RECREATIONAL KETAMINE

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

Street use of the anesthetic ketamine is on the rise. Kylie, a 28-year-old professional female, recently told me about her experience snorting recreational ketamine: “I was feeling anxious and I was feeling sad. My friend suggested I try snorting some ketamine crystals she had, and when I did . . . I had the best feeling of my life. The drug made me happier. It made the next hour a fun experience without any sadness, and when the high wore off an hour later my sadness was still gone. It was as if I’d been treated with some antidepressant drug, and the improvement in my mood was more lasting than the initial buzz. Now I see my future using ketamine as a periodic antidepressant. When you read about it on the internet, doctors are prescribing ketamine as a treatment for depression, but the whole medical clinic intravenous treatment is really expensive. It’s a lot easier to do it myself with ketamine I buy on the streets.”

Hmmm. We’re all aware of the dangers of recreational drug use with cocaine or methamphetamine or narcotics. We’re all aware of the dangers of recreational drugs laced with fentanyl, a powerful drug that can stop a person’s breathing and kill them in minutes. In this context, what kind of a threat is street ketamine?

 

KETAMINE AS AN ANESTHETIC

Ketamine is a powerful general anesthetic drug in an anesthesiologist’s toolbox. In 1962 Calvin Stevens, a professor of chemistry at Wayne State University, synthesized ketamine from phencyclidine (PCP), an animal tranquilizer/anesthetic also known as angel dust, with the desired goal of discovering a safer anesthetic with fewer hallucinogenic effects than PCP.

Anesthesiologists administer ketamine intravenously to produce general anesthesia without utilizing any anesthesia gas. We call ketamine a dissociative drug, because it can distort sensory perception and impart a feeling of detachment from oneself and the environment. The drug can produce bizarre and unpleasant nightmares, so anesthesiologists are trained to pair ketamine with an intravenous benzodiazepine such as Versed to temper ketamine’s potentially frightening dream world. Anesthesiologists are also trained to pair ketamine with an anticholinergic (mouth-drying) medication such as atropine or glycopyrrolate (Robinul), because ketamine can produce excessive salivating, which can lead to a patient choking on a rising tide of saliva.

For anesthesia usage, ketamine is a clear liquid with a concentration of 100 mg/ml or 50 mg/ml.

Because ketamine is an effective general anesthetic in one syringe, it’s included on the World Health Organization’s list of essential drugs.  For medical sedation, ketamine is typically diluted and administered intravenously in small boluses of 20 to 30 mg, and titrated to obtain the desired depth of anesthesia.  To induce general anesthesia, the intravenous dose is 1 – 4.5 mg/kg, or a mean dose of 2 mg/kg = 100 mg for a 50 kg adult. If it’s not possible to insert an IV line (e.g. if a patient is uncooperative, developmentally delayed, or is a child), a combination of 2 mg/kg of ketamine, 0.2 mg/kg of midazolam, and .02 mg/kg of atropine can be administered as an intramuscular injection into the deltoid muscle of the shoulder or the quadriceps muscle of the anterior thigh. To induce general anesthesia with intramuscular ketamine alone, dosing levels are higher than for intravenous use, for example the intramuscular dose is 6.5 – 13 mg/kg, or a mean dose of 10 mg/kg = 500 mg ketamine for a 50 kilogram adult.

How does medical ketamine affect a patient’s ABCs of airway, breathing, and circulation? Patients typically maintain an adequate airway and breathing during ketamine sedation and anesthesia, which is advantageous in short surgical procedures because this often eliminates the need for a breathing tube. Ketamine causes stimulation of the cardiovascular system, with the potential side effect of increasing blood pressure.

There is no reversal agent for ketamine. If an administered ketamine dose is excessive, a patient’s airway and breathing may become compromised, resulting in inadequate oxygen delivery to the lungs, heart, and brain. Patients who are obese, or who have obstructive sleep apnea, may lose their safe airway and breathing status during ketamine sedation. Ketamine can elevate blood pressure, so vigilant monitoring of the blood pressure is required, and acute treatment for hypertension may be necessary. Because of these risks, ketamine administration is typically limited to anesthesia professionals or physicians who are experts in the emergency management of airways and acute vital sign changes.

 

KETAMINE AS AN INTRAVENOUS ANTIDEPRESSANT DRUG

Multiple meta-analyses have concluded that IV ketamine is an effective rapid-acting antidepressant for major depressive disorders.  Ketamine was first reported to have antidepressant properties in the year 2000, when published data showed that an intravenous administration of a sub-anesthetic ketamine dose resulted in a reduction of symptoms in major depressive disorder (MDD). MDD is a common disorder with significant consequences. A 2012 epidemiological study of mental health in Canada showed the lifetime prevalence of major depressive disorder was 3.9%. The prevalence was higher in women and in younger age groups. Ketamine is a treatment option for patients suffering from treatment-resistant depression (TRD). IV ketamine can exert rapid antidepressant effects as early as several hours after administration. In contrast, traditional oral antidepressant pills usually require several weeks of therapy for a clinical response. Ketamine has a unique mechanism of action on the central nervous system, at the NMDA (N-methyl-D-aspartate) and AMPA (𝛼-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) receptors, rather than at the serotonin and/or noradrenaline neurotransmitters that are the sites of action for traditional antidepressant pills such as Prozac, Paxil, or Zoloft.

Intravenous ketamine clinics are typically supervised by an attending anesthesiologist whose is present is to ensure the safe management of airway, breathing, and circulation during these brief sedation anesthetics. Intravenous ketamine administered in a clinic setting can result in adverse effects during the infusion period and immediately afterward, including nausea, vomiting, drowsiness, dizziness, confusion, dissociation, or an increase in blood pressure.Typically an infusion of 0.5 mg/kg of ketamine (e.g. 40 mg for an 80 kg patient) is administered slowly over 40 – 60 minutes. The patient will remain onsite in a recovery room until the sedative effects have cleared. Patients report positive antidepressant effects within two hours, and these effects last for one to two weeks. Data demonstrate a positive response rate of 44% after six intravenous ketamine treatments in patients with treatment-resistant depression.  A series of anesthetics will cost significantly more than one Prozac pill per day, so the use of ketamine as an antidepressant is directed at treatment-resistant depression.

 

KETAMINE AS AN INTRANASAL ANTIDEPRESSANT DRUG

In 2019 the FDA approved a nasal spray called Spravato (active ingredient esketamine) for major depression that failed treatment with two or more oral antidepressants.

Per the Spravato website:

SPRAVATO® is a non-competitive N-methyl D-aspartate (NMDA) receptor antagonist indicated, in conjunction with oral antidepressant, for the treatment of:  treatment-resistant depression in adults, depressive symptoms in adults with major depressive disorder (MDD) with acute suicidal ideation or behavior.

SPRAVATO® is intended for use only in a certified healthcare setting.

SPRAVATO® is intended for patient administration under the direct observation of a healthcare provider, and patients are required to be monitored by a healthcare provider for at least 2 hours. SPRAVATO® must never be dispensed directly to a patient for home use. 

 

 

The advantage of intranasal ketamine is that it does not require an IV, and it requires monitoring by a healthcare provider but does not require an anesthesiologist to supervise its administration.

 

KETAMINE AS A RECREATIONAL DRUG

To supply the illicit street market, diverted pharmaceutical liquid ketamine is evaporated from its liquid solution into a powdered form.

How popular is recreational ketamine? The number of ketamine seizures by federal, state and local law enforcement in the United States increased from 55 in 2017 to 247 in 2022. The total weight of ketamine confiscated increased by more than 1,000 percent over the five years. The majority of the confiscated ketamine was in powder form. According to the DEA (Drug Enforcement Agency), powdered ketamine is typically packaged in “small glass vials, small plastic bags, and capsules as well as paper, glassine, or aluminum foil folds. . . . powdered ketamine is cut into lines known as bumps and snorted, or it is smoked, typically in marijuana or tobacco cigarettes. . . . Ketamine is found by itself or often in combination with MDMA, amphetamine, methamphetamine, or cocaine. . . . Ketamine produces hallucinations. It distorts perceptions of sight and sound and makes the user feel disconnected and not in control. A ‘Special K’ trip is touted as better than that of LSD or PCP because its hallucinatory effects are relatively short in duration, lasting approximately 30 to 60 minutes as opposed to several hours. . . . An overdose can cause unconsciousness and dangerously slowed breathing.” (bold lettering mine.)

Recreational users call the phenomenon of a deep ketamine high as a “K-hole.” Falling into a K-hole means the drug user is temporarily unable to interact with others or the world around them. Some people refer to a K-hole as an out-of-body or near-death experience. The effects of long-term use of dissociative drugs such as ketamine haven’t been exhaustively studied, but ketamine use is thought to be reinforcing, meaning that individuals find the ketamine high an experience they wish to repeat. Repeated ketamine usage likely leads to some degree of tolerance and physical dependence.

The website The Cut states that “most of the recreational users . . . take K in very small doses, seeking a pleasant buzz that wears off within 30 minutes or can be re-upped as needed. It’s often taken to compliment other drugs — a garnish instead of the main course. For a generation that has less free time for sprawling multi-day psychedelic trips, ketamine has an appealing choose-your-own-adventure quality. . . . Claire says it actually feels like a healthier and more mature lifestyle. ‘People are like: I used to go out and have 16 drinks and do a bunch of cocaine and feel like shit the next day. And then it was this total shift [to ketamine]: Oh, yeah, I can do this. And it still feels like stepping out of my life, but I also feel fine tomorrow.’ At this point, she says: ‘I wouldn’t say that it’s different than like, a bunch of people getting off work and going out for drinks.’”

 

KETAMINE AS A RECREATIONAL ANTIDEPRESSANT?

Can a layperson use ketamine recreationally to treat themself for depression? The specter of self-treatment reminds one of the saying that a physician who treats himself has a fool for a doctor and a fool for a patient. A corollary of this is: a person who treats his or her mood disorder with recreational ketamine has a fool for a caretaker and a fool for a patient.

Kylie will attempt to titrate ketamine recreationally to treat her depression. But a precise, tailored medical dose is required for patients to experience optimal benefit from ketamine with safety. Individuals who self-administer ketamine expose themselves to serious health risks. Ketamine may make their symptoms worse, or they may even die from the habit. Kylie has no plans to have a healthcare provider present when she self-administers ketamine. Kylie has no idea of the milligram dose she is snorting. Her ketamine is not FDA-approved, and may in fact contain fentanyl at a dose that could cease her breathing and kill her.

How dangerous is ketamine? A meta-analysis of the published medical literature showed a total of 312 overdose cases and 138 deaths from recreational ketamine. There were no cases of overdose or death related to the use of ketamine as an antidepressant in a therapeutic setting. Street ketamine may seem cheaper, as the cost of ketamine on the street is approximately $100 per gram (1000 mg), and a single dose is approximately 100 mg. Medical treatment with 50 mg IV ketamine costs approximately $400-$800 per treatment. But ketamine administered by anesthesiologists in a clinic is safe, while there are legitimate respiratory and cardiac risks involved in the recreational use of ketamine.

If Kylie is depressed and seeks relief, an appropriate action would be to consult a psychiatrist. The alternative of intermittent recreational intranasal ketamine as a self-administered treatment for her depression is a dangerous detour.

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The most popular posts for laypeople on The Anesthesia Consultant include: How Long Will It Take To Wake Up From General Anesthesia? Why Did Take Me So Long To Wake From General Anesthesia? Will I Have a Breathing Tube During Anesthesia? What Are the Common Anesthesia Medications? How Safe is Anesthesia in the 21st Century? Will I Be Nauseated After General Anesthesia? What Are the Anesthesia Risks For Children?

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include: 10 Trends for the Future of Anesthesia Should You Cancel Anesthesia for a Potassium Level of 3.6? 12 Important Things to Know as You Near the End of Your Anesthesia Training Should You Cancel Surgery For a Blood Pressure = 170/99? Advice For Passing the Anesthesia Oral Board Exams What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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

MY ANESTHESIOLOGIST ADMINISTERED FENTANYL TO ME. IS THAT OK?

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

America is in the midst of a fentanyl crisis. There were 71,238 fentanyl overdose deaths in the United States in 2021. The Drug Enforcement Administration (DEA) states, “fentanyl is involved in more deaths of Americans under 50 than any cause of death, including heart disease, cancer, homicide, suicide and other accidents.”

Despite this, during surgery your anesthesiologist injected fentanyl into your IV as part of your anesthetic. Is that safe?

Yes.

As a street drug, fentanyl overdose is a critical problem in the United States, but anesthesiologists administer fentanyl to most patients, and do so safely. I review charts from all regions of the U.S., and virtually every anesthetic includes the safe use of fentanyl. Fentanyl was introduced in the 1960s when it was first patented under the brand name Sublimaze, and fentanyl quickly became the most commonly administered narcotic by anesthesia providers. In operating room anesthesia, the narcotic fentanyl is a clear liquid usually marketed in vials of two milliliters or five milliliters.

Why do anesthesiologists utilize fentanyl? Most surgeries cause pain, and our pharmaceutical options for relieving pain include local anesthetics, anesthesia gases,  or narcotics. When possible, we advocate for the injection of local anesthetics by the surgeon or the anesthesiologist to block postoperative pain. Local anesthetics include lidocaine, bupivacaine (also known as Marcaine), or ropivacaine. In addition, most general anesthetics include a potent inhaled anesthesia gas such as sevoflurane. Sevoflurane vapor maintains unconsciousness, blocks memory, and renders a patient pain-free, but when the surgery concludes, the anesthesia gases are turned off so that the patient will awaken. As the anesthesia gas is exhaled, a patient becomes progressively more alert, and will eventually be awake enough to feel surgical pain. The intravenous injection of a narcotic medication such as fentanyl is a common antidote to postoperative pain.

Narcotics relieve pain, but also have the undesirable side effects of respiratory depression, sedation, nausea, and constipation. Narcotics available to an anesthesiologist include morphine, Demerol, Dilaudid, or fentanyl. We commonly administer fentanyl because it has a rapid onset and rapid offset of its effect when compared to the other three drugs. The onset of action of intravenous fentanyl is less than 60 seconds. Its peak effect is at 2–5 minutes, with a half-life of 90 minutes and a duration of action of 30–60 minutes. In contrast, intravenous morphine has a slower peak effect at 5–15 minutes, with a longer half-life of 1.5–2 hours, and a longer duration of action of 3–4 hours. Because the peak effect of morphine, Demerol, or Dilaudid does not occur as rapidly as fentanyl, titrating the intravenous loading of morphine, Demerol, or Dilaudid is a slower process. Fentanyl’s rapid onset of narcotic effect is desirable because anesthesia providers quickly know whether an additional dose is necessary to achieve the titrated level of pain relief we seek. We can administer an IV dose of fentanyl every five minutes, waiting only those five minutes to evaluate how effective the preceding dose was.

Respiratory Depression:

The most serious side effect of intravenous fentanyl in anesthesia usage is the same side effect that makes street fentanyl dangerous, and that’s the side effect of respiratory depression. In layman’s terms, an excessive dose of fentanyl quickly causes a patient to stop breathing. The medical term for cessation of breathing is apnea. In an anesthesiologist’s hands, apnea is easily handled because we are skilled at ventilating oxygen into a patient’s lungs safely via a mask or an airway tube.

Street overdoses of fentanyl are best treated with naloxone (brand name Narcan). Nasal Narcan is now approved for over the counter (OTC) sale in the United States. In a medical setting, intravenous Narcan is injected to reverse a narcotic overdose. Injection of one ampule of Narcan (0.4 mg) will completely reverse narcotic apnea and unconsciousness in an overdosed patient in less than a minute.

The protocol for treating an emergency room patient who is unconscious on admission for unknown reasons includes an empirical intravenous injection of Narcan. If the patient’s coma was caused by any narcotic overdose, the patient will awaken within seconds.

Fentanyl is one hundred times more potent than morphine.  Medical fentanyl doses are prescribed in micrograms, while morphine is prescribed in milligrams. One microgram is only 1/1000 of a milligram. A narcotic as potent as fentanyl is typically only utilized by MDs expert at handling apneic patients, and the IV antidote Narcan is always immediately available. Most medical doctors other than anesthesiologists never prescribe intravenous fentanyl. Your general practitioner or primary care doctor will never prescribe fentanyl. A cardiologist may prescribe IV fentanyl sedation for a procedure such as a cardiac catheterization, or a or surgeon may prescribe fentanyl for a superficial excision surgery, but anesthesiologists are typically the only physicians who pick up a fentanyl ampule, insert a needle and syringe into the ampule, and then inject the drug into a patient’s IV. In the intensive care unit (ICU), fentanyl can be used to sedate patients who already have a breathing tube (endotracheal tube) in their windpipe, and who are on a mechanical ventilator. An ICU physician will write an order for the dosing of intravenous fentanyl, and the ICU nurse will be in constant attendance to monitor the patient’s vital signs and level of sedation.

Addiction:

Are you at risk for becoming an addict because your anesthesiologist gives you doses of intravenous fentanyl? No. Most patients have no idea they received IV fentanyl as part of their anesthetic care. The effects of fentanyl wear off within several hours after the end of the surgery, and there is no data that a patient will have a craving for additional fentanyl. After surgery, hospital inpatients who have postoperative pain are typically treated with longer acting narcotics such as morphine or Dilaudid. After surgery, outpatients who have postoperative pain are typically treated with narcotic pain pills such as Oxycontin or Norco. There is no pill form of fentanyl that a patient goes home with, or that a patient can overdose with.

Note that in medical settings, fentanyl can be given by means other than IV injection:

FENTANYL PATCH

Can medical fentanyl be stolen, find its way to the streets, and be a cause of overdose deaths of non-medical people? No. The DEA forces all hospitals, surgery centers, and medical offices to keep a strict tally of all narcotics and controlled substances. At the end of every day, a precise count of all ampules of fentanyl is done, and unless one of the doctors or nurses falsifies their count, it is unlikely any fentanyl escapes a medical facility and winds up in the hands of dealers, addicts, or individuals in the outside world.

Conclusion:

It’s true that medically administered intravenous fentanyl can cause a person to stop breathing, but if an anesthesiologist is present watching every breath, you’re safe. When an airway specialist is present and fentanyl is administered in a hospital operating room, an emergency room, an ambulatory surgery center, or a physician’s office operating room, this represents safe care in the United States today. Don’t worry if you hear your anesthesia provider is going to give you fentanyl. It’s OK. Medical administration of fentanyl has been going since the 1960s. Deaths from fentanyl overdose in a medical setting would be almost unheard of.

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The most popular posts for laypeople on The Anesthesia Consultant include: How Long Will It Take To Wake Up From General Anesthesia? Why Did Take Me So Long To Wake From General Anesthesia? Will I Have a Breathing Tube During Anesthesia? What Are the Common Anesthesia Medications? How Safe is Anesthesia in the 21st Century? Will I Be Nauseated After General Anesthesia? What Are the Anesthesia Risks For Children?

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include: 10 Trends for the Future of Anesthesia Should You Cancel Anesthesia for a Potassium Level of 3.6? 12 Important Things to Know as You Near the End of Your Anesthesia Training Should You Cancel Surgery For a Blood Pressure = 170/99? Advice For Passing the Anesthesia Oral Board Exams What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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

HOW LONG WILL IT TAKE ME TO WAKE UP FROM GENERAL 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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT

One of the most frequent questions I hear from patients before surgery is, “How long will it take me to wake up from general anesthesia?”

 

The answer is, “It depends.”

Your wake up from general anesthesia depends on:

  1. What drugs the anesthesia provider uses
  2. How long your surgery lasts
  3. How healthy, how old, and how slender you are
  4. What type of surgery you are having
  5. The skill level of your anesthesia provider

In best circumstances you’ll be awake and talking within 5 to 10 minutes from the time your anesthesia provider turns off the anesthetic. Let’s look at each of the five factors above regarding your wake up from general anesthesia depends on:.

  1. YOUR WAKE UP FROM ANESTHESIA DEPENDS ON WHAT DRUGS THE ANESTHETIST USES. The effects of modern anesthetic drugs wear off fast.
  • The most common intravenous anesthetic hypnotic drug is propofol. Propofol levels in your blood drop quickly after administration of the drug is terminated, resulting in rapid awakening.
  • The most common inhaled anesthetic drugs are sevoflurane, desflurane, and nitrous oxide. Each of these gases are exhaled from the body quickly after their administration is terminated, resulting in rapid awakening.
  • The most commonly used intravenous narcotic is fentanyl. Fentanyl levels in your blood drop quickly after administration of the drug is terminated, resulting in rapid awakening.
  • The most commonly used intravenous anti-anxiety drug is midazolam (Versed). Midazolam levels in your blood drop quickly after administration of the drug is terminated, resulting in rapid awakening.
  1. YOUR WAKE UP FROM ANESTHESIA DEPENDS ON HOW LONG YOUR SURGERY LASTS
  • The shorter your surgery lasts, the less injectable and inhaled drugs you will receive.
  • Lower doses and shorter exposure times to anesthetic drugs lead to a faster wake up time.
  1. YOUR WAKE UP FROM ANESTHESIA DEPENDS ON HOW HEALTHY, HOW OLD, AND HOW SLENDER YOU ARE
  • Healthy patients with fit hearts, lungs, and brains wake up sooner
  • Young patients wake up quicker than geriatric patients
  • Slender patients wake up quicker than very obese patients
  1. YOUR WAKE UP FROM ANESTHESIA DEPENDS ON WHAT TYPE OF SURGERY YOU ARE HAVING
  • A minor surgery with minimal post-operative pain, such a hammertoe repair or a tendon repair on your thumb, will lead to a faster wake up.
  • A complex surgery such as an open-heart procedure or a liver transplant will lead to a slower wake up.
  1. YOUR WAKE UP FROM ANESTHESIA DEPENDS ON THE SKILL LEVEL OF YOUR ANESTHETIST
  • Like any profession, the longer the duration of time a practitioner has rehearsed his or her art, the better they will perform. An experienced pilot is likely to perform smoother landings of his aircraft than a novice. An experienced anesthesiologist is likely to wake up his or her patients more quickly than a novice.
  • There are multiple possible recipes or techniques for an anesthetic plan for any given surgery. An advantageous recipe may include local anesthesia into the surgical site or a regional anesthetic block to minimize post-operative pain, rather than administering higher doses of intravenous narcotics or sedatives which can prolong wake up times. Experienced anesthesia providers develop reliable time-tested recipes for rapid wake ups.
  • Although I can’t site any data, I believe the additional training and experience of a board-certified anesthesiologist physician is an advantage over the training and experience of a certified nurse anesthetist.

YOUR WAKE UP FROM ANESTHESIA: EXAMPLE TIMELINE FOR A MORNING SURGERY

Let’s say you’re scheduled to have your gall bladder removed at 7:30 a.m. tomorrow morning. This would be a typical timeline for your day:

6:00            You arrive at the operating room suite. You check in with front desk and nursing staff.

7:00             You meet your anesthesiologist or nurse anesthetist. Your anesthesia provider reviews your chart, examines your airway, heart, and lungs, and explains the anesthetic plan and options to you. After you consent, he or she starts an intravenous line in your arm.

7:15             Your anesthesia provider administers intravenous midazolam (Versed) into your IV, and you become more relaxed and sedated within one minute. Your anesthesia provider wheels your gurney into the operating room, and you move yourself from the gurney to the operating room table. Because of the amnestic effect of the midazolam, you probably will not remember any of this.

7:30             Your anesthesia provider induces general anesthesia by injecting intravenous propofol and fentanyl, places a breathing tube into your windpipe, and administers inhaled sevoflurane and intravenous propofol to keep you asleep.

7:40            Your anesthesia provider, your surgeon, and the nurse move your body into optimal position on the operating room table. The nurse preps your skin with antiseptic, and the scrub tech frames your abdomen with sterile paper drapes. The surgeons wash their hands and don sterile gowns and gloves. The nurses prepare the video equipment so the surgeon can see inside your abdomen with a laparoscope during surgery.

8:00            The surgery begins.

8:45             The surgery ends. Your anesthesia provider turns off the anesthetics sevoflurane and propofol.

8:55             You open your eyes, and your anesthesia provider removes the breathing tube from your windpipe.

9:05             Your anesthesia provider transports you to the Post Anesthesia Care Unit (PACU) on the original gurney you started on.

9:10            Your anesthesia provider explains your history to the PACU nurse, who will care for you for the next hour or two. The anesthesia provider then returns to the pre-operative area to meet their next patient. Your anesthesia provider is still responsible for your orders and your medical care until you leave the PACU. He or she is available on cell phone or beeper at all times. No family members are allowed in the PACU.

10:40            You are discharged from the PACU to your inpatient room, or to home if you are fit enough to leave the hospital or surgery center.

YOUR WAKE UP FROM ANESTHESIA . . . TO REVIEW:

  1. Even though the surgery only lasted 45 minutes, you were in the operating room for one hour and 35 minutes.
  2. It took you 10 minutes to awaken, from 8:45 to 8:55.
  3. Even though you were awake and talking at 8:55, you were unlikely to remember anything from that time.
  4. You probably had no memory of the time from the midazolam administration at 7:15 until after you’d reached in the PACU, when your consciousness level returned toward normal.

I refer you to a related column AN ANESTHESIA PATIENT QUESTION: WHY DID IT TAKE ME SO LONG TO WAKE UP AFTER ANESTHESIA?”

 

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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HOW DOES A HEROIN OVERDOSE KILL? AN ANESTHESIOLOGIST’S VIEW

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


On February 2, 2014, Academy Award-winning actor Phillip Seymour Hoffmann was found dead with a needle in his arm and syringes and packets of heroin in his room. How does a heroin overdose kill a person?

 phillip seymour hoffman heroin overdose

Anesthesiologists are uniquely qualified to answer this question. Anesthesiologists administer intravenous narcotics every day, because narcotics are important pain-relieving drugs in anesthetic care. If an anesthesiologist is attending to you while narcotics are injected into your bloodstream, you are safe. If an addicts chooses to inject narcotics into his or her bloodstream while they are alone in their apartment, they can die.

Heroin (diacetylmorphine or morphine diacetate) is in the same category of drugs as morphine, Demerol, and fentanyl. Heroin is prescribed as a controlled drug in the United Kingdom for use as a potent analgesic or pain reliever, but the drug is not approved for any medical use in the United States.

Within minutes, injected heroin crosses from the bloodstream to the brain. Once inside the brain, heroin is metabolized to the active drug 6-monoacetylmorphine (6-MAM), and then to morphine. Each of these chemicals binds to opioid receptors in the brain, which results in heroin’s euphoric, pain relieving, and anxiety-relieving effects. The duration of a single dose of heroin is 3-4 hours.

In addition to sensations of euphoria, calmness, sleepiness, pain relief, and blunting of anxiety, narcotics cause significant decrease in both the rate of breathing and the depth of each breath. This respiratory depression can be lethal, especially at higher doses.

In all acute care medicine, whether in the operating room, the intensive care unit, the emergency room, or the battlefield, physicians follow the mantra of “Airway-Breathing-Circulation.” A doctor’s first priority to keep the upper airway open, using a variety of techniques including jaw thrusts, extending the neck, inserting an oral airway, or placement of a breathing tube.  A doctor’s second priority is to assure that breathing, or ventilation, is ongoing. The doctor may assist breathing by delivering breaths of oxygen into the patient’s lungs via a ventilation bag (e.g. an Ambu bag). A doctor’s third priority is to assure that adequate circulation, or heart function, is ongoing.

If a large dose of narcotic is administered, breathing may cease or become so obstructed by the tongue and soft palate that no air moves in and out through the lungs. If an addict injects heroin while alone in their home, and they lose consciousness, their airway may become obstructed and breathing may cease. Oxygen levels to the brain and heart will plummet. After only minutes of inadequate oxygen, their heart will arrest and the addict will die.

Simultaneous usage of additional central nervous system depressant drugs, such as alcohol, benzodiazepines (Xanax, Valium, Librium, Ativan), or narcotic pills (oxycodone, Vicodin, Percocet) along with heroin can intensify the respiratory depression, and place the addict at even higher risk of ineffective breathing and resultant cardiac arrest.

Tolerance to heroin develops quickly, and users require more of the drug to achieve the same effects. This prompts addicts to inject increasing doses to achieve the desired “high,” with the attendant risk that each increased dose will be excessive, and lead to airway obstruction, inadequate breathing, and cardiac arrest.

Intravenous heroin usage carries additional risks, including viral infection (hepatitis or AIDS) from contaminated needles, bacterial infection of the heart valves (bacterial endocarditis), reactions to contaminants (e.g. starch, talc, or other drugs) in the heroin preparation, localized infections (abscesses) at the site of injection, and powerful withdrawal symptoms on cessation of heroin use.

But cardiac arrest from respiratory depression looms as the most frequent cause of sudden death in heroin addicts.

 

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

 

 

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

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

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:

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

 

DO YOU NEED AN ANESTHESIOLOGIST FOR A COLONOSCOPY?

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

Do you need an anesthesiologist for a colonoscopy?  The answer is:  it depends. It depends on 1) your health, 2) the conscious sedation skills of your gastroenterologist, and 3) the facility you have your colonoscopy at.

 

1)  YOUR HEALTH. The majority of colonoscopies in the United States are performed under conscious sedation.  Conscious sedation is administered by a registered nurse, under specific orders from the gastroenterologist.  The typical drugs are Versed (midazolam) and fentanyl.  Versed is a benzodiazepine, or Valium-like medication, that is superb in reducing anxiety, sleepiness, and producing amnesia.  Fentanyl is a narcotic pain reliever, similar to a short-acting morphine.  The combination of these two types of medications renders a patient sleepy but awake.  Most patients can minimal or no recollection of the colonoscopy procedure when under the influence of these two drugs.  I can speak from personal experience, as I had a colonoscopy myself, with conscious sedation with Versed and fentanyl, and I remembered nothing of the procedure.

If you are a reasonably healthy adult, you should be fine having the procedure under conscious sedation.  Patients with high blood pressure, diabetes, asthma, obesity, mild to moderate sleep apnea, advanced age, or stable cardiac disease are have conscious sedation for colonoscopies in America every day, without significant complications.

Certain patients are not good candidates for conscious sedation, and require an anesthesiologist for sedation or general anesthesia.  Included in this category are a) patients on large doses of chronic narcotics for chronic pain, who are tolerant to the fentanyl and are therefore difficult to sedate, b) certain patients with morbid obesity, c) certain patients with severe sleep apnea, and d) certain patients with severe heart or breathing problems.

2)  THE CONSCIOUS SEDATION SKILLS OF YOUR GASTROENTEROLOGIST.  Most gastroenterologists are comfortable directing registered nurses in the administration of conscious sedation drugs.  Some, however, are not.  These gastroenterologists will disclose this to their patients, and recommend that an anesthesiologist administer general anesthesia for the procedure.

3) THE FACILITY YOU HAVE YOUR COLONOSCOPY AT.  Most endoscopy facilities have nurses and gastroenterologists comfortable with conscious sedation.  Some do not.  The facility you are referred to may have a consistent policy of having an anesthesiologist administer general anesthesia with propofol for all colonoscopies.  If this is true, they should disclose this to you, the patient, before you start your bowel prep for the procedure.  A facility which always utilizes general anesthesia means that you, the patient, will incur one extra physician bill for your procedure, from an anesthesiologist.

I refer you to an article from the New York Times, which summarizes this phenomenon in the New York region:

One last point: If the drugs Versed and fentanyl are used, there exist specific and effective antidotes for each drug if the patient becomes oversedated. The antagonist for Versed is Romazicon (flumazenil), and the antagonist for fentanyl is Narcan (naloxone). If these drugs are injected promptly into the IV of an oversedated patient, the patient will wake up in seconds, before any oxygen deprivation affects the brain or heart.

Propofol, however, has no specific antagonist. Propofol only wears off as it is redistributed out of the blood stream into other tissues, and its blood level declines. A propofol overdose can cause obstruction of breathing, and/or depression of breathing, such that the blood oxygen level is insufficient for the brain and heart. The Food and Drug Administration (FDA) mandates that a Black Box warning be included in the packaging of every box of propofol. That warning states that propofol “should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure.”

Anesthesiologists are experts at using propofol. I administer propofol to 99% of my patients who are undergoing general anesthesia for a surgical procedure. Anesthesiologists are experts at managing airways and breathing. Individuals who are not trained to administer general anesthesia should never administer propofol to a patient, in a hospital or in an outpatient surgery center.

I serve as the Medical Director of an outpatient surgery center in Palo Alto, California. We perform a variety of orthopedic, head and neck, plastic, ophthalmic, and general surgery procedures safely each year. In addition, our gastroenterologists perform thousands of endoscopies each year. I review the charts of the endoscopy patients as well as the surgical patients prior to the procedures, and in our center, approximately 99% of endoscopies can be safely performed under Versed and fentanyl conscious sedation, without the need for an anesthesiologist attending to the patient.

If you have an endoscopy, ask questions. Will you receive conscious sedation with drugs like Versed and fentanyl, or will an anesthesiology professional administer propofol? You deserve to know.

 

 

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

DSC04882_edited

 

 

FACTS FOR LAYPEOPLE: DRUGS ANESTHESIOLOGISTS ADMINISTER

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

INTRAVENOUS MEDICATIONS:

1.  PROPOFOL.  Propofol is an intravenous sedative-hypnotic, and the most commonly used general anesthetic medication in the United States.  Because propofol can cause the patient to stop breathing, its use is restricted to physicians who are expert in the management of airway and breathing.  Propofol has ultra-fast onset and offset times, usually causing sleep within seconds of injection.  Because the drug is short-acting, it is often administered by a continuous intravenous drip or infusion When propofol is administered without other anesthetic drugs, the patient usually awakens within minutes of discontinuing the drug.  Propofol does not relieve pain, and most painful surgeries require additional medication(s).

2.  MIDAZOLAM (Brand name VERSED).  Midazolam is a short-acting anxiety-reducing drug of the Valium or benzodiazepine class.  Midazolam is commonly injected as the first drug to begin an anesthetic, because it gives patients a sense of calm, and often gives them amnesia for a period of minutes afterward.  Midazolam is a common drug given during sedation for colonoscopy procedures, because most patients have no awareness during the procedure, even though they are usually awake.

3.  NARCOTICS.  Most surgical procedures cause pain, and narcotic drugs are intravenous pain-relievers.  Commonly used narcotics are morphine, meperidine (brand name Demerol), fentanyl, and remifentanil.  Narcotics have the desired effect of dulling the brain’s perception of pain.  Narcotics cause sleepiness in higher doses, and have the common side-effect of nausea in some patients.  Morphine and Demerol are slower-onset, longer-lasting narcotics, while fentanyl and remifentanil are faster-onset, shorter-acting narcotics.

4.  PARALYZING DRUGS.  Some surgeries and anesthetics require the patient to be paralyzed, i.e. muscles must be rendered flaccid so that the patient can not move.  It is imperative that the patient be given adequate intravenous or inhaled anesthetic drugs first, so that the patient has no awareness that they can not move.  Commone paralyzing drugs are vecuronium, rocuronium, pancuronium, and succinylcholine.  Because paralyzing drugs cause the patient to stop breathing, their use is restricted to physicians who are expert in the management of airway and breathing.  Paralyzing drugs are used by anesthesia providers prior to the placement a breathing tube (endotracheal tube) into the patient’s windpipe (trachea).  Paralyzing drugs are used during certain surgical procedures in which the surgeon requires the patient’s muscles to be relaxed, for example, abdominal surgeries, some throat surgeries, and some surgeries inside the chest.

INHALED ANESTHETICS:

1.  POTENT INHALED ANESTHETICS.  Potent inhaled anesthetics include sevoflurane, isoflurane, and desflurane.  These drugs are liquids, administered via anesthesia vaporizers than turn them into inhaled gases.  They are usually administered in low concentrations (1% to 4% for sevoflurane, 1% to 2% for isoflurane, and 3% to 6% for desflurane), because sustained higher concentrations fo these drugs cause life-threatening depression of heart and breathing functions.  Because potent inhaled anesthetics can cause patients to stop breathing, their use is restricted to physicians who are expert in the management of airway and breathing.

2.  NITROUS OXIDE.  Nitrous oxide is a relatively weak inhaled anesthetic drug, usually administered in concentrations of 50% to 70%.  At these doses, nitrous oxide does cause significant sleepiness, but will not render the patient unconscious.  Nitrous oxide has the advantage of being a quick-onset, quick-offset drug, and it is non-expensive.  Because every patient must inhale a minimum of 21% oxygen, the maximum dose of nitrous oxide is 100 – 21, or 79%.  As a measure of safety, oxygen is usually administered at concentration of at least 30%, which is the reason why administered nitrous oxide concentrations rarely exceed 70%.

LOCAL ANESTHETICS:

1.  LIDOCAINE.  Lidocaine is injected into tissue to block pain at that site.  The onset of local anesthesia occurs within seconds, and the duration is short, usually less than one hour.  Lidocaine can be injected into the back during either a spinal anesthetic or an epidural anesthetic, to numb part of the patient’s body without causing unconsciousness.  Lidocaine can also be injected near major nerves, in what is called a nerve block.  Nerve blocks include injections to numb one arm, one leg, the hand, or the foot.

2. PROCAINE (Brand name Novocaine).  Although the term Novocaine is commonly heard, use of this drug has been largely abandoned, replaced by lidocaine instead.

3. BUPIVICAINE (Brand name Marcaine).  Bupivicaine is injected into tissue to block pain at that site.  The onset of local anesthesia occurs within minutes, and the duration is longer than lidocaine, usually from 2 – 6 hours, depending on the location of the injection.  Bupivicaine can be injected into the back during either a spinal anesthetic or an epidural anesthetic, to numb part of the patient’s body without causing unconsciousness.  Bupivicaine can also be injected near major nerves, in what is called a nerve block.  Nerve blocks include injections to numb one arm, one leg, the hand, or the foot.

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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

 

 

CAN WE PREVENT AGITATION IN PEDIATRIC PATIENTS FOLLOWING 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.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT

Clinical Case of the Month:  A 5-year-old boy is scheduled for general anesthesia for a cochlear implant.  On your pre-operative phone call to the mother, she tells you that after the same surgery on the other ear, the child was severely agitated in the Recovery Room.  The last anesthesiologist told her that agitation was a common side effect for the sevoflurane anesthetic that was used.  What will you do?

Discussion:  How about this plan:  You obtain the old anesthesia record, duplicate the technique exactly, and give earplugs to everyone within ten yards of the Recovery Room?  Don’t buy it?  Read on.

Before you begin, a colleague says,  “Who cares about crying?  As long as the anesthetic care is safe, crying in the PACU is no big deal.  It’s a sign of an adequate airway.”  He continues:  “Why, I went on an Interplast trip fixing cleft palates in South America, and all the kids screamed in the Recovery Room.  They all survived.”

I’ve got news for him — a screaming child in the Recovery Room is a problem for several people:  the nurse, the mother of the child (she’s freaking out herself), the attending anesthesiologist (who, by inference, looks like he doesn’t know how to finish an anesthetic), and every other PACU patient within earshot.  I’d submit that the goals of a 21st Century anesthetic go beyond safety — patients or their families feel entitled to wake up as pain-free, nausea-free, and side-effect-free as possible.

Sevoflurane was introduced in Japan in the late 1980’s and in the United States in the 1990’s (Miller’s Anesthesia, 2005, p. 18).  Because of its low solubility, sevoflurane represented a significant advance over isoflurane, which dominated the inhaled anesthetic market prior to that time.  In addition to its low solubility, sevoflurane was less pungent than isoflurane and could be used instead of halothane for inhalational induction in children.  As well, sevoflurane had a lower incidence of cardiac arrhythmias than halothane.  These properties made sevoflurane the drug of choice for inhalation induction in children (Johannesson GP, Acta Anaesthesiol Scand. 1995 May;39(4):546-50).

Soon after its introduction into clinical practice, reports of sevoflurane and post-operative agitation and delirium in preschool patients began to appear in the anesthesia literature.  The described agitation was unrelated to pain, was inversely related to age, and was most frequent in children 5 years of age or younger.  (Miller’s Anesthesia, 2005, p. 2373).   Emergence delirium with sevoflurane exceeded the rate of emergence delirium with halothane.  Aono reported a 40% incidence of delirium during recovery in preschool boys aged 3 – 5 years old who underwent urologic surgery under sevoflurane, vs. a 10% incidence of delirium for those who were anesthetized with halothane (Anesthesiology, 1997 Dec;87(6):1298-300).

A variety of remedies appeared in the peer-reviewed literature over the ensuing years.  A complete discussion of all reported techniques is beyond the scope of this short column.  I refer you to PubMed with the keywords sevoflurane, agitation, where you’ll find multiple references to support multiple techniques.  Statistical significance was obtained in controlled studies with the following techniques either before or after sevoflurane induction:  use of oral midazolam prior to induction; use of a single dose of fentanyl 1 mcg/kg ten minutes prior to emergence;  conversion to propofol infusion anesthesia after induction;  conversion to isoflurane anesthesia after induction;  conversion to desflurane anesthesia after induction;  use of IV dexmedetomidine 0.3 – 0.5 mcg/kg after induction;  use of PO clonidine premedication 4 mcg/kg before induction;  or use of IV clonidine 2 mcg/kg immediately after induction.

I polled my private practice Stanford Adjunct Clinical Faculty colleagues on their preferred methods to minimize pediatric emergence delirium, and three strategies prevailed:  1) the use of heavy midazolam premedication (up to .8 mg/kg);  2) the use of titrated doses of intravenous fentanyl or meperidine prior to emergence; and 3) discontinuance of sevoflurane after inhalation induction — instead substituting isoflurane or propofol for maintenance anesthesia.  No one used dexmedetomidine or clonidine.

Let’s return to your 5-year-old patient.  You decide to utilize all three options described in the previous paragraph.  You begin with the oral midazolam premedication 20 minutes prior to induction.  (Because the duration of this surgery is estimated to be 90 minutes, you realize that most of the effect of the midazolam premed will be dissipated at the time of emergence.)   After an uneventful sevoflurane mask induction, you place an I.V. and intubate the trachea.  At this point you turn off the sevo and switch to isoflurane.  Cochlear implant surgery involves drilling into the skull, and despite use of local anesthesia by the surgeon, you can anticipate post-operative pain.  It seems prudent to use a narcotic to treat both pain and delirium.  At the conclusion of the anesthetic, you administer doses of 5 mg of meperidine, titrated to the child’s respiratory rate.  After extubation, you supplement with additional narcotic as needed to affect comfort and tranquility.  Because both the surgery and the anesthetic technique may stimulate post-operative nausea or vomiting, you administer doses of I.V. ondansetron and metoclopramide for nausea prophylaxis.  You request the mother sit at the bedside in the PACU as soon as the child begins to reawaken, as a humane non-pharmacologic method of easing the child’s emotional discomfort .

There are no trophies given for rapid wake-ups in the pediatric PACU.  Your technique produces a gradual calm emergence characterized by safe maintenance of the airway and a relaxed, comfortable child.   The 5-year-old’s mother is thrilled with the improvement over the last anesthetic, and the PACU nurses respect that you care about the quality of your patient’s wake-up.

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

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

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