LANDING THE ANESTHESIA PLANE: WHEN SHOULD YOU EXTUBATE THE TRACHEA?

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

This column is for my readers who are anesthesia professionals. When should you extubate the trachea? Clinical Case for Discussion: You’re anesthetizing a 60-year-old woman for a thyroidectomy. The surgeon tells you, “If this woman bucks on the endotracheal tube on awakening it could cause a neck hematoma and damage my surgical closure. Can you extubate her deep?”

 

Discussion: The patient has a normal airway, and she is healthy and slender. You decide to comply with the surgeon’s request and remove the endotracheal tube (ET tube) at the end of surgery while the patient is still fully anesthetized. You turn off the nitrous oxide, allow the patient to breath 100% oxygen and 3% sevoflurane, and suction the patient’s throat. You deflate the cuff on the ET tube and remove the tube. Once the tube is withdrawn, you turn off all anesthetics. At this point the patient coughs and her mouth fills with yellow gastric contents. You suction the mouth again, but the patient develops upper airway obstruction. The oxygen saturation drops to 80%. Your diagnosis is laryngospasm. You attempt to apply continuous positive airway pressure with an anesthesia mask, but her oxygen saturation falls to 70%. Panicked, you inject 100 mg of IV succinylcholine to re-paralyze the patient, and you perform laryngoscopy and reintubate her. After the ET tube is replaced, the oxygen saturation returns to 100%. You suction through the lumen of the ET tube, and you find yellow gastric material inside the lungs. You diagnose aspiration.

After a 10½ hour flight from Seoul, Korea, an Asiana airplane crashed on landing at San Francisco Airport on July 6, 2013. Aviation and anesthesia have similarities. The takeoff and landing of an airplane, just as induction and emergence from anesthesia, are more complex events than piloting the middle of a plane flight or managing the maintenance phase of a long anesthetic.

The timing of the removal of the endotracheal tube at the end of an anesthetic requires skill and judgment. Does deep extubation ever make sense? During my first year after residency training, a gray-haired anesthesia attending at my new medical center told me, “Richard, in private practice you never extubate anyone deep.” Twenty-seven years later, I’m writing to convince you he was right.

Let’s define “deep extubation.” Per Miller’s Anesthesia, 7th Edition, 2009, Chapter 50, “Extubation may be performed at different depths of anesthesia, with the terms ‘awake,’ ‘light,’ and ‘deep’ often being used. ‘Light’ implies recovery of protective respiratory reflexes and ‘deep’ implies their absence. ‘Awake’ implies appropriate response to verbal stimuli. ‘Deep’ extubation is performed to avoid adverse reflexes caused by the presence of the tracheal tube and its removal, at the price of a higher risk of hypoventilation and upper airway obstruction. Straining, which could disrupt the surgical repair, is less likely with ‘deep’ extubation. Upper airway obstruction and hypoventilation are less likely during ‘light’ extubation, at the price of adverse hemodynamic and respiratory reflexes.”

The medical literature describes deep extubation as extubating a patient who is still breathing 1.5 times the minimal alveolar concentration (MAC) of inhaled anesthetic. A 2004 study examined 48 children tracheally extubated while deeply anesthetized with 1.5 times the MAC of desflurane (Group D) or sevoflurane (Group S). No serious complications occurred in either group, and the time to discharge was not significantly different between groups. The study concluded that deep extubation of children can be performed safely with desflurane or sevoflurane. (Valley RD, Anesth Analg. 2003 May;96(5):1320-4, Tracheal extubation of deeply anesthetized pediatric patients: a comparison of desflurane and sevoflurane.)

In a prospective trial, 100 children age<16 years, each with at least one risk factor for perioperative respiratory adverse events (e.g. current or recent upper respiratory tract infection or asthma) were randomized to extubation under deep anesthesia or extubation when fully awake after tonsillectomy. There were no differences in respiratory adverse events (laryngospasm, bronchospasm, persistent coughing, airway obstruction, or desaturation <95%). Tracheal extubation in fully awake children was associated with a greater incidence of persistent coughing (60 vs. 35%, P = 0.028), however the incidence of airway obstruction relieved by simple airway maneuvers in children extubated while deeply anaesthetized was greater (26 vs. 8%, P = 0.03).

Seventy healthy patients between 2 and 8 yr of age who had elective strabismus surgery or tonsillectomy were randomly assigned to group 1 (awake extubation) or group 2 (anesthetized extubation). The incidence of airway-related complications such as laryngospasm, croup, sore throat, excessive coughing, and arrhythmias was not different between the two groups. The authors concluded that the anesthesiologist’s preference or surgical requirements may dictate the choice of extubation technique in otherwise healthy children undergoing elective surgery. (Patel RI, Anesth Analg. 1991 Sep;73(3):266-70. Emergence airway complications in children: a comparison of tracheal extubation in awake and deeply anesthetized patients).

In an informal poll of the private practice anesthesiologists at Stanford University, the incidence of deep extubation (i.e. patient extubated asleep while breathing >1.5 MAC of inhaled anesthetic) approached zero. Why do I and my colleagues avoid deep extubation? If you have a life-saving and life-preserving device such as an endotracheal tube safely in place in your patient, and your goal is to maintain the values of Airway, Breathing, and Circulation, why remove that life-preserving device prematurely without any evidence that such a removal is beneficial? Why leave your anesthetized patient with an unprotected airway?

I cannot cite you outcome data that shows awake extubation provides superior outcomes to deep extubation, but with modern short-acting anesthetics such as propofol, sevoflurane, and desflurane, a well-trained anesthesiologist can decrease anesthetic depth quickly and have their patient very awake within minutes after the conclusion of surgery. Per Miller’s Aesthesia, “Rapid recovery of consciousness shortens the at-risk time during extubation and may reduce morbidity, particularly in obese patients. … Nitrous oxide, sevoflurane, and desflurane all contribute to rapid recovery, particularly after prolonged procedures.”

If your patient vomits on emergence and the ET tube is still in situ, the cuff on the ET tube will protect their lower airway. And if you choose to extubate your patient awake, the occurrence of laryngospasm will be, in this author’s experience, rare.

It’s true that coughing on an ET tube can disrupt surgical repairs, increase intracranial pressure, increase intraocular pressure, or cause hypertension and tachycardia, but per Miller’s Anesthesia, “Marked increases in arterial blood pressure and heart rate occur frequently at the time of ‘light’ extubation. These effects are alarming but normally transient, and there is little evidence of adverse consequences.”

My advice: Use light levels of general anesthetics on your intubated patients, and learn how to wake your patients from general anesthesia quickly at the conclusion of surgery. Don’t suction the patient until you are ready to remove the ET tube, because the suction catheter stimulates early coughing.

The ET tube is your friend. I’d recommend you don’t pull it out until you’re certain you don’t need it any more.

The definitive reference from the medical literature on this topic is Difficult Airway Society Guidelines for the management of tracheal extubation, written by Popat M.

 

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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

 

 

AMBULATORY SURGERY AND THE ANESTHESIOLOGIST: HOW TO BE EFFICIENT IN THE OPERATING ROOM

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

You are an attending anesthesiologist, and you are scheduled to do 8 breast biopsy cases beginning at 0730 and ending at 1730 hours.  How will you manage your day?

Discussion:   doeverythingrealfastanddonttakebreakstheend.  So it can be in the “real world” of anesthesia.  At the American Society of Anesthesiologists National Meeting each October, you will not hear a Refresher Course on how to manage a day of 8 cases in 10 hours.  The slow pace of surgeons-in-training makes it unlikely most university faculty anesthesiologists have ever experienced such a day, so it’s unlikely they would lecture on the topic.

Safe anesthesia care is the most important goal of any day in the operating room.  But to be outstanding in practice, you will have to be efficient as well as safe.  Operating room time is expensive, and in addition,  surgeons will judge you on how rapidly you work.  To a surgeon, the time between when they put the dressing on one patient until they make the incision on the next patient is “down time.”  They want this minimized.   Surgeons as well as patients are your customers in private practice.  If you do not believe this, try ticking off your surgeons on a regular basis, and see how long you have a position in any private group.

If the surgeon does each breast biopsy in 30 minutes, and there are 8 cases, that adds up to 4 hours of operating time.  The other 6 hours are  for the anesthesiologist and the nurse to wake the patient up,   get the room turned over, and get  the next patient to sleep and prepped.

Some surgeons prefer to do  breast biopsies under general anesthesia, and some request deep sedation plus local anesthesia.   For general anesthesia, you choose propofol for induction, with sevoflurane, nitrous oxide, and/or propofol for maintenance.    A laryngeal mask airway is used for most patients.  For cases done under local plus deep sedation, you may choose a small dose of narcotic, followed by a propofol infusion starting at 100 mcg/kg/minute.   Oxygen is delivered by face mask.

I will offer  a few  labor and time saving suggestions for a rapid pace of practice:

1)  When the patient moves onto the operating room table, attach and activate the automated blood pressure cuff first.  While it is inflating, place the oximeter and the ECG leads.  When the blood pressure cuff has finished its initial reading,  you ask the patient to use  that hand to hold the oxygen mask over her  face.  This frees both of your hands to begin the induction once the oxygen saturation reaches 100%.

2)  As soon as the patient is asleep, finish the paperwork or the computerized medical records.  The paperwork on a day like this one is a burden.  Your paperwork errands include the history and physical, the recovery room orders, the anesthesia record, your billing form,  and the narcotic form – and all these will be repeated 8 times on this work day.  My advice  is to simplify the paperwork or computerized forms at your facility, so that all the pertinent medical-legal information is present, but the forms can still be filled out in minutes.

3)  When the paperwork is finished, get your syringes and equipment ready for the next case.

4)  When the surgery ends, you wake the patient, and transport her to the recovery room.  After a sign-out to the nurse there, you return to the pre-operative room to meet the next patient.  Patients are often very nervous before breast biopsy, both because of the surgery, and  because of the worries of the outcome of the biopsy.  You  attempt to ease her  anxiety as much as possible, at first with your verbal skills.   After discussion  of the procedure and risks, you place the IV,  further relieve anxiety with a dose of midazolam, and transport her to the operating room.  At some private hospitals, the   IV may be placed by a nurse while you are in the operating room, saving turnover time.  At most private hospitals or surgery centers, someone other than the anesthesiologist will transport the patient into the operating room.  This is your best chance for a short break between cases, without slowing the system down by your absence.

In a fee-for-service practice, both you and the surgeon have the same incentives:  to do as many cases as safely possible, and finish the day promptly.   There is an incentive to do an extra case, because every extra case is extra income.  The patients definitely benefit in this system, because in addition to the opportunity to practice their healing art, their doctors are receive extra renumeration for extra work.

Anesthesia professionals who are salaried employees do not have this incentive.  They earn as much if they do 4 cases or if they do 8 cases, as long as they serve out their 8-hour shift.  For this reason, salaried anesthesia professionals may work at a slower pace.  In an era where every labor union has mandatory lunch breaks and coffee breaks, the idea of  working for 10 straight hours on 8 patients may seem unreasonable, but it does happen in community anesthesia practice.  Thousands of  anesthesiologists you walked at the American Society of Anesthesiologists National Meeting could give you a lecture on it.  Every one will have their own advice on how best to handle a day like this one.

I’d wager that every anesthesiologist who is in a private practice would envy the opportunity to do 8 surgeries in 10 hours.

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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

 

 

PRODUCTION PRESSURE IN THE OPERATING ROOM

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

Clinical Case of the Month:  The head of your anesthesia group tells you that both the surgeons and the fellow anesthesiologists in your group want you to work faster, and if you do not, you will not make partner in that group.  You are worried about succumbing to “production pressure.”  You don’t want to work faster.  What do you do?

Discussion:   At the end of your day in the operating room, the most important issue is the safe medical care of each patient you were asked to consult on.  Patients don’t care if you were a racehorse or a turtle; they only care about their results.  Your malpractice insurance company doesn’t care if you were a racehorse or a turtle; they want you to practice at or above the standard of care, and not get sued.

I refer you to the article “Production Pressure in the Work Environment, California Anesthesiologists’ Attitudes and Experiences,” by David Gaba and Steve Howard of the Stanford faculty (Anesth, 1994 Aug;81(2):488-500).   The authors mailed a survey to California anesthesiologists, seeking their responses to questions pertaining to production pressure.  The authors noted that “Every modern industrial activity involves a balance between production efficiency and safety.”  They defined production pressure as “overt or covert pressures and incentives on personnel to place production, not safety, as their primary priority.”

Fifty-four per-cent of respondents agreed they had made an error attributable to fatigue, and 63% suggested that they had made errors because of the work load within a case.  Most respondents believed they had a duty to cancel cases if necessary, but 35% indicated that it was possible they would lose their job if they canceled too many cases.

The types of pressure were divided into two categories:  internal pressures (pressures anesthesiologists put on themselves), and external pressures (pressures from surgeons, family, colleagues, or administrators).  The greatest internal pressures were:  a) to avoid delaying surgery, b) to get along with surgeons, and c) to avoid litigation.  The greatest external pressures were:  a) from the surgeon, to proceed with a case instead of canceling, b) from the surgeon, to hasten anesthesia procedures, and c) from administrators, to reduce turnover time.

Fee-for-service respondents reported more internal pressure than did salaried practitioners to:  maximize cases (P=0.0007), accrue income from high paying cases (P=0.0001), and avoid litigation (P=.0002).

I worked a short stint in a salaried anesthesia job with Kaiser in 1986, before I began working in my current arrangement of fee-for-service (FFS) practice.  Production pressure exists, and I can attest that it is more apparent in FFS practice.  In FFS practice, you have incentives to proceed with cases rather than cancel them, to turn over rooms quickly rather than take a 30-minute lunch break, and to keep your surgeon-customers happy rather than fight with them over cancellations.

I discussed today’s question with other anesthesiologists in top Bay Area FFS practices.  Among their expectations for new hires is that the individual will possess The Three A’s, of Ability, Availability, and Amiability.  Part of the Ability ingredient is the talent to multi-task, that is, the ability to work with your hands, do paperwork, think, plan anesthetics, and monitor your patient simultaneously.

Some anesthesiologists are racehorses, and some anesthesiologists are turtles.  Consider this:  All else being equal, the turtles will not last in FFS job opportunities.

Surgeons in private practice in are faster than surgeons in residency.  When you graduate and enter the private practice of anesthesia, you will have to speed up to succeed.  The message here is a wake-up call:  Don’t stand in the middle of the operating room and complain about production pressure.  Work as efficiently as you can.  Do not take short-cuts that endanger your patient, but get the job done.

If it sounds like I am applying production pressure with my comments, you may be right.  Safety is the number one goal, but high production is an expectation, and not an unreasonable one.

The years of residency and fellowship are the time to hone your skills.  Attempting to work at an efficient pace during the first weeks of your first FFS job will be impossible if you haven’t valued efficiency in your training.  If you are a turtle, will you lose your job?  I know of several anecdotes where private FFS anesthesia groups washed out promising candidates because they were too slow for the private world.  The candidates spent too much time starting IV’s and other lines, getting their patients to sleep, placing regional anesthetics, waking their patients up, taking longer-than-expected breaks between cases, and arguing with surgeons instead of getting patients anesthetized.

Some surgeons are better than others.  Anesthesiologists, nurses, and OR techs all know which surgeons possess excellent judgment and are skilled with their hands.   In the same light, surgeons, nurses, and OR techs all know which anesthesiologists possess excellent judgment and are skilled with their hands.

You want to be one of the anesthesiologists they admire.

If the pace of the FFS world feels unsafe to you, I would advise you to find a different job model, perhaps a salaried job at a more languid tempo.  In a FFS practice, you need to be both safe and efficient.

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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

 

 

HOW MANY SYRINGES DOES IT TAKE TO GIVE A GENERAL ANESTHETIC?

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

Clinical Case of the Month:   You’re setting up to give anesthesia for a laparoscopic cholecystectomy.  How many syringes and labels do you draw up and prepare?  For a D & C?  For an open abdominal aortic aneurysm repair?

Discussion:  Try something new.  When  preparing for a cholecystectomy, open two syringes, both unlabelled, and don’t open any ampules until the patient is in the OR.  More on that later.

Let’s examine two questions:  Why do we label syringes, and why do we load syringes with drugs ahead of time?  The answer to the first question is easy — we label syringes because we want to know what’s inside of them.  The Institute of Medicine’s report from 1999, entitled, To Err is Human:  Building a Safer Health Care System, reported that 98,000 patients died in U.S. hospitals each year due to medical errors.  Administering the wrong drug is a known anesthesia risk which we all try to avoid.

In a study of 55,426 anesthetics in Norway over 36 months, drug error was reported in 63 cases, or 0.11% of cases. (Fasting S, Can J Anaesth.2004 Oct;51(8):853-4.)  Drug errors included 28 syringe swaps, 9 ampule swaps, 8 ‘other wrong drug’ cases, and 18 cases where the wrong dose of the correct drug was given.  In the second 18 months of their study, they switched to color-coded syringe labels, and found their results unchanged except for a decreased number of ampule swaps (P=.04).  They concluded that drug errors were uncommon, that syringe swaps occurred most often between syringes of equal size, and that drug errors were not eliminated by color-coding of labels.

In a study of 896 drug errors reported in Australia, syringe and drug preparation errors accounted for 452 (50.4%) incidents, including 169 (18.9%) involving syringe swaps where the drug was correctly labeled but given in error, and 187 (20.8%) due to selection of the wrong ampule or drug labeling errors. (Abeysekera A, Anaesthesia. 2005 Mar;60(3):220-7).  Contributing factors included inattention, haste, drug labeling error, communication failure, and fatigue.  Factors minimizing the events included prior experience and training.

According to the first reference, a drug error was reported about once per 1000 cases in Norway.  I’d ask you to consider how many incidents of drug error occur, versus how many are actually reported.  I submit that the real prevalence probably exceeds the amount of cases that anesthesiologists admit to, and the real prevalence is significantly greater than .11%.  And even though labeling syringes is important and mandated, it fails to decrease medication error to zero.  In the future, we may see computerized visual and auditory bar-code verification of ampules and/or labels just before drug administration.

My second question to you was “why do we load syringes with drugs ahead of time?”  Common sense answers might be, “because it makes our work more efficient,” or “we might need them fast, and we don’t want to draw the drugs up at the last moment.”  Opinions regarding the preparation of pre-drawn emergency syringes differ.  In a study from New Zealand, a quarter of respondent anesthesiologists routinely drew up emergency drugs, and a third either never or very infrequently did so(Ducat CM, Anaesth Intensive Care. 2000 Dec;28(6):692-7).  Among the drugs most commonly drawn up were succinylcholine, atropine, and ephedrine.  Pediatric, obstetric, or vascular cases were cited as factors which prompted anesthesiologists to draw up one or more of these drugs.

Drug wastage is a known to be a significant portion of anesthesia drug budgets.  In one fiscal year, the cost of unadministered drugs at Rhode Island Hospital was $165,667 (Gillerman RG, Anesth Analg. 2000 Oct;91(4):921-4).  Efficiency indexes, defined as the percent of a restocked drug that was actually administered to patients, were as follows:  succinylcholine, 33%, propofol, 49%, rocuronium, 61%, and thiopental, 31%.  In a study at UC San Diego, drug wastage was quantitated in 166 cases during  a two week period (Weinger MB, J Clin Anesth. 2001 Nov;13(7):491-7).  Based on hospital drug acquisition costs, $1802 of drugs were wasted in two weeks.  Six drugs accounted for three quarters of the total wastage:  phenylephrine (20.8%), propofol (14.5%), vecuronium (12.2%), midazolam (11.4%), labetolol (9.1%), and ephedrine (8.6%).

Think about it, my colleagues.  Do you really need to draw up atropine and ephedrine before every case?

I queried Fred Hurt from the Stanford OR Pharmacy, and he gave me the following drug ampule acquisition costs:  atropine $.23, ephedrine $.74, phenylephrine $2.47, vecuronium $2.51, rocuronium $18.89, succinylcholine $1.93, propofol 20ml $4.76, and propofol 50 ml $11.91.

I’ll admit, in the scope of the healthcare budget of the United States, these numbers are miniscule, and you may not give a damn if your unused atropine and ephedrine costs Stanford 97 cents.  But let’s go back to the first paragraph, and a technique to avoid drawing up a lot of drugs and labeling them.  Part of the rationale is to avoid drug wastage, but the greater issue is the KISS principle — Keep It Simple Stupid.  In a 20 year career you’ll do 14,000 cases, and any practice that avoids wasted time and energy on each case is of value.

Try this:  For a cholecystectomy, use an unlabelled 5 ml syringe to draw 2 mg of midazolam from its already labeled ampule, and inject it into the patient’s IV.  Minutes later, use the same syringe to draw 100 micrograms of fentanyl from its already labeled ampule, and inject it into the patient’s IV.  Then use a second syringe, a 20 ml syringe, to draw 200 mg of propofol from its already labeled ampule, and inject it into the patient’s IV.  Finally, use the first syringe to draw 10 ml of Lactated Ringers from the IV bag and inject it into an already labeled ampule of vecuronium, mix it up, and inject 0.1mg/kg of vecuronium into the patient’s IV.

Reusing the same syringe on the same patient for several single-patient use ampules is safe.  The ampules are already labeled — why add another intermediate step and store them in a labeled syringe?  The exception to this practice is for drugs that need to be diluted — this would include phenylephrine (for a case you expect you might need it, such as vascular surgery or geriatric surgery), or narcotics such as morphine and meperidine.  These syringes need to be prepared and labelled.  Syringes should not be carried over from one patient to the next.

Like Burger King used to say, “Have it your way!”  You don’t have to agree with or accept the above suggestions, but I’d be interested in hearing if you’ve changed your mind, 14,000 cases from now.

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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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