb, to extract the baby without the child requiring a vaginal delivery.  Anesthesia for Cesarean section is usually a spinal or an epidural anesthetic, which leaves the mother as alert as possible, while rendering surgical anesthesia to her abdomen and pelvis.  Spinal or epidural anesthesia is accomplished by injection of local anesthetics, with or without a narcotic medication, into the low back into the subarachnoid or the epidural space. The anesthesiologist remains present for the entire surgical procedure, to assure that the mother is comfortable and that all vital signs are maintained as close to normal limits as possible.

In a minority of cases, the anesthesia provider will administer a general anesthetic for Cesarean section surgery.  The most common indications for general anesthesia are (1) emergency Cesarean, when there is no time for a spinal or epidural block;  and (2) significant bleeding by the mother, leading to a low blood volume, which is an unsafe circumstance to administer a spinal or epidural block.  General anesthetics for Cesarean section carry an increased risk over spinal/epidural anesthesia, primarily because the mother is no longer able to breath on her own and maintain her own airway.

open heart surgery

II.  CARDIAC SURGERY/OPEN HEART SURGERY:

Open heart surgery requires specialized equipment.  Anesthesia for cardiac surgery is complex, and the following is a brief summary:  Prior to the surgery, the anesthesiologist inserts a catheter into the radial artery at the wrist, to monitor the patient’s blood pressure continuously, rather than relying on a blood pressure cuff.  This enables the anesthesiologist to fine-tune the blood pressure, never allowing it to be too high or too low for an extended period of time.  The anesthesiologist also inserts a catheter (a central venous catheter, or CVP catheter) into a large vein in the patient’s neck.  The anesthesiologist uses this catheter to monitor the pressure inside the heart, and also to administer infusions of potent medications into the central circulation to raise or lower the blood pressure, or to increase the heart’s pumping function.

After the patient is anesthetized, the anesthesiologist often inserts a Transesophageal Echocardiogram (TEE) probe into the patient’s mouth, down the esophagus, and into the stomach.  The TEE gives the anesthesiologist a two-dimensional image of the beating heart and the heart valves in real time, and enables him or her to adjust medications and fluid administration as needed to keep the patient stable.

For open heart surgery, once the chest is open, the cardiac surgeon inserts additional tubes into the veins and arteries around the heart, diverting the patient’s blood from the heart and lungs into a heart-lung machine located alongside the operating table.  During the time the patient is connected to the heart-lung machine, the patient’s heart can be stopped so that the surgeon can operate on a motionless heart.

When the surgeon has completed the cardiac repair, the heart is restarted, and the heart-lung machine is disconnected from the patient.

As the heart resumes beating, the anesthesiologist manages the drug therapy and intravenous fluid therapy to optimize the cardiac function.

III.  ANESTHESIA FOR NEUROSURGERY (BRAIN SURGERY):

Intracranial (brain) surgery requires exacting maintenance of blood pressure, heart rate, and respiratory control.  Prior to the surgery, the anesthesiologist inserts a catheter into the radial artery at the wrist, to monitor the patient’s blood pressure continuously, rather than relying on a blood pressure cuff.  This enables the anesthesiologist to fine-tune the blood pressure, never allowing it to be too high or too low for an extended period of time.  The anesthesiologist also inserts a catheter (a central venous catheter, or CVP catheter) into a large vein in the patient’s neck.  The anesthesiologist uses this catheter to monitor the pressure inside the heart, and also to administer infusions of potent medications into the central circulation to raise or lower the blood pressure.

The anesthetic technique is designed to provide a motionless operating field for the surgeon.  After the anesthesiologist anesthetizes the patient, he or she inserts the endotracheal tube into the windpipe.  The patient is often hyperventilated, because hyperventilation causes the blood vessels in the brain to constrict, and makes the volume of the the brain decrease.  The relaxed brain affords the surgeon more room to dissect and expose brain tumors or aneurysms.

An important goal of the anesthetic is a quick wake-up at the conclusion of surgery, so that (1) normal neurological recovery of the patient can be confirmed, and (2) the patient is alert enough to  maintain their own airway and breathe on their own.  Most brain surgery patients spend at least one night in the intensive care unit (ICU) after surgery.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

 

*
*
*
*

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

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ANESTHESIA FACTS FOR LAYPEOPLE: TYPES OF ANESTHESIA

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

There are several types of anesthesia:

GENERAL ANESTHESIA

A general anesthetic renders the patient asleep and insensitive to pain for surgery. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. Before the anesthetic, oxygen is administered by mask to fill the patient’s lungs with 100% oxygen. Most adult patients are given general anesthesia by intravenous injection, usually of the medication propofol. This injection causes the patient to lose consciousness within 10 – 20 seconds. This is called the induction of anesthesia. The maintenance of anesthesia during surgery is done by mixing an anesthesia gas or gases with the oxygen. Typical inhaled anesthesia gases are nitrous oxide, sevoflurane, or isoflurane. Sometimes a continuous infusion of intravenous anesthetic such as propofol is given as well. The choice and dose of drugs is done by the anesthesia attending, based on the patient’s size, age, the type of surgery, and the anesthesiologist’s experience.

Many patients are given prophylactic anti-nausea medication during the anesthetic. If postoperative pain is anticipated, the anesthesiologist can also administer intravenous narcotics such a morphine, meperidine (Demerol), or fentanyl.

Depending on the patient’s medical condition and type of surgery, the anesthesiologist may protect the patient’s airway during the general anesthetic by placing a breathing tube through the mouth, either an endotracheal tube (ET Tube) into the patient’s windpipe, or a laryngeal mask airway (LMA) just above the voice box.

At the conclusion of surgery, the general anesthetic gases and/or intravenous anesthetic infusion(s) are discontinued. The patient usually regains consciousness within 5 – 15 minutes. The patient is then transferred to the recovery room.

SPINAL ANESTHESIA

Spinal anesthesia is done by the injection of local anesthetic solution into the low back into the subarachnoid space. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The word subarachnoid translates to “below the arachnoid”. The arachnoid is one of the layers of the meninges covering the nerves of the spinal column. In the subarachnoid space lies the cerebral spinal fluid (CSF) which surrounds the spinal cord and brain. In a spinal anesthetic, the subarachnoid space is located with a needle by the anesthesiologist, and the appropriate anesthetic medications are injected.

Local anesthetics, such as lidocaine or bupivicaine (brand name Marcaine), given into the subarachnoid space, bring on sensory and motor numbness. The anesthesiologist chooses the dose and type of drug depending on the patient’s age, size, height, medical condition, and the type of surgery.

Following the onset of numbness from spinal anesthesia, the patient may either stay awake for surgery, or more often intravenous anesthesia is given to achieve a light sleep. Sometimes light general anesthesia is given to supplement spinal anesthesia.

EPIDURAL ANESTHESIA

Epidural anesthesia is done by the injection of local anesthetic solution, with or without a narcotic medication, into the low back into the epidural space. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The word epidural translates to “outside the dura”. The dura is the outermost lining of the meninges covering the nerves of the spinal column. The epidural space is located with a needle by the anesthesiologist, and the appropriate anesthetic medications are injected.   Often, a tiny catheter is left in the epidural space, taped to the patient’s low back, to allow repeated doses of the medication to be given.  The catheter is removed at the end of surgery, or sometimes days later if continued epidural medications are administered for postoperative pain control.

Local anesthetics, such as lidocaine or bupivicaine (brand name Marcaine), given into the epidural space, bring on sensory and motor numbness. The anesthesiologist chooses the dose and type of drug depending on the patient’s age, size, height, medical condition, and the type of surgery.

Following the onset of numbness from epidural anesthesia, the patient may either stay awake for surgery, or more often intravenous sedation is given to achieve a light sleep. Sometimes light general anesthesia is given to supplement epidural anesthesia.

REGIONAL ANESTHESIA

Regional anesthesia is the injection of local anesthetic (either lidocaine or Marcaine) near a nerve to block that nerve’s function.  Examples of regional anesthesia include arm blocks (axillary block, interscalene block, subclavicular block), and leg blocks (femoral block, sciatic block, popliteal block, ankle block).  An advantage of regional anesthesia blocks is that the patient may remain awake for the surgery.  If desired, the anesthesia provider may administer intravenous sedation or general anesthesia in addition to the regional anesthetic, to allow the patient to sleep during the surgery–the advantage of this combined anesthetic technique is the regional anesthetic blocks all surgical pain and less sleep drugs are required.

INTRAVENOUS ANESTHESIA

Some minor surgical procedures (for example: breast biopsies, eyelid surgery, some hernia surgeries) can be done with the combination of local anesthesia plus intravenous anesthesia sedation. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The anesthesiologist is present for the entire surgery, and administers intravenous sedatives as required for the patient’s comfort and the surgeon’s needs.  If the sedation is deep enough, the intravenous sedation will be termed general anesthesia. While the patient is sedated, the surgeon usually injects local anesthetics into the surgical site to block both surgical and post operative pain.

Vigilance by an anesthesiologist during intravenous sedation is also known as Monitored Anesthesia Care, or MAC.

PEDIATRIC ANESTHESIA

Because the separation of a young child from his or her parents can be one of the most distressing aspects of the perioperative experience, many children benefit significantly from oral preoperative sedation with midazolam. This relatively pleasant-tasting liquid is given by mouth about twenty minutes prior to the start of the anesthetic. Although the midazolam rarely causes children to fall asleep, it does reduce anxiety dramatically, allowing for a much smoother separation from parents. It also tends to cause a wonderful short term amnesia, so that the children often have no recollection of separating from their parents, or even of going to the operating room.
Although the initial anesthetic is usually administered via an intravenous infusion in adult patients, this approach requires starting an IV while the patient is still awake. This technique would be quite unpopular with younger children.  Most young children prefer to go to sleep breathing a gas, a technique known as an inhalation induction. This technique is used for almost all routine surgeries, but cannot safely be employed in certain rare situations, such as emergencies.

An inhalation induction consists of the child breathing a relatively pleasant smelling anesthetic vapor – usually sevoflurane – via a facemask for approximately 30 to 60 seconds. The child loses consciousness while breathing the gas, and the IV can then be started painlessly. Generally, the child continues to breath the gas throughout the duration of the surgery, either via the facemask or an endotracheal tube, depending on the duration and type of surgery. It is this breathing of the gas which keeps the child anesthetized. At the end of the surgery, the gas is discontinued, and the child begins to awaken.

Prior to awakening, children may be given either analgesics (pain medicines) or anti-emetics (drugs which reduce the likelihood of nausea and vomiting). The type of surgery will determine which of the many possible medications will be used for these purposes. The purpose of these medications is to make the child’s awakening as calm and pleasant as possible. Equally important in this regard is reuniting the child with his or her parents as quickly as possible.
Despite best attempts, it is important for parents to realize that children, especially those less than five years of age, often are somewhat cranky and irritable following anesthesia and surgery. We do our best to minimize this, but we cannot prevent it in all cases. Similarly, some children will experience postoperative nausea and vomiting despite receiving medications which are intended to prevent it.

 

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