Tag Malignant hyperthermia

8-YEAR-OLD CONGOESE BOY DIES FROM ANESTHESIA. WHAT HAPPENED?

THE ANESTHESIA CONSULTANT 2 Comments
THE ANESTHESIA CONSULTANT
THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
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8-year-old Matadi Sela Petit, who journeyed from the Democratic Republic of Congo to Los Angeles for surgery, died at Cedars-Sinai Hospital on December 16, 2018, from what has been described as “a rare genetic reaction to the anesthesia.” Matadi was born with a cleft lip and a tumor on the left side of his face/cheek that grew into the size depicted in this photograph:

Matadi-Sela-Petit

Matadi Sela Petit

The Dikembe Mutombo Foundation, created by retired National Basketball Association star Dikembe Mutombo, sponsored the boy to come from Congo to the United States for the surgery. Matidi’s cleft lip was treated earlier with help from the foundation.

According to The Washington Post, “The Dikembe Mutombo Foundation . . . headed by the former NBA star said that during the delicate surgery on Dec. 16, the boy suffered a rare and unexpected genetic reaction to anesthesia.”

This was a tragic outcome, and my sympathies go out to the patient’s family, to the Foundation, and also to the physicians who treated the boy. Cedars-Sinai is an outstanding medical center—one of the finest in the United States—and has a reputation of having an outstanding medical staff.

What “genetic reaction” could have occurred during the anesthetic? No details have been released in the press, and readers are left to puzzle over what went wrong. As a practicing pediatric anesthesiologist, I’m interested in what happened. I have no access to medical records, nor any inside information on the case, but based on my education and experience my impressions follow below.

Regarding “a rare and unexpected genetic reaction to anesthesia,” the phrase used in the press release to describe the event, I see these possibilities:

  1. Malignant Hyperthermia. Malignant Hyperthermia (MH) is a disease in which a severe reaction occurs during general anesthesia, only among patients who are genetically susceptible. Symptoms include hypermetabolism, muscle rigidity, high fever, acidosis, sudden high blood potassium levels, and a risk of cardiac arrest. MH can only occur in patients who have the genetic predisposition to the disease, and who are then exposed to a potent anesthetic gas (e.g. sevoflurane, desflurane, or isoflurane), or the intravenous muscle relaxant succinylcholine. The treatment for MH involves emergency intravenous injection of the antidote dantrolene, immediate cooling of the patient, and immediate treatment for acidosis and elevated potassium concentration. The treatment for MH is usually effective if the diagnosis is made promptly. The quoted mortality rate for MH is now less than 5%. A potent anesthetic gas such as sevoflurane is commonly used in most pediatric anesthetics, and could have been used in Matidi’s case. Succinylcholine carries a Black Box Warning from the U.S. Food and Drug Administration regarding its use in pediatric patients, and it was unlikely to be used in this Matidi’s anesthetic. Even if Matidi had a previous surgery for his cleft palate, it is not unheard of for a patient to fail to develop MH on their first exposure to potent inhaled anesthetics, and yet develop MH on a later exposure.
  2. An occult muscular dystrophy. A patient who has an undiagnosed genetic muscular dystrophy can develop a sudden cardiac arrest after the administration of the muscle relaxant succinylcholine. Administration of succinylcholine to a patient with an occult muscular dystrophy can cause sudden cardiac arrhythmias, and for this reason succinylcholine carries a Black Box Warning from the U.S. Food and Drug Administration, restricting its use in pediatric patients to emergencies. Because of the Black Box Warning against using succinylcholine in pediatric anesthesia, it is unlikely succinylcholine was used in this patient’s anesthetic.
  3. The mass effect of the tumor in this patient’s face. If one can assume Matidi was born with this tumor, then the existence of this congenital mass lesion next to his airway and breathing passages is a genetic issue. From the photograph of Matidi, the tumor dominated his face. The tumor pushed his mouth to the right, and likely encroached on breathing anatomy. Once general anesthesia is induced, large tumors like this can compress the airway further. Every general anesthetic requires safe management of A-B-C, or Airway-Breathing-Cardiac, in that order. A child such as Matidi with markedly abnormal facial anatomy brings the risk of the loss of control of the airway at any point during the anesthesia or surgery. Loss of airway means there is no clear path for oxygen to traverse from the anesthesia machine through the head and neck to the lungs. Lack of oxygen to the lungs can lead to lack of oxygen to the brain and heart. Five minutes of oxygen depletion to the brain can cause anoxic brain damage. Oxygen depletion to the heart can cause cardiac arrest. Airway problems related to congenital diseases are discussed in the article Specific Genetic Diseases at Risk for Sedation/Anesthesia Complications, in the journal Anesthesia & Analgesia.

After scouring the world’s anesthesia literature and textbooks, I can find no other plausible “genetic reaction to anesthesia” to explain this patient’s death.

This patient’s care will be discussed in peer review and quality assurance committees at the hospital where the event occurred. There is always an autopsy on any unexpected death in an operating room, and more information may come from that. But whenever there is an adverse patient outcome, for medical-legal reasons, do not expect the healthcare professionals to reveal the specifics of what happened to the outside world.

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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?

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How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

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

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11 THINGS YOU CAN DO TO MAKE YOUR ANESTHETIC SAFER

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THE ANESTHESIA CONSULTANT
THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
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What can you do to make your anesthetic safer? This is what the anesthesia experience is like for most patients: You show up for surgery, and some anesthesia professional you’ve never met or talked to appears 10 minutes before you are to be wheeled into the operating room. The anesthesia professional might be an MD, a CRNA, or both a MD and a CRNA might be involved. At an academic/university hospital, the anesthesiologist might be a resident MD in his or her first, second, or third year of anesthesia training, and that resident will then be supervised by a faculty member who is responsible for either one operating room or two.

It doesn’t have to be this way. Anesthesiologists in our practice telephone their patients the night before to discuss the anesthesia care. Some hospitals have an anesthesia preoperative clinic where patients are interviewed and examined one day or more prior to surgery. Patient questions are answered at such a clinic, but it’s uncommon for you to meet the person who actually anesthetize you at such a clinic visit.

I’m going to put on my patient advocate hat. Let’s say you’re going to have surgery six weeks from now.

  • What can you do to make your anesthesia experience safer?
  • What can you do to otherwise optimize the anesthesia care you’re about to receive?

 

Here’s my list of 11 things you can do:

  1. Don’t choose to schedule your surgery at a teaching hospital in July or August. On June 30th every year, each intern and resident physician advances one year in his or her training. An intern who finished a 12-month rotating internship suddenly becomes an anesthesia trainee as of July 1st. An anesthesia resident who trained for 12 months and performed perhaps 700 anesthetics, is now a second year resident. An anesthesia resident who trained for 24 months and performed perhaps 1400 anesthetics, is now a third year resident. Each of these residents is completely inexperienced in their new level. The curriculum for residents is more complex each year, with 2nd and 3rd year residents covering progressively more complex cases such as open heart, brain, chest, or neonatal surgeries. A faculty member will supervise each resident, but often the supervision is one faculty member covering two operating rooms concurrently. The individual who monitors you minute-to-minute during your surgery will be a relatively inexperienced resident. If you’re scheduled for surgery at an academic medical center in July or August, I’d advise you to move up your surgery to May or June instead.
  2. Using the Internet, check the roster of anesthesia physicians at the facility where you’re about to have surgery. Virtually every medical center has a list of staff anesthesiologists posted on their website, and most websites will provide a summary of each physician’s academic training. Peruse the list. Are the majority of anesthetists MDs or CRNAs, or is the staff a mix of both? Did the MDs train at reputable universities, or were they trained at hospitals you’ve never heard of? Is there a phone number you can call if you wish to speak to an anesthesiologist prior to your week of surgery if you have a special concern?
  3. Talk to your surgeon about the proposed anesthesia. He or she will usually know whether your case requires a general anesthetic, with or without a regional anesthetic (such as a spinal, an epidural or a nerve block). Ask your surgeon if they have an anesthesiologist colleague they recommend for your specific case, and ask whether you can request a specific anesthesiologist prior to the surgery date.
  4. If you have chronic health issues (e.g. heart problems, lung problems, high blood pressure, diabetes, neurologic problems, kidney failure, obesity, or sleep apnea) you can expect the surgical/anesthesiologist team to require a clearance note from your primary care physician (PCP) prior to the surgery. The purpose of this clearance is to document that no further diagnostic or treatment interventions are necessary prior to your anesthetic and surgery. This is important. Planning a visit to your PCP in the month or two prior to surgery is strongly recommended.
  5. Are you unusually sensitive to drugs, sedatives, or alcohol? Tell your anesthesiologist when you meet him or her. Without question, certain individuals are unusually sensitive to normal doses of narcotics, sedatives, and general anesthetics. These individuals are often female, petite (under 120 pounds), geriatric, or persons who rarely expose themselves to central nervous system depressants such as alcohol. Armed with this information, your anesthesiologist will administer adequate doses of drugs, but no more than the minimum necessary.
  6. The standard of care is for your anesthesiologist to explain the alternate anesthesia techniques for your surgery, as well to explain the risks and benefits of each alternative. I’d advise you to listen, ask questions, and consider the KISS principle (Keep It Simple Stupid). The correct anesthetic is usually the simplest technique that works for the surgeon, the anesthesiologist, and for you. You get a vote. Use it, and choose wisely when alternatives are explained to you.
  7. If you have a family history of a blood relative who died under anesthesia, share this information with your anesthesiologist. The rare but serious malady Malignant Hyperthermia (MH) is an inherited disease which causes intense fevers, muscle rigidity, and hypermetabolism, and is triggered by specific anesthetic drugs such as sevoflurane, desflurane, isoflurane, or succinylcholine. The disease is rare (1 out of 100,000 anesthetics), but if your family has a history suggestive of MH, or if any of your family died under anesthesia, the anesthesiologist needs to know.
  8. You must stop eating and drinking prior to an elective anesthetic. The purpose is to keep your stomach empty at the induction of anesthesia. If you vomit or regurgitate stomach contents while you are unconscious, the food can be inhaled into your lungs, and you could acquire a serious pneumonia that could require an Intensive Care Unit stay, a prolonged hospitalization, or even loss of life. American Society of Anesthesiologists guidelines are nothing to eat after midnight the night before surgery, except clear liquids may be ingested up until 2 hours prior to surgery. Here’s an anecdote to relate how a patient can break this rule: Several years ago an anesthesiologist colleague of mine was scheduled to anesthetize a professional athlete for knee surgery. When this patient was asked if he’d followed the protocol and had nothing to eat or drink after midnight, the patient said yes, he had followed the rules. The surgery and anesthesia were performed without complication. In the post-anesthesia recovery room the patient boasted, “I knew it wouldn’t make any difference. I had bacon, eggs, and toast for breakfast this morning before surgery. I didn’t tell anyone because I knew it was a bogus rule.” It’s not a bogus rule. Don’t be like this local sports legend/difficult patient. Listen to the fasting rules and follow them.
  9. Sleep well the night before your surgery. For the majority of surgeries in the United States, a patient sleeps at home in their own bed the night before surgery. It’s rare to be sick enough to require inpatient admission to the hospital the day before surgery. Many patients are nervous regarding the impending anesthetic, and a wild array of thoughts and fears swirl through their brain regarding anesthesia and surgery. Many patients are too wired on their own adrenaline to sleep normally the evening prior to their surgery. What about sleeping pills? Are they safe the night prior to anesthesia? Yes, they are almost never unsafe. Common sleep medications such as Ambien, Ativan, or Valium taken at 10 pm won’t complicate the anesthetic course which begins 9 hours or more into the future on the following day. Because your anesthesiologist hasn’t personally met you and examined you, they cannot prescribe these medicines the night before for you. Your surgeon may prescribe sleep meds when he or she examines you. What about a glass of wine or an alcoholic beverage to aid sleepiness? Is this safe? Yes. If you’re an occasional wine drinker, there’s no serious harm to imbibing one glass of wine the night before surgery to help you relax and sleep.
  10. Trust your anesthesiologist as you would your airline pilot. When you board a commercial airplane, do you cast a glance into the cockpit to see what your pilots look like? I do. I’m reassured to see a touch of gray. It’s possible that a pilot in his or her 30s is outstanding, but the experience of a midcareer, gray-sideburned pilot is more reassuring to me. During your surgery you’ll be unconscious and unable to control your fate. You’re dependent on the anesthesiologist and his or her training and experience. The overwhelming majority of physician anesthesiologists are well trained and excellent. Calm yourself and trust your doctor.
  11. Read theanesthesiaconsultant.com as well as other reputable anesthesia sources on the Internet, such as the American Society of Anesthesiologists website, or Pubmed. Can you find misinformation on some healthcare websites? Yes. You’ll need to be careful regarding the source of your Internet education. But knowledge is a powerful tool, and I’d encourage you to expand your understanding of what anesthesiologists do to prepare for your upcoming surgery. Good luck!

 

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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ANESTHESIA FACTS FOR NON-MEDICAL PEOPLE: WHAT IS MALIGNANT HYPERTHERMIA?

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THE ANESTHESIA CONSULTANT
THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
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What is Malignant Hyperthermia? Patients frequently have concerns and misunderstandings.  Patients wonder what the disease is, if it could possibly strike them during anesthesia, and how the disease would be treated.

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The word “malignant” in Malignant Hyperthermia has nothing to do with malignancy or cancer. Hyperthermia is the medical term for high temperature, and Malignant Hyperthermia, or MH, refers to an acute medical disorder associated with dangerously elevated body temperature. MH is rare, life threatening, and triggered by general anesthetic drugs. The disease runs in families. For this reason, if any of your ancestors or relatives died during anesthesia it’s important you reveal that fact to your anesthesiologist.

The inheritance is autosomal dominant, which means one of your parents must have had the disease for you to inherit it. To manifest MH, you must have both the gene for MH and also be exposed to one of the triggering anesthetic drugs. The triggering drugs are succinylcholine (a paralyzing drug/muscle relaxant) and the potent inhaled anesthetic gases sevoflurane, desflurane, isoflurane, or halothane.

The incidence of MH varies from 1:5000 to 1:100,000 anesthetics. Most MH cases appear during a patient’s first anesthetic, therefore most MH cases appear in children or young adults. I’ve performed 25,000 anesthetics over 30+ years, and none of my patients have developed MH. Nonetheless, every anesthesiologist must be knowledgeable and ready to diagnose and treat an MH crisis should one occur.

The clinical signs of MH are increased temperature, increased heart rate, increased breathing rate, and increased carbon dioxide production. These changes are caused by increased metabolism within muscle cells. The onset of MH causes individual muscle cells to become hypermetabolic, which leads to increased heat, increased carbon dioxide production, and acidosis in the bloodstream. As temperature increases, the heart beats faster and the lungs hyperventilate to blow off the excessive carbon dioxide and acid production from the muscle cells.

Early diagnosis can be difficult. There is no specific blood test to diagnose the disease. If a child receiving his first anesthetic develops a temperature of 104 degrees Fahrenheit, a heart rate of 180 beats per minute, and a respiratory rate of 60 breaths per minute, the diagnosis is apparent. As well, the patient’s jaw, trunk, or total body may become rigid. However, in some patients the initial presentation may only include increases in heart rate and respiratory rate, and high temperature may be a late sign.

A hallmark of diagnosis is evidence of increased carbon dioxide production. During surgery, anesthesiologists measure the carbon dioxide concentration of every breath you inhale and exhale. If the carbon dioxide concentration increases steadily in the context of increased heart rate and respiratory rate, with or without an increase in temperature, the anesthesiologist must suspect MH. Late clinical findings include hypertension, abnormal heart rhythms, poor blood supply to the extremities (skin turning bluish in color), and sudden unexpected cardiac arrest in children.

Blood tests drawn during MH show low pH (both metabolic and respiratory acidosis), elevated potassium, and elevated muscle enzymes (elevated CPK). The urine will become cola-colored (colored by myoglobin in the urine).

The emergency treatment for MH:

  1. Notify the surgeon. Stop the surgery as soon as possible.
  2. Call for help from all available MDs and RNs in the vicinity.
  3. Stop the triggering anesthetic drug(s).
  4. Administer dantrolene. Dantrolene is a specific inhibitor of the MH cascade within the muscle cells. All anesthetizing locations are required to have a supply of dantrolene on site. The drug is manufactured in a powdered form, and must be mixed with sterile water to form an injectable solution. Large doses of dantrolene (2.5 mg/kg, which is 8 vials of dantrolene powder for an average-sized man) must be given IV as soon as possible. Doses may be repeated as needed, for a total dose up to 30 mg/kg if necessary.
  5. Administer sodium bicarbonate IV to buffer acidosis.
  6. Cool the patient. This can be done by applying bags of cold fluid to the skin surface, administering cold IV fluids, or by immersion of the body into an ice bath if available.
  7. Treat abnormal heart rhythms with appropriate IV cardiac drugs.
  8. Treat elevated potassium levels with hyperventilation, and empiric administration of calcium chloride, insulin, and glucose IV.
  9. Draw blood tests for electrolyte levels/arterial blood gas determinations, insert a catheter into the bladder to monitor urine output, and insert a catheter into the radial artery at the wrist to monitor blood pressure and for intravascular access for rechecking the levels of acidosis and potassium in the blood.
  10. Prepare for transfer to an intensive care unit.

If a family member of yours died during anesthesia and you don’t know if they died because of MH, your doctor may advise you to have a muscle biopsy to determine if you are MH susceptible. This biopsy of the anterior thigh muscle (quadriceps) is done under local anesthesia. You are not at risk of developing MH during local anesthesia.

If a family member of yours died during anesthesia and you don’t know if they died because of MH, and you choose not to undergo a muscle biopsy, you should wear a MedicAlert bracelet that states that you are susceptible to Malignant Hyperthermia, and all your anesthetic care should be done with trigger-free anesthetics (as listed below).

If you have a positive muscle biopsy test for MH, or if a family member of yours had well-documented MH, you should wear a MedicAlert bracelet that states you are susceptible to Malignant Hyperthermia, and all your anesthetic care should be done with trigger-free anesthetics (as listed below).

A trigger-free anesthetic includes no succinylcholine, sevoflurane, isoflurane, desflurane, or halothane. A trigger-free anesthetic includes any of the following:

  1. Local anesthesia, with or without sedation with IV drugs such as Versed, fentanyl, or propofol.
  2. Regional anesthesia, such as spinal anesthesia, epidural anesthesia, or a regional nerve block, with or without sedation with IV drugs such as Versed, fentanyl, or propofol.
  3. A general anesthetic without succinylcholine, sevoflurane, isoflurane, or desflurane. A typical recipe would include all intravenous drugs, e.g. Versed as a premed, propofol for anesthetic induction, rocuronium for paralysis/muscle relaxation, fentanyl or remifentanil infusion for pain relief, and possibly ketamine. The gas nitrous oxide can also be used.

In the 1980’s, prior to the availability of dantrolene, the mortality from an MH episode was greater than 80%. In the 21st century, the mortality from an MH episode should be less than 5%.

For further information, I refer you to http://www.mhaus.org, the website of the Malignant Hyperthermia Association of the United States.

 

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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THE TOP 10 MOST STRESSFUL JOBS IN AMERICA versus THE TOP 10 MOST STRESSFUL SITUATIONS IN ANESTHESIOLOGY PRACTICE

THE ANESTHESIA CONSULTANT 2 Comments
THE ANESTHESIA CONSULTANT
THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
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Anesthesia has been described as 99% boredom and 1% panic. Is anesthesiology one of America’s most stressful jobs? Not according to prominent Internet media sources.

Careercast.com listed the Top 10 Most Stressful Jobs in America in 2015, and those jobs were:

  1. Firefighter
  2. Enlisted Military Personnel
  3. Military General
  4. Airline Pilot
  5. Police Officer
  6. Actor
  7. Broadcaster
  8. Event Coordinator
  9. Photo Journalist
  10. Newspaper Reporter.

ABCnews.go.com listed the Top 10 Most Stressful Jobs in America in 2014, and those jobs were:

  1. Working Parents
  2. Deployed Military Personnel
  3. Police Officer
  4. Teacher
  5. Medical Professionals (The article highlighted surgeons for their need to constantly focus, psychiatrists for their need to intently listen, dentists for being on their feet all day, and interns for their lack of sleep).
  6. Emergency Personnel (The article highlighted firefighters and emergency medical technicians).
  7. Pilots and Air Traffic Controllers
  8. Newspaper Reporters
  9. Corporate Executive
  10. Miner

Salary.com listed the Top 10 Most Stressful Jobs in America, and those jobs were:

  1. Military Personnel
  2. Surgeon
  3. Firefighter
  4. Commercial Airline Pilot
  5. Police Officer
  6. Registered Nurse in an Emergency Room
  7. Emergency Dispatch Personnel
  8. Newspaper Reporter
  9. Social Worker
  10. Teacher

“Anesthesiologist” is absent from every list. This is a public relations failure for our specialty. The challenges and stressors anesthesia professionals face every day are seemingly unknown to the media and the populace.

I’ll admit there are pressures involved with being a taxi driver, a news reporter, a photo journalist, an events coordinator, or a public relations executive. Being a working parent is a challenge, although in Northern California where I live millions of adults are working parents because both husbands and wives have to work to pay hefty Bay Area living expenses. But none of these jobs involve the risk and possibility of their clients dying each and every day.

Every surgical patient requires the utmost in vigilance from their physician anesthesiologist in order to prevent life-threatening disturbances of Airway-Breathing-Circulation. The public perceives surgeons as holding patients’ life in their skilled hands, and they are correct. But most surgeons spend the majority of their work time in clinics and on hospital wards attending to pre-operative and post-operative patients. On the 1 – 3 days a week most surgeons spend operating, they are joined in the operating room by anesthesiologists who attend to surgical patients’ lives every day.

Surgeons in trauma, cardiac, neurologic, abdominal, chest, vascular, pediatric, or microsurgery specialties have intense pressure during their hours in the operating room, but each time they don their sterile gloves and hold a scalpel, an anesthesiologist is there working with them.

What follows is my own personal “Top 10 Most Stressful” list, a list of the Most Stressful Anesthesia Situations based on my thirty years of anesthesia practice. Anesthesia practice has been described as 99% boredom and 1% panic, (http://theanesthesiaconsultant.com/is-anesthesia-99-boredom-and-1-panic) and the 1% panic times can be frightening. Read through this list. I believe it will convince you that the job of an anesthesiologist deserves to be on everyone’s Top 10 Most Stressful Jobs list.

TOP 10 MOST STRESSFUL SITUATIONS IN AN ANESTHESIOLOGIST’S JOB

  1. Emergency general anesthesia in a morbidly obese patient. Picture a 350-pound man with a bellyful of beer and pizza, who needs an emergency general anesthetic. When a patient with a Body Mass Index (BMI) > 40 needs to be put to sleep urgently, it’s dangerous. Oxygen reserves are low in a morbidly obese patient, and if the anesthesiologist is unable to place an endotracheal tube safely, there’s a genuine risk of hypoxic brain damage or cardiac arrest within minutes.
  1. Liver transplantation. Picture a patient ill with cirrhosis and end-stage-liver-failure who needs a complex 10 to 20-hour-long abdominal surgery, a surgery whichfrequently demands massive transfusion equal to one blood volume (5 liters) or more. These cases are maximally stressful in both intensity and duration.
  1. An emergency Cesarean section under general anesthesia in the wee hours of the morning. Picture a 3 a.m. emergency general anesthetic on a pregnant woman whose fetus is having cardiac decelerations (a risky slow heart rate pattern). The anesthesiologist needs to get the woman to sleep within minutes so the baby can be delivered by the obstetrician. Pregnant women have full stomachs and can have difficult airway because of weight changes and body habitus changes of term pregnancy. If the anesthesiologist mismanages the airway during emergency induction of anesthesia, both the mother and the child’s life are in danger from lack of oxygen within minutes.
  1. Acute epiglottitis in a child. Picture an 11-month-old boy crowing for every strained breath because the infection of acute epiglottis has caused swelling of his upper airway passage. These children arrive at the Emergency Room lethargic, gasping for breath, and turning blue. Safe anesthetic management requires urgently anesthetizing the child with inhaled sevoflurane, inserting an intravenous line, and placing a tracheal breathing tube before the child’s airway shuts down. A head and neck surgeon must be present to perform an emergency tracheostomy should the airway management by the anesthesiologist fails.
  1. Any emergency surgery on a newborn baby. Picture a one-pound newborn premature infant with a congenital defect that is a threat to his or her life. This defect may be a diaphragmatic hernia (the child’s intestines are herniated into the chest), an omphalocele (the child’s intestines are protruding from the anterior abdominal wall, spina bifida (a sac connected to the child’s spinal cord canal is open the air through a defect in the back), or a severe congenital heart disorder such as a transposition of the great vessels (the major blood vessels: the aorta, the vena cavas and the pulmonary artery, are attached to the heart in the wrong locations). Anesthetizing a patient this small for surgeries this big requires the utmost in skill and nerve.
  1. Acute anaphylaxis. Picture a patient’s blood pressure suddenly dropping to near zero and their airway passages constricting in a severe acute asthmatic attack. Immediate diagnosis is paramount, because intravenous epinephrine therapy will reverse most anaphylactic insults, and no other treatment is likely to be effective.
  1. Malignant Hyperthermia. Picture an emergency where an anesthetized patient’s temperature unexpectedly rises to over 104 degrees Fahrenheit due to hypermetabolic acidotic chemical changes in the patient’s skeletal muscles. The disease requires rapid diagnosis and treatment with the antidote dantrolene, as well as acute medical measures to decrease temperature, acidosis, and high blood potassium levels which can otherwise be fatal.
  1. An intraoperative myocardial infarction (heart attack). Picture an anesthetized 60-year-old patient who develops a sudden drop in their blood pressure due to failed pumping of their heart. This can occur because of an occluded coronary artery or a severe abnormal rhythm of their heart. Otherwise known as cardiogenic shock, this syndrome can lead to cardiac arrest unless the heart is supported with the precise correct amount of medications to increase the pumping function or improve the arrhythmia.
  1. Any massive trauma patient with injuries both to their airway and to their major vessels. Picture a motorcycle accident victim with a bloodied, smashed-in face and a blood pressure of near zero due to hemorrhage. The placement of an airway tube can be extremely difficult because of the altered anatomy of the head and neck, and the management of the circulation is urgent because of the empty heart and great vessels secondary to acute bleeding.
  1. The syndrome of “can’t intubate, can’t ventilate.” You’re the anesthesiologist. Picture any patient to whom you’ve just induced anesthesia, and your attempt to insert the tracheal breathing tube is impossible due to the patient’s anatomy. Next you attempt to ventilate oxygen into the patient’s lungs via a mask and bag, and you discover that you are unable to ventilate any adequate amount of oxygen. The beep-beep-beep of the oxygen saturation monitor is registering progressively lower notes, and the oximeter alarms as the patient’s oxygen saturation drops below 90%. If repeated attempts at intubation and ventilation fail and the patient’s oxygen saturation drops below 85-90% and remains low, the patient will incur hypoxic brain damage within 3 – 5 minutes. This situation is the worst-case scenario that every anesthesia professional must avoid if possible. If it does occur, the anesthesia professional or a surgical colleague must be ready and prepared to insert a surgical airway (cricothyroidotomy or tracheostomy) into the neck before enough time passes to cause irreversible brain damage.

So goes my list of Top 10 List of Stressful Anesthesia situations. If you’re an anesthesia professional, what other cases would you include on the list? Which cases would you delete? How many of these situations have you personally experienced?

This Top 10 Stressful Situations in Anesthesiology list should be enough to convince you that “Anesthesiologist” belongs on everyone’s Most Stressful Jobs list.

I would reassemble the Top 10 List of Most Stressful Jobs to be as follows:

The Anesthesia Consultant’s List of Top 10 Most Stressful Jobs

  1. Enlisted military personnel
  2. Military general in wartime
  3. Police Officer
  4. Firefighter
  5. Anesthesiologist
  6. Surgeon
  7. Emergency Room Physician
  8. Airline Pilot
  9. Air Traffic Controller
  10. Corporate Chief Executive Officer

SUCCINYLCHOLINE: VITAL DRUG OR OBSOLETE DINOSAUR?

THE ANESTHESIA CONSULTANT 6 Comments
THE ANESTHESIA CONSULTANT
THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT
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Succinylcholine: vital drug or dinosaur? Succinylcholine (sux) has the wonderful advantage of rendering a patient paralyzed in less than a minute, and the discouraging disadvantage of a long list of side effects that make the drug problematic.

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A vial of succinylcholine

I would never begin an anesthetic without succinylcholine being immediately available. No other muscle relaxant supplies as rapid an onset of action and as short a duration of action. An intravenous dose of 1 mg/kg of succinylcholine brings complete paralysis of the neuromuscular junction at 60 seconds, and recovery to 90% of muscle strength in 9 – 13 minutes. (Miller’s Anesthesia, 7th Edition, 2009, Chapter 29, Pharmacology of Muscle Relaxants and Their Antagonists). If a patient has an acute airway disaster on induction such as laryngospasm or pulmonary aspiration, no drug enables emergency endotracheal intubation as quickly as succinylcholine. That said, I never use succinylcholine unless I have to. The drug has too many side effects and rocuronium is often a better choice. For an elective anesthetic on a patient who has fasted and has an empty stomach, one almost never needs to use succinylcholine. If you do use sux, you are exposing your patient to the following side effects:

1. Myalgias. Your patient complains to you the following day, “Doc, I feel like I was run over by a truck.” Because the majority of anesthetics are currently done on outpatients, and because you do not personally interview these patients the following day, you won’t be aware of the degree of muscle pain you’ve induced by using the depolarizing relaxant succinylcholine. Published data quantitates the incidence of post-succinylcholine myalgia as varying from 0.2 % to 89% (Brodsky JB, Anesthesiology 1979; 51:259-61), but my clinical impression is that the number is closer to 89% than it is to 0.2%. Myalgias aren’t life-threatening, but if you ever converse with your patient one day after succinylcholine and they complain of severe muscle aches, you’ll wish you’d chosen another muscle relaxant if possible.
2. Risk of cardiac arrest in children. Succinylcholine carries a black box warning for use in children. Rare hyperkalemia and ventricular arrhythmias followed by cardiac arrest may occur in apparently healthy children who have an occult muscular dystrophy. The black box warning on succinylcholine recommends to “reserve use in children for emergency intubation or need to immediately secure the airway.”
3. Hyperkalemia, with an average increase of 0.5 mEq in potassium concentration after intravenous succinylcholine injection.
4. Cardiac arrest in patients with a history of severe trauma, neurologic disease or burns. There’s a risk of cardiac arrest with succinylcholine use in patients with severe burns, major trauma, stroke, prolonged immobility, multiple sclerosis, or Guillian-Barré syndrome, due to an up-regulation of acetylcholine. The increase in serum potassium normally seen with succinylcholine can be greatly increased in these populations, leading to ventricular arrhythmia and cardiac arrest. There is typically no risk using succinylcholine in the first 24 hours after the acute injury.
5. Cardiac arrhythmias. Both tachy and bradycardias can be seen following the injection of succinylcholine.
6. Increase in intraocular pressure, a hazard when the eye is open or traumatized.
7. Increase in intragastric pressure, a hazard if gastric motility is abnormal or the stomach is full.
8. Increase in intracranial pressure, a hazard with head injuries or intracerebral bleeds or tumors.
9. Malignant Hyperthermia (MH) risk. The incidence of MH is low. A Danish study reported one case per 4500 anesthetics when triggering agents are in use (Ording H, Dan Med Bull, 43:111-125), but succinylcholine is the only injectable drug which is a trigger for MH, and this is a disincentive to use the drug routinely.
10. Prolonged phase II blockade. Patients who have genetically abnormal plasma butyrylcholinesterase activity have the risk of a prolonged phase II succinylcholine block lasting up to six hours instead of the expected 9 – 13 minutes. If you’ve ever had to stay in the operating room or post-anesthesia recovery room for hours with a ventilated patient after their surgery ended because your patient incurred prolonged blockade from succinylcholine, you won’t forget it, and you’ll hope it never happens again.

What does a practicing anesthesiologist use instead of succinylcholine? Rocuronium.

A 0.6 mg/kg intubating dose of the non-depolarizing relaxant rocuronium has an onset time to maximum block of 1.7 minutes and a duration of 36 minutes. The onset time can be shortened by increasing the dose to a 1.2 mg/kg, a dose which has an onset time to maximum block of 0.9 minutes and a duration of 73 minutes. These durations can be shortened by reversing the rocuronium blockade as soon as one twitch is measured with a neuromuscular blockade monitor. Thus by using a larger dose of rocuronium, practitioners can have an onset of acceptable intubation conditions at 0.9 X 60 seconds = 54 seconds, compared to the 30 seconds noted with succinylcholine, without any of the 10 above-listed succinylcholine side effects. The duration of rocuronium when reversed by neostigmine/glycopyrrolate can be as short as 20 – 25 minutes, a time short enough to accommodate most brief surgical procedures.

Now that sugammadex is commercially available, we can reverse rocuronium blockade in seconds, making rocuronium shorter in duration than succinylcholine.

Here is a list of surgical cases once thought to be indications for using succinylcholine, which I would argue are now better served by using a dose of rocuronium followed by early reversal with sugammadex:

1) Brief procedures requiring intubation, such as bronchoscopy or tonsillectomy.
2) Procedures which require intubation plus intraoperative nerve monitoring, such as middle ear surgery.
3) Procedures requiring intubation of obese and morbidly obese patients who appear to have no risk factors for mask ventilation.
4) Procedures requiring full stomach precautions and cricoid pressure, in which the patient’s oxygenation status can tolerate 54 seconds of apnea prior to intubation. This includes emergency surgery and trauma patients. Miller’s Anesthesia (Chapter 72, Anesthesia for Trauma) discusses the induction of anesthesia and endotracheal intubation for emergency patients who are not NPO and may have full stomachs. Either succinylcholine or rocuronium can be used, with succinylcholine having the advantage of a quicker onset and the 1.2 mg/kg of rocuronium having the advantage of lacking the 10 side effects listed above. The fact that succinylcholine takes 9 – 13 minutes to wear off makes it riskier than rocuronium, which can be reversed in seconds by sugammadex. Waiting for 9 minutes for a return to spontaneous respirations after succinycholine would be associated with severe hypoxia.

On the other hand, succinylcholine is the sole recommended muscle relaxant for:

1) Cesarean sections. Miller’s Anesthesia (Chapter 69, Anesthesia for Obstetrics) still recommends thiopental and succinylcholine for Cesarean sections that require general anesthesia, and I would be loath to disagree with our specialty’s Bible.
2) Electroconvulsive therapy (ECT) for depression. Miller’s Anesthesia (Chapter 79, Anesthesia at Remote Locations) recommends partial muscle relaxation during ECT, and recommends small doses of succinylcholine (0.5 mg/kg) to reduce the peripheral manifestations of the seizure and to prevent musculoskeletal trauma to the patient.
3) Urgent intubation or re-intubation in a patient when every second counts, e.g. a patient who is already hypoxic. A subset of this indication is the patient who is being mask-induced and becomes hypoxic and requires intramuscular succinylcholine injection.
4) Laryngospasm either during mask induction or post-extubation, in which the patient requires urgent paralysis to relax the vocal cords.

In conclusion, most indications for muscle relaxation are better handled by using the non-depolarizing drug rocuronium rather than succinylcholine. However, because of the four recommended uses for succinylcholine listed in the previous paragraph, none of us would ever practice anesthesia without a vial of succinylcholine in our drawer for immediate availability.

I try very, very hard to minimize my use of succinylcholine, and so should you. But to answer our original question… succinylcholine is still a vital drug and not a dinosaur at all.

 

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