WAS JUSTICE ANTONIN SCALIA’S DEATH FROM OBSTRUCTIVE SLEEP APNEA?

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)

Justice Antonin Scalia’s death was unexpected. I’ve never examined Justice Scalia, never had access to his medical records, and have no information other than what has been published over the Internet regarding the events of the last 24 hours of his life. According to published news reports, APNewsBreak: Justice Scalia Suffered From Many Health Problems, the Justice suffered from obstructive sleep apnea (OSA), chronic obstructive pulmonary disease, and hypertension.

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As an experienced anesthesiologist, I’ve personally watched over 25,000 patients sleep during my career. Thousands of these patients carried the diagnosis of OSA. I’ve witnessed first hand what happens when a patient with OSA obstructs their airway and stops breathing during sleep.

Obstructive sleep apnea is a chronic condition of cyclic obstruction of the upper airway during sleep, usually combined with excessive daytime sleepiness and loud snoring.Apnea is the medical word for the suspension or stopping of breathing. Observation of at least five obstructive events (apneic events) per hour of sleep during a formal sleep study is a minimal criterion for diagnosing OSA in adults.

Let’s discuss a hypothetical male patient. He is 79 years old, overweight, and has a thick neck. Perhaps he is a Supreme Court Justice, and perhaps he is not. Because of his age and his body habitus, he’s at risk for the diagnosis of OSA, but we have no knowledge of any sleep study to document this.

We’re going to sedate this patient for a medical procedure. Intravenous sedative drugs will include some combination of a benzodiazepine such as Versed, a narcotic such as fentanyl, and a hypnotic such as propofol. The procedure does not require a breathing tube, so we’ll administer the sedation and be vigilant regarding what happens to the patient’s vital signs. As with all anesthetics, the patient will be fully monitored for heart rate, blood pressure, oxygen saturation, respiratory rate, and exhaled carbon dioxide level.

This is what happens when we administer strong sedatives to this hypothetical male patient who is 79 years old, overweight, and who has a thick neck:

  1. With the onset of sleep, the rate of breathing becomes slower and the volume of each breath decreases.
  2. Because of the decrease in ventilation, the oxygen saturation level will drop.
  3. As anesthesiologists, we administer oxygen via nasal cannula or via a mask, and the oxygen saturation will increase to a safe level again.
  4. If we progress to administering deeper sedation, the patient’s airway will obstruct. Typically this occurs because the base of the tongue drops back and occludes the airway, or redundant tissue in the oral pharynx relaxes and occludes the airway. With partial obstruction, we hear the patient snore, but ventilation continues. With total obstruction, the patient’s chest moves in an attempt to draw in a breath, but there is no ventilation through the obstructed upper airway.
  5. If this airway obstruction is not remedied, the oxygen saturation will drop below a safe level of 90%. At these low blood oxygen levels, the brain and heart will be deprived of necessary oxygen. A prolonged low blood oxygen level can lead to life threatening cardiac dysrhythmias or a cardiac arrest.
  6. With a physician anesthesiologist present, the airway obstruction is relieved by applying a jaw lift, extending the patient’s neck, inserting an oral airway, or inserting an airway tube.
  7. Without an anesthesiologist present, the patient could die.

In a related scenario, what if our hypothetical male patient who is 79 years old, overweight, and who has a thick neck doesn’t have medical sedation, but rather has a long busy day at 4,400 feet of altitude, and perhaps consumes alcohol with its attendant sedative effects, along with perhaps a sleeping pill or an oral narcotic analgesic taken to relieve the symptoms of a painful shoulder ailment? All of these factors (fatigue, altitude, alcohol, medications) serve to make a patient more sedated. Heavy sleep accompanied by snoring ensues. The partial airway obstruction of snoring progresses to the total airway obstruction of obstructive sleep apnea. The blood oxygen level drops, the heart is denied adequate oxygen delivery, and the patient suffers a cardiac arrhythmia and then a cardiac arrest.

Is this a “heart attack?”

Every one of us will die one day, and every one of our deaths will be accompanied by a heart that ceases to beat. The cause of the “heart attack” will differ for each of us. If someone has significant narrowing of a major coronary artery and attempts to run up a mountain, this event may increase the oxygen demand of the heart and precipitate a lethal heart rhythm. When a hypothetical male patient who is 79 years old, overweight, and who has a thick neck dies in the middle of the night, you can bet the cessation of the heart beat was due to airway obstruction and inadequate oxygen to the heart.

According to APNewsBreak, on the morning the Justice was found dead “a breathing apparatus was found on the night stand next to Scalia’s bed when his body was found, but he was not hooked up to it and it was not turned on.” Most likely this was a CPAP machine, or a Continuous Positive Airway Pressure machine. A CPAP machine includes a mask which the patient straps over their nose or over their nose and mouth prior to going to sleep. The CPAP machine delivers a stream of compressed air via a hose to the nose mask or the full-face mask, splinting the airway to keep it open under air pressure so unobstructed breathing becomes possible. The main problem with a CPAP machine is non-compliance, that is, the patient refuses to wear it. This was seemingly the case with Justice Scalia’s last night.

A take home message from this column is to respect the specter of OSA in your own life and in the lives of your loved ones. If you are a physician, respect the specter of OSA in your patients. Persons with an increased risk of OSA include people older than 60 years of age, patients with hypertension, prior strokes, heart failure, atrial fibrillation, obesity, or the metabolic syndrome including hyperlipidemia and diabetes. The most common symptoms are excessive daytime sleepiness and loud snoring. Persons who fit this profile should undergo a formal sleep study to screen for OSA. Most formal sleep studies require overnight monitoring of breathing patterns and oxygen saturation. The studies are not cheap, so screening every elderly obese snorer in America would be expensive. However, a diagnosis of OSA can lead to a cascade of effective therapies, including:  1) an oral orthodontic appliance to keep the jaw advanced, or 2) a continuous positive airway pressure machine to be worn while sleeping, or 3) airway surgeries on the palate, uvula, mandible, and/or maxilla, or 4) aggressive treatment of the OSA comorbidities of obesity, hypertension, and diabetes.

The American Academy of Sleep Medicine estimates that 25 million Americans may have OSA, and up to 90 percent of these patients are undiagnosed.

Questions will continue to swirl around the circumstances of Justice Antonin Scalia’s death. Was there a pillow over his head, as was first described by John Poindexter, the owner of the ranch who first discovered Scalia’s body? Were sedating medications or alcohol present in his bloodstream? Why did Presidio County Judge Cinderela Guevara pronounce Scalia dead of natural causes without even seeing the body? Why was no autopsy ordered? Was the Justice murdered, as if this was the plot of some John Grisham legal thriller?

We may never know the answers to these questions, but query most any anesthesiologist about the likelihood that OSA was involved in the death of Justice Antonin Scalia, and the answer you will get is . . .

“Yes, with a high degree of medical probability, obstructive sleep apnea is what killed Justice Antonin Scalia.”

 

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:

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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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 RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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HOW DO YOU START A PEDIATRIC ANESTHETIC WITHOUT A SECOND ANESTHESIOLOGIST?

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: In your first week in community practice post-residency and fellowship, you’re scheduled to anesthetize a 4-year-old for a tonsillectomy. You’ll start the anesthetic without an attending or a second anesthesiologist. How do you start a pediatric anesthetic alone?

 

Discussion: During residency it’s standard to initiate pediatric cases with an attending at your right hand to mentor and assist you through the induction of anesthesia. The second pair of hands is critical—one of you manages the airway for the inhalation induction, and the second anesthesiologist starts the IV. In community practice you’ll have to manage all this yourself.

A significant percentage of pediatric anesthetics are performed in regional hospitals and surgery centers rather than in pediatric tertiary hospitals. How does the community practice of pediatric anesthesia differ from pediatric anesthesia in residency?

In community practice you’ll likely telephone the parents the night prior to surgery to discuss the anesthetic. It’s uncommon for a 4-year-old and his family to visit any pre-anesthesia clinic. You’ll take a history over the phone from the parents, explain the basics of anesthetic care, and answer any questions they have.

On the morning of surgery you’ll meet the parents and the child. It’s likely you’ll prescribe an oral midazolam premedication. You’ll set up your operating room with appropriate sized pediatric equipment, heeding the M-A-I-D-S mnemonic for Machine and Monitors-Airway-IV-Drugs-Suction.

What about a request from the mother and/or father to accompany the child into the operating room? This author advises against bringing parents into the O.R. Instead premedicate the child to minimize the emotional trauma of separation from the parent(s), and explain that the duration of time from when they hand you their child to when the gas mask is applied will only be a few minutes.

It’s common to induce anesthesia with the child in a sitting position. The one most important monitor you can place prior to induction is the pulse oximeter. Once unconsciousness is attained, the child is laid supine and a pretracheal stethoscope, the ECG leads, and the blood pressure cuff are applied. If you’re not using a pretracheal stethoscope during mask inductions, let me recommend it to you. No other monitor gives you immediate information on the patency of the airway like the stethoscope does. You can remedy partial or total airway obstruction more promptly than if you wait for oxygen desaturation or end-tidal CO2 changes.

Most children have an easy airway and require no more than occasional positive airway pressure via the mask to keep spontaneous ventilation open. Young children scheduled for tonsillectomy sometimes carry the diagnosis of obstructive sleep apnea (OSA) based on a clinical history of snoring, noisy breathing, or daytime somnolence. It’s uncommon for these patients to have a formal sleep study to document OSA. OSA children may have more challenging airways and have an increased incidence of partial airway obstruction during inhalation induction.

In residency I was taught to supplement the potent volatile anesthetic (halothane in decades past) with 50-70% nitrous oxide. Because the blood:gas partition coefficient of sevoflurane is 0.65, comparable to nitrous oxide’s 0.45, anesthetic induction with sevoflurane alone is nearly as fast as sevoflurane-nitrous oxide. The addition of nitrous oxide to the induction mix is unnecessary, and using an FIO2 of 1.0 affords an extra cushion of oxygen reservoir if the airway is difficult or if the airway is lost.

How will you start the IV after induction? There are several options: 1) You can ask the surgeon or a nurse to start the IV. In my experience, neither surgeons nor O.R. nurses are as skilled in starting pediatric IV’s as an anesthesiologist is, so I don’t recommend this plan; 2) You can ask the surgeon or the O.R. nurse to hold the mask and manage the airway while you start the IV. This option is safe if the airway is easy and you trust the airway skills of the other individual; 3) You can stand at your normal anesthesia position, hold the mask over the patient’s airway with your left hand, and ask the nurse to bend the patient’s left arm back toward you. The nurse tourniquets the patient’s arm at the wrist, and with your right hand you perform a one-handed IV start in the back of the patient’s left hand; 4) The option I feel most comfortable with is to fit mask straps behind the patient’s head, and secure the mask in place with the four straps after the patient is fully anesthetized (when their eyes have returned to a conjugate gaze). While the straps hold the mask in place, you listen to the patient’s breathing via the pretracheal stethoscope to assure yourself that the airway is patent. Then move to the left-hand side of the table and start the IV in the child’s left arm. The typical length of time away from the airway should be less than one minute. If the child has no obvious veins, fit the automated blood pressure cuff (in stat mode) on top of the tourniquet on the upper arm. The BP cuff is a superior tourniquet and the inflated cuff makes it easier to find a suitable vein.

Once the IV is in place, proceed with intubating the patient. In community practice the surgical duration of tonsillectomies can be very short, so the choice of muscle relaxant is important. Succinylcholine carries a black box warning for non-emergent use in children, and should not be used for elective intubation. You can: 1) administer rocuronium and later reverse the paralysis with neostigmine plus atropine; 2) administer a dose of propofol, e.g. 2 mg/kg, which blunts airway reflexes enough to allow excellent intubating conditions in most patients; or 3) you can do perform two laryngoscopies, the first to inject 1 ml of 4% lidocaine from a laryngotracheal anesthesia (LTA) kit, and another 30 seconds later to place the endotracheal tube in the now-anesthetized trachea. Some anesthesiologist/surgeon teams prefer an LMA rather than an endotracheal tube. LMA use for tonsillectomy is not routine in our practice, but one advantage is that an LMA does not require paralysis for insertion.

What if you’re working alone and your patient develops acute oxygen desaturation with airway obstruction and/or laryngospasm during inhalation induction before any IV has been placed? What do you do?

If you anesthetize enough children you will have this experience, and it can be frightening. The immediate management is to inject succinylcholine 4 mg/kg plus atropine 0.02 mg/kg intramuscularly, usually into the deltoid. Then you do your best to improve mask ventilation using an oral airway or LMA if necessary. The oxygen saturation may dip below 90% for a short period of time while you wait for the onset of the intramuscular paralysis. Once muscle relaxation is achieved, ventilation should be successful and the oxygen saturation will climb to a safe level. The trachea can then be intubated, and an IV can be started following the intubation.

If such a desaturation occurs, should you cancel the case? It depends. I’d recommend cancelling the case if: 1) the duration of the oxygen saturation was so prolonged that you are worried about hypoxic brain damage; or 2) gastric contents are present in the airway and you are concerned with possible pulmonary aspiration.

Working pediatric cases alone is rewarding as well as stressful. Nothing in my practice brings me as much joy as walking into the waiting room following a pediatric case to inform parents their child is awake and safe. The parents are relieved, and watching the mother-child reunion minutes later in the Post Anesthesia Care Unit is a heart-warming experience.

Not all anesthesiologists will choose to do pediatric cases during their post-residency career. If you will be anesthetizing children alone in community practice, it’s a good idea toward the end of your anesthesia residency or fellowship to ask your pediatric anesthesia attending keep their hands off during induction, so you can hone your skills managing both the airway and IV. That way you’ll be ready and capable of inducing a child alone after you leave training.

 

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

 

 

HOW TO SCREEN OUTPATIENTS PRIOR TO 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)

Screening prior to outpatient surgery is important. Over 70% of elective surgeries in the United States are ambulatory or outpatient surgeries, in which the patient goes home the same day as the procedure. There are increasing numbers of surgical patients who are elderly, obese, have sleep apnea, or who have multiple medical problems. How do we decide which 70% of surgical candidates are appropriate for outpatient surgery, and which are not?

For the past 16 years I’ve been the Medical Director at a busy Ambulatory Surgery Center (ASC) in Palo Alto, California. ASC Medical Directors are perioperative physicians, responsible for the preoperative, intraoperative, and postoperative management of ambulatory surgery patients. Our surgery center is freestanding, distanced one mile from Stanford University Hospital. The hospital-based technologies of laboratory testing, a blood bank, an ICU, arterial blood gas measurement, and full radiology diagnostics are not available on site. It’s important that patient selection for a freestanding surgery center is precise and safe.

The topic of Ambulatory Anesthesia is well reviewed in the textbook Miller’s Anesthesia, 7th Edition, 2009, Chapter 78, Ambulatory (Outpatient) Anesthesia. With the information in this chapter as a foundation, the following 7 points are guidelines I recommend in the preoperative consultation and selection of appropriate outpatient surgery patients:

  1. The most important factor in deciding if a surgical case is appropriate is not how many medical problems the patient has, but rather the magnitude of the surgical procedure. A patient may have morbid obesity, sleep apnea, and a past history of congestive heart failure, but still safely undergo a non-invasive procedure such as cataract surgery. Conversely, if the patient is healthy, but the scheduled surgery is an invasive procedure such as resection of a mass in the liver, that surgery needs to be done in a hospital.
  2. Because of #1, an ASC will schedule noninvasive procedures such as arthroscopies, head and neck procedures, eye surgeries, minor gynecology and general surgery procedures, gastroenterology endoscopies, plastic surgeries, and dental surgeries. What all these scheduled procedures have in common is that the surgeries (a) will not disrupt the postoperative physiology in a major way, and (b) will not cause excessive pain requires inpatient intravenous narcotics.
  3. One must screen patients preoperatively to identify individuals who have serious medical problems. Our facility uses a comprehensive preoperative telephone interview performed by a medical assistant, two days prior to surgery. The interview documents age, height, weight, Body Mass Index, complete review of systems, list of allergies, and prescription drug history. All information is entered in the patient’s medical record at that time.
  4. Each surgeon’s office assists in the preoperative screening. For all patients who have (a) age over 65, (b) obstructive sleep apnea, (c) cardiac disease or arrhythmia history, (d) significant lung disease, (e) shortness of breath or chest pain, (f) renal failure or hepatic failure, (g) insulin dependent diabetes, or (h) significant neurological abnormality, the surgery office is required to obtain medical clearance from the patient’s Primary Care Provider (PCP).    This PCP clearance note concludes with two questions: 1) Does the patient require any further diagnostic testing prior to the scheduled surgery? And 2) Does the patient require any further therapeutic measures prior to the scheduled surgery?
  5. For each patient identified with significant medical problems, the Medical Director must review the chart and the Primary Care Provider note, and confirm that the patient is an appropriate candidate for the outpatient surgery. The Medical Director may telephone the patient for a more detailed history if indicated. On rare occasions, the Medical Director may arrange to meet and examine the patient prior to the surgical date.
  6. Medical judgment is required, as some ASA III patients with significant comorbidities are candidates for trivial outpatient procedures such as gastroenterology endoscopy or removal of a neuroma from a finger, but are inappropriate candidates for a shoulder arthroscopy or any procedure that requires general endotracheal anesthesia.
  7. What about laboratory testing? Per Miller’s Anesthesia, 7th Edition, 2009, Chapter 78, few preoperative lab tests are indicated prior to most ambulatory surgery. We require a recent ECG for patients with a history of hypertension, cardiac disease, or for any patient over 65 years in age. If this ECG is not included with the Primary Care Provider consultation note, we perform the ECG on site in the preoperative area of our ASC, at no charge to the patient. All diabetic patients have a fasting glucose test done prior to surgery. No electrolytes, hematocrit, renal function tests, or hepatic tests are required on any patient unless that patient’s history indicates a specific reason to mandate those tests.

Utilizing this system, cancellations on the day of surgery are infrequent—well below 1% of the scheduled procedures. The expense of and inconvenience of an Anesthesia Preoperative Clinic are eliminated.

What sort of cases are not approved? Here are examples from my practice regarding patients/procedures who are/are not appropriate for surgery at a freestanding ambulatory surgery center:

  1. A 45-year-old patient with moderately severe obstructive sleep apnea (OSA) is scheduled for a UPPP (uvulopalatalpharyngoplasty). DECISION: NOT APPROPRIATE. Reference: American Society of Anesthesiologist Practice Guidelines of the Perioperative Management of Patients with OSA (https://www.asahq.org/coveo.aspx?q=osa). For airway and palate surgery on an OSA patient, the patient is best observed in a medical facility post-surgery. For any surgery this painful in an OSA patient, the patient will require significant narcotics, which place him at risk for apnea and airway obstruction post-surgery.
  2. A morbidly obese male (Body Mass Index = 40) is scheduled for a shoulder arthroscopy and rotator cuff repair. DECISION: NOT APPROPRIATE. Obesity is not an automatic exclusion criterion for outpatient surgery. Whether to cancel the case or not depends on the nature of the surgery. A shoulder repair often requires significant postoperative narcotics. The intersection of morbid obesity and a painful surgery means it’s best to do the case in a hospital. One could argue that this patient could be done with an interscalene block for postoperative analgesia and then discharged home, but I don’t support this decision. If the block is difficult or ineffective, the anesthesiologist has a morbidly obese patient requiring significant doses of narcotics, and who is scheduled to be discharged home. If this surgery had been a knee arthroscopy and medial meniscectomy it could be an appropriate outpatient surgery, because meniscectomy patients have minimal pain postoperatively.
  3. An 18-year-old male with a positive family history of Malignant Hyperthermia is scheduled for a tympanoplasty. DECISION: APPROPRIATE. A trigger-free general total-intravenous anesthetic with propofol and remifenantil can be given just as safely in an ASC as in a hospital.
  4. A 50-year-old 70-kilogram male with a known difficult airway (ankylosing spondylitis) is scheduled for endoscopic sinus surgery. DECISION: APPROPRIATE. In our ASC, for safety reasons, we have advanced airway equipment including a video laryngoscope and a fiberoptic laryngoscope. If a patient needs an awake intubation, we are prepared to do this safely. This case would be scheduled with a second anesthesiologist available to assist the primary anesthesia attending in securing the airway.
  5. An 80-year-old woman with shortness of breath on exertion is scheduled for a bunionectomy. DECISION: NOT APPROPRIATE. Although foot surgery is not a major invasive procedure, any patient with shortness of breath is inappropriate for ASC surgery. The nature of the dyspnea needs to be determined and remedied prior to surgery or anesthesia of any sort.
  6. A 6-year-old female born without an ear is scheduled for a 9-hour ear graft and reconstruction. DECISION: APPROPRIATE. With modern general anesthetic techniques utilizing sevoflurane and propofol, patients awake promptly. Even after long anesthetics, if the surgery is not painful, patients are usually discharged in stable condition within 60-90 minutes.

There are infinite combinations of patient comorbidities and types of surgeries. The decision regarding which scheduled procedures are appropriate and which are not is both an art and a science. The role of an anesthesiologist/Medical Director as the perioperative physician making these decisions is invaluable.

 

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

 

 

HOW RISKY IS A TONSILLECTOMY?

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)

13-year-old Jahi McMath of Oakland, California suffered sudden bleeding from her nose and mouth and cardiac arrest following a December 9th 2013 tonsillectomy, a surgery intended to help treat her obstructive sleep apnea. After the bleeding she lapsed into a coma. Three days later she was declared brain-dead.

tonsillectomy-recovery-day-by-day-12

How could this happen?

Behind circumcision and ear tubes, tonsillectomy is the third most common surgical procedure performed on children in the United States. 530,000 tonsillectomies are performed children under the age of 15 each year. Tonsillectomy is not a minor procedure. It involves airway surgery, often in a small child, and often in a child with obstructive sleep apnea. The surgery involves a risk of bleeding into the airway. The published mortality associated with tonsillectomy ranges from 1:12,000 to 1:40,000. 

Between 1915 and the 1960’s, tonsillectomy was the most common surgery in the United States, done largely to treat chronic throat infections. After the 1970’s, the incidence of tonsillectomies dropped, as pediatricians realized the procedure had limited success in treating chronic throat infections. The number of tonsillectomies has increased again in the last thirty years, as a treatment for obstructive sleep apnea (OSA). Currently 90 percent of tonsillectomies are performed to treat OSA. Only 1 – 4 % of children have OSA, but many of these children exhibit behavioral problems such as growth retardation, poor school performance, or daytime fatigue. The American Academy of Otolaryngology concluded that “a growing body of evidence indicates that tonsillectomy is an effective treatment for sleep apnea.”

Tonsillar and adenoid hypertrophy are the most common causes of sleep-disordered breathing in children. Obstructive sleep apnea is defined as a “disorder of breathing during sleep characterized by prolonged upper airway obstruction and/or intermittent complete obstruction that disrupts normal ventilation during sleep.” (Miller’s Anesthesia, 7th edition, 2009, Chapter 82).

In OSA patients, enlarged tonsils can exacerbate loud snoring, decrease oxygen levels, and cause obstruction to breathing. Removal of the tonsils can improve the diameter of the breathing passageway. Specific diagnosis of OSA can be made with an overnight sleep study (polysomnography), but applying this test to large populations of children is a significant expense. Currently only about 10 percent of otolaryngologists request a sleep study in children with sleep-disordered breathing prior to surgery (Laryngoscope 2006;116(6):956-958). In our surgical practice in Northern California, most pediatricians and otolaryngologists forego the preoperative overnight sleep study if the patient has symptoms of obstructed sleep, confirmed by a physical exam that reveals markedly enlarged tonsils.

Every tonsillectomy requires general anesthesia, and anesthesiologists become experts in the care of tonsillectomy patients. Prior to surgery the anesthesiologist will review the chart, interview the parent(s), and examine the child’s airway. Most children under the age of 10 will be anesthetized by breathing sevoflurane via an anesthesia mask, which is held by the anesthesiologist. Following the child’s loss of consciousness, the anesthesiologist will place an intravenous (IV) catheter in the child’s arm. The anesthesiologist then inserts a breathing tube into the child’s windpipe, and turns the operating table 90 degrees away so the surgeon has access to operate on the throat. The surgeon will move the breathing tube to the left and right sides of the mouth while he or she removes the right and left tonsils. (note: children older than the age of 10 will usually accept an awake placement of an IV by the anesthesiologist, and anesthetic induction is accomplished by the IV injection of sleep drugs including midazolam and propofol, rather than by breathing sevoflurane via an anesthesia mask).

The child remains asleep until the tonsils are removed, and all bleeding from the surgical site is controlled. The anesthesiologist then discontinues general anesthetic drugs and removes the breathing tube when the child awakens. Care is taken to assure that the airway is open and that breathing is adequate. Oxygen is administered until the child is alert. Tonsillectomy is painful, and intravenous opioid drugs such as fentanyl or morphine are commonly administered to relieve pain. The opioids depress respiration, and monitoring of oxygen levels and breathing is routinely done until the child leaves the surgical facility.

Most tonsillectomy patients have surgery as an outpatient and are discharged home within hours after surgery. Prior to the 1960’s patients were hospitalized overnight routinely post-tonsillectomy. In 1968 a case series of 40,000 outpatient tonsillectomies with no deaths was reported, and performance of tonsillectomy on an outpatient basis became routine after that time. (Miller’s Anesthesia, 7th edition, 2009, Chapter 33).

Published risk factors for postoperative complications after tonsillectomy include: (1) age younger than 3 years; (2) evidence of OSA; (3) other systemic disorders of the heart and lungs); (4) presence of airway abnormalities; (5) bleeding abnormities; and (6) living a long distance from an adequate health care facility, adverse weather conditions, or home conditions not consistent with close observation, cooperativeness, and ability to return quickly to the hospital. (Miller’s Anesthesia, 7th edition, 2009, Chapter 82).

The incidence of post-tonsillectomy bleeding increases with age. In a national audit of more than 33,000 tonsillectomies, hemorrhage rates were 1.9% in children younger than 5 years old, 3% in children 5 to 15 years old, and 4.9% in individuals older than 16. The return to the operating room rate was 0.8% in children younger than 5 years old, 0.8% in children 5 to 15 years old, and 1.2% in individuals older than 16. (Miller’s Anesthesia, 7th edition, 2009, Chapter 75).

Primary bleeds usually occur within 6 hours of surgery. Hemorrhage is usually from a venous or capillary bleed, rather than from an artery. Complications occur because of hypovolemia (massive blood loss), the risk of blood aspiration into the lungs, or difficulty with replacing the breathing tube should emergency resuscitation be necessary. Early blood loss can be difficult to diagnose, as the blood is swallowed and not seen. Signs suggesting hemorrhage are an unexplained increasing heart rate, excessive swallowing, pale skin color, restlessness, sweating, and swelling of the airway causing obstruction. Low blood pressure is a late feature. (Miller’s Anesthesia, 7th edition, 2009, Chapter 75).

What happened to 13-year-old Jahi McMath in Oakland following her tonsillectomy? We have no access to her medical records, and all we know is what was reported to the press. The following text was published in the 12/21/2013 Huffington Post:

After her daughter underwent a supposedly routine tonsillectomy and was moved to a recovery room, Nailah Winkfield began to fear something was going horribly wrong.

Jahi was sitting up in bed, her hospital gown bloody, and holding a pink cup full of blood.

“Is this normal?” Winkfield repeatedly asked nurses.

With her family and hospital staff trying to help and comfort her, Jahi kept bleeding profusely for the next few hours then went into cardiac arrest, her mother said.

Despite the family’s description of the surgery as routine, the hospital said in a memorandum presented to the court Friday that the procedure was a “complicated” one.

“Ms. McMath is dead and cannot be brought back to life,” the hospital said in the memo, adding: “Children’s is under no legal obligation to provide medical or other intervention for a deceased person.”

In an interview at Children’s Hospital Oakland on Thursday night, Winkfield described the nightmarish turn of events after her daughter underwent tonsil removal surgery to help with her sleep apnea.

She said that even before the surgery, her daughter had expressed fears that she wouldn’t wake up after the operation. To everyone’s relief, she appeared alert, was talking and even ate a Popsicle afterward.

But about a half-hour later, shortly after the girl was taken to the intensive care unit, she began bleeding from her mouth and nose despite efforts by hospital staff and her family.

While the bleeding continued, Jahi wrote her mother notes. In one, the girl asked to have her nose wiped because she felt it running. Her mother said she didn’t want to scare her daughter by saying it was blood.

Family members said there were containers of Jahi’s blood in the room, and hospital staff members were providing transfusions to counteract the blood loss.

“I don’t know what a tonsillectomy is supposed to look like after you have it, but that blood was un-normal for anything,” Winkfield said.

The family said hospital officials told them in a meeting Thursday that they want to take the girl off life support quickly.

“I just looked at the doctor to his face and I told him you better not touch her,” Winkfield recalled.

Despite the family’s description of the surgery as routine, the hospital said in a memorandum presented to the court Friday that the procedure was a “complicated” one.

 

Despite the precaution of hospitalizing Jahi McMath post-tonsillectomy, when her bleeding developed it seems the management of her Airway-Breathing-Circulation did not go well. I’ve attended to bleeding post-tonsillectomy patients, and it can be a harrowing experience. It can be an extreme challenge to see through the blood, past the swollen throat tissues post-surgery, and locate the opening to the windpipe so that one can insert the breathing tube needed to supply oxygen to the lungs. Assistance from a second anesthesiologist is often needed. The surgeon will be unable to treat or control severe bleeding until an airway tube is in place.  Difficult intubation and airway management can lead to decreased oxygen levels and ventilation, jeopardizing oxygen delivery to the brain and heart. If severe bleeding is unchecked and transfusion of blood cannot be applied swiftly, the resulting low blood pressure and shock can contribute to the lack of oxygen to a patient’s brain.

A bleeding tonsillectomy patient can be an anesthesiologist’s nightmare.

 

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

 

 

THE OBESE PATIENT AND 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)

Obese patients make anesthesiologists’ work more arduous.  Obese patients, especially morbidly obese and super obese patients, are at increased risk when they need surgery.

Perhaps you’re overweight and you wish you weren’t.

Your anesthesiologist wishes the same thing.  Let’s look at the reasons why.

Two hundred million Americans, or 65% of the U.S. adult population, are overweight or obese. Obesity as a disease is second only to smoking as a preventable cause of death.

The body mass index (BMI) has become the most widely applied classification tool used to assess individual weight status.  BMI is defined as the patient’s weight, measured in kilograms, divided by the square of the patient’s height, measured in meters.

A normal BMI is between 18.5 and 24.9.  Patients are considered to be overweight with a BMI between 25 and 29.9 obese with a BMI between 30 and 39.9, morbidly obese between 40 and 49.9, and super obese at greater than 50.

Morbid obesity is associated with far more serious health consequences than moderate obesity, and creates additional challenges for health care providers.  Between 2000 and 2010, the prevalence of morbid obesity in the U.S. increased by 70%, whereas the prevalence of super obesity increased even faster.  It’s estimated that in 2010, 15.5 million adult Americans, or 6.6% of the population, had an actual BMI >40, and carried the diagnosis of morbid obesity.

MEDICAL PROBLEMS ASSOCIATED WITH OBESITY

Obesity is an independent risk factor for heart disease, hypertension, stroke, hyperlipidemia, osteoarthritis, diabetes mellitus, cancer, and obstructive sleep apnea (OSA).  A neck circumference > 17 inches in men or > 16 inches cm in women is associated with obstructive sleep apnea. As a result of these concomitant conditions, obesity is also associated with early death.

There is a clustering of metabolic and physical abnormalities referred to as the “metabolic syndrome.” To be diagnosed with metabolic syndrome, you must have at least three of the following: abdominal obesity, elevated fasting blood sugar, hypertension, low HDL levels, or hypertriglyceridemia.  In the United States, nearly 50 million people have metabolic syndrome, for an age-adjusted prevalence of almost 24%. Of people with metabolic syndrome, more than 83% meet the criterion of obesity. Patients with metabolic syndrome have a higher risk for cardiovascular disease and are at increased risk for all-cause mortality.

Obstructive sleep apnea (OSA) is a condition characterized by recurrent episodes of upper airway obstruction occurring during sleep. Obesity is the greatest risk factor for OSA, and about 70% of patients (up to 80% of males and 50% of females) with OSA are obese.  OSA is defined as complete blockage of airflow during breathing lasting 10 seconds or longer, despite maintenance of neuromuscular ventilatory effort, and occurring five or more times per hour of sleep (Apnea Hypopnea Index, or AHI, greater than or equal to five), and accompanied by a decrease of at least 4% in arterial oxygen saturation.  This diagnosis can be made only in patients who undergo a sleep study. Obstructive sleep apnea is classified as mild, moderate, or severe, as follows:

  • Mild OSA =A HI of 5 to 15 events per hour
  • Moderate OSA = AHI of 15 to 30 events per hour
  • Severe OSA = AHI of more than 30 events per hour

Treatment is recommended for patients with moderate or severe disease, and initial treatment is the wearing of a continuous positive airway pressure (CPAP) device during sleep.

ANESTHETIC CHALLENGES

Every anesthesia task can be more difficult to perform in an obese patient.  Excess adipose tissue (fat) on the upper extremities makes it harder to place an IV catheter.  Excess fat surrounding the mouth, throat, and neck can make it more difficult to place an airway tube.  Excess fat can make it more difficult to place a needle in the proper position for a spinal anesthetic, an epidural anesthetic, or a regional block of a specific peripheral nerve.  On thick, cone-shaped upper arms, it can be difficult for a blood pressure cuff to detect the blood pressure accurately.

During surgery, an anesthesiologist’s job is to maintain the patient’s A-B-C’s of Airway, Breathing, and Circulation, in that order.  All three tasks are more difficult in obese patients.

Airway procedures are often much more difficult to perform in obese patients than in patients with normal BMIs.  Every general anesthetic begins with the anesthesiologist injecting intravenous medications that induce sleep.  Next the anesthesiologist controls the breathing by using a mask over the patient’s face, and then he or she places an airway tube through the patient’s mouth into the windpipe.

The airway anatomy of obese patients, with or without OSA, may show a short, thick neck, large tongue, and significantly increased amounts of soft tissue surrounding the uvula, tonsils, tongue, and lateral aspects of their throats.  This can contribute to the development of airway obstruction and also increase the probability that it will be more difficult to keep the airway open during mask ventilation.  This can also contribute to difficulty placing an anesthesia airway tube into the windpipe at the beginning of general anesthesia.

What about breathing difficulties?  The chief reason that obese patients have difficulty with breathing during anesthesia is that they have abnormally low lung volumes for their size.  When lying flat on their back, a patient’s increased abdominal bulk pushes up on their lungs, and prevents the lungs from inflating fully.  Once the patient is anesthetized, this mechanical situation is worsened, because breathing is impaired by the anesthetic drugs and muscle relaxation allows the abdomen to sink further into the chest.  The essence of the problem is that the abdomen squashes the lungs and makes them less efficient both as a reservoir and as an exchange organ for oxygen.  Because of this, the obese patient is at risk for running out of oxygen and turning blue more quickly than a lean patient.

In one study,  patients undergoing general anesthesia received 100% oxygen by facemask before induction of general anesthesia. After the induction of general anesthesia, the patients were left without ventilation until their oxygen saturation fell from 100% to 90%.  Patients with normal BMIs took 6 minutes for their oxygen level to fall to 90%. Obese patients reached that end point in less than 3 minutes.

What about circulation?  Maintaining stable circulatory status can be difficult because obese patients have a higher prevalence of cardiovascular disease, including hypertension, arrhythmias, stroke, heart failure, and coronary artery disease. During anesthesia and surgery, unexpected high or low blood pressure events are more common in obese patients than in those with normal BMIs.  Morbidly obese patients have a higher rate of heart attack postoperatively than patients with normal BMIs.

Regional anesthesia, especially epidural and spinal anesthesia, is often a safer technique than general anesthesia in obese patients. However, regional anesthesia can be  technically more difficult because of the physical challenge of the anatomy being obscured by excess fat.

Operative times are often longer in obese patients, owing to technical challenges for the surgeon regarding anatomy distorted or hidden behind excessive fat.  Longer surgery means a longer time under general anesthesia, which is a cause of delayed awakening from anesthesia. At the conclusion of surgery, obese patients wake more slowly than lean patients. Anesthetic drug and gas concentrations drop more slowly post-surgery, because traces of the chemicals linger in the reservoirs of excessive adipose tissue.

Common serious postoperative complications in obese patients include blood clots in the legs (deep venous thrombosis) and wound infections at the surgical incision line.

(Reference for this section:  Miller’s Anesthesia, 7th Edition, 2009, Chapter 64).

DATA ON THE RISKS OF OBESITY AND SURGERY

In one landmark study, researchers analyzed postoperative complications in 6,773 patients treated between 2001 and 2005 at the University of Michigan. Of the patients who had complications, 33% were obese and 15% were morbidly obese. Obese patients had much higher rates of postoperative complications than nonobese patients, as follows:  5 times more heart attacks, 4 times more peripheral nerve injuries, 1.7 times more  wound infections, and 1.5 times more urinary tract infections. The overall death rate was no different for obese and nonobese patients, but the death rate was nearly twice as high among morbidly obese patients as compared with nonobese patients (2.2% vs. 1.2%).

CONCLUSIONS

Experienced anesthesiologists respect the risks and difficulties presented by obese, morbidly obese, and super obese patients.  The ranks of overweight Americans are growing, and every week we anesthetize thousands of them for surgery.  As an obese American, are you safe in the operating room?  You probably are, because anesthesia professionals are well-educated in the risks of taking care of you. But you must realize that you are at higher risk for a complication than those with a normal BMI.

What can you do about all this? If you are morbidly obese and your surgery is optional, you may consider not having surgery at all.  If you have time before surgery, you can try to lose weight.  Before any surgery, you should consult your primary care physician to make sure that any obesity-related medical problems have been addressed.  You may be placed on medication for hypertension, hyperlipidemia, or diabetes.  You may have undiagnosed OSA, and may benefit from a nightly CPAP treatment for that disorder.

Bariatric surgery (e.g., gastric banding, gastric bypass) is a well-accepted and effective treatment for weight loss in super obese and morbidly obese patients.  Bariatric surgery refers to surgical alteration of the small intestine or stomach with the aim of producing weight loss. More than 175,000 bariatric surgeries were performed in 2006, and more than 200,000 were performed in 2008 (Miller’s Anesthesia, 7th Edition, 2009, Chapter 64). Weight loss after bariatric surgery is often dramatic. On the average, patients lose 60% of their extra weight. For example, a 350-pound person who is 200 pounds overweight could lose about 120 pounds.  All the anesthetic considerations and risks discussed above would still apply to any patient coming to the operating room for weight loss surgery.

Obesity was considered a rarity until the middle of the 20th century.  Now more than 300,000 deaths per year in the United States and more than $100 billion in annual health care spending are attributable to obesity. Obesity most frequently develops when food calorie intake exceeds energy expenditure over a long period of time.

If you’re obese, this doctor recommends you eat less, and exercise more.  Stay lean if you can.  Your anesthesiologist will thank you.

 

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?

 

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

DSC04882_edited

 

 

PEDIATRIC ANESTHESIA: WHO IS ANESTHETIZING YOUR CHILD?

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)

Your 4-year-old son Jake is scheduled for a tonsillectomy next Friday morning.  Who will do Jake’s anesthesia, and how will the anesthesia care be done?

Jake may or may not be diagnosed with Obstructive Sleep Apnea (OSA), based on his history of snoring.  Most children who snore and have enlarged tonsils are not subjected to a formal sleep study.  In a formal sleep study, doctors attach monitors such as pulse oximeters and apnea monitors to the child during a night’s sleep, to determine how often the child stops breathing during sleep and how low the oxygen level in his or her arterial blood drops during disordered sleep.  A sleep study is commonly done for adults with suspected OSA, but  not commonly ordered in children.

The decision to excise tonsils in pediatric patients is a clinical decision, based on the judgment of the pediatrician and ENT surgeon.  The surgery can be scheduled at a community hospital, a university hospital, a pediatric hospital, an ambulatory surgery center, or a freestanding ambulatory surgery center.  The nature of the anesthesia personnel can vary significantly depending on which type of facility the surgery is scheduled at.

In a community hospital, the anesthesia staff will be medical doctors (anesthesiologists), and/or nurse anesthetists (CRNA’s).  The anesthesiologists may or may not be pediatric specialists, but all anesthesiologists receive training in anesthetizing children.  Most likely, the ENT surgeon operates with an anesthesia team he or she is comfortable with, and this anesthesia team is comfortable anesthetizing children for a routine, elective surgery like tonsillectomy.  At a community hospital, it is possible but unlikely that the anesthesiologist will have completed extra years of training in pediatric anesthesia called a pediatric anesthesia fellowship.

In a university hospital, the anesthesia staff will include anesthesiologist faculty and also anesthesiologist residents and fellows who are in training.  The anesthesia care is directed or performed by a faculty member.  The actual hands-on anesthesia care, such as the placement of breathing tubes and IV catheters, is usually done by the residents and fellows, who are in the midst of their training.  An advantage of university hospitals is that pediatric anesthesia specialists are plentiful.  A disadvantage is that the anesthesia care is usually done by the trainee anesthesiologists who are supervised by these specialists.  At times, one faculty anesthesiologist may be supervising trainee anesthesiologists in two separate operating rooms for two separate surgeries concurrently.

In a pediatric hospital, the anesthesia care will be done by specialty pediatric anesthesiologists.  However, if the pediatric hospital is a university pediatric hospital, all the analysis in the preceding paragraph pertaining to university hospitals will apply.

An ambulatory surgery center (ASC) is a set of surgical suites that is designed to take care of outpatient surgeries, and designed to send the patient home directly from the ASC after recovery from surgery and anesthesia.  Most tonsillectomies are done as outpatient surgeries, and therefore many tonsillectomy patients are operated on in an ASC.  If the ASC is located inside a hospital, the anesthesia care will follow the analysis of community, university, and pediatric hospitals as discussed in the paragraphs above.  Many ASC’s are freestanding–that is, they are not on site in a hospital.  Many are located miles away from hospitals.  It is commonplace in the United States for tonsillectomies to be safely done in freestanding ASC’s.  The anesthesia care in most freestanding ASC’s will be anesthesiologists and/or nurse anesthetists, and once again the ENT surgeon will select an anesthesia provider he or she feels will provide safe care for his patient.

Some anesthesia teams prefer to meet and interview their patients days before surgery.  For a routine surgery such as tonsillectomy, it is common for the family to not meet the anesthesiologist until the day of surgery shortly before the procedure.  Some anesthesiologists will telephone the parent(s) the night before surgery to interview them and provide a preview of what to expect on the day of surgery.

The actual anesthesia care will typically follow this scenario:  Most practitioners will premedicate the child with oral midazolam (Versed) 20 minutes before the surgery.  This medication will make the child sleepy and relaxed, and calm the patient through the time when they separate from their parent(s).  Most facilities in the United States will not allow parents into the operating room.  Inside the operating room, the anesthesiologist will apply standard monitors of oxygen level, pulse, and blood pressure, and induce anesthesia by having the child breath the anesthesia gas sevoflurane through a mask.  Once the child is asleep, the anesthesiologist will place an IV in the child’s arm and a breathing tube in the child’s airway.  After the surgery is completed, the anesthesiologist will discontinue the anesthetics, awaken the child, and remove the breathing tube.  He or she will accompany the child to the Post Anesthesia Care Unit (PACU) and turn over the care of the child to a nurse there.

Is it safer if your child has a pediatric anesthesiologist, rather than a general practitioner anesthesiologist who takes care of both adults and children?  It depends.  It’s important to ask how often the practitioner anesthetizes children.  Someone who rarely anesthetizes a child under 6 years of age will be less comfortable with such a case, and may be less skillful in dealing with a complication or emergency should one occur.

Is it safer if your child has a fully-trained anesthesiologist rather than an anesthesia trainee/faculty team such as at a university hospital program?  Once again, it depends.  It depends on how much of the care is done by the trainee, and how intensive the faculty supervision is, as compared to an alternative facility where a fully-trained anesthesiologist stays present throughout the entire surgery.

At a community hospital or ASC, it is uncommon to have multiple specialist anesthesiologists on call each day, e.g. one for pediatrics, one for cardiac cases, one for trauma, one for obstetrics, and others for the general operating rooms.  Instead, general anesthesia practitioners cover many or all specialties.  If an anesthesiologist is not comfortable with an individual case, they can seek out a better trained anesthesiologist to cover the case, if such an anesthesiologist is available.  The trend for having a specialist anesthesiologist for every type of case is a difficult one to staff.  The goal at a community hospital is to assure that the standard of anesthesia care can be met with the physicians who are on staff and available.

In my opinion, neonates and  young infants should be cared for by  anesthesiologists with specialized pediatric training.  Whether specialized training should be mandated for children older than infants is debatable.  Policies to define a minimum age limit for patients of general anesthesiologists may be a hot topic in the future.

In the meantime, I recommend you ask your child’s anesthetist:  1) who is doing the actual anesthesia care today, a fully-trained anesthesia doctor, a doctor-in-training, or a nurse anesthetist?  2) how much training does the anesthetist have with children Jake’s age? and 3) how many children of Jake’s age have they anesthetized for a similar surgery in the past 12 months?  If you are uncomfortable with any of the answers, find another place for Jake to have his surgery.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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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

 

 

EMERGENCY AIRWAY BLEEDING AFTER SLEEP APNEA 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)

Clinical Case for Discussion:   You are called at 0200 hours  to anesthetize a 50-year-old man who is bleeding from his palate.  He is 14 hours status-post  a uvulopalatopharyngeoplasty (UPPP) for sleep apnea.  He is 6 feet tall, weighs 200 pounds, and  he is spitting up blood.  What do you do?

Discussion:   You meet the patient in the ICU.  He is sitting up in bed,  spitting out small amounts of blood and swallowing the rest.  He has been bleeding for four hours, and the total volume of blood seen has been less than a cup.   Vital signs are:  pulse 100, blood pressure 160/90, and oxygen saturation 97% on room air.  The airway exam reveals dried blood on the mouth and tongue, moderate edema of the  pharynx, tongue, and mucous membranes, and no bleeding point is seen.  Review of the chart reveals that your partner intubated the trachea with a Miller #2 blade without difficulty that morning for elective surgery. The surgeon wants the patient asleep as soon as possible.  You transport the patient to the operating room, and have him breath 100% oxygen through a mask while you prepare for the anesthetic.

The A-B-C’s of Airway-Breathing-Circulation dictate that the Airway is the most important factor to consider in this case.   You have the principles of the ASA Difficult Airway Algorithm (see www.ASAhq.org) committed to memory.  You plan a strategy for the airway management.  Per the Algorithm, you begin by assessing the likelihood of four basic problems:  1) Difficult ventilation, 2) Difficult intubation, 3) Difficulty with patient cooperation, and 4) Difficult tracheostomy.   You assess that you will be able to mask ventilate this patient, but there is some chance that the blood and edema will make intubation difficult.  You also consider that blood and edema could make both mask ventilation and intubation difficult.  Patient cooperation is adequate, and the surgeon states that he would not have difficulty doing a tracheostomy or cricothyroidotomy.

Next you consider the choices of:   a) awake intubation vs. inducing general anesthesia first, b) use of non-invasive techniques as the initial approach to intubation vs. surgical techniques like tracheostomy, and c) preservation of spontaneous ventilation during intubation attempts vs. ablation of spontaneous ventilation.

Your assessment is that awake fiber optic intubation would be difficult secondary to the active airway bleeding.  Blind awake nasal intubation is a possibility, but looking at the patient, you make a different choice.   You are confident that you can induce general anesthesia, use cricoid pressure, paralyze the patient, and intubate the trachea using a Miller #2 blade as your partner did the previous morning.  If you have difficulty seeing the larynx, you will use a Yankauer suction to clear blood, try alternate laryngoscope blades, and support oxygenation by mask ventilation while cricoid pressure is continued. You may utilize other options as necessary, including a bougie or a light wand.  If ventilation becomes difficult, you will insert an LMA.  If ventilation becomes impossible, the surgeon will perform an emergency surgical airway.

You need an assigned individual to assist you during your airway management.  Because there is no other anesthesiologist in the hospital, your otolaryngology colleague is the obvious assistant.   Before you induce anesthesia, you bring the difficult airway cart into the operating room, as well as a tracheostomy tray for the surgeon.

You discuss this plan with the surgeon.  After  preoxygenation, you induce anesthesia with propofol and succinylcholine.  Cricoid pressure is applied.  When you insert the  laryngoscope  into the mouth, all you see is blood, swollen tissues, and no view of the larynx.  Your next action is aggressive suctioning with a Yankauer catheter, and after repositioning the laryngoscope, you are able to see the larynx.  The tracheal tube is placed, the cuff is inflated, and its location confirmed by CO2 and auscultation.  You recheck vital signs, begin  maintenance anesthesia with sevoflurane, and the surgery begins.

I had a case of this type twice in the last 5 months.  Both cases were effective in raising the endogenous catecholamine level of this anesthesiologist.   Both were good exercises in planning airway management.  The most striking characteristic of each case was the amount of blood in the airway when I inserted the laryngoscope.  The Yankauer suction catheter was essential, and I recommend inserting it immediately after inserting the laryngoscope.

The literature documents the prevalence of bleeding after UPPP as 1.4% (Mickelson SA, Is Postoperative Intensive Care Monitoring Necessary After UPPP?, Otol Head Neck Surg 1998 Oct, 119(4) 352-6.)   The bleeding patient post-tonsillectomy is a similar presentation.  Miller (Anesthesia, 2000, p 2188) writes “The incidence of post-tonsillectomy bleeding that requires surgery is 0.3 to 0.6 %. . . The extent of blood loss may not be obvious and is usually underestimated. . . Most problems before induction of anesthesia for bleeding tonsil are caused by unsuspected hypovolemia, full stomach, and airway obstruction. . . At induction of anesthesia, an additional person should be available to provide good suctioning of blood.  A rapid-sequence induction of anesthesia with application of cricoid pressure and slight head-down positioning of the patient will protect the trachea and glottis from aspiration of blood.”

The ASA Difficult Airway Algorithm. . . learn it well, and be prepared to apply it in the middle of the night.  Your heart rate may be faster than the patient’s.

Introducing …,  THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel. Publication date September 9, 2014 by Pegasus Books.

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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

 

 

STOP-BANG AND OBSTRUCTIVE SLEEP APNEA IN A FREESTANDING SURGERY CENTER

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)

Airway obstruction at the base of the tongue in a patient with obstructive sleep apnea

Clinical Case for Discussion: You’re the anesthesiologist for a 51-year-old man scheduled for arthroscopic rotator cuff surgery at a freestanding surgery center.  His wife volunteers that the patient is a loud snorer.  The patient denies ever being diagnosed with obstructive sleep apnea.  Should you proceed with the surgery?  Can the patient safely be discharged home after surgery at a freestanding facility ?  What would you do?

You discuss the case with an anesthesia colleague.  She recommends you utilize a STOP-BANG questionnaire on the patient.  What is she talking about?

Discussion: Frequent snoring is present in 34% of men and women over the age of 40. (Baldwin, et al, Sleep disturbances, quality of life, and ethnicity: the sleep heart health study, J Clin Sleep Med. 2010 Apr 15;6(2):176-83).  Does any physician ever cancel a surgery at a freestanding surgery center because the patient is a snorer?  Should we?  Is there any data?

STOP-BANG may sound like a title from the next James Bond movie, but it has nothing to do with spies, guns, or crime.  STOP-BANG is a tool for diagnosing obstructive sleep apnea.

Obstructive sleep apnea (OSA) is a common comorbidity in surgical populations. It’s estimated that approximately 4% of men and 2% of women, 18 million Americans overall, have OSA (Miller’s Anesthesia, 2010, p 2776). An estimated 82% of men and 92% of women with moderate or severe sleep apnea have not been diagnosed (Chung F, Elsaid H, Screening for obstructive sleep apnea before surgery: why is it important? Curr Opin Anaesthesiol. 2009 Jun;22(3):405-11). Patients with OSA are at higher risk for post-operative respiratory arrest (Cullen DJ: Obstructive sleep apnea and postoperative analgesia—a potentially dangerous combination. J Clin Anesth  2001; 13:83).

OSA is defined as complete cessation of airflow during breathing lasting 10 seconds or longer despite maintenance of neuromuscular ventilatory effort, and occurring five or more times per hour of sleep, accompanied by a decrease of at least 4% in Sao2. (Miller’s Anesthesia, 2010, p 2092). The gold standard for diagnosis is an overnight sleep study, or polysomnography, which is both expensive and resource-intensive. The results of polysomnography are reported as the apnea/hypopnea index (AHI).  The AHI is derived from the total number of episodes of apnea and hypopnea divided by the total sleep time.  The American Academy of Sleep Medicine classifies the disease as follows:

Mild OSA = AHI of 5 to 15 events per hour

Moderate OSA = of 15 to 30 events per hour

Severe OSA = AHI of greater than 30 events per hour

The STOP questionnaire was first published in Anesthesiology in 2008, where it was validated in surgical patients at preoperative clinics as a screening tool. (Chung F, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008 May;108(5):812-21).

The STOP questionnaire queried patients on:

(S) Snoring: Do you snore loudly (loud enough to be heard through closed doors?”

(T) Tired:  Do you often feel tired, fatigued, or sleepy during daytime?

(O) Observed:  Has anyone observed you stop breathing during sleep?

(P) Blood Pressure:  Do you have high blood pressure?

A patient with a STOP score of 2 out of 4 was considered at high risk for OSA.  Patients’ scores from the STOP questionnaire were evaluated versus his or her AHI total from polysomnography. In Chung’s study, the STOP questionnaire was given to 2,467 patients, and 211 of these patients underwent polysomnography. The sensitivities of the STOP questionnaire in identifying patients with an AHI greater than 5, greater than 15, and greater than 30 were 65.6, 74.3, and 79.5%, respectively.

In the same study, the STOP questionnaire was expanded into a STOP-BANG questionnaire, which also queried patients on:

(B) Body mass index>35 kg/m2?

(A) Age>50?

(N) Neck circumference >40 cm (15 ¾ inches)?

(G) Gender=male?

With the added four questions, a patient with a score of 3 out of the possible 8 was considered at high risk for OSA. With STOP-BANG, sensitivities in identifying patients with an AHI greater than 5, greater than 15, and greater than 30 were increased to 83.6, 92.9, and 100%.

In a recent study, (Ong TH, et al, Simplifying STOP-BANG: use of a simple questionnaire to screen for OSA in an Asian population. Sleep Breath. 2010 Apr 26), 348 patients undergoing polysomnography were asked to fill in the 8-question STOP-BANG questionnaire. The sensitivities of the STOP-BANG screening tool for an AHI of >5, >15, and >30 were 86.1%, 92.8%, and 95.6%, respectively.

Thus STOP-BANG has been validated as a tool with high sensitivity that can be used to screen patients for moderate and severe OSA.  As a clinician, what do you do with the STOP-BANG information?

You ask your shoulder arthroscopy patient the 8 STOP-GANG questions, and he scores 1 point for snoring, 1 point for age>50, and 1 point for male gender.  These results qualify him for a possible diagnosis of OSA.  Will you still anesthetize him for this outpatient surgery?

The most useful reference to answer this question is the ASA Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea (Anesthesiology 2006; 104:1081–93).  If a sleep study is available, the Practice Guidelines feature an OSA Scoring System which scores on three criteria:  (A) the severity of sleep apnea, (B) the invasiveness of the surgery and anesthesia, and (C) the requirement for post-operative opioids.  Per this OSA Scoring System, our shoulder arthroscopy patient scores (A) 2 points for presumed moderate OSA, (B)  2 points for peripheral surgery with general anesthesia, and (C) 2 points for possible high doses of oral or parenteral opioids post-op.  His OSA Score is the total of (A) and the higher of (B) or (C), or 2 + 2 = 4 points.  The Practice Guidelines state that, “Patients with a score of 4 may be at increased perioperative risk from OSA.”

The Practice Guidelines state that for “minor orthopedic surgery/general anesthesia” on patients suspected of having OSA, the decision to discharge the patient home after outpatient surgery is “equivocal,” as there is no convincing data advising one way or another.  The Practice Guidelines also state that “these patients should not be discharged from the recovery area to an unmonitored setting (i.e., home or unmonitored hospital bed) until they are no longer at risk for postoperative respiratory depression, . . . and may require a longer stay as compared with non-OSA patients undergoing similar procedures.”

The Practice Guidelines suggest regional techniques rather than systemic post-operative opioids, in an attempt to reduce the likelihood of adverse outcomes in patients at increased perioperative risk from OSA.

So what do you do?

You go ahead and anesthetize the patient.  If you’re comfortable with upper extremity regional blocks, you may utilize this technique in your anesthetic.  In any case, you’ll use your excellent judgment to delay discharge until the patient looks safe to be discharged home.  If his oxygen saturation, airway status, or opioid requirements are unsatisfactory, you’ll transfer him to a hospital for overnight stay.

With STOP-BANG or without STOP-BANG, your clinical judgment . . . based on your training . . . will still be your most valuable tool.

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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

 

 

IS IT SAFE TO GIVE BETA-BLOCKERS TO ASTHMATIC PATIENTS?

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 of the Month:  A 62-year-old asthmatic with obstructive sleep apnea develops a heart rate of 125 and a blood pressure of 160/95 in the Recovery Room, thirty minutes following a UPPP.  His pain is well controlled, and he has no dyspnea or chest pain.  The patient is two years status-post an inferior myocardial infarction, and is known to have 60% occlusions of his left anterior and circumflex coronary arteries.  The nurse asks if you can use a beta blocker in asthma patients.  What do you do?

Chemical formula for propanolol, the first beta blocker

 

Discussion:   By the time you receive the call from the Recovery Room, you’ve already returned to the OR.  You’ve already induced and intubated your next patient.  You give the Recovery Room nurse a verbal order to administer 10 mg of IV labetolol.  The nurse calls back five minutes later, and says that the patient developed severe wheezing, the oxygen saturation dropped to 60%, and he’s complaining of substernal chest pain.  You call one of your partners to take over your anesthetized patient, and you rush to the Recovery Room.  You arrive just in time to witness your cyanotic wheezing patient go into cardiac arrest.

A miserable scenario.  Is it possible?  If your patient died, do you think a plaintiff’s attorney would be willing to sue you for malpractice?  Can you imagine this question at the deposition:  “Doctor, what were you thinking when you treated this patient with known bronchospastic disease with a drug known to reverse beta-mediated bronchodilation?”

There are multiple case reports in the medical literature where non-selective beta-blockers led to exacerbations of bronchospasm in patients with asthma.  As recently as 1995, one could find admonishments like this in the medical literature:  “Worsening or precipitation of asthma by beta-adrenoceptor antagonists is well recognized. Severe bronchoconstriction may be induced even in ‘mild’ asthmatics, and the dose of beta blocker required may be low, as in the case of eye drops of timolol, a nonselective beta blocker used to treat glaucoma. The severity of bronchoconstrictor response is not predictable. Nonselective beta blockers are more likely to precipitate bronchospasms in patients with asthma. The mechanism of beta-blocker-induced asthma is still not certain. Normal subjects develop neither a deterioration in lung function nor an increased bronchial hyperreactivity; therefore, beta blocker drugs should in general be avoided by asthma patients.”  (Im Hof, Schweiz Rundsch Med Prax. 1995 Mar 14;84(11):319-20).

Let’s step back to paragraph one, and think things over again.  Because your tachycardic, hypertensive patient has coronary artery disease, you are concerned about his risk for an acute cardiac event.  You run through a quick benefit-risk analysis.  If you do nothing, the patient may develop angina or a myocardial infarction.  If you treat the hypertension with a vasodilator, you can decrease the blood pressure, but you’re likely to increase heart rate further.  If you give a beta-blocker, you’re aware that there is some risk of inducing bronchospasm.

What about a beta-1 cardioselective beta-blocker?  How safe would a beta-1 blocker be in this situation?  You order the nurse to titrate in 2 mg IV increments of metoprolol.  After 6 mg, the heart rate decreases to 72 beats per minute, and the blood pressure is 110/75.  The patient does not develop wheezing.

In their paper Safety of therapeutic beta-blockade in patients with coexisting bronchospastic airway disease and coronary artery disease (Am J Ther. 2003 Jan-Feb;10(1):48-50), S. Khosla et al prospectively followed 835 consecutive outpatients with symptomatic coronary artery disease at Mt. Sinai Hospital in Chicago.  Thirty of the 835 patients had concurrent bronchospastic disease.  All patients were treated with an oral beta-1 antagonist.  Twenty-nine of the thirty patients attained successful beta blockade (defined as heart rate less than 70) without bronchospasm.  One patient discontinued the beta-1 blocker as a result of lifestyle-limiting bronchospasm.  He had no serious adverse outcome, and did not require hospitalization.  The authors concluded that selective beta-1 blocker usage was safe in this population.

What about intravenous beta-1 blockers in the setting of acute cardiovascular disease?  In their paper, Beta-blocker therapy of cardiovascular diseases in patients with bronchial asthma or COPD: The pro viewpoint, Ashrafian and Violaris reported:  “Extensive randomized clinical trial data support the view that beta-blockers have a significant impact on the prognosis of patients with cardiovascular disease, especially those with coronary artery disease and chronic heart failure. Unfortunately, this essential treatment is often withheld from patients with asthma and from some patients with Chronic Obstructive Pulmonary Disease (COPD). The principal concern, a concern supported by a number of guidelines, is that beta-blockers may precipitate severe and potentially fatal bronchospasm. However, a number of studies, culminating in a recent meta-analysis, show that cardioselective beta-blockers are not only safe but are beneficial in patients with co-existing airways and coronary disease. In this article we review the evidence supporting the position that cardioselective beta-blockers, when introduced with care in both community and hospital settings, are safe in patients with mild airways disease and can significantly improve prognosis.” (Prim Care Respir J. 2005 Oct;14(5):236-41).

Although I was unable to find a prospective, randomized trial documenting the safety of intravenous beta-1 blockers in patients with both bronchospastic disease and coronary artery disease, it’s my impression that the literature supports this practice.

I queried the other private practice anesthesiologists on the faculty at Stanford University Hospital regarding their use of beta-blockers in asthmatic patients, and the results were consistent.  The private attendings favored a risk-benefit analysis, but almost everyone admitted to titrating small doses of beta-1 antagonists, when indicated, in patients with bronchospastic disease.  None of my colleagues reported a complication with this practice.

When I finished my Stanford anesthesia residency in 1986, almost no one dared to give IV beta-blockers to an asthmatic.  Things change. That’s my advice to the residents of today:  keep on reading after residency, because . . . things will keep changing.

 

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

DSC04882_edited