ANESTHETIC RISKS IN CHILDREN

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)

What are the anesthetic risks for children? What should you do if your 2-year-old son or daughter requires surgery and anesthesia? Should you consent to proceed? Should you wait until he or she is 3 years old?

The answer to all these questions is: “It depends.”

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Let’s look at recommendations as they exist in 2018.

On December 14, 2016, the United States Food and Drug Administration (FDA) issued a Drug Safety Communication Drug Safety Communication Warning that general anesthesia and sedation drugs used in children less than 3 years of age who were undergoing anesthesia for more than 3 hours, or repeated use of anesthetics, “may affect the development of children’s brains.”

The text of this December 2016 FDA statement reads:

The U.S. Food and Drug Administration (FDA) is warning that repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children’s brains. . . . Consistent with animal studies, recent human studies suggest that a single, relatively short exposure to general anesthetic and sedation drugs in infants or toddlers is unlikely to have negative effects on behavior or learning. However, further research is needed to fully characterize how early life anesthetic exposure affects children’s brain development. . . . Health care professionals should balance the benefits of appropriate anesthesia in young children and pregnant women against the potential risks, especially for procedures that may last longer than 3 hours or if multiple procedures are required in children under 3 years. Discuss with parents, caregivers, and pregnant women the benefits, risks, and appropriate timing of surgery or procedures requiring anesthetic and sedation drugs.”

This FDA warning resulted in a labeling change for these 11 common general anesthetics drugs and sedative agents:

  • Propofol
  • Sevoflurane
  • Midazolam
  • Isoflurane
  • Desflurane
  • Halothane
  • Pentobarbital
  • Etomidate
  • Ketamine
  • Lorazepam
  • Methohexital

Of these, sevoflurane and propofol are mainstay drugs used in pediatric anesthetics. Anesthesia for infants and children is most frequently initiated with an inhalation induction of sevoflurane vapor, because most infants and children do not have an IV line prior to induction. The primary intravenous hypnotic drug for children is propofol.

Because of this FDA statement, the propofol package insert warning label now reads:

Pediatric Use; ANIMAL TOXICOLOGY AND/OR PHARMACOLOGY). Some published studies in children suggest that similar deficits may occur after repeated or prolonged exposures to anesthetic agents early in life and may result in adverse cognitive or behavioral effects. These studies have substantial limitations, and it is not clear if the observed effects are due to the anesthetic/sedation drug administration or other factors such as the surgery or underlying illness. Anesthetic and sedation drugs are a necessary part of the care of children needing surgery, other procedures, or tests that cannot be delayed, and no specific medications have been shown to be safer than any other. Decisions regarding the timing of any elective procedures requiring anesthesia should take into consideration the benefits of the procedure weighed against the potential risks.”

For sevoflurane, the package insert warning label now reads:

Repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in neonates, infants, and children younger than 3 years, including in utero exposure during the third trimester, may have negative effects on brain development. Consider the benefits of appropriate anesthesia in young children against the potential risks, especially for procedures that may last more than 3 hours or if multiple procedures are required during the first 3 years of life. It may be appropriate to delay certain procedures if doing so will not jeopardize the health of the child. No specific anesthetic or sedation drug has been shown to be safer than another. Human studies suggest that a single short exposure to a general anesthetic in young pediatric patients is unlikely to have negative effects on behavior and learning; however, further research is needed to fully characterize how anesthetic exposure affects brain development.

There are no real alternatives to these 11 general anesthetic drugs regarding pediatric anesthesia. Dexmedetomidine and narcotics are not on the FDA list, but dexmedetomidine and narcotics are not sufficient to provide general anesthesia by themselves.

What does this mean to physicians and parents regarding anesthetics on children under the age of 3 years?

The most common indications for infants and toddlers to be placed under general anesthesia are for short procedures such as ear tubes for chronic ear infections, hernia repair, or removal of the adenoids. At times infants or toddlers require general anesthesia or sedation so they will stay still during a procedure, such as when they need an MRI or a CT scan.

There are an estimated 1.5 -2 million children under 3 years of age who undergo anesthesia annually in the United States. Prior to the FDA statement, Texas Children’s Hospital performed more than 43,000 cases each year. Approximately 13,000 of these cases involved patients under 3 years of age, and more than 11,000 of these anesthetics lasted more than 3 hours. Nearly all of the prolonged anesthetics were for serious congenital conditions for which treatment could not be delayed until the patient reached 3 years of age. Because of the FDA warning, the hospital adopted the warning’s recommendation that a discussion occur among parents, surgeons and other physicians, and anesthesiologists regarding the duration of anesthesia, any plan for multiple general anesthetics for multiple procedures, and the possibility that the procedure could be delayed until after 3 years of age.1

Dr. Constance Houck, chair of the American Academy of Pediatrics’ Surgical Advisory Panel and an Associate Professor of Anesthesia at Harvard Medical School said, “two recently published studies examining short-term anesthesia exposure for hernia repair did not show neurobehavioral differences between those who had received a general anesthetic and those who had not. . . . Most surgeries are less than one hour, but some infants and children with significant congenital defects require more prolonged surgery. . . Examples would include such defects as cleft lip and palate and malformations of the urinary or gastrointestinal tract.” Postponing major reconstructive surgery until children are older is generally not an option. “There is no evidence to suggest that short procedures should be postponed, but parents should always discuss with their child’s pediatrician and surgeon the risks and benefits of timing of procedures.2

The American Society of Anesthesiologists response to the FDA statement read: “the accumulated human data suggest that one brief anesthetic is not associated with cognitive or behavioral abnormalities in children. Most but not all studies in children do however suggest an association between repeated and or prolonged exposure and subsequent difficulties with learning or behavior.”3

In addition to the FDA drug recommendations, there are well documented surgical concerns with operating on children under age 3. For example, the recommendations for pediatric tonsillectomy are to delay until age 3, based on a high degree of evidence for increased respiratory complications at ages younger than 3.4

An overriding important consideration regarding pediatric anesthetics is: Who will be doing the anesthesia? It’s important to inquire regarding the experience and training of the physician anesthesiologist who is about to anesthetize your child. (See my related column Pediatric Anesthesia: Who is Anesthetizing Your Child?)

Some anesthesiologists do specialty fellowship education for one or two years in pediatric anesthesia, usually at an academic pediatric hospital, and are therefore well-trained to attend to your child. In community hospitals, experienced physician anesthesiologists who have attended to children since their residency training commonly do pediatric anesthetics. My practice fits this model: I am not a fellowship-trained pediatric anesthesiologist, but I have anesthetized thousands of children safely over 33+ years since my Stanford residency.

Let’s return to the question of whether your 2-year-old should have anesthesia and surgery.

My family had a personal experience with this question. My oldest son fell and cracked his upper right incisor when he was 1½ years old. He had three general anesthetics in the following nine months for dental surgeries: the first surgery to place a cap on the fractured tooth, the second surgery to extract the tooth because it died, and a third surgery to place a prosthetic incisor to replace the lost tooth. These three surgeries were performed in 1998 and 1999 when my son was between 1½ and 3 years of age. He suffered no apparent developmental delays secondary to anesthesia, but in the present day, following the FDA statement, both the physicians and the parents would be unlikely to proceed with three repeated anesthetics on such a young child.

The answer for you depends on whether your child’s surgery is elective and can wait until he or she is 3 years old, whether it is a one-time surgery, whether the surgery is brief, whether it is an emergency or whether it is to remedy a congenital deformity and can not be delayed. You’ll need to have an informed consent discussion with the surgeon, the physician anesthesiologist, and perhaps your pediatrician. If your child’s surgery is a one-time anesthetic for a common short procedure such as ear ventilation tubes or an inguinal hernia repair, it’s likely that proceeding with anesthesia and surgery will be the correct answer. If the surgery is urgent or if delaying surgery will cause an adverse outcome, then proceeding with anesthesia and surgery will be the correct answer. Trust your surgeon and physician anesthesiologist as consultants, and you’ll make the correct choice.

Be reassured. The Society for Pediatric Anesthesiology states that “complications are extremely rare. In the United States, the chance (risk) of a healthy child dying or sustaining a severe injury as a result of anesthesia is less than the risk of traveling in a car.”5

 

References:

  1. Andropoulos DB, Greene MF. Anesthesia and Developing Brains — Implications of the FDA Warning. N Engl J Med 2017; 376:905-907
  2. https://www.forbes.com/sites/ritarubin/2016/12/17/fda-has-ordered-new-label-warnings-but-its-not-clear-that-anesthesia-is-risky-in-pregnancy-kids/#45afde9138c9
  3. https://www.asahq.org/advocacy/fda-and-washington-alerts/washington-alerts/2016/12/asa-response-to-the-fda-med-watch
  4. Lescanne E, et al. Pediatric tonsillectomy: clinical practice guidelines. Eur Ann Otorhinolaryngol Head Neck Dis. 2012 Oct;129(5):264-71.
  5. http://www2.pedsanesthesia.org/patiented/risks.iphtml

 

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 RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

The anesthesiaconsultant.com, copyright 2010, Palo Alto, California

For questions, contact:  rjnov@yahoo.com

 

 

 

 

 

 

 

 

 

THE JOY OF BEING A DOCTOR

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)

My greatest joy of being a doctor comes immediately after the conclusion of a pediatric anesthetic.

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I stay with the child until the anesthetic depth has dissipated, the breathing tube is removed, and the child is awake and safe with the recovery room nurse in the Post Anesthesia Care Unit. At that point I walk out to the waiting room to find the parents so I bring them back to see their child. I invariably have a bounce to my step, and I’m a bit choked up with anticipation. I’ve done this enough times to know what to expect. The mother and father are waiting with wide eyes and worried looks on their faces. I give them a reassuring smile and my first words are, “Everything went perfectly. Your son (or daughter) is safe. Follow me.” The three of us return to the bedside in the recovery room, where the mother and child reunion occurs (cue up the Paul Simon soundtrack). The parents fawn over their child, the child reaches out his or her arms, the relief is palpable, and I’m proud to have contributed to the positive outcome.

Why go to medical school? Bright, hard-working college students have choices to make. Many ambitious young people wonder if they should apply to medical school. It’s difficult to get into med school, the journey is long (four years of medical school followed by three to seven years of residency), and the tuition can be high.

Why go to medical school? The daughter of one of my friends is an undergraduate business school student, and her last summer internship was with Proctor and Gamble working in the sales and marketing force selling Clorox. Selling bleach is a career choice radically different from going to medical school.

Do you want to sell bleach, or do you want to help people? The answer to “Why do you want to go to medical school?” is almost that simple. So many jobs in America are related to selling some product, some service, or some commodity. Becoming a physician is about helping people, and it’s also about making your own life have a greater purpose.

“Why do you want to be a doctor?” is the first question asked at most medical school interviews. Answers vary. Why do young men and women choose to become doctors nowadays? One guiding factor might be economics. The average salary for a physician in the United States is in excess of $250,000. To a 22-year-old, that high salary is alluring. Non-medical students who pursue careers in teaching, engineering, or business will start at lower annual salaries, but the future income of a physician is balanced against the deferred gratification of the years involved in their education. The student must pay for four years of medical school tuition and living expenses, and then work for meager wages for 3-7 years afterwards as a resident. The medical student delays the onset of their “real world” employment until age 30-32.

Non-medical students who go to work straight out of college at age 22 may already have families, mortgages, multiple cars, and perhaps a vacation home, while the 32-year-old physician has an 80-hour-a-week job, $250,000 of student loans, and the obligation to take care of sick patients at 3 a.m. It’s not an easy life, it’s not all fun, and most doctors wonder at one time or another whether they made the right choice. Making a lot of money is not the right answer to the question of why you want to go to medical school.

So why do we go to medical school? Young men and women who have a physician parent are in the best position to reply from the heart—they’re aware that their parent works long hours, reads incessantly to stay well informed, and gets out of bed in the middle of the night to handle emergencies. A doctor’s son or daughter has heard all the good and bad stories that describe a physician’s lifestyle. But most college students don’t have a doctor for a parent, and most college students have a little idea what the lifestyle of a physician would feel like. My father was a welder. I had no family experience to guide my career choice. For students like me, without a physician parent, it’s important to work medical volunteer jobs and/or research jobs to test the waters before applying to medical school, to decide whether the life of a doctor would appeal to them.

Why go to medical school? Each new patient I meet treats me with respect—a respect I don’t get if I’m outside of the hospital walking down the street or shopping at a grocery store. Years ago I shared this impression with my wife, and she said, “Of course your patients treat you with respect. You’re about to take their lives into your hands. They’re nervous, they’re scared, and the last thing they want to do is to get you in a bad mood!” This may be true, but the respect your patients give you is bona fide, and it’s a feeling few other jobs can offer.

Why go to medical school? I don’t think you’ll ever get equivalent joy out of selling bleach (or some other commodity) that you’ll gain helping other human beings with their health problems. Medicine is a profession. A career in medicine is an opportunity to entwine your work life with other people’s lives in a meaningful and remarkable way. You might make more money as a CEO or a venture capitalist, but few other jobs bring the potential to change lives for the better to the degree that being a physician does.

When you go to your medical school interview and the professor asks you “Why do you want to be a doctor,” the answer from your heart must be five words long:

“I want to help people.”

Your reward for becoming a doctor will arrive years later, when you feel what I feel when I reunite parents with their child after surgery. You’ll feel the joy and satisfaction of a purposeful life.

 

P.S. In 2012 the journal Anesthesiology published my poem “The Metronome,” which describes a scene from my life as a pediatric anesthesiologist:

 

The Metronome

 

To Jacob’s mother I say,

“The risk of anything serious going wrong…”

She shakes her head, a metronome ticking without sound.

“with Jacob’s heart, lungs, or brain…”

Her lips pucker, proving me wrong.

“isn’t zero, but it’s very, very close to zero…”

Her eyes dart past me, to a future of ice cream and laughter.

“but I’ll be right there with him every second.”

The metronome stops, replaced by a single nod of assent.

She hands her only son to me.

 

An hour later, she stands alone,

Pacing like a Palace guard.

Her pupils wild. Lower lip dancing.

The surgery is over.

Her eyebrows ascend in a hopeful plea.

I touch her hand. Five icicles.

I say, “Everything went perfectly. You can see Jacob now.”

The storm lifts. She is ten years younger.

Her joy contagious as a smile.

The metronome beat true.

 

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 RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

The anesthesiaconsultant.com, copyright 2010, Palo Alto, California

For questions, contact:  rjnov@yahoo.com

 

 

 

 

 

 

 

 

 

 

THE CHILD WITH AN OPEN EYE INJURY AND A FULL STOMACH

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)

A 3-year-old boy is eating a McDonalds Happy Meal on the lawn of the restaurant. A lawn mower approaches, and a rock is ejected from the mower, hitting the child in the eye. The boy suffers a penetrating open eye injury, and is taken to the nearest hospital. You are on call for the repair. You’re are an experienced practitioner, but not a pediatric anesthesia specialist. What do you do?

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Discussion: There are two issues. One is how to safely perform the open-eye, full stomach anesthetic, and the other is the performance of pediatric anesthesia by non-pediatric anesthesia specialists.

Your goals for this anesthetic are to protect the airway and to avoid increases in intraocular pressure (IOP). Sudden increases in IOP in patients with an open globe injury can lead to vitreous loss and blindness. The list of things that increase IOP and risk further eye damage includes crying, coughing, the Valsalva maneuver, vomiting, firm pressure with an anesthesia face mask, laryngoscopy, and endotracheal intubation. Ketamine and succinylcholine also increase IOP. Trying to start an IV without causing crying and the attendant increase in IOP in a 3-year-old can be difficult.

True ophthalmic emergencies (e.g. central retinal artery occlusions or chemical burns) must be treated within minutes to avoid blindness or permanent vision loss. A penetrating open globe injury is usually urgent, rather than emergent. At times urgent procedures are delayed until the patient has been fasting for 6 hours, and has an appropriate NPO status.

Let’s assume your surgeon is determined to operate urgently, and doesn’t want to wait 6 hours after the patient’s meal. In his judgment delaying the surgery would increase the patient’s risk of loss of vision.

No single approach to this patient is ideal, but a proposed approach is:

  1. Apply EMLA cream with an occlusive dressing over several potential IV sites 45-60 minutes before the IV attempt. Next give the boy an oral midazolam premedication (0.67 mg/kg), and wait until he becomes sedated enough to start an intravenous line.
  2. Once the IV is in place, a modified rapid sequence induction is done with cricoid pressure, using rocuronium as the muscle relaxant. A dose of 1-1.5 mg/kg is used to speed the pace of neuromuscular blockade. With the availability of sugammadex to reverse deep rocuronium motor block, the risks of a high dose of rocuronium in this setting are minimal. A nerve stimulator is used to confirm that depth of muscled blockade is adequate, to avoid any coughing during laryngoscopy. The FDA black box warning regarding pediatric use of succinylcholine allows for its use for emergency intubation or for patients with a full stomach, but this author prefers to avoid it if alternatives exist. Succinylcholine causes a transient tonic increase (4-20 minutes) in extraocular muscle tone, which causes an increase in IOP of 10 to 20 mm Hg.
  3. If the child has chubby arms, hands, ankles and feet, and you are not able to place the IV despite adequate oral sedation, you may proceed with an inhalation induction. Utilize sevoflurane with cricoid pressure maintained throughout. Once the child is asleep, the IV can be placed, relaxant given, and the endotracheal tube inserted.
  4. An oral gastric tube is used to suction out the stomach.
  5. Controlled ventilation is recommended, to insure the field is quiet for the surgeon.
  6. At the conclusion of surgery, because of the full stomach, the patient is extubated awake. For tips on a smooth emergence, see my column on Smooth Emergence from Anesthesia.
  7. Postoperative nausea and vomiting can increase IOP. Prophylactic IV ondansetron is recommended.
  8. Postoperatively, a pain-free child will cry less and have fewer increases in IOP. The surgeon should consider a regional block of the eye to decrease the need for postoperative narcotics.

The second issue in this case is that you’re not a pediatric anesthesiologist. A children’s hospital or a university hospital will have a team of pediatric anesthesiologists with specialized training on call for emergencies. Call schedules and staffing are different in community hospitals, where a smaller team of anesthesiologists shares night call. Unless the hospital is very large, it’s uncommon to have anesthesiologists of multiple specialties on call each day, e.g. one for pediatrics, one for cardiac cases, one for trauma, one for obstetrics, and one for the general operating rooms. It’s common for general anesthesia practitioners to cover many or all specialties when they’re on call. If the on-call anesthesiologist is not comfortable with an individual case, he or she can seek out and call in a better-trained anesthesiologist, if one is available. The goal of producing a specialist anesthesiologist for every type of case at all hours of the night and weekend is a difficult one to staff. The decision to care for this patient at a community hospital at all is a judgment as to whether standards of care can be met with the physicians who are available. I’m double-boarded in internal medicine and anesthesiology, and have no extra post-graduate training in pediatric anesthesia, yet I have cared for children age 10 months and over for over 30 years. I consider myself expert and confident in the anesthesia care of children of these ages in a community setting.

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

 

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?

 

*
*
*
*

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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DENTAL ANESTHESIA DEATHS . . . GENERAL ANESTHESIA FOR PEDIATRIC PATIENTS IN DENTAL OFFICES

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)

GENERAL ANESTHESIA FOR DENTAL OFFICES CASE PRESENTATION: A 5-year-old developmentally delayed autistic boy has multiple dental cavities. The dentist consults you, a physician anesthesiologist, to do sedation or anesthesia for dental restoration. What do you do?

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DISCUSSION:  Children periodically die in dental offices due to complications of general anesthesia or intravenous sedation. Links to recent reports include the following:

3-year-old girl dies in San Ramon, CA after a dental procedure in July 2016.

A 14-month-old child, scheduled to have 2 cavities filled, dies in an Austin, TX dental office. The dentist and an anesthesiologist were both present.

A 6-year-old boy, scheduled to have teeth capped at a dental clinic, has anesthesia and dies after the breathing tube is removed.

Another 6-year-old boy, scheduled to have a tooth extracted by an oral surgeon, dies after the oral surgeon administers general anesthesia.

Pediatric dentists use a variety of tactics to keep a typical child calm during dental care. The child is encouraged to view a movie or cartoon while the dental hygienist or dentist works. The parent or parents are encouraged to sit alongside their child to provide emotional support. If a typical child requires a filling for a cavity, the dentist can utilize nitrous oxide via a nasal mask with or without local anesthesia inside the mouth.

These simple methods are not effective if the child has a developmental delay, autism, behavioral problems, or if the child is very young. Such cases sometimes present to a pediatric hospital for anesthetic care, but at times the child will be treated in a dental office. Possible anesthesia professionals include a physician anesthesiologist, a dental anesthesiologist, or an oral surgeon (who is trained in both surgery and anesthesia).

 

HOW WOULD A PHYSICIAN ANESTHESIOLOGIST ANESTHETIZE A CHILD IN A DENTAL OFFICE?

There are a variety of techniques an anesthesiologist might use to sedate or anesthetize a young child. The correct choice is usually the simplest technique that works. Alternative methods include intramuscular sedation, intravenous sedation, or potent inhaled anesthetics.

 

ANESTHESIA INDUCTION:

The first decision is how to begin the anesthetic on an uncooperative child. Options for anesthesia induction include:

  1. Intramuscular sedation. A typical recipe is the combination of 2 mg/kg of ketamine, 0.2 mg of midazolam, and .02 mg/kg of atropine. These three medications are drawn up in a single syringe and injected into either the deltoid muscle at the shoulder or into the muscle of the anterior thigh. Ketamine is a general anesthetic drug that induces unconsciousness and relieves pain. Midazolam is a benzodiazepine which induces sleepiness and decreases anxiety. Ketamine can cause intense dreams which may be frightening. Midazolam is given because it minimizes ketamine dreams. Atropine offsets the increased oral secretions induced by ketamine. Within minutes after the injection of these three drugs, the child will become sleepy and unresponsive, and the anesthesiologist can take the child from the parent’s arms and bring the patient into the operating room. Most anesthesiologists will insert an intravenous catheter into the patient’s arm at this point, so any further doses of ketamine, midazolam, or propofol can be administered through the IV.
  2. Oral sedation with a dose of 0.5-0.75 mg/kg of oral midazolam syrup (maximum dose 20 mg). If the child will tolerate drinking the oral medication, the child will become sleepy within 15- 20 minutes. At this point, the anesthesiologist can take the patient away from the parent and proceed into the operating room, where either an intravenous anesthetic or an inhaled sevoflurane anesthetic can be initiated.

 

MONITORING THE PATIENT:

  1. The patient should have all the same monitors an anesthesiologist would use in a hospital or a surgery center. This includes a pulse oximeter, an ECG, a blood pressure cuff, a monitor of the exhaled end-tidal carbon dioxide, and the ability to monitor temperature.
  2. The anesthesiologist is the main monitor. He or she will be vigilant to all vital signs, and to the Airway-Breathing-Circulation of the patient.

 

MAINTENANCE OF ANESTHESIA:

  1. Regardless of which anesthetic regimen is used, oxygen will be administered. Room air includes only 21% oxygen. The anesthesiologist will administer 30-50% oxygen or more as needed to keep the patient’s oxygen saturation >90%.
  2. Intravenous sedation: This may include any combination of IV midazolam, ketamine, propofol, or a narcotic such as fentanyl.
  3. Local blocks by the dentist. The dentist may inject local anesthesia at the base of the involved tooth, near the superior alveolar nerve to block all sensation to the upper teeth, or near the inferior alveolar nerve to anesthetize all sensation to the lower jaw.
  4. Inhaled nitrous oxide. The simplest inhaled agent is nitrous oxide, which is inexpensive and rapid acting. Used alone, nitrous oxide is not potent enough to make a patient fall asleep. Nitrous oxide can be used as an adjunct to any of the other anesthetic drugs listed in this column.
  5. Potent inhalation anesthesia (sevoflurane). Most dental offices will not have a machine to administer sevoflurane. (Every hospital operating room has an anesthesia machine which delivers sevoflurane vapor.) Portable anesthesia machines fitted with a sevoflurane vaporizer are available. A colleague of mine who worked full time as a roving physician anesthesiologist to multiple pediatric dental offices leased such a machine and used it for years. The advantages of sevoflurane are: i) few intravenous drugs will be necessary if the anesthesiologist uses sevo, and ii) the onset and offset of sevo is very fast—as fast as nitrous oxide. The administration of sevoflurane usually requires the use of a breathing tube, inserted into the patient’s windpipe.
  6. The anesthesiologist will be present during the entire anesthetic, and will not leave.

 

AWAKENING FROM ANESTHESIA:

  1. With intramuscular and/or intravenous drugs, the wake-up is dependent on the time it takes for the administered drugs to wear off or redistribute out of the blood stream. This may take 30-60 minutes or more following the conclusion of the anesthetic.
  2. With inhaled agents such as sevoflurane and nitrous oxide, the wake-up is dependent on the patient exhaling the anesthetic gas. The majority of the inhaled anesthetic effect is gone within 20-30 minutes after the anesthetic is discontinued.
  3. The patient must be observed and monitored until he or she is alert enough to be discharged from the medical facility. This can be challenging if a series of patients are to be anesthetized in a dentist’s office. The medical staff must monitor the post-operative patient and also attend to the next patient’s anesthetic care. It’s imperative that the earlier patient is awake before the anesthesiologist turns his full attention to the next patient.

 

THE ANESTHETIC FOR OUR CASE PRESENTATION ABOVE:

  1. The anesthesiologist meets the parents and the patient, and explains the anesthetic options and procedures to the parent. The parent then consents.
  2. The anesthesiologist prepares the dental operating room with all the necessary equipment in the mnemonic M-A-I-D-S, which stands for Monitors and Machine, Airway equipment, Intravenous line, Drugs, and Suction.
  3. The anesthesiologist injects the syringe of ketamine, midazolam, and atropine into the child’s deltoid muscle. The child becomes sleepy and limp within one minute, and the anesthesiologist carries the child into the operating room.
  4. All the vital sign monitors are placed, and oxygen is administered via a nasal cannula.
  5. An IV is started in the patient’s arm.
  6. The dentist begins the surgery. He or she may inject local anesthesia as needed to block pain.
  7. Additional IV sedation is administered with propofol, ketamine, midazolam, or fentanyl as deemed necessary.
  8. When the surgery is nearing conclusion, the anesthesiologist will stop the administration of any further anesthesia. When the surgery ends, the anesthesiologist remains with the patient until the patient is awake. The patient may be taken to a separate recovery room, but that second room must have an oxygen saturation monitor and a health care professional to monitor the patient until discharge.

CHALLENGES OF DENTAL OFFICE ANESTHESIA:

  1. You’re do all the anesthesia work alone. If you have an airway problem or an acute emergency, you’ll have no other anesthesia professional to assist you. Your only helpers are the dentist and the dental assistant.
  2. The cases are difficult, otherwise you wouldn’t be there at all. Every one of the patients will have some challenging medical issue(s).
  3. You have no preop clinic, so you don’t know what you’re getting into until you meet the patient. I’d recommend you telephone the parents the evening before, so you can glean the past medical and surgical histories, and so you can explain the anesthetic procedure. Nonetheless, you can’t evaluate an airway over the phone, and on the day of surgery you may encounter more challenge than you are willing to undertake.
  4. It’s OK to cancel a case and recommend it be done in a hospital setting if you aren’t comfortable proceeding.
  5. The anesthesiologist usually has to bring his or her own drugs. The narcotics and controlled substances need to be purchased and accounted for by the anesthesiologist with strict narcotic logs to prove no narcotics are being diverted for personal use. All emergency resuscitation drugs need to be on site in the dental office or brought in by the anesthesiologist.
  6. If a sevoflurane vaporizer is utilized, dantrolene treatment for Malignant Hyperthermia must be immediately available.

 

BENEFITS OF DENTAL OFFICE SEDATION AND GENERAL ANESTHESIA:

  1. The parents of the patients are grateful. The parents know how difficult dental care on their awake child has been, and they’re thankful to have the procedures facilitated in a dental office.
  2. The dentist and their staff are grateful. They don’t have a method to safely sedate such patients, and are thankful that you do.
  3. Most cases are not paid for by health insurance, rather they are cash pay in advance.

 

HOW SAFE IS ANESTHESIA AND SEDATION IN A DENTAL OFFICE?

No database can answer the question at present. In 2013 the journal Paediatric Anesthesia published a paper entitled Trends in death associated with pediatric dental sedation and general anesthesia. (1) The paper reported on children who had died in the United States following receiving anesthesia for a dental procedure between1980-2011. Most deaths occurred among 2-5 year-olds, in an office setting, and with a general or pediatric dentist (not a physician anesthesiologist or dental anesthesiologist) as the anesthesia provider. In this latter group, 17 of 25 deaths were linked with a sedation anesthetic.

Another study analyzed closed claims databases of 17 malpractice claims of adverse anesthesia events in pediatric patients in dental offices from 1992 – 2007. (2) Thirteen cases involved sedation, 3 involved local anesthesia alone, and 1 involved general anesthesia. 53% of the claims involved patient death or permanent brain damage. In these claims the average patient age was 3.6 years. Six cases involved general dentists as the anesthesia provider, and 2 involved local anesthesia alone. The adverse event occurred in the dental office in 71% of the claims. Of the 13 claims involving sedation, only 1 claim involved the use of vital sign monitoring. The study concluded that very young patients (≤ 3-years-old) were at greatest risk during administration of sedative and/or local anesthetic agents. The study concluded that some practitioners were inadequately monitoring patients during sedation procedures. Adverse events had a high chance of occurring at the dental office where care is being provided.

If general anesthesia or deep sedation are performed in a dental office, the anesthetist must practice with the same vigilance and standards of care as they would in a hospital or surgery center. Either a physician anesthesiologist, an oral surgeon (acting as both the dental surgeon and the anesthetist), or a dental anesthesiologist may perform the anesthesia. There are no data at this time to affirm that a physician anesthesiologist is the safest practitioner in this setting.

Note: This column addressed the office practice of pediatric dental anesthesia as seen from a physician anesthesiologist’s point of view.

References:

(1) Lee HH et al, Trends in death associated with pediatric dental sedation and general anesthesia. Paediatr Anaesth. 2013 Aug;23(8):741-6.

(2) Chicka MC et al, Adverse events during pediatric dental anesthesia and sedation: a review of closed malpractice insurance claims. Pediatr Dent.2012 May-Jun;34(3):231-8.

 

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 RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

 

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 PREPARE TO SAFELY INDUCE GENERAL ANESTHESIA IN TWO MINUTES

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)

How do you prepare to induce general anesthesia in two minutes? You’re called to induce anesthesia for a patient being rushed to the operating room for emergency surgery. You arrive at the operating room only minutes before the patient is scheduled to arrive. I recommend you use the mnemonic M-A-I-D-S as a checklist to prepare yourself and your equipment.

 

 

M stands for MACHINE and MONITORS. Check out your anesthesia machine first. Determine the oxygen sources are intact, and that the circle system is airtight when the pop-off valve is closed and your thumb occludes the patient end of the circle. Make sure the anesthesia vaporizer liquid anesthetic level is adequate. Check out your routine monitors next. Determine that the oximeter, end-tidal gas monitor, blood pressure cuff, and EKG monitors are turned on and ready.

A stands for AIRWAY equipment. Make sure an appropriate-sized anesthesia mask is attached to the circle system. Determine that your laryngoscope light is in working order. Prepare an appropriate sized endotracheal tube with a stylet inside. Have appropriate-sized oral airways and a laryngeal mask airway (LMA) available in case the airway is difficult. Make sure you have a stethoscope so you can examine the patient’s heart and lungs.

I stands for IV. Have an IV line prepared, and have the equipment to start an IV ready if the patient presents without an intravenous line acceptable for induction of anesthesia.

D stands for DRUGS. At the minimum you’ll need an induction agent (e.g. propofol or etomidate) and a muscle relaxant (succinylcholine or rocuronium), each loaded into a syringe. You’ll need narcotics and perhaps a dose of midazolam as well. Cardiovascular drugs to raise or lower blood pressure will be available in your drug drawer or Pyxis machine.

S stands for SUCTION. Never start an anesthetic without a working suction catheter at hand. You must be ready to suction vomit or blood out of the airway acutely if the need arises.

For pediatric patients the M-A-I-D-S mnemonic is followed, but in addition the size of your anesthesia equipment must be tailored to the age of the patient. Let’s say your patient is 4 years old. For M=MACHINE, you may need a smaller volume ventilation bag and hoses. For M=MONITORS, you’ll need a smaller blood pressure cuff, a smaller oximeter probe, and a precordial stethoscope if you use one. For A=AIRWAY, you’ll need smaller endotracheal tubes and airways. For I=IV, you’ll need smaller IV catheters and IV bags.

As a last-second check before a pediatric anesthetic, I recommend you pull out each drawer on your anesthesia machine, and then on your anesthesia cart, one at a time. Scan the contents of each drawer to ascertain whether you need any of the equipment there before you begin your anesthetic.

If you have any suspicion that the patient’s airway is going to be difficult, I recommend you ask to have a video laryngoscope and a fiberoptic laryngoscope brought into the operating room.

Once the patient arrives, utilize time to assess the situation as any doctor does. Take a quick history and perform a pertinent exam of the vital signs, airway, heart, lungs, and also a brief neuro check. Assist in positioning the patient on the operating room table, supervise the placement of routine monitors, and begin preoxygenating the patient. Induce anesthesia when you are ready.

Never be coerced to rush an anesthesia induction if your anesthesia setup or the patient’s physiology are not optimized. And always utilize the mnemonic M-A-I-D-S as an anesthesia checklist to confirm that your equipment is ready.

 

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

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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 rick novak.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

 

 

ANESTHESIA FACTS FOR NON-MEDICAL PEOPLE: ANESTHETIC TECHNIQUES

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

This column is for non-medical laypeople, and pertains to the different types of anesthetic techniques used in the 21st century. See below:

GENERAL ANESTHESIA

A general anesthetic renders the patient asleep and insensitive to pain for surgery. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. Before the anesthetic, oxygen is administered by mask to fill the patient’s lungs with 100% oxygen. Most adult patients are given general anesthesia by intravenous injection, usually of the medication propofol. This injection causes the patient to lose consciousness within 10 – 20 seconds. This is called the induction of anesthesia. The maintenance of anesthesia during surgery is done by mixing an anesthesia gas or gases with the oxygen. Typical inhaled anesthesia gases are nitrous oxide, sevoflurane, or isoflurane. Sometimes a continuous infusion of intravenous anesthetic such as propofol is given as well. The choice and dose of drugs is done by the anesthesia attending, based on the patient’s size, age, the type of surgery, and the anesthesiologist’s experience.

Many patients are given prophylactic anti-nausea medication during the anesthetic. If postoperative pain is anticipated, the anesthesiologist can also administer intravenous narcotics such a morphine, meperidine (Demerol), or fentanyl.

Depending on the patient’s medical condition and type of surgery, the anesthesiologist may protect the patient’s airway during the general anesthetic by placing a breathing tube through the mouth, either an endotracheal tube (ET Tube) into the patient’s windpipe, or a laryngeal mask airway (LMA) just above the voice box.

At the conclusion of surgery, the general anesthetic gases and/or intravenous anesthetic infusion(s) are discontinued. The patient usually regains consciousness within 5 – 15 minutes. The patient is then transferred to the recovery room.

SPINAL ANESTHESIA

Spinal anesthesia is done by the injection of local anesthetic solution into the low back into the subarachnoid space. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The word subarachnoid translates to “below the arachnoid”. The arachnoid is one of the layers of the meninges covering the nerves of the spinal column. In the subarachnoid space lies the cerebral spinal fluid (CSF) which surrounds the spinal cord and brain. In a spinal anesthetic, the subarachnoid space is located with a needle by the anesthesiologist, and the appropriate anesthetic medications are injected.

Local anesthetics, such as lidocaine or bupivicaine (brand name Marcaine), given into the subarachnoid space, bring on sensory and motor numbness. The anesthesiologist chooses the dose and type of drug depending on the patient’s age, size, height, medical condition, and the type of surgery.

Following the onset of numbness from spinal anesthesia, the patient may either stay awake for surgery, or more often intravenous anesthesia is given to achieve a light sleep. Sometimes light general anesthesia is given to supplement spinal anesthesia.

EPIDURAL ANESTHESIA

Epidural anesthesia is done by the injection of local anesthetic solution, with or without a narcotic medication, into the low back into the epidural space. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The word epidural translates to “outside the dura”. The dura is the outermost lining of the meninges covering the nerves of the spinal column. The epidural space is located with a needle by the anesthesiologist, and the appropriate anesthetic medications are injected.   Often, a tiny catheter is left in the epidural space, taped to the patient’s low back, to allow repeated doses of the medication to be given.  The catheter is removed at the end of surgery, or sometimes days later if continued epidural medications are administered for postoperative pain control.

Local anesthetics, such as lidocaine or bupivicaine (brand name Marcaine), given into the epidural space, bring on sensory and motor numbness. The anesthesiologist chooses the dose and type of drug depending on the patient’s age, size, height, medical condition, and the type of surgery.

Following the onset of numbness from epidural anesthesia, the patient may either stay awake for surgery, or more often intravenous sedation is given to achieve a light sleep. Sometimes light general anesthesia is given to supplement epidural anesthesia.

REGIONAL ANESTHESIA

Regional anesthesia is the injection of local anesthetic (either lidocaine or Marcaine) near a nerve to block that nerve’s function.  Examples of regional anesthesia include arm blocks (axillary block, interscalene block, subclavicular block), and leg blocks (femoral block, sciatic block, popliteal block, ankle block).  An advantage of regional anesthesia blocks is that the patient may remain awake for the surgery.  If desired, the anesthesia provider may administer intravenous sedation or general anesthesia in addition to the regional anesthetic, to allow the patient to sleep during the surgery–the advantage of this combined anesthetic technique is the regional anesthetic blocks all surgical pain and less sleep drugs are required.

INTRAVENOUS SEDATION ANESTHESIA

Some minor surgical procedures (for example: breast biopsies, eyelid surgery, some hernia surgeries) can be done with the combination of local anesthesia plus intravenous anesthesia sedation. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The anesthesiologist is present for the entire surgery, and administers intravenous sedatives as required for the patient’s comfort and the surgeon’s needs.  If the sedation is deep enough, the intravenous sedation will be termed general anesthesia. While the patient is sedated, the surgeon usually injects local anesthetics into the surgical site to block both surgical and post operative pain.

Vigilance by an anesthesiologist during intravenous sedation is also known as Monitored Anesthesia Care, or MAC.

PEDIATRIC ANESTHESIA

Because the separation of a young child from his or her parents can be one of the most distressing aspects of the perioperative experience, many children benefit significantly from oral preoperative sedation with midazolam. This relatively pleasant-tasting liquid is given by mouth about twenty minutes prior to the start of the anesthetic. Although the midazolam rarely causes children to fall asleep, it does reduce anxiety dramatically, allowing for a much smoother separation from parents. It also tends to cause a wonderful short term amnesia, so that the children often have no recollection of separating from their parents, or even of going to the operating room.
Although the initial anesthetic is usually administered via an intravenous infusion in adult patients, this approach requires starting an IV while the patient is still awake. This technique would be quite unpopular with younger children.  Most young children prefer to go to sleep breathing a gas, a technique known as an inhalation induction. This technique is used for almost all routine surgeries, but cannot safely be employed in certain rare situations, such as emergencies.

An inhalation induction consists of the child breathing a relatively pleasant smelling anesthetic vapor – usually sevoflurane – via a facemask for approximately 30 to 60 seconds. The child loses consciousness while breathing the gas, and the IV can then be started painlessly. Generally, the child continues to breath the gas throughout the duration of the surgery, either via the facemask or an endotracheal tube, depending on the duration and type of surgery. It is this breathing of the gas which keeps the child anesthetized. At the end of the surgery, the gas is discontinued, and the child begins to awaken.

Prior to awakening, children may be given either analgesics (pain medicines) or anti-emetics (drugs which reduce the likelihood of nausea and vomiting). The type of surgery will determine which of the many possible medications will be used for these purposes. The purpose of these medications is to make the child’s awakening as calm and pleasant as possible. Equally important in this regard is reuniting the child with his or her parents as quickly as possible.
Despite best attempts, it is important for parents to realize that children, especially those less than five years of age, often are somewhat cranky and irritable following anesthesia and surgery. We do our best to minimize this, but we cannot prevent it in all cases. Similarly, some children will experience postoperative nausea and vomiting despite receiving medications which are intended to prevent it.

 

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?

 

 

 

 

*
*
*
*

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

 

 

USEFUL PEDIATRIC ANESTHESIA EQUATIONS

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)

You are driving to the hospital, en route to doing a pediatric anesthetic on a 2-year-old that will require an endotracheal tube. You are thinking through the case in advance. What can you do to plan your anesthetic? There are some useful pediatric anesthesia equations you can use to prepare yourself.

 

intubated anesthetized child

 

During my anesthesia training at Stanford, Dr. Stanley Samuels, the co-author of Anesthesiologist’s Manual of Surgical Procedures, by Jaffe and Samuels, (Fourth Edition, 2009, Lippincott Williams and Wilkins), taught me a series of equations regarding pediatric anesthetics. These equations are listed below, and provide time-tested guidelines to help the anesthesiologist select the correct endotracheal tube size, the correct intravenous infusion rate, and to estimate a child’s weight and dosing requirements of intravenous drugs.

As Dr. Samuels told me, “You can be driving in toward the hospital, knowing that your patient is 2 years old, and plan details of  your anesthetic in advance.” The equations are as follows:

  • The endotracheal tube size = age/4 + 4
  • Estimating a child’s weight:

Newborn = 3 kg

1-year-old = 10 kg

Add 2 kg per year up until the age of 6 years.

  • The IV rate per hour = 40 ml/hr (first 10 kg) + 20 ml/hr (second 10 kg) plus 10 ml/hr for every extra 10 kg
  • Dosing of IV medications:

A 7-year-old takes ½ of adult dose

A 1-year-old takes ¼ of adult dose

A newborn takes 1/10 of adult dose

For your 2-year-old patient, you will prepare a 4.5 ID endotracheal tube, expect the patient to weigh about 12 kilograms, plan a maintenance IV rate of 45 ml/hour, and expect that all drug doses (including emergency resuscitation drug doses) will be in a range of slightly more than ¼ of typical adult doses.

 

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?

 

 

 

*
*
*
*

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited

 

 

CAN YOU CHOOSE YOUR 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)

You choose the car you drive, the apartment you rent, the smart phone in your pocket, and the flavor of ice cream among 31 flavors at Baskin-Robbins.  Most of you  choose your family physician, your dermatologist, and your surgeon.  But can you choose your anesthesiologist?

 

It depends.

To answer the question, let’s look at how anesthesia providers are assigned for each day of surgery.

Who makes the decision as to which anesthesia provider is assigned to your case? The anesthesia service at every hospital or healthcare system will have a scheduler.  This scheduler is an individual (usually an anesthesiologist) who surveys the list of the surgical cases one day ahead of time.  There will be multiple operating rooms and multiple cases in each operating room. Each operating room is usually scheduled for six to ten hours of surgical cases.  The workload could vary from one ten-hour case to eight shorter cases.  The total number of operating rooms will vary from hospital to hospital.  Typically each room is specialty-specific, that is, all the cases in each room are the same type of surgery.  The scheduler will an assign appropriate anesthesia provider to each room, depending on the skills of the anesthesia provider and the type of surgery in that room.

There are multiple surgical specialties and multiple types of anesthetics.  An important priority is to schedule an anesthesia provider who is skilled and comfortable with the type of surgery scheduled.  An open-heart surgery will require a cardiac anesthesiologist.  A neonate (newborn) will require a pediatric anesthesiologist.  Most surgeries, e.g., orthopedic, gynecologic, plastic surgery, ear-nose-and-throat, abdominal, urologic, obstetric, and pediatric cases over age one, are bread-and-butter anesthetics that can be handled by any well-trained provider.

Each day certain anesthesiologists are “on-call.”  When an anesthesiologist is on-call, he or she is the person called for emergency add-on surgeries that day and night.  The on-call anesthesiologist is expected to work the longest day of cases, and the scheduler will usually assign that M.D. to an operating room with a long list of cases.  If you have emergency surgery at 2 a.m., you will likely be cared for by the on-call anesthesiologist.  A busy anesthesia service may have a first-call, a second-call, and a third-call anesthesiologist, a rank order that defines which anesthesia provider will do emergency cases if two or three come in simultaneously.  A busy anesthesia service will have on-call physicians in multiple specialties, i.e., there will be separate on-call anesthesiologists for cardiac cases, trauma cases, transplant cases, and obstetric cases.

Different hospitals have different models of anesthesia services.  In parts of the United States, especially the Midwest, the South, and the Southeast, the anesthesia care team is a common model.  An anesthesia care team consists of both certified registered nurse anesthetists (CRNA’s) and M.D. anesthesiologists.  For complex cases such as cardiac cases or brain surgeries, an M.D. anesthesiologist may be assigned as the solitary anesthesia provider.  For simple cases such as knee arthroscopies or breast biopsies, the primary anesthesia provider in each operating room will be a CRNA, with one M.D. anesthesiologist serving as the back-up consultant for up to four rooms managed by CRNA’s.

In certain states, the state governor has opted out of the requirement that an M.D. anesthesiologist must supervise all CRNA-provided anesthesia care.  In these states, a CRNA may legally provide anesthesia care without a physician supervising them.  Currently, the seventeen states that have opted out of physician supervision of CRNA’s include Alaska, California,  Colorado, Iowa, Idaho, Kansas, Kentucky, Minnesota, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, South Dakota, Washington, and Wisconsin.  In some hospitals in these states, your anesthesia provider may be an unsupervised nurse anesthetist, not a doctor at all.

Some hospitals have only M.D. anesthesiologists who personally do all the cases.

Academic hospitals, or university hospitals, have residents-in-training who administer most of the anesthetic care.  In academic hospitals, faculty members supervise anesthesia residents in a ratio of one faculty to one resident or one faculty to two residents.

Can a surgeon request a specific anesthesia provider?  Yes.  At times, a surgeon may have certain anesthesia providers that he or she requests and uses on a regular basis.  It’s far easier for a surgeon to request a specific anesthesia provider than it is for you to do so.

The assignment of your anesthesia provider is usually made by the scheduler on the afternoon prior to surgery, and you the patient will have little or no say in the matter. If you are like most patients, you have no idea who is an excellent anesthesia provider and who is less skilled. You won’t find much written about anesthesiologists on Yelp, Healthgrades, or other consumer social-media websites.  Most patients don’t even remember the name of their anesthesia provider unless something went drastically wrong.  Such is the nature of our specialty.  Your anesthesia provider will spend a mere ten minutes with you while you’re awake, and during those ten minutes your mind will be reeling with worries about surgical outcomes and risks of anesthesia.  The anesthesia provider’s name is not a high priority.  After the surgery is over, anesthesiologists are a distant memory.

What if your next-door neighbor is an anesthesiologist whom you respect?  What if you are scheduled for surgery at his hospital or surgery center, and you want him to take care of you?  Can this be arranged?  Most likely, it can.  The best plan for requesting a specific anesthesiologist is to have the anesthesiologist work the system from the inside, several days prior to your surgery date.  He will talk to the scheduler and make sure that he is assigned into the operating room list that includes your surgery.  You’ll be happy and reassured to see him on the day of surgery, and he’ll likely be happy to take care of you.  Anesthesiologists love to be requested by patients.  It makes us feel special.  Doctors aspire to be outstanding clinicians, and a request from a specific patient validates that we are unique.

As you can see, the decision of who is assigned to be the anesthesia provider for your surgery is a multifaceted process. Your best strategy for requesting a specific anesthesiologist is to (1) contact the anesthesiologist yourself and ask that he or she contact anesthesia scheduling and make sure that he or she is scheduled to do your case, or (2) contact your surgeon and ask your surgeon if they can arrange to have the specific anesthesia provider that you request.

 

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

 

 

ON PEDIATRIC ANESTHESIA: THE METRONOME

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)

The Russell Museum of Medical History and Innovation at Massachusetts General Hospital presented an audio recording of The Metronome at Perspectives on Anesthesia, at Boston City Hall Plaza as part of HUBweek, Boston’s festival of innovation, in October 2017.

THE METRONOME, a poem by Richard Novak, M.D.     (as published in ANESTHESIOLOGY, Mind to Mind Section 2012: 117:417).

metronome medical

To Jacob’s mother I say,

“The risk of anything serious going wrong…”

She shakes her head, a metronome ticking without sound.

“with Jacob’s heart, lungs, or brain…”

Her lips pucker, proving me wrong.

“isn’t zero, but it’s very, very close to zero…”

Her eyes dart past me, to a future of ice cream and laughter.

“but I’ll be right there with him every second.”

The metronome stops, replaced by a single nod of assent.

She hands her only son to me.

An hour later, she stands alone,

Pacing like a Palace guard.

Her pupils wild.  Lower lip dancing.

The surgery is over.

Her eyebrows ascend in a hopeful plea.

I touch her hand.  Five icicles.

I say, “Everything went perfectly.  You can see Jacob now.”

The storm lifts.  She is ten years younger.

Her joy contagious as a smile.

The metronome beat true.

 

 

 

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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*
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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

 

 

10-HOUR OUTPATIENT PEDIATRIC ANESTHETICS FOR COMBINED ATRESIA-MICROTIA (CAM) EAR RECONSTRUCTION

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)

Our anesthesia group routinely performs 10-hour outpatient pediatric anesthetics for combined atresia-microtia ear reconstruction surgeries. As of 2018, we are the only surgical/anesthetic practice in the world performing this surgery in high volume, and we are proud to have restored hearing and a cosmetic ear to hundreds of children from North America, Asia, Europe, and South America.

 SUCCESSFUL TEN-HOUR OUTPATIENT PEDIATRIC GENERAL ANESTHETICS FOR EAR COMBINED ATRESIA-MICROTIA RECONSTRUCTION

Richard J. Novak, M.D.

Adjunct Clinical Professor of Anesthesia, Stanford University School of Medicine

Joseph Roberson, M.D.

California Ear Institute, Palo Alto, California

John Reinisch, M.D.

Cedar Sinai Hospital, Los Angeles, California and Children’s Hospital  Los Angeles

Introduction

The surgical team of Joseph Roberson, M.D. and John Reinisch, M.D. regularly performs Combined Atresia-Microtia (CAM) ear reconstruction surgery on children born without normal ear anatomy.  The total anesthetic time for these surgeries regularly totals 9- 10 hours.  These children, who are generally in good health other than their undeveloped ear, are observed in the recovery room for 1 – 1 ½ hours, and are then discharged home with their parents.  As of 2018, the total number of CAM reconstructions have totaled over 350 cases.  Surgeries are performed at California Ear Institute in East Palo Alto, CA, and Waverley Surgery Center in Palo Alto, CA.  The text below describes a the anesthetic care for a typical CAM reconstruction.

Case Report

A 5-year-old male was with congenital atresia and microtia of the left ear was scheduled for combined atresia repair and microtia reconstruction under general anesthesia. The estimated duration of the surgery was 9 hours, and the case was scheduled as outpatient surgery with no overnight stay planned.  The child was healthy.  A previous general anesthetic for adenoidectomy at the age of 2 was unremarkable.  The child weighed 17 kg, and the physical exam was normal except for the deformed ear.  One anesthesiologist administered the anesthetic care.

Premedication was oral midazolam 0.75 mg/kg.  The well-sedated child was brought into the operating room 20 minutes later.  Standard non-invasive monitors were applied, and a mask induction with 8% inspired sevoflurane was carried out.  A 20-gauge IV was inserted into the left arm, and the trachea was intubated.   Maintenance anesthesia was sevoflurane 1 – 1.5% end-tidal, nitrous oxide 50%, propofol infusion at 25 – 50 mcg/kg/min, and incremental doses of fentanyl as needed. Prophylactic antiemetics included ondansetron 2 mg, dexamethasone 4 mg,  and metoclopramide 4 mg.

The operating room table was turned 180 degrees, the circulating nurse inserted a Foley catheter, and a Bair Hugger warming blanket was applied to the patient’s torso.

The surgical procedure was carried out by the otologist and plastic surgeon as previously described (1).   Local anesthesia of bupivicaine 0.5% with 1/200,000 epinephrine was injected into the scalp and ear by the surgeons as indicated.  The surgical procedure was  combined atresia repair of the middle ear, reconstruction of the external auditory canal, and Medpor microtia reconstruction of an external ear.  Total surgical time was 8 ½ hours.

A total of 160 mcg of fentanyl was administered.  Total fluids for the case were 1000 ml of Lactated Ringers intravenously, and the estimated blood loss was 20 ml.  Vital signs were stable throughout, and there was minimal physiologic perturbation. Esophageal temperature was maintained as normal.

In addition to two surgical attendings and one anesthesiologist, staffing included two R.N.’s and one scrub tech.  The surgery concluded and the surgical dressing was applied 8 ½ hours after the induction of general anesthesia.  The Foley catheter was removed.  The anesthetics were discontinued, and the trachea was extubated when the patient opened his eyes.  Post-operative pain was treated by incremental 5 mcg doses of intravenous fentanyl until the patient was comfortable and calm, and the patient was transferred to the recovery room.  The parents were allowed into the recovery room 15 minutes after extubation.  The patient was discharged from the facility 70 minutes after extubation.  At the time of discharge, the patient was alert, pain-free, nausea-free, and tolerating oral fluids, and his Aldrete Score was 9.

Discussion

This combined atresia and microtia repair, requiring a total anesthetic time approaching ten hours, is a new procedure being carried out by our surgical team.   The atresia surgery involves a post-auricular incision, drilling through the mastoid to access the middle ear, and ossiculoplasty, tympanoplasty, creation and skin grafting of an external auditory canal as necessary to reconstruct the atresia.  The microtia repair involves the implantation of the Medpor synthetic auricular prosthesis, and covering the prosthesis with skin grafts obtained from the patient’s abdomen. The surgical-anesthetic team to date has successfully performed the combined procedure on 55 patients, 90% of who were of the ages between 2 and 5 years old.  All patients are ASA I – II, without significant medical comorbidity.  Every procedure to date has been performed as an outpatient.  Patients are discharged when their post-anesthesia care unit Aldrete Score reaches 8/10, and the family and physicians agree that the patient was stable to leave the facility. The discharge times vary between 70 – 100 minutes post-extubation for the 55 patients in our series, with a mean time of 91 minutes.  Post-operative pain is well-controlled by the bupivicaine injected into the operative sites, and because of the minimal post-operative pain, it has been possible to discharge the patients home despite the very long duration of their endotracheal anesthetic.

None of the combined surgeries were performed in a hospital.  The first 20 patients were operated on at a freestanding surgery center, 2 miles distant from the nearest hospital.  Ten of the following 35 patients had their surgery in an operating room in the surgeon’s office. To date there have been no complications from the anesthetic management, and no admissions to a hospital or an emergency room following the combined procedures.

This case, one of 120+ in a series of similar cases, is noteworthy in that it markedly expands the boundaries of what is possible to safely accomplish with pediatric outpatient general anesthesia performed in a freestanding surgery center or in a surgeon’s office.

Outpatient pediatric surgery is increasingly common.  In 2006, an estimated 2.3 million ambulatory anesthetics were provided in the United States to children younger than 15 years.  Only 14,200 of these 2.3 million pediatric ambulatory anesthetics patients were admitted to the hospital postoperatively, a rate of 6 per 1000 ambulatory anesthesia episodes.  In 1996, 26 per 1000 children under the age of 15 experienced ambulatory pediatric surgery, while in 2006 that statistic increased to 38 per 1000 children.

Parents are often more satisfied with outpatient surgery over post-operative hospitalization. (3) The advantages of outpatient surgery are significant: reduced costs, lower rate of infection, avoidance of hospitalization with the inherent psychological stress, and timely return of the patients to their familiar home environment. (4)

This case report is evidence that pediatric patients can be discharged safely following a prolonged outpatient anesthetic.  Our current experience with such CAM reconstructions, exceeding 120 such cases without serious complication or adverse outcome, demonstrates that this combined procedure can be successfully carried out as an outpatient.  The duration of an anesthetic is not in itself an indication for overnight hospitalization post-operatively.  As well, selected pediatric ambulatory anesthetics of long duration can be safely performed in well-staffed operating rooms in a surgeon’s office, in addition to using a freestanding surgery center..

References:

(1)     Roberson JB Jr, Reinisch J, Colen TY, Lewin S. Atresia repair before microtia reconstruction: comparison of early with standard surgical timing.  Otol Neurotol. 2009 Sep;30(6):771-6.

(2)     Rabbitts JA, Groenewald CB, Moriarty JP, Flick R. Epidemiology of ambulatory anesthesia for children in the United States: 2006 and 1996.  Anesth Analg. 2010 Oct;111(4):1011-5. Epub 2010 Aug 27.

(3)     Erden IA, Pamuk AG, Ocal T, Aypar U. Parental satisfaction with pediatric day case surgery.Middle East J Anesthesiol. 2006 Oct;18(6):1113-21.

(4)     Mehler J.  Analgesia in pediatric outpatient surgery. Schmerz. 2006 Feb;20(1):10-6.

 

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?

*
*
*
*

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

 

 

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

 

 

PEDIATRIC ANESTHESIA: DO YOU NEED A SPECIALIST PEDIATRIC ANESTHESIOLOGIST TO ANESTHETIZE CHILDREN?

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

Clinical Case for Discussion: A 3-year-old boy is eating a McDonalds Happy Meal on the lawn of the restaurant.  A lawn mower approaches, and a rock is ejected from the mower, hitting the child in the eye.  The boy suffers  an open eye injury, and is taken to the nearest hospital.  You are on call for the  repair.  You are an experienced practitioner, but not a pediatric anesthesia specialist.  What do you do?

Discussion:  There are two issues.  One is how to do the open-eye, full stomach anesthetic, and the other is pediatric anesthesia by non-pediatric anesthesia specialists.

Your goals for this anesthetic are to protect the airway, and to avoid increases in intraocular pressure (IOP).   The list of things which increase IOP, and risk further eye damage, includes crying, coughing,  the Valsalva manuver, laryngoscopy, and endotracheal intubation.   Ketamine and succinylcholine may also increase IOP.   Trying to start an IV without causing crying in a 3 year old can be  difficult.

No single approach to this patient is ideal, but a proposed approach to this patient is:   (1)  Apply EMLA cream, with occlusive dressing, over several potential IV sites 45 – 60 minutes before the IV attempt.  Next, give the child an oral midazolam premedication (.75 mg/kg), and wait until he becomes sedated enough to start the IV.

(2)  Once the IV is in place, a modified rapid sequence induction is done with cricoid pressure, using  rocuronium  as the muscle relaxant.  Either a priming dose of the relaxant, or a dosage of 2 X the normal intubating dose is used to speed the pace of neuromuscular blockade.  A nerve stimulator is used to  confirm that depth of muscle blockade is adequate, to avoid coughing during laryngoscopy.  The FDA black box warning regarding pediatric use of succinylcholine allows for its use for emergency intubation or for patients with a full stomach, but this author prefers to avoid it if alternatives exist.   Succinylcholine causes a transient (4 – 6 minute) increase in IOP of 10 to 20 mm Hg, although there have been no clinical case reports of further eye damage or other complications in open eye surgery following succinylcholine.  (Miller, Anesthesia, 2000, 2176-79).

(3)  If the child is chubby, and you are not able to place the IV despite adequate oral sedation, you may proceed with an inhalation induction with cricoid pressure maintained throughout.  Once the child is asleep, the IV can be placed, relaxant given, and the endotracheal tube inserted.

(4)  An oral gastric tube is used to suction out the stomach.

(5)  At the conclusion of surgery, the patient is extubated awake.  The approach to this type of patient is well summarized in Gregory, Pediatric Anesthesia, 1994, p 683.

The second issue in this case is that you are not a pediatric anesthesiologist.   Los Angeles Times  articles on February 24,  and March 6, 2003, described  an infant death and a near-death at a Southern California Kaiser hospital, when pediatric anesthesia care was given by a general anesthesiologist.  This Kaiser hospital has adopted  an interim policy to  limit anesthesia care for patients under the age of  2 years to anesthesiologists with specialized pediatric training.

At Stanford University Medical Center and Packard Children’s Hospital, the University service has a team of pediatric anesthesiologists with specialized training who attend to each pediatric anesthetic.  When private or University attendings reapply for medical staff privileges at Stanford every 2 years, we are required to tally the number of children we have anesthetized in the following age groups:  (a) newborn to 6 months,  and (b)  6 months to 6 years.  A minimum number of cases is needed to maintain privileges.

Things are different at a community hospital, where a  smaller team of anesthesiologists shares night call.  Unless the hospital is very large, 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 one for the general OR.  It is common for general anesthesia practitioners to cover many or all specialties when they are on call.  If they are not comfortable with an individual case, they can seek out a better trained anesthesiologist, if one is available.  The trend for having a specialist anesthesiologist for every type of case, at all hours of the night and weekend, is a difficult one to staff.  The decision to care for a patient at  a community hospital is a judgment as to whether standards of care can be met with the physicians who are 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 older children is debatable.  Policies to define a minimum age limit for patients of general anesthesiologists may be a hot topic for the future.

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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

 

 

ANESTHESIA FACTS FOR LAYPEOPLE: TYPES OF 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)

There are several types of anesthesia:

GENERAL ANESTHESIA

A general anesthetic renders the patient asleep and insensitive to pain for surgery. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. Before the anesthetic, oxygen is administered by mask to fill the patient’s lungs with 100% oxygen. Most adult patients are given general anesthesia by intravenous injection, usually of the medication propofol. This injection causes the patient to lose consciousness within 10 – 20 seconds. This is called the induction of anesthesia. The maintenance of anesthesia during surgery is done by mixing an anesthesia gas or gases with the oxygen. Typical inhaled anesthesia gases are nitrous oxide, sevoflurane, or isoflurane. Sometimes a continuous infusion of intravenous anesthetic such as propofol is given as well. The choice and dose of drugs is done by the anesthesia attending, based on the patient’s size, age, the type of surgery, and the anesthesiologist’s experience.

Many patients are given prophylactic anti-nausea medication during the anesthetic. If postoperative pain is anticipated, the anesthesiologist can also administer intravenous narcotics such a morphine, meperidine (Demerol), or fentanyl.

Depending on the patient’s medical condition and type of surgery, the anesthesiologist may protect the patient’s airway during the general anesthetic by placing a breathing tube through the mouth, either an endotracheal tube (ET Tube) into the patient’s windpipe, or a laryngeal mask airway (LMA) just above the voice box.

At the conclusion of surgery, the general anesthetic gases and/or intravenous anesthetic infusion(s) are discontinued. The patient usually regains consciousness within 5 – 15 minutes. The patient is then transferred to the recovery room.

SPINAL ANESTHESIA

Spinal anesthesia is done by the injection of local anesthetic solution into the low back into the subarachnoid space. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The word subarachnoid translates to “below the arachnoid”. The arachnoid is one of the layers of the meninges covering the nerves of the spinal column. In the subarachnoid space lies the cerebral spinal fluid (CSF) which surrounds the spinal cord and brain. In a spinal anesthetic, the subarachnoid space is located with a needle by the anesthesiologist, and the appropriate anesthetic medications are injected.

Local anesthetics, such as lidocaine or bupivicaine (brand name Marcaine), given into the subarachnoid space, bring on sensory and motor numbness. The anesthesiologist chooses the dose and type of drug depending on the patient’s age, size, height, medical condition, and the type of surgery.

Following the onset of numbness from spinal anesthesia, the patient may either stay awake for surgery, or more often intravenous anesthesia is given to achieve a light sleep. Sometimes light general anesthesia is given to supplement spinal anesthesia.

EPIDURAL ANESTHESIA

Epidural anesthesia is done by the injection of local anesthetic solution, with or without a narcotic medication, into the low back into the epidural space. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The word epidural translates to “outside the dura”. The dura is the outermost lining of the meninges covering the nerves of the spinal column. The epidural space is located with a needle by the anesthesiologist, and the appropriate anesthetic medications are injected.   Often, a tiny catheter is left in the epidural space, taped to the patient’s low back, to allow repeated doses of the medication to be given.  The catheter is removed at the end of surgery, or sometimes days later if continued epidural medications are administered for postoperative pain control.

Local anesthetics, such as lidocaine or bupivicaine (brand name Marcaine), given into the epidural space, bring on sensory and motor numbness. The anesthesiologist chooses the dose and type of drug depending on the patient’s age, size, height, medical condition, and the type of surgery.

Following the onset of numbness from epidural anesthesia, the patient may either stay awake for surgery, or more often intravenous sedation is given to achieve a light sleep. Sometimes light general anesthesia is given to supplement epidural anesthesia.

REGIONAL ANESTHESIA

Regional anesthesia is the injection of local anesthetic (either lidocaine or Marcaine) near a nerve to block that nerve’s function.  Examples of regional anesthesia include arm blocks (axillary block, interscalene block, subclavicular block), and leg blocks (femoral block, sciatic block, popliteal block, ankle block).  An advantage of regional anesthesia blocks is that the patient may remain awake for the surgery.  If desired, the anesthesia provider may administer intravenous sedation or general anesthesia in addition to the regional anesthetic, to allow the patient to sleep during the surgery–the advantage of this combined anesthetic technique is the regional anesthetic blocks all surgical pain and less sleep drugs are required.

INTRAVENOUS ANESTHESIA

Some minor surgical procedures (for example: breast biopsies, eyelid surgery, some hernia surgeries) can be done with the combination of local anesthesia plus intravenous anesthesia sedation. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The anesthesiologist is present for the entire surgery, and administers intravenous sedatives as required for the patient’s comfort and the surgeon’s needs.  If the sedation is deep enough, the intravenous sedation will be termed general anesthesia. While the patient is sedated, the surgeon usually injects local anesthetics into the surgical site to block both surgical and post operative pain.

Vigilance by an anesthesiologist during intravenous sedation is also known as Monitored Anesthesia Care, or MAC.

PEDIATRIC ANESTHESIA

Because the separation of a young child from his or her parents can be one of the most distressing aspects of the perioperative experience, many children benefit significantly from oral preoperative sedation with midazolam. This relatively pleasant-tasting liquid is given by mouth about twenty minutes prior to the start of the anesthetic. Although the midazolam rarely causes children to fall asleep, it does reduce anxiety dramatically, allowing for a much smoother separation from parents. It also tends to cause a wonderful short term amnesia, so that the children often have no recollection of separating from their parents, or even of going to the operating room.
Although the initial anesthetic is usually administered via an intravenous infusion in adult patients, this approach requires starting an IV while the patient is still awake. This technique would be quite unpopular with younger children.  Most young children prefer to go to sleep breathing a gas, a technique known as an inhalation induction. This technique is used for almost all routine surgeries, but cannot safely be employed in certain rare situations, such as emergencies.

An inhalation induction consists of the child breathing a relatively pleasant smelling anesthetic vapor – usually sevoflurane – via a facemask for approximately 30 to 60 seconds. The child loses consciousness while breathing the gas, and the IV can then be started painlessly. Generally, the child continues to breath the gas throughout the duration of the surgery, either via the facemask or an endotracheal tube, depending on the duration and type of surgery. It is this breathing of the gas which keeps the child anesthetized. At the end of the surgery, the gas is discontinued, and the child begins to awaken.

Prior to awakening, children may be given either analgesics (pain medicines) or anti-emetics (drugs which reduce the likelihood of nausea and vomiting). The type of surgery will determine which of the many possible medications will be used for these purposes. The purpose of these medications is to make the child’s awakening as calm and pleasant as possible. Equally important in this regard is reuniting the child with his or her parents as quickly as possible.
Despite best attempts, it is important for parents to realize that children, especially those less than five years of age, often are somewhat cranky and irritable following anesthesia and surgery. We do our best to minimize this, but we cannot prevent it in all cases. Similarly, some children will experience postoperative nausea and vomiting despite receiving medications which are intended to prevent it.

 

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

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SMART PHONES AND PEDIATRIC ANESTHESIA INDUCTION

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

Clinical Case for Discussion:  A 5-year-old male is scheduled for tonsillectomy.  The child is fearful in the preoperative suite, and is crying, agitated, and clinging to his mother.  The patient refuses to swallow oral midazolam. During the preoperative interview, the mother reveals the patient’s interest in the cartoon show SpongeBob SquarePants.  What do you do?

Discussion:  You pull your smart phone out of your pocket, cue up YouTube, enter “sponge bob” into the search window, and select a SpongeBob SquarePants video.  Once the video is playing on the screen, you hand the phone to the child.  The boy immediately becomes calmer, and grows absorbed and distracted with watching the video.  You are able to wheel the patient’s gurney away from the mother and take the patient into the operating room.  The patient holds onto the phone and watches the video while the staff positions him on the operating room table, and a smooth and uneventful sevoflurane mask induction is carried out.

Anxiety at induction of anesthesia was studied in 1250 children aged 3-12 (Davidson AJ, Shrivastava PP, et al: Risk factors for anxiety at induction of anesthesia in children: a prospective cohort study,  Paediatr Anaesth 16(9):919-27.2006).  The incidence of high anxiety at induction was 50.2%. Younger age, behavioral problems with previous healthcare attendances, a longer duration of procedure, having more than five previous hospital admissions and anxious parents were all associated with high anxiety in the patients.

Cancellation of planned surgery because of child refusal is not uncommon. Nine percent of anesthesiologists responding to a survey cancelled one or more cases for child refusal in the past year, and 45% cancelled one or more cases for child refusal during their career (Lewis I, et al: Children who refuse anesthesia or sedation: a survey of anesthesiologists.  Paediatr Anaesth 17(12),1134-42.2007)

Oral midazolam premedication is the most common method for relieving anxiety in pediatric patients prior to inhalation induction.  The majority of patients are calm and sedated after oral midazolam, and separate from their parents without excessive crying.   Oral midazolam may have a delayed onset or be spit up, and child cooperation is the main variable.  Intramuscular medications are effective but cause pain, and are usually reserved for children who refuse oral premedication or those in whom lighter premedication regimens have failed in the past.  Intravenous medications are effective but require an IV be inserted in an awake child. Mask induction can be achieved without premedication.  The anesthesiologist can hold the mask over the face of a screaming child, and inhalation induction can be achieved in less than one minute, but the child may have unpleasant or fearful memories of the event.

Non-pharmacologic methods to reduce preoperative pediatric anxiety have been studied. Parents commonly request to be present during induction of anesthesia.  Many anesthetizing locations in the United States, including all facilities where the author practices, no longer permit or encourage parental presence at induction of anesthesia (PPIA).  Adding PPIA to oral midazolam premedication to treat preoperative anxiety in children has been studied versus a control group using midazolam premedication alone, and anxiety levels at the introduction of the anesthesia mask did not differ significantly between the two groups with or without PPIA.  Parents who accompanied their children to the operating room, however, were less anxious and more satisfied (Kain ZN, et al: Parental presence and a sedative premedicant for children undergoing surgery: a hierarchical study, Anesthesiology 92(4).939-46.2000).

Use of a hand-held video game for pediatric preoperative anxiolysis has been described (Patel, et al: Distraction with a hand-held video game reduces pediatric preoperative anxiety. Paediatr Anaesth 16(10).1019-27.2006).  In a randomized, prospective study of 112 children (4-12 years of age) undergoing outpatient surgery, anxiety was assessed after admission and again at mask induction of anesthesia. Patients were randomly assigned to three groups: parent presence at induction (group P), parent presence at induction + a hand-held video game (group VG), and parent presence at induction +  oral midazolam (group M). There was a statistically significant increase in anxiety (P<0.01) in groups P and M compared with baseline, but not in the video game group. A hand-held video game was concluded to be a low cost, easy to implement, portable, and effective method to reduce anxiety in children in the preoperative area and during induction of anesthesia.

The use of YouTube prior to pediatric anesthesia induction has been previously described, using a video screen attached to the anesthesia machine in the operating room (Gomes SH: YouTube in pediatric anesthesia induction. Paediatr Anaesth 18(8).801-2.2008).  The disadvantage of this method is that the YouTube video cannot be screened until the patient has already entered the foreign and sometimes-fearful environment of the operating room.  If parents are not be allowed into the operating room, the child must separate from his parent(s) prior to viewing any cartoon video.

In the 21st Century, the availability and portability of smart phones or iPads make for a superior method of inducing relaxation prior to pediatric surgery. YouTube includes a library of thousands of video clips including videos of nearly every cartoon known to children, all accessible via a 3G or wireless Internet network.  Children love cartoons, and watching a cartoon is a favorite activity of presumably every pediatric patient.  Merging the smart phone from the physician’s pocket with the children’s love of cartoons creates a wonderful opportunity for a new non-pharmaceutical premedication–video relaxation.  In addition to video entertainment, a smart phone provides access to thousands of game applications.  Playing a video game of the child’s choice prior to pediatric induction can help relax both child and the parent in the minutes prior to surgery.

If you haven’t tried it previously, pull out your smart phone and hand it to the next 5-year-old you’re scheduled to anesthetize.  The patient, his parents, and the anesthesiologist will all be smiling within minutes!

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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

 

 

HYPERTHERMIA IN A 7-YEAR-OLD PATIENT DURING EAR 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)

You are anesthetizing a 7-year-old male for middle ear surgery.  At hour two of the case, the heart rate rises to 130 beats per minute, the respiratory rate is 36 breaths per minute, and the nasal temperature is 38.5 degrees Centigrade.  What do you do?

Discussion:   Because you are a brilliant anesthesiologist, you make a diagnosis of hyperthermia.  The patient’s anesthetic drugs include  sevoflurane, but not succinylcholine.  The circulating nurse is looking over your shoulder, and says, “My God, it’s  malignant hyperthermia!  I just read about that in a nursing journal last week.  Should I start mixing up the dantrolene?  Should I get the orderlies to bring a tub of ice in here?”

Because you are a brilliant doctor, you reach over and turn off the Bair hugger, you turn off the warming blanket in the mattress, and you remove all the blankets covering the child.  You examine the patient, and confirm that he is warm and sweaty.  His pulse is rapid and otherwise feels normal.  The cardiac and pulmonary exams are normal.

You turn your attention to the other monitors.  The oximeter reads 100%, and the blood pressure is 100/60.   The end-tidal gas monitor shows the measured end-tidal CO2 concentration is 28 mm Hg.

Your nursing colleague tells the surgeon that the patient is hyperthermic, and the surgeon says to you, “What the hell is going on?  Should I stop operating?  Should they bring the malignant hyperthermia cart in here?”

Before panic sets in, you reassure them.  You tell them that malignant hyperthermia (MH) is a disorder of hypermetabolic state, which creates increased CO2 production and heat from skeletal muscle.  In MH, if ventilation is controlled at a constant rate, the end-tidal CO2 will increase.  In this patient, the spontaneous respiratory rate has increased, and your spirometer reading indicates that the minute ventilation is 200 ml X 36 breaths per minute = 7.2 liters per minute.  This patient is hyperventilating, and has a low end-tidal CO2.

In MH you expect a combined metabolic and respiratory acidosis, due to massive CO2 production.  You do not have an arterial blood gas on this patient, but the end-tidal CO2 of 28 argues against respiratory acidosis.  You are aware that measured end-tidal CO2 may be much lower than the arterial pCO2 when there is high dead space or high pulmonary shunting, but you have no reason to expect either in this healthy young patient.  The low end-tidal CO2 does not fit with fulminant MH.

You tell the surgeon and nurse that you could confirm the patient’s acid-base status by measuring an arterial blood gas, but your first move is to discontinue all the heating devices and blankets and see if the temperature and pulse rate decrease.  You inform the surgeon that your diagnosis is passive hyperthermia due to excessive patient heating, and ask him to continue operating.

In the next thirty minutes, the heart rate drifts down to 110, and the temperature decreases to 37.2.  The respiratory rate is 24 breaths per minute, and the end-tidal CO2 is 35.  The surgery finishes, the patient is awakened and the tracheal is extubated.  In the recovery room, the patient is reunited with his mother, and he has a normal temperature.

How common is malignant hyperthermia?  Miller’s Anesthesia (2010, p 1181) quotes an incidence of 1:62,000 anesthetics.  It is important that we are knowledgeable about the disease, and how to recognize and treat it, but it is the ultimate “low frequency, high impact” disease for an anesthesiologist.  Patients can die if dantrolene and the other MH protocol therapies are not utilized when MH is diagnosed.  According to Miller, even treated MH has a mortality which approaches five percent.

On the other hand, passive hyperthermia is more common, and does occur in circumstances such as those described in our patient above (Miller’s Anesthesia, 2010, p 1548).  There is very little published about the incidence of passive hyperthermia, but be aware that it exists.  Make the right diagnosis, and don’t feed dantrolene or other zebra food to hyperthermic horses.

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited

 

 

CAN WE PREVENT AGITATION IN PEDIATRIC PATIENTS FOLLOWING ANESTHESIA?

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

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

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

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

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

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

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

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

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

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

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited