IS YOUR GRANDMOTHER TOO OLD FOR SURGERY?

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

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

 

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

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

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

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

Let’s look at each of these four factors:

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

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

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

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

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

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

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

Class II  – A patient with mild systemic disease.

Class II  – A patient with severe systemic disease.

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

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

She is an ASA Class II.

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

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

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

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

How will the anesthesiologist proceed?

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

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

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

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

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

What about mental decline following geriatric surgery?

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

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

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

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

DSC04882_edited

 

 

NEEDLE PHOBIA BEFORE GENERAL ANESTHESIA

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

Clinical Case for Discussion:  A needle-phobic 16-year-old male is scheduled for a shoulder arthroscopy at a freestanding surgery center.  He is tearful and refuses any needles while he is awake.  He is 5 feet 3 inches tall, weighs 220 pounds, and has a Body Mass Index of 39.

What would you do?

 

Discussion:  You bring the patient into the operating room and apply the standard monitors.  You begin an inhalation induction with 70% inspired nitrous oxide and sevoflurane.  You increase the concentration of sevoflurane gradually after each breath.  After 2 minutes, at 4% inspired sevoflurane, the patient begins to cough, buck, and have stridor, and the oxygen saturation plummets below 60%.  You see no site to place an I.V., and the nurse and surgeon are no help.  You are not able to improve the airway with jaw thrust, mask ventilation, continuous positive airway pressure, or an oral airway.  You place an laryngeal mask airway (LMA), but the patient continues to have stridor and a weak cough.  No ventilation is possible.  You give intramuscular succinylcholine at 4 mg/kg, but while you are waiting for the drug to take effect,  the patient’s ECG changes to ventricular fibrillation.  You scream for the defibrillator, and do direct laryngoscopy to attempt placement of an endotracheal tube in the now-flaccid patient.  Your heart rate is 180 beats–per-minute, and you are praying for the patient’s heartbeat to return.  You can’t believe that this boy walked into the surgery center as healthy as can be, and that within minutes you have brought on the circumstances of cardiac and respiratory arrest.

In a parallel universe, you anticipate all the above issues, and prepare yourself.  You are aware that his BMI = 39 places him at increased risk for an inhalational induction.  You explain to the patient and his parents that there are risks for an overweight patient being anesthetized without an I.V., and lobby hard for him to permit you to attempt an awake I.V. placement.  You offer him oral midazolam as an anti-anxiety premedication, and topical EMLA to numb the I.V. site.  Alas, he is crying and still refuses any needle. You place an automated blood pressure cuff on his upper arm, and note that veins are visible on his hand when you inflate the cuff in Stat mode on that extremity.  His airway appears normal.  You describe to the parents that there is a risk that their son might have dangerous low oxygen levels during the mask induction of anesthesia.  They agree to accept this risk, and you document the same in the medical records.  You make a plan to proceed with inhalation induction, using the automated cuff to maximize the size of the veins on his hand.

(Note:  If you do not have confidence in proceeding, you may delay the patient until another anesthesiologist is present to assist you, or cancel the case.  Also note that if the anesthetic is done in a hospital rather than a freestanding surgery center, the identical clinical issues will be present, and the anesthetic plan will be similar except for the presence of additional backup anesthesia personnel.)

You enter the operating room and apply the standard monitors.  You place a mask strap behind the patient’s head to help hold the anesthesia mask over his airway, and have him breathe 100% oxygen with high flows of 10 liters/minute for two full minutes prior to beginning induction.  Next you add 8% sevoflurane to the gas mixture, and ask the patient to take deep vital capacity breaths your anesthetic circle system.  This technique is known as Vital Capacity Rapid Inhalation Induction.  For safety reasons, I prefer sevoflurane induction with 100% oxygen instead of using nitrous oxide, which limits the delivered oxygen concentration.

As soon as the patient is anesthetized deeply enough, (seeing the eyes conjugate in the midline is a useful monitoring sign), you activate the blood pressure cuff on his upper arm in the Stat mode, and you move to his lower arm to start the I.V.  You leave the patient breathing on his own with the straps holding the mask over his face, and use both of your hands to place a 20-gauge I.V. catheter.  Once the intravenous catheter is placed, you continue the anesthetic using intravenous and inhalation drugs, with either an LMA or endotracheal tube for airway management.

Ambulatory anesthesia in freestanding facilities is a gravy train of healthy patients and straightforward cases, right?  Not all the time.

In the hospital, when you anesthetize elderly, sick patients for complex surgeries, you have a multitude of advanced technologies at your disposal.  You have invasive monitoring, transesophageal echocardiogram machines, laboratories, blood banks, and intensive care unit backup, as well as dozens of other anesthesia providers available within seconds to assist you if you get into trouble.  In addition, it’s understood by the patient and family that there are significant risks if the patient is old, sick, or if the surgery is complex.

In anesthetics for healthy outpatient surgery, the patient and the family expect the rate of adverse outcomes to be … zero.  Despite your informed consent that rare problems could occur, there will be anguish and anger if problems indeed do occur.

Treat needle phobia with respect.  It can be a life-threatening problem in the hands of an inexperienced anesthesia provider.

 

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

 

 

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

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

Clinical Case: A 45-year-old woman is scheduled for a hysterectomy.  She is being treated for hypertension, and is otherwise healthy.  During your preoperative discussion, do you explain to her as informed consent that she could die during anesthesia?

Discussion:   “Hi, Mrs. Smith,” the anesthesiologist said.  “It looks like you are in good health. I need to tell you that there is about a 1 in 100,000 chance that you could die from your anesthetic. I need to tell you that so you don’t sue me if you die.  Don’t look so worried, Mrs. Smith.  Do you have any questions?”

“Yes.  What is that sticker on your forehead?” she asked.

“It says ‘I just got out of residency yesterday,’”  the doctor answered with a smile.

Sound absurd?  Let’s start by looking at  data that  is available on anesthetic risks.  A review article by Jenkins and Baker  summarizes the incidence of mortality and morbidity associated with anesthesia.  The authors conducted a Medline search from 1966 to the present for all anesthesia publications with keywords relevant to mortality and morbidity.

Anesthetic-related mortality was found to be rare.   The incidence of death related to anesthesia was 1:50,000, and the incidence in ASA I and II patients was 1:100,000.  Total perioperative mortality within 30 days of surgery was much higher, with rates of 1:200 for elective surgery, and 1:40 for emergency surgery.  Thirty day mortality was two times higher in 60-79 year olds,  five times higher in 80-89 year olds, and  seven times higher in patients over 90 years old.

What were the most common complications of anesthesia?  The complications and their incidences  were:  drowsiness (1:2), sore throat after tracheal tube (1:2), pain (1:3), post-op nausea and vomiting (1:4), dizziness (1:5), headache (1:5), and sore throat after laryngeal mask (1:5).

Informed consent is a discussion of the risks and benefits of the anesthetic proposed, and discussion of any alternative methods available.  It is followed by documentation that the patient understands and consents to the plan.  Our original question today regarded what risks to discuss.  Per Benumof and Saidman (Anesthetic and Perioperative Complications, Mosby, 1999, 781-2), “There must be a balance between giving enough information to allow a reasoned decision and frightening the patient with a long list of potential, extremely rare, severe complications, the latter making a trusting doctor-patient relationship difficult.”

I collected opinions  from  20 private-practice anesthesiologist colleagues at Stanford via e-mail.   Only one of  the twenty replied that he would tell the hysterectomy patient that she could die.  He cited the philosophy that if she consented despite the risk of death, that any smaller complication such as the loss of her singing voice due to the endotracheal tube, was trivial in comparison.

Another private attending disagreed, using the following reasoning, which I agree with:  “If you tell the healthy patient that they could die, and they die, you are still in trouble.   If you  do something negligent and you are sued,  you will lose the lawsuit, despite your anxiety-producing informed consent.”

For healthy patients, most private attendings discuss only the common risks such as drowsiness, pain, nausea, and sore throat.  Many  ask if the patient wants to know any more details about more serious risks.  If the patient wants to, the anesthesiologist will then give more information about incidence of serious complications, possibly quoting numbers such as the 1:50,000 to 1:100,000 noted above.  Others will reassure each patient with a statement such as  “anesthesia is safer than the risk you take each time you drive your car on a freeway,” implying that you could  have a  bad outcome in either situation, yet not using the words “you could die.”  For less healthy patients, older patients,  emergency or more complex surgeries, the increased risks  are discussed  so the patient can make a well-informed choice.

In discussing the risks of anesthesia to healthy patients, I commonly say, “The chance that any serious complication to your heart, lungs, brain, or blood pressure is very close to zero, but it’s not zero.  If anything unexpected occurs, I will be right there with you the entire time, and based on my training and experience, I will do the right thing for you.”  This sentence informs them that although risks are rare, risks are possible, and reassures the patient that their anesthesiologist is there to treat any unexpected problems.

The purpose of obtaining consent is to  give the patient  enough information to make an informed decision whether to agree to the anesthetic plan, or not.  Most private-practice anesthesiologists at Stanford would handle the informed consent for today’s patient without telling her she could die.  Patients are nervous enough when they put on the gown and hop onto that gurney before surgery.

 

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

DSC04882_edited