DO DOCTORS EVER RIDE IN AMBULANCES?

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

Do doctors ever ride in ambulances? Ambulances are a territory usually staffed by Emergency Medical Technician (EMT) personnel, but yes, in certain emergencies doctors do ride in ambulances.

In the process of doing 30,000 anesthetics, I’ve taken several rides in the back of an ambulance with my patients. Why? Sixty-six percent of surgeries in the United States take place as an outpatient, and many of these surgeries are performed at freestanding facilities distant from hospitals. When a patient decompensates emergently at a freestanding ambulatory surgery center or in an operating room at a doctor’s office, the facility will call for an ambulance staffed with EMT personnel. If the patient is unstable, a physician, usually an anesthesiologist, will need to accompany the patient and the EMTs to the hospital emergency room.

The following are examples of cases in which I or my colleagues have ridden in ambulances from freestanding surgery centers to the Stanford Emergency Room and Stanford Hospital in Palo Alto, California:

  1. A 3-year-old girl developed negative pressure pulmonary edema with plummeting pulse oximetry readings 10 minutes after a tonsillectomy. Her breathing tube had been removed, but she developed upper airway obstruction in the Post Anesthesia Care Unit (PACU) and needed urgent reintubation. She was extubated one hour later at the surgery center after treatment with diuretic, oxygen, and ventilation via the tube. She was then transferred to the hospital for overnight observation of her airway, pulmonary function, and oxygenation. The duty in the ambulance included monitoring her oxygenation, her airway and her breathing.  The presence of an anesthesiologist was reassuring to the stunned parents who had no expectation of a complication after a common surgery such as a tonsillectomy. The patient was discharged the following day without further complication.
  2. A 75-year-old female underwent lateral epicondylitis release surgery on her right elbow, and developed acute pulmonary edema with failing oxygen saturation levels at the conclusion of surgery. The patient had a past history of aortic stenosis, and had her aortic valve replaced with a small metal valve two years earlier. She was active, although she did experience mild shortness of breath on walking stairs. She was obese with a BMI=35. She received a general anesthetic with an endotracheal tube. The surgery was simple and the surgical duration was only 17 minutes. When the anesthetics were discontinued at the end of surgery, her blood pressure climbed to markedly high levels, and her heart failed to pump effectively against the elevated blood pressure. Pulmonary edema fluid filled her lungs and filled the hoses of the anesthesia machine. Her oxygenation returned to normal after titrating her BP down with a nitroprusside drip, and her blood pressure needed to be monitored continuously by an arterial line inserted into her radial artery at the wrist. The duty in the ambulance included ventilating the patient via the Ambu bag, keeping the patient sedated, watching the arterial line pressure continuously, and titrating the level of the vasodilating nitroprusside infusion. She remained intubated overnight in the hospital and was extubated the next day. She survived without any further complication and did not have a myocardial infarction. 
  3. A healthy 45-year-old woman developed acute hypotension 6 hours following a laparoscopic hysterectomy. The surgery was done in a small community hospital where there was no ICU, blood bank, or emergency room. The patient had multiple low-normal blood pressure readings over the first 5 hours postoperatively, and was being observed by the nursing staff. At hour 6 her blood pressure dropped to a dangerously low level and her hematocrit level on a portable device came back as 9.9%, indicative of a severe acute anemia. She was transferred urgently to the hospital. The duty in the ambulance included resuscitation with IV fluids, and observation of her airway and breathing as her level of consciousness dropped. She required repeat surgery at the hospital to control the intraabdominal bleeding, as well as preoperative transfusion to treat her anemia and hypovolemic shock.

These three cases are examples of surgical patients who became acutely ill miles from the nearest hospital. Each case illustrates how a failure of airway, breathing, or circulation can lead to an emergency. The problem in the first case was airway obstruction leading to pulmonary edema. The problem in the second case was lungs filled with fluid which made normal breathing impossible. The problem in the third case was bleeding which caused the normal circulation of blood within the body to be inadequate.

Why did an anesthesiologist travel with each patient? 

  1. Each patient was extremely sick and required acute monitoring and treatment, and medical decisions needed to be made during the trip to the hospital. EMTs are trained in resuscitation, but EMT training is only a fraction of anesthesiologist training. Having the anesthesiologist who was already resuscitating the patient continue to care for the patient en route to the hospital was the wisest course.
  2. Acute medical emergencies are defined by resuscitation of Airway-Breathing-Circulation. Anesthesiologists are the physicians with the highest level of airway skills, as well they are experts in acute resuscitation. If any physician is to travel with the patient, an anesthesiologist is the wisest choice to manage Airway-Breathing-Circulation in ongoing emergencies.
  3. Medical-legal risk is minimized if the most highly trained physician involved in the case continues to manage the case. The handoff or transfer of medical care from one practitioner to another is a high risk time for errors. The anesthesiologist  is responsible for the safety and care of his or her patient, and the highest continuity of care occurs when the anesthesiologist who managed the emergency attends to the patient during the transfer to the hospital.

I’ve been the Medical Director at a freestanding surgery center near Stanford for the past 17 years. Surgery centers strive to minimize the potential of emergencies in outpatient surgeries. Medical Directors work to limit the types of cases performed in a freestanding surgery center. This includes avoiding procedures that cause major pain, bleeding, or disruption of physiology. Typical surgeries performed in freestanding centers include:

  • Arthroscopic orthopedic surgeries
  • Simple ear nose and throat surgeries
  • GI endoscopies and colonoscopies
  • Simple general surgery procedures
  • Simple ophthalmologic surgeries
  • Plastic surgeries

Surgery centers also strive to operate on healthier patients who lack major comorbidities. Surgery centers are reluctant to approve general anesthesia in a freestanding outpatient setting to patients who have: 

  • Severe sleep apnea
  • Severe cardiac problems such as shortness of breath or ongoing chest pain
  • Severe morbid obesity or super-morbid obesity
  • Renal dialysis
  • Severe abnormal airways
  • Markedly abnormal blood pressures, heart rates, or blood oxygen levels

Regarding ambulance rides, no one is going to advocate that MDs take over EMTs roles regarding riding in ambulances. But when surgery or anesthesia leads to an acute event at a site distant from a hospital, the anesthesiologist involved in that patient’s care is responsible for that patient’s safety and for the ongoing care and resuscitation. The anesthesiologist will be riding in the ambulance and doing what anesthesiologists routinely do–managing Airway-Breathing-Circulation.

If any anesthesia professionals have stories regarding their own emergency ambulance rides resuscitating patients, I invite you to share them with my readers. 

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INTRAVENOUS CAFFEINE FOLLOWING GENERAL ANESTHESIA

the anesthesia consultant

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

Data exists that intravenous caffeine may be effective in assisting the awakening of patients following general anesthesia. Will future anesthesiologists routinely use caffeine to wake patients after surgery? Will a shot of IV espresso be the stimulus for you to return to consciousness after your general anesthetic? Perhaps. 

Caffeine is the most popular and commonly used psychoactive drug in the world.In 2014 85% of American adults consumed some form of caffeine daily, 164 mg/person/day on the average.1A cup of coffee contains from 80 to 120 mg of caffeine.A 12-ounce cola contains from 30 to 50 mg. Currently intravenous caffeine is marketed as a three milliliter ampule that contains only 20 mg/ml of caffeine, or 60 mg total. Multiple commercial energy drinks include significantly higher doses of caffeine per the chart below

The safety of caffeine has been well established, and the energy drink market is expected to reach 83.4 billion dollars by 2024.

The market share for leading energy drink brands is shown below.

 

Intravenous caffeine post-surgery is not a new idea. When I first went into the private practice of anesthesia in 1986, gray-haired anesthesiologists at our community hospital in Fremont, California occasionally injected 100 mg of caffeine into a patient’s IV after a surgery if the patient was slow to wake. “It helps a lot!” my fellow anesthesiologists reported. I tried it on several of my patients who had prolonged awakening after general anesthesia. It seemed to speed the time to eye opening, but I had no metrics or data to evaluate whether this was a bona fide finding. Now we have more information.

The Department of Anesthesia and Critical Care at my alma mater the University of Chicago School of Medicine published two landmark papers on IV caffeine and anesthesia awakening. The first studies were conducted on rats.2Researchers placed rats in a gas-tight anesthesia box where the animals were exposed to 3% isoflurane until they became unconscious. The rats were then removed from the box, 2% isoflurane was delivered to them via an anesthesia nose cone, an intravenous line was inserted into their tails, and the rats were returned to the anesthesia box. After a total of 45 minutes of exposure to isoflurane, either IV caffeine 25 mg/kg or a placebo was injected into the IV. Anesthesia was terminated 5 minutes later and the rats were placed on their backs on a table. The recovery time was the time from when the animals were removed from the anesthesia box until they stood with four paws on the table. Rats who received IV caffeine doses awakened more quickly (in as quick as only 40% of the time) compared to those who received placebo.

In a second experiment they exposed rats to propofol anesthesia. The researchers placed the rats in a gas-tight anesthesia box where they were exposed to 3% isoflurane until they became unconscious. The rats were then removed from the box, an intravenous line was inserted into their tails, and they were allowed to wake up. A bolus of 4 mg/kg propofol was injected into the IV along with either 25 mg/kg caffeine or a placebo. Those treated with caffeine woke within an average of 6 minutes compared to 9.8 minutes for controls. There were no vital signs differences between the groups treated with caffeine or placebo in either rat experiment.

The Chicago researchers followed the rat studies with a randomized controlled study on human volunteers.3Eight healthy males each underwent two general anesthetics, one with IV caffeine and one without. The induction was with IV propofol, a laryngeal mask airway (LMA) was placed, and anesthesia was continued with isoflurane for one hour. Ten minutes before the termination of each anesthetic, the subjects were randomized to receive either IV caffeine 15 mg/kg or a saline placebo. (Note that this dose approximates 1000 mg of caffeine for a 70 kg adult, a large dose.) The recovery time was charted as the time from when the isoflurane was discontinued until the time the patient first gagged on the LMA. The average recovery time in the caffeine group was 9.6 minutes versus 16.5 minutes in the control group (P=0.002), a 42% reduction in time. Once again, there were no vital signs differences between the subjects treated with caffeine or with placebo.

Why does caffeine accelerate awakening from anesthesia? The Chicago researchers cited two mechanisms: caffeine acts by inhibiting phosphodiesterase to elevate intracellular cAMP, and it also antagonizes adenosine receptors A1and A2A. Caffeine reversibly blocks the action of adenosine on its receptors and consequently prevents the onset of drowsiness induced by adenosine.

Currently the only medical uses for caffeine are to treat neonatal apnea and to treat migraine or postdural puncture spinal headaches. Despite the fact that caffeine is considered safe,caffeine overdose can result in a central nervous system overstimulation called caffeine intoxication which typically occurs only after ingestion of large amounts of caffeine, (e.g. more than 400–500 mg at a time).4This is only half the dose that Chicago researchers administered in their human study. Symptoms of caffeine intoxication include restlessness, anxiety, a rambling flow of thought and speech, irritability, and irregular or rapid heartbeat.5Massive overdoses of caffeine can result in death. The LD50(lethal dose in 50% of cases) of caffeine in humans is estimated to be 150–200 mg per kilogram of body mass (i.e. 100-130 cups of coffee for a 70 kilogram adult).6

It’s too soon for caffeine use to become routine in the operating room. The Chicago researchers did not envision caffeine as a routine reversal agent for all general anesthetics. Anesthesiologists are skilled at weaning their patients from anesthetics for timely wakeups after the conclusion of most surgeries, but there are always outliers who are slow to wake. For these patients, a dose of IV caffeine may be helpful without introducing any increased risk. The Chicago researchers wrote, “the judicious use of caffeine could provide a tool to accelerate emergence in those individuals who manifest unanticipated prolonged emergence times and populations, such as the elderly, that are prone to prolonged emergence and recovery. . . . Further work is needed, and will follow, to extend these findings to other anesthetics including common IV agents like propofol, as well as demonstrating that these results are reproducible in patient populations, including females, older individuals, and those with chronic medical conditions undergoing operative procedures who receive multiple classes of pharmacologic agents in the course of a normal anesthetic.”

We may see intravenous caffeine following general anesthesia in the future for selected patients. Those private anesthesiologists I worked with in 1986 may have been correct when they injected IV caffeine into their sleepy patients after surgery and judged that “It helps a lot!”

References:

  1. Mitchell DC, et al (January 2014). “Beverage caffeine intakes in the U.S”. Food and Chemical Toxicology. 63: 136–42.
  2. Wang Q, et al. Caffeine accelerates recovery from general anesthesia, J Neurophysiol, 2014 Mar;111(6), 1331-1340.
  3. Fong R, et al. Caffeine accelerates emergence from isoflurane anesthesia in humans, Anesthesiology. 2018 Nov;129(5):912-920.
  4. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). American Psychiatric AssociationISBN 978-0-89042-062-1.
  5.  “Caffeine (Systemic)”. MedlinePlus. 25 May 2000. 
  6.  Holmgren P, Nordén-Pettersson L, Ahlner J (January 2004). “Caffeine fatalities–four case reports”. Forensic Science International. 139 (1): 71–3.

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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ARTIFICAL INTELLIGENCE IN ANESTHESIA AND PERIOPERATIVE MEDICINE IS COMING

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

artificial_intelligence_ai_healthcare

 

My editorial “Artificial Intelligence in Anesthesia and Perioperative Medicine is Coming” was just published in EC Anaesthesia. I refer you to the direct link here.

Highlights from the paper follow:

Artificial intelligence in medicine (AIM) will grow in importance in the decades to come and will change anesthesia practice, surgical practice, perioperative medicine in clinics, and the interpretation of imaging. AI is already prevalent in our daily life. Smartphones verbally direct us to our destination through mazes of highways and traffic. Self-driving cars are in advanced testing phases. The Amazon Echo brings us Alexa, an AI-powered personal assistant who follows verbal commands in our homes. AIM advances are paralleling these inventions in three clinical arenas:

1. Operating rooms: Anesthesia robots fall into two groups: manual robots and pharmacological robots. Manual robots include the Kepler Intubation System intubating robot, designed to utilized video laryngoscopy and a robotic arm to place an endotracheal tube [1], the use of the DaVinci surgical robot to perform regional anesthetic blockade [2], and the use of the Magellan robot to place peripheral nerve blocks [3,4]. Pharmacological robots include the McSleepy intravenous sedation machine, designed to administer propofol, narcotic, and muscle relaxant [5], and the iControl-RP machine, described in The Washington Post as a closed-loop system intravenous anesthetic delivery system which makes its own decisions regarding the IV administration of remifentanil and propofol [6]. This device monitors the patient’s EEG level of consciousness via a BIS monitor device as well as traditional vital signs [7]. One of the machine’s developers, Mark Ansermino MD stated, “We are convinced the machine can do better than human anesthesiologists.” The current example of surgical robot technology in the operating room is the DaVinci operating robot. This robot is not intended to have an independent existence, but rather enables the surgeon to see inside the body in three dimensions and to perform fine motor procedures at a higher level. The good news for procedural physicians is that it’s unlikely any AIM robot will be able to independently master manual skills such as complex airway management or surgical excision. No device on the horizon can be expected to replace anesthesiologists. Anesthetizing patients requires preoperative assessment of all medical problems from the history, physical examination, and laboratory evaluation; mask ventilation of an unconscious patient; placement of an airway tube; observation of all vital monitors during surgery; removal of the airway tube at the conclusion of most surgeries; and the diagnosis and treatment of any complication during or following the anesthetic.

2. Clinics: In a clinic setting a desired AIM application would be a computer to input information on a patient’s history, physical examination, and laboratory studies, and via deep learning establish a diagnosis with a high percentage of success. IBM’s Watson computer has been programmed with over 600,000 medical evidence reports, 1.5 million patient medical records, and two million pages of text from medical journals [8]. Equipped with more information than any human physician could ever remember, Watson is projected to become a diagnostic machine superior to any doctor. AIM machines can input new patient information into a flowchart, also known as a branching tree. A flowchart will mimic the process a physician carries out when asking a patient a series of increasingly more specific questions. Once each diagnosis is established with a reasonable degree of medical certainty, an already-established algorithm for treatment of that diagnosis can be applied. Because anesthesiology involves preoperative clinic assessment and perioperative medicine, the role of AIM in clinics is relevant to our field.

3. Diagnosis of images: Applications of image analysis in medicine include machine learning for diagnosis in radiology, pathology, and dermatology. The evaluation of digital X-rays, MRIs, or CT scans requires the assessment of arrays of pixels. Future computer programs may be more accurate than human radiologists. The model for machine learning is similar to the process in which a human child learns–a child sees an animal and his parents tell him that animal is a dog. After repeated exposures the child learns what a dog looks like. Early on the child may be fooled into thinking that a wolf is a dog, but with increasing experience the child can discern with almost perfect accuracy what is or is not a dog. Deep learning is a radically different method of programming computers which requires a massive database entry, much like the array of dogs that a child sees in the example above, until a computer can learn the skill of pattern matching [9]. An AIM computer which masters deep learning will probably not give yes or no answers, but rather a percentage likelihood of a diagnosis, i.e. a radiologic image has a greater than a 99% chance of being normal, or a skin lesion has a greater than 99% chance of being a malignant melanoma. In pathology, computerized digital diagnostic skills will be applied to microscopic diagnose. In dermatology, machine learning will be used to diagnosis skin cancers, based on large learned databases of digital photographs. Imaging advances will not directly affect anesthesiologists, but if you’re a physician who makes his or her living by interpreting digital images, you should have real concern about AIM taking your job in the future.

There’s currently a shortage of over seven million physicians, nurses and other health workers worldwide [10]. Can AIM replace physicians? Contemplate the following: All medical knowledge is available on the Internet; most every medical diagnosis and treatment can be written as a decision tree algorithm; voice interaction software is excellent; the physical exam is of less diagnostic importance than scans and lab tests which can be digitalized; and computers are cheaper than the seven-year post-college education required to train a physician. There is a need for cheaper, widespread healthcare, and the concept of an automated physician is no longer the domain of science fiction. Most sources project an AIM robot doctor will likely look like a tablet computer. For certain applications such as clinical diagnosis or new image retrieval, the AIM robot will have a camera, perhaps on a retractable arm so that the camera can approach various aspects of a patient’s anatomy as indicated. Individual patients will need to sign in to the computer software system via retinal scanners, fingerprint scanners, or face recognition programs, so that the computer can retrieve the individual patient’s EHR data from an Internet cloud. It’s possible individual patients will be issued a card, not unlike a debit or credit card, which includes a chip linking them to their EHR data.

It’s inevitable that AIM will change current medical practice. In all likelihood these changes will be more powerful and more wonderful than we can imagine. A bold prediction: AIM will change medicine more than any development since the invention of anesthesia in 1849. How physicians interact with these machines will be a leading question for the twenty-first century.

 

SURGICAL CASES IN FOREIGN LANDS—INTERPLAST

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

Interplast1-750x403

International Plastic Surgery

Imagine . . . rare unrepaired surgical cases in foreign lands, coupled with surgeons in America who rarely have the opportunity to operate on such cases. A win-win situation would be to fly American medical teams overseas to help these patients. This model for plastic and reconstructive surgery was born at Stanford University Medical Center in the 1960s in an organization named Interplast. During my anesthesia training at Stanford in the 1980s I was present through the growth years of Interplast, when traveling teams were dispatched to countries around the world to perform reconstructive surgeries on cleft lip and palate patients. Interplast was founded by Donald Laub MD, who was the Chief of the Division of Plastic and Reconstructive Surgery at Stanford from 1968-1980.

220px-DRLaub

Donald Laub MD

The idea for Interplast grew from the surgical history of Antonio Victoria, a 13-year-old with cleft lip and palate deformities that made him a social outcast in his home country of Mexico. Antonio arrived at Stanford University Medical Center in 1965. Dr. Robert Chase restored the boy’s appearance with three operations. Dr. Laub witnessed Antonio’s transformation and the idea for Interplast germinated.

In 1969 Dr. Laub founded Interplast (now called ReSurge International) with a mission statement to transform lives through the art of plastic and reconstructive surgery. Dr. Laub chronicles his history on his website Many People, Many Passports. Dr. Laub was the first academic to develop and lead multidisciplinary teams on humanitarian surgical trips to developing countries. The teams included plastic surgeons, anesthesiologists, pediatricians, and nurses experienced in the care of cleft palate reconstructions. The first trip to Mexicali was financed with a mere $500 of donations. Through contact with the governments and medical authorities in four countries, initial trips were scheduled to Mexico, Guatemala, Honduras, and Nicaragua. Seven hundred and fifty patients received treatment during the first five years, and an additional 150 were transported to Stanford for reconstructions in California. Through the 1970s and 1980s Interplast made trips to multiple other countries. The teams were made up of volunteers, and the trips were financed by charity donations.

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Cleft lip deformity before and after reconstruction

Cleft lip and cleft palate deformities were common in Mexico and Central America, and the chances for surgical repair in the poor areas of these countries were minimal. Individuals with other deformities such as extensive burn scars were also social pariahs because of their appearance. Interplast made it a humanitarian goal to reconstruct these patients as well.

In addition to reconstructing patients, Interplast doctors educated local physicians in modern techniques. This was the medical equivalent of “give a man a fish and he eats for a day, but teach a man to fish and he will eat for a lifetime.” The opportunity to reconstruct patients with deforming diagnoses uncommon in the United States was life-changing for the American doctors as well. In the United States, the specialty of plastic surgery was seen as one concerned with enhancing the cosmetic appearance of cash-paying customers who desired a more youthful or beautiful appearance. In the third world, helping change a deformed child’s appearance was a unique emotional reward for American physicians who traveled there.

The administration of the Stanford University School of Medicine understood the value of the program. Stanford lent financial support to Interplast and financed Interplast rotations as part of the residency training programs in plastic surgery and anesthesiology. In our final year of anesthesia residency, each resident was assigned to a one week Interplast trip to perform anesthetics overseas. The week was not a vacation—we were paid during that week and the expenses of our airfare were covered by Interplast. Trip members typically lodged with members of the local community.

In 1986 I was assigned to San Pedro Sula, Honduras for my Interplast experience. Two weeks before we were to depart, our team assignment was changed to Montego Bay, Jamaica. I asked my faculty member if that was a positive change and he remarked, “You just traded the dusty streets of San Pedro for a Caribbean resort city. What do you think?”

Each Interplast anesthesia team included one faculty member and one or more resident. For my trip the anesthesia staff consisted only of myself and one Stanford attending—thus I received both an introduction to international pediatric anesthesia and one-on-one teaching from an experienced professor.

A striking difference between Interplast anesthesia and American anesthesia was the lack of sophisticated equipment overseas. Interplast members carried no narcotic medications across borders, for obvious political reasons. All postoperative pain was treated with local anesthesia injections from the surgeons (if local anesthetics were available), or by verbal reassurance from the nurses in the Post Anesthesia Recovery Unit (PACU). The PACU was often full of children screaming in pain after their palate surgeries. There are many nerve endings in the human palate, and after cleft palate reconstruction the pain is roughly equivalent to the pain of a tonsillectomy without any narcotic analgesia. It was difficult to listen to the children crying, but in time their pain would subside.

In the 1980s Interplast teams carried halothane, a potent liquid general anesthetic, as well as a halothane vaporizer to convert the drug into an inhaled gas. General anesthetics were initiated by holding a mask over a child’s face while they inhaled halothane vapor until they fell asleep. We started intravenous lines after the induction of anesthesia, but we had very few medications to inject into those IVs. Because there were dozens of cases to be done, the anesthesia attending and the anesthesia resident each did their cases alone and independently, in adjoining operating rooms. The rooms were primitive and usually had piped in oxygen, but lacked nitrous oxide availability.

Complications were rare, but their incidence was not zero. The combination of tiny patients, a paucity of medical drugs, a relatively inexperienced (i.e. not fully trained yet) anesthesia resident working alone, no ICU, no laboratory, and no emergency backup made every case an adventure. We had no complications on our trip, but there were a few anecdotes of cardiac or respiratory arrests from my colleagues who went to other countries.

As a partially-trained resident, I’d anesthetized less than 20 children in my life by the time of my Interplast trip. I was nervous during every anesthetic induction and every anesthetic wakeup. There were no American lawyers or malpractice suits to worry about in Montego Bay, but my job required me to accept responsibility for a child’s life. I’d take a child from his or her parents prior to the surgery and I didn’t want anything but a happy ending for that child, his parents, or me at the end of the day. We performed anesthetics from dawn until dusk. The lines of patients awaiting surgery were long, and each family clamored for the opportunity for their child to receive life-changing free surgeries from the American team.

Dr. Laub set the tone for Interplast. He made 159 trips and personally performed over 1500 operations overseas. He was and is a giving, confident, warm, and intellectual visionary. HIs office was decorated with a 1986 photograph of himself and President Reagan in Washington DC, marking the 1986 Private Sector Initiatives award Dr. Laub received for the creation of Interplast.In 2000 Dr. Laub was diagnosed with an aggressive intravascular central nervous system lymphoma. He survived the malignancy but retired from active clinical practice. I admire him for his surgical skills, entrepreneurial skills and positive attitude. No matter what difficulties arose in one’s life, Dr. Laub was ready to listen, quick to smile, and in closing he’d say, “May the wind always be at your back.”

I’ve continued to anesthetize children throughout my career. Anesthetizing toddlers by yourself is not like riding a bike. Once you learn to do it, the skills must be retained with frequent repetition or else you run the risk of being unsafe. The majority of anesthesiologists cease anesthetizing children soon after residency, and choose not to build on the pediatric anesthesia skills they learned as trainees. I feel fortunate that my practice still includes anesthetizing children every week. In part I owe this to Interplast for introducing me to my early pediatric anesthesia experiences.

A medical career requires years of memorizing facts as well as tireless nights and days attending to sick patients to learn the art and science of healing. Interplast taught more—the doctors and nurses who journeyed to foreign lands to improve the lives of poor children reaped the emotional benefits of being a medical professional. Nothing in our job feels better than helping a sick child become healthier or helping a family gain a new lease on that child’s future.

Interplast has now become Resurge International (REF https://www.resurge.org). To date Resurge has performed 95,000 operations in 15 countries. The times are different, but the issues are still the same. Opportunities with Resurge are described on their website.

We’re lucky in America. Despite criticisms of our medical system and its costs, the availability of outstanding medical care is just a few miles down the road for most of us. Interplast patients were elated to benefit from American medicine abroad.

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

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

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

Will I Have a Breathing Tube During Anesthesia?

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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GRADY HARP REVIEWS DOCTOR VITA. “A SPLENDID AND TIMELY NOVEL”

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

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Grady Harp, Amazon Hall of Fame Top 100 Reviewer

April 20, 2019

Once again Rick Novak serves up a virulent novel that addresses an ongoing change in medicine that worries most of us – the growing dependence on robotics in surgery and the dehumanization of medicine: doctor patient interaction is altered by EMR and IT reporting of visits to insurance companies and the warmth of communication suffers. Rick takes this information to create a story about the extremes of AI in the form of a glowing globe that is Dr Vita and the struggle computer scientist/anesthesiologist Dr Lucas assumes as he tries to save medicine from the extremes of the ‘new age’ called FutureCare. As expected, Rick’s recreation of the tension in the OR and in interaction of the physicians is on target: his own experiences enhance the veracity of the story’s atmosphere.

Rick Novak writes so extremely well that likely has answered the plea of his readers to continue this `hobby’. He is becoming one of the next great American physician authors – think William Carlos Williams, Theodore Isaac Rubin, Oliver Wolf Sacks, Richard Selzer, and also the Brits Oliver Wendell Holmes et al. Medicine and writing can and do mix well in hands as gifted as Rick Novak. Highly Recommended. Grady Harp, April 19

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THE FIRST CHAPTER OF DOCTOR VITA BY RICK NOVAK

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

robotic-procedures

The first chapter of Doctor Vita by Rick Novak opens with a scene unlike any you’ve ever read before.

Chapter 1    THE BRICKLAYER

Alec Lucas’s first contact with FutureCare came in operating room #19 at the University of Silicon Valley Medical Center, where his patient Elizabeth Anderson blinked into the twin suns of the surgical lights hanging from the ceiling. A clear plastic oxygen mask covered Elizabeth’s nose and mouth, her cheeks were pale and tear-stained, and a strand of gray hair protruded from a blue paper bonnet. Her hand trembled as she reached up to remove the mask.

“I’m scared,” she said.

“I’m not,” said Dr. Lucas, who was her anesthesiologist. A green paper mask covered his face, but his pale blue eyes sparkled at her. He hummed to himself as he injected a dose of midazolam into Elizabeth’s IV to relax her.

“Am I crazy to go through this?” she said. “A 78-year-old lady with cancer?”

“We’re hoping your cancer can be cured with surgery,” Alec said. “Right now you’re doing great. Everything is perfect. Have a wonderful dream.” Elizabeth had cancer of the stomach, and presented today for robot-assisted laparoscopic surgery to remove half her stomach. It was a huge surgery—a risky surgery. Alec wondered why they were doing this operation on this lady. He questioned the aggressive strategy for a woman this old, but his job was to anesthetize, not to philosophize.

He’d seen presurgery anxiety like hers hundreds of times. The best way to cure her fears was to get her off to sleep. He injected doses of propofol and rocuronium into her intravenous line. The drugs flowed into Elizabeth’s arm, and within ten seconds her eyes closed. He inserted the lighted blade of a laryngoscope into her mouth, and visualized the white and shining upside-down “V” of her vocal cords, hovering in a sea of pink tissue. He slid a hollow plastic tube between the cords and into the blackness of the trachea beyond. Then he activated the ventilator, which blew a mixture of oxygen and sevoflurane through the tube into her lungs.

“I haven’t worked with you before, Dr. Lucas,” said the circulating nurse, who stood at the patient’s side. “My name is Maggie.”

“Of course you’ve never worked with me,” he said. “I told the nursing supervisor I never wanted to work with Maggie.” Then he winked at her and said, “We haven’t worked together because today is my first day on staff here. I’ve been at the University of Chicago since my first day of medical school. After fifteen years of shoveling snow, it was time to give California a try.”

Alec looked up as the surgeon, Xavier Templeton, entered the room. A tall scrawny man, Templeton had pale hairless matchstick arms that looked better hidden within a surgical gown. His bushy eyebrows met in the midline, and his left eye squeezed in an involuntary tic. Templeton’s hands wouldn’t touch Elizabeth Anderson’s skin or stomach today. His hands would control two levers on a console worthy of a spacecraft, and each move he made would be translated into the movement of a five-armed machine named the Michelangelo III, also known as The Bricklayer.

The five slender mechanical arms of The Bricklayer, dull gunmetal gray in color, dangled like the legs of a giant spider above Elizabeth Anderson’s abdomen. Each arm was draped in clear plastic to keep The Bricklayer sterile when it entered her body through tiny incisions.

Alec accepted his role of goaltender at the Pearly Gates. His assignment was to keep Elizabeth Anderson asleep and alive, while Templeton and The Bricklayer resected her tumor.

Twenty minutes into the surgery, Xavier Templeton sat on a chair in the corner of the room with his back to the operating table, and peered into a binocular stereo viewer. His hands maneuvered two levers on the console before him. On the operating table, the five robot arms reached into the abdomen though five one-centimeter incisions. One of the arms held a camera on a thin metal rod, movable at the surgeon’s control. A seventh-year resident worked as a surgical assistant, and attached appropriate operating instruments to the other 18-inch-long robot arms.

The two surgeons murmured to each other in quiet voices. Alec watched the surgery on a large flat screen video monitor that hung above him. He saw pink tissues, robot fingers moving, and a lot of irrigating and blunt dissection. The surgery was going well, and Alec made only minor adjustments in his drug doses and equipment as needed.

Then one thing changed.

One of the robot fingers on the video screen convulsed in staccato side-to-side slicing movements of its razor-sharp tip. A clear plastic suction tube exiting from the patient’s abdomen lurched and became an artery of bright red blood. The scarlet tube emptied into a bottle two feet in front of Alec. In sixty seconds the three-liter bottle was full of blood. Fifty-eight seconds prior to that, Alec was on his feet and both hands were moving. A flip of a switch sent a stream of fluid through the biggest IV into the patient. He turned off all the anesthesia gases and intravenous anesthetic medications.

“Big time bleeding, Dr. Templeton,” Alec shouted to the surgeon.

As fast as he could infuse fluid into two IVs, Alec could not keep up with the blood loss draining into the suction tube. The blood pressure went from normal to zero, and a cacophony of alarms sounded from the anesthesia monitoring system.

Templeton descended from his perch on the far side of the room, and put on a sterile gown and gloves. He took a scalpel from the scrub tech, and in one long stroke made an incision down the midline of the abdomen from the lower end of the breastbone to the pubic bone. With two additional long swipes, the left and right sides of Elizabeth Anderson parted. A red sea rose between them. The surgical resident and the scrub tech held suction catheters in the abdomen, but the stream of blood bubbled upward past the catheters. Templeton cursed and reached his right hand deep to the posterior surface of the abdominal cavity, feeling for the blood vessel on the left side of the spinal column. He found it, and squeezed the empty and pulseless aorta.

Alec looked at the monitors. The blood pressure was zero, and the electrocardiogram showed the heart was whipping along at a rate of 170 beats per minute. His patient had one foot in the grave. “Have you got control up there?” he screamed at Templeton.

“God damn it! I’m squeezing the aorta between my fingers,” Templeton answered. “As soon as I can see, I’ll put a clamp on the vessel. The bleeding is everywhere. I can’t see a damn thing.” Templeton’s face, mask, hat, and gown were drenched with the blood of Elizabeth Anderson. His unibrow was a red and black dotted line.

“Fire up the Maytag,” Alec said to Maggie. “Call the blood bank and activate the massive transfusion protocol.” Alec bent over the Maytag, a rapid blood infusion device with a bowl the size of a small washing machine. He turned the Maytag to its top flow rate. The machine hummed and spun, and the basin of IV fluid emptied into Elizabeth Anderson through a hose as wide as a small hot dog.

Despite the infusion of fluid, her blood pressure peaked at a dismal 65/40. “Have you found the hole yet?” he said to Templeton.

“Torn aorta. There are multiple holes—the aorta’s leaking like a sprinkler hose,” Templeton said without looking up. His left eye was blinking and squeezing repeatedly as he worked. “It’s terrible. The inferior vena cava is shredded and the blood from the lower half of her body is pouring out into her abdomen. The blood is everywhere.” Blink, squeeze. “Her vessels are falling apart like tissue paper.”

An orderly ran into the operating room carrying a red plastic beer cooler. Alec grabbed the cooler and popped off the top. Inside were six units of packed red blood cells, six units of fresh frozen plasma, and six units of platelets from the blood bank. “Check all the units and let’s get them flowing,” he said to Maggie.

Maggie picked up each bag and double-checked the patient’s name and the unit numbers with a second nurse, and then she handed the entire cooler to Alec. He drained each of the units of blood products into the basin of the Maytag, and the bowl hummed and pumped the blood into Elizabeth Anderson. The blood pressure began to climb, but one look at the crimson suction tubes exiting the patient’s stomach told Alec they were still in trouble. The bleeding wasn’t slowing. Blood was exiting faster than he could pump it in.

“We need a second cooler of blood products stat!” he said. Maggie picked up a telephone and relayed the order to the blood bank.

Alec looked at the surgical field, and the patient’s blood was everywhere—on Templeton’s face, hands, gown, on the surgical drapes and on the floor. It was everywhere but where it needed to be—inside her blood vessels. Templeton’s resident was jamming a suction catheter into the abdomen next to Templeton’s fingers, trying to salvage as much blood as he could.

“Damn it,” Templeton said. “She’s still bleeding, and now she’s bleeding pink piss water. I can see through her blood, it’s so dilute. How much fluid have you given her?”

“Six units of blood, six units of plasma, six units of platelets, and eight liters of saline.”

Alec glanced at the monitors and saw that her blood pressure had plateaued at a near-lethal level of 40/15.

“Her blood isn’t clotting anymore,” Templeton said. “The blood’s oozing and leaking everywhere I place a suture.”

Alec palpated her neck, and there was no pulse. “She has no blood pressure and no pulse,” he said. “We need to start CPR.”

Templeton’s resident placed the palms of his hands on Elizabeth Anderson’s breastbone and began chest compressions. The patient’s heart rate of 180 beats per minute slowed to 40 beats per minute, with premature beats and pauses between them. After twenty seconds of a slow irregular rhythm, her heartbeat tracing faded into the quivering line diagnostic of ventricular fibrillation.

Alec injected 1 milligram of epinephrine, and screamed, “Bring in the defibrillator.”

A second nurse pushed the defibrillator unit up to the operating room table. Templeton charged the paddles, applied them to the patient’s chest, and pushed the buttons. Elizabeth Anderson’s body leapt into the air as the shock of electrical energy depolarized every muscle of her body. All eyes turned to the ECG rhythm, and it was worse than ever.

Flat line.

“Damn it. Give me the scalpel back,” Templeton said. He carved a long incision between the ribs on the left side of Elizabeth Anderson’s chest, and inserted his hand into her thorax.

“I have her heart in my hand and I’m giving her direct cardiac massage,” he said. Alec looked at the monitors, and the direct squeezing of the heart was doing nothing. The blood pressure was still zero, and now blood was oozing from the skin around her IV sites, as well as from the surgical wounds in her abdomen.

Elizabeth Anderson’s heart was empty. Her blood vessels were empty. Her blood pressure had been near-zero for twenty-five minutes.

“What do you think, sir, should we call it?” Templeton’s resident said.

Templeton pulled his hand out of Elizabeth Anderson’s chest, and looked at the clock. “I pronounce her dead, as of 8:48 a.m. Damn, damn, damn it!”

Alec reached over and turned off the ventilator. The mechanical breathing ceased, and there was nothing left to do. He looked down at Elizabeth Anderson’s bloated face. Two strips of clear plastic tape held her eyes fastened shut, and her cheeks were as white as the bed sheet she rested on. A length of pink tape held the breathing tube fixed to her upper lip, and blood oozed from her nose and from the membranes between her teeth. This lady walked into the University of Silicon Valley Medical Center today hoping for a surgical miracle, and instead she was going to the morgue looking like this.

Xavier Templeton peeled his gloves off. “Goddamn it! The fricking robot went berserk. Sliced into the artery like a goddamned hedge trimmer. Now I have to tell the family she’s dead. Goddamn damn it!” He scowled in Alec’s direction. “Are you coming with me, Dr. Lucas?”

Alec nodded a yes. He looked at the gloomy outline of The Bricklayer’s arms, and then back at Templeton. Templeton was a fool to blame the medical device for his own ineptitude. The machine could do no wrong on its own.

This was the surgeon’s fault. Alec had heard it all before. Accept compliments and deflect all blame—it was an adage as old as the profession of surgery.

Templeton commanded The Bricklayer. And The Bricklayer was no better than the human hands that led it.

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

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

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

Will I Have a Breathing Tube During Anesthesia?

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?

WHICH ANESTHESIA FELLOWSHIPS ARE MOST POPULAR?

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

Which anesthesia fellowships are most popular? How many anesthesia residents choose further subspecialty fellowship education at the end of their residency, and which subspecialties are those graduates choosing?

The grid below, published in the California Society of Anesthesiologists Vital Times 2018, lists the fellowship choices from the last five years of Stanford anesthesia resident graduates:

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The totals from most popular to least popular fellowship choices from this grid are as follows:

SUBSPECIALTY:

Cardiac anesthesia                17

Regional anesthesia              14

Pediatric anesthesia              12

ICU/critical care                        10

Pain medicine                             8

Research                                         8

Obstetric anesthesia               2

Neuro anesthesia                      1

ENT/airway                                    1

Transfusion medicine            1

Palliative care                              1

TOTAL                                             75

Approximately 28 residents graduate from Stanford each year, for a total of 140 graduates over five years. If 75 out of 140 graduates pursued fellowships, then approximately 53% of residents chose fellowships, while 47% entered the workforce without further fellowship training.

I’m a private practice/community anesthesiologist who also practices in a major university medical center at Stanford, and I have some reflections on this data. The fact that 47% of the graduates do not pursue subspecialty fellowship training doesn’t surprise me. If an anesthesiologist proceeds directly through college, medical school, internship, and then a three-year residency, he or she will be at a minimum 30 years old. Twelve years of post-high school education is enough for many graduates, and the desire to earn a paycheck can trump any desire to complete any more training. A board-eligible anesthesiologist without a fellowship can find a job in most geographical areas without difficulty. In a competitive marketplace such as the San Francisco Bay Area, I believe an anesthesiologist with fellowship training gains an advantage in the search for a plum job over someone who did not complete a fellowship.

Let’s look at the fellowships Stanford graduates chose, and discuss the merits of each subspecialty as of 2019:

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Cardiac anesthesia continues to be popular. Stanford has outstanding cardiac surgery and cardiac anesthesia departments. The technology and challenges of cardiac anesthesia tend to draw ambitious residents into this subspecialty. I practiced cardiac anesthesia for 15 years. Those years were notable for very early morning arrival at the hospital (circa 6 a.m.), lots of invasive anesthesia preoperative procedures (arterial lines, central venous pressure catheters, pulmonary artery catheters, and transesophageal echocardiography), long complicated surgeries, sick patients, takebacks for bleeding in the middle of the night, and several surgeons with demanding difficult personalities. The field of cardiac surgery has changed dramatically since the 1980s and 1990s, when one of my surgical colleagues then lamented, “What’s the difference between a cardiac surgeon and a dinosaur?” His answer was, “Nothing.” In the 1980s invasive cardiologists began inventing techniques to apply balloons and stents in the coronary arteries to replace the open-chest coronary artery bypass grafting that cardiac surgeons used to do. Today even valve replacements can be done by cardiologists. Today cardiac surgeries are primarily difficult tertiary cases and revision procedures, i.e. cases that cardiologists cannot fix via intravascular access.

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Regional anesthesia is a growing field. Both academic and community anesthesia groups need individuals with expertise in ultrasound-guided regional blocks. Regional anesthesia specialists should have no trouble finding jobs.

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Pediatric anesthesia specialists are found in every large anesthesia department. Pediatric hospitals need fellowship-trained graduates on their staff, but for private/community groups, the role of fellowship-trained pediatric anesthesiologists depends on the volume of pediatric surgery. Community groups often expect multiple anesthesiologists to cover routine pediatric cases (e.g. age 1 and over) when they are on call. If only 10% of cases are pediatric and those cases sometimes occur on weekends or at night when an on call anesthesiologist will staff the cases, it’s unlikely the group will hire a specialist pediatric anesthesiologist to be on call every night. For a large group, this may be possible, but for a smaller group, it may not.

Respiratory_therapist

ICU/critical care medicine fellowships have always been popular at Stanford. For years the anesthesia department ran the intensive care units at Stanford, and these anesthesia/ICU attendings were outstanding role models. I decided to follow my internal medicine residency at Stanford with an anesthesia residency because I was so impressed with the ICU attendings and their training. The current Stanford anesthesiologist department chairman, Ron Pearl MD PhD, was initially a Stanford internal medicine resident who then completed the Stanford ICU fellowship, and after all that enrolled in and graduated from the Stanford anesthesia residency program. The unique value of an ICU fellowship is that you attend to sick patients of every type, and you become comfortable managing the most demanding medical situations day and night. ICU/critical care graduates are become outstanding clinical anesthesiologists who add value in either an academic or a community setting. Note that in a private/community practice setting, the clinical work in an ICU setting often becomes secondary to operating room anesthesia work, because there have always been superior financial reimbursements for the time anesthesiologists spend in the operating room versus the time they spend in the ICU.

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Pain medicine is a vast frontier for anesthesiology. The anesthesia department at Stanford renamed itself the Department of Anesthesiology, Perioperative and Pain Medicine to emphasize the inclusion of pain medicine within our specialty. While the clinical features of operating room anesthesia care have changed very little in recent decades, the possibilities for research and growth in pain medicine are limitless. As an internal medicine doctor, I can tell you that almost everyone hurts in some part of their body, and the treatments for pain, especially for chronic pain, are still in their infancy. Opioid medications work for a while, but patients can become tolerant and addicted to the drugs. More specific pain treatments without the opioid side effects of respiratory depression, addiction, constipation, and nausea are desperately needed. The potential for basic science research in pain medicine is unequaled in any other field of anesthesia. In either community or academic practice, pain doctors staff pain clinics where other physicians can refer their most difficult and unhappy patients. Pain clinic waiting rooms are rarely empty.

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Research fellowships are a launching pad to an academic career. Selecting an outstanding mentor is a key factor. If a mentor is known to publish extensively, he or she can teach their fellow how to select important projects, design experiments and studies, write grants, write research papers, and get those papers published. Basic science laboratory research is becoming the domain of investigators with PhDs. Significant clinical research is done primarily by MD anesthesia faculty members at universities. The reputation of a professors is judged by the extent of their publishing and research. Research fellowships are not an important step to a career in private/community clinical medicine.

obanesth

Obstetric anesthesia is a valid subspecialty in academic centers. In private/community jobs, it’s expected that all anesthesiologists who are on call on weekends and nights can handle both routine and emergency obstetric cases. Completing an OB fellowship isn’t a direct link to landing a graduate an outstanding community job—almost every community anesthesiologist will be expected to have to have OB skills.

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Neuro anesthesia training will prepare a graduate for a wide array of brain surgery cases. This specialty will be valued in an academic practice or in a private/community group that does a large amount of neurosurgery.

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In Ear, nose and throat/airway subspecialty training, a graduate will gain expertise in managing difficult airway cases. This field will appeal to graduates seeking an academic job doing complex head and neck surgical cases.

I don’t have access to national data on the distribution of fellowships in graduates of anesthesia programs other than Stanford. While it’s possible that Stanford is an atypical peer group, I hope this analysis of the fellowships Stanford graduates choose gives you a better idea of the career choices available to anesthesia residents.

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

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

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

Will I Have a Breathing Tube During Anesthesia?

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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MEDICARE FOR ALL and Anesthesiology

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

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Multiple Democratic candidates for President of the United States are advocating Medicare for All. Medicare for All would decimate the specialty of physician anesthesiologists in America. Medicare for All would cause an exodus from the specialty of anesthesiology.

I’m an independent voter—neither a Democrat nor a Republican, and this column is not in opposition to Democratic candidates or in any way supportive to a Republican agenda. My aim is to inform my readers, both anesthesia professionals and laypersons, that if Medicare for All becomes reality, there will be a dire consequence regarding anesthesia staffing and services to patients.

The Medicare pay rate for anesthesiologists is a mere fraction of the current insurance pay rate. Based on the 2018 American Society of Anesthesiologists report, the national average insured conversion factor for anesthesia (the amount paid for a 15-minute time period of service) was $76.32. The current national Medicare conversion factor for anesthesia is $22.18, or only 29% of the 2018 overall mean commercial conversion factor.

Anesthesia practices have varying ratios of insured patients, Medicare patients, Medicaid patients (which pay slightly less than Medicare), and patients with no insurance (who often pay zero). What happens if every anesthesia patient pays only Medicare rates in a Medicare for All future? Let’s look at some examples.

If a practice currently has 75% insured patients and 25% Medicare/Medicaid patients, the income for that practice would be (.75 X $76) + (.25 X $22) = $62.50 per unit. Under Medicare for All, their income would be $22.18 per unit. This is a pay cut of $40.32 per unit, or a decrease in pay to 35% of their prior income.

If a practice currently has 50% insured patients and 50% Medicare/Medicaid patients, the income for that practice would be (.50 X $76) + (.50 X $22) = $49 per unit. Under Medicare for All, their income would be would be $22.18 per unit. This is a pay cut of $26.82 per unit, or a decrease in pay to 45% of their prior income.

If a plumber, an accountant, a truck driver, an attorney, or a fast-food worker was forced to take a pay cut to 35%-45% of their previous income, they would be upset. Would they be looking for another career? Probably.

If a physician anesthesiologist is forced to take a pay cut to 35%-45% of their previous income, they will be upset too. Will they be looking for another career? Probably.

Expect the exodus from physician anesthesiology to look like this:

  • Older anesthesiologists would simply retire, rather than work for 35%-45% of their prior income.
  • Medical students who are evaluating different specialties for their lifetime vocation would look at anesthesiology and flee. Even prior to its arrival, it’s possible that the specter of Medicare for All in the near future will drive students away from careers in anesthesiology. Medicare pay rates for anesthesiology are significantly lower than Medicare pay rates for all other specialties. See the graph below, which shows the ratio of commercial pay rates/Medicare rates for various services. For most medical services, the ratio of the average insured payment/Medicare payment is between 1.0 and 2.0. This means that, at the lowest, the average Medicare rates are about 50% of insured rates. You’ll recall that the Medicare anesthesia rate is only 29.1% of insured rates.

Screen Shot 2019-03-19 at 11.13.44 AM

The declining number of the oldest and the youngest physician anesthesiologists would radically decrease the census of anesthesiologists in the United States. This likely would lead to an increased role for certified nurse anesthetists (CRNAs), and an eventual increase in the number of schools training CRNAs, but in the short term there would be no way to staff adequate numbers of anesthesia professionals. It’s possible the U.S. may increase immigration of anesthesiologists from other countries where, their pay rate is less than the new Medicare for All pay rate is in America.

Might Medicare for All be forced to quickly increase anesthesiology payment rates to secure an adequate number of physician anesthesiologists? Perhaps, but I wouldn’t bet on it. Medicare has always been a zero-sum system. If anesthesiologists are going to be paid more, then someone else would be paid less, and it would be hard to predict which specialties would be on the end of that further pay cut.

But take a deep breath and relax. Medicare for All will be debated for some time. Even if a liberal Democrat wins the presidency and Congress gains a majority of Democrats in both the Senate and the House, they will all have to overcome multiple powerful lobbies, including the medical insurance industry, hospitals, the pharmacology industry, and organized physician groups. Currently there are so many jobs and so much money involved in the health care systems in American that the battle of Medicare for All will be a true war. Patients would have a significant transition as well. David Brooks wrote in The New York Times on March 4, 2019, “Right now, roughly 181 million Americans receive health insurance through employers. About 70 percent of these people say they are happy with their coverage. Proponents of Medicare for All are saying: We’re going to take away the insurance you have and are happy with, and we’re going to replace it with a new system you haven’t experienced yet because, trust us, we’re the federal government!”

If you’re a layperson, you may think Anesthesiologists are overpaid right now, that’s the true problem with what you’re discussing in this column. Keep in mind that anesthesiologists must complete four years of college, four years of medical school, and at least four years of post-medical school internship and residency training to become board-eligible for work as a physician anesthesiologist. LINK. This means they are at a minimum 30 years old, have borrowed hundreds of thousands in student loans to pay for their training, and have endured significant delayed gratification compared to others they went to college with. Procedural specialties such as surgery and anesthesiology are higher paying than primary care specialties such as internal medicine or pediatrics. Why? The work of procedural physicians requires specialized skills, and their work incurs more risk than interviewing and examining patients in a clinic. I have worked as both an internal medicine doctor and an anesthesiologist, and I can attest that it is almost impossible to harm a patient in an internal medicine clinic, while it is possible to lose a patient to anoxic brain damage in five minutes in an operating room as an anesthesiologist if you err. Risk during an anesthesia career is omnipresent.

As I stated on the home page of my blog, “The profession of medicine offers a lifetime of fascination, and no specialty is more fascinating than anesthesiology.” In addition, freeing patients from pain and ushering them through surgery safely is a wonderful vocation. But if anesthesiology jobs someday pay 35%-45% of their current income, the exodus of anesthesiologists will occur despite the fascination and emotional rewards of the profession.

Life will go on, there will just be less anesthesiologists, which will be OK unless you need one for your upcoming surgery.

Further information on proposed Medicare for All is available at their home page at http://www.medicareforall.org/pages/Know.

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

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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FREE SOLO

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

Every anesthesia provider must learn to free-solo anesthesia early in his or her career. The 2018 movie Free Solo showcases Alex Honnold as he became the first person to free solo climb the 3000-feet high El Capitan wall of granite in Yosemite National Park without ropes or safety gear. This has been called the greatest feat in rock climbing history, and the movie is nominated for a 2019 Academy Award in the Feature Documentary category.

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FREE SOLO movie poster 2018

Believe it or not, but Free Solo could have been an anesthesiologist’s movie. How can that be? “Free-soloing” describes the most anxiety–producing event in every anesthesiologist’s life: the transition from anesthesia training when your faculty member is backing up your every move and every mistake, to the real world of anesthesia when you have to do scary cases alone without assistance.

During the dayshift, working alone is seldom an issue for any anesthesiologist. A typical hospital will have dozens of other anesthesia providers working in the same building. Within seconds or minutes, any anesthesiologist can be assisted or bailed out by a colleague.

Unlike Alex Honnold, the anesthesiologist is not putting their own life at risk—rather it is their patient who is at risk. The degree of risk is variable. For healthy patients undergoing elective surgery the anesthetic risks are minimal, and are similar to the risks of driving on a freeway in an automobile. For emergency surgeries, cardiac surgeries, chest surgeries, brain surgeries, or for anesthetics on patients with significant heart, lung, blood pressure, or airway problems, the risks of anesthesia are higher. The patient is totally dependent on their anesthesiologist to return them to consciousness safely.

Commercial aviation is sometimes compared to anesthesia practice. When commercial pilots take off in airliners, their passengers are totally dependent on the pilot to return them to the ground safely. But in commercial aviation there is one important difference: by law there must be a second pilot in the cockpit.

In anesthesia there is no guaranteed second anesthesiologist. There are multiple different models of anesthesia care. In an anesthesia care team, a physician anesthesiologist supervises up to four operating rooms and each operating room is staffed with a certified registered nurse anesthetist (CRNA). In a university hospital, a faculty member may supervise two operating rooms each with a resident anesthesiologist-in-training in attendance. In many hospital operating rooms, a solitary physician anesthesiologist attends to his or her patient alone. In seventeen “opt-out” states in America a solitary CRNA can attend to a patient without any physician anesthesiologist backup. Working alone may be less safe. A 2019 study from Europe reported an outcome advantage for anesthesiologist working in teams: The study showed that anesthesia given by teams of anesthesiologists and anesthesia nurses was associated with decreased 30-day postoperative mortality and a shorter length of stay when compared with solo anesthesiologists. There was no evidence for the specific cause of the decreased mortality.

Because of manpower necessities, there will never be a law mandating a second anesthesiologist for every surgery as there is in commercial aviation. There will always be emergencies at 2 a.m. or on weekend afternoons when all other anesthesiologists are elsewhere. As well, there are tens of thousands of freestanding surgery centers and office operating rooms where only one anesthesia professional is present.

Is there any data in the medical literature documenting that inexperienced anesthesia professionals have a greater incidence of adverse outcomes? Per Pubmed, there is no such publication. But there is no publication that denies the truth of this correlation. There is a paucity of data on the topic. The issue has not been rigorously studied in a scientific basis.

I review malpractice legal cases, and I can attest that inexperienced anesthesia personnel (who are less than board-certified physician anesthesiologists) are involved in many cases. I believe recent graduates are at particular risk when they work alone. In most cases with severe complications, the anesthesia professional (an MD or a CRNA) was managing the anesthetic alone until it was too late to save the patient.

During physician anesthesia training, a faculty member teaches, supervises, advises, and bails out each resident should there be a mishap. Following their three years of residency, a graduate is free to take a job as an attending anesthesiologist in any hospital system, multi-specialty clinic, or anesthesia group who will hire him or her. This is when the free-soloing begins.

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Let me cite some examples of anesthesia free-soloing:

  1. The new graduate is on duty at 2 a.m., and a three-hundred-pound man arrives at the emergency room with the abdominal emergency of a dying, obstructed intestine. The surgeon decides the case is an emergency and cannot wait until morning. The typical anesthetic for this surgery is a rapid-sequence induction of intravenous general anesthesia, followed by the placement of a hollow breathing tube through the mouth into the patient’s windpipe. This sounds easy enough, except when it isn’t. Morbidly obese patients can be very difficult to intubate, and without a properly placed breathing tube these patients can be difficult to keep oxygenated. Five minutes without oxygen causes irreversible brain death. Sound scary? It is.
  2. The new graduate is on duty at 3 p.m. at a community hospital. A two-year-old girl arrives at the emergency room gasping for breath, crowing with each inspiration, febrile, drooling, and barely conscious. Both the emergency room physician and the anesthesiologist quickly make the diagnosis of acute epiglottitis, a rare bacterial infection which causes the epiglottis (the flap which covers the windpipe when you swallow) to become inflamed and swollen. This causes a severe obstruction during each inhaled breath. The patient needs a breathing tube within minutes, before the swollen epiglottis cuts off all passage for air inflow into the lungs. I had this very case during my first year in private practice. I’d read about the proper management, but I’d never seen acute epiglottitis myself. The appropriate treatment is to bring the patient to the operating room urgently, and to staff an experienced head and neck surgeon at the bedside. The anesthesiologist’s job is to induce sleep with an inhaled anesthetic (sevoflurane) via a mask, while carefully supporting the airway and facilitating the passage of oxygen and anesthesia gas in and out of the lungs until the patient falls asleep. Once the patient is asleep, a physician or nurse must place an IV catheter in the patient’s arm, and then the anesthesiologist must insert a lighted scope into the patient’s mouth, locate the swollen epiglottis and the opening to the windpipe below it, and insert a tiny hollow plastic breathing tube into the windpipe. If anything goes wrong and the breathing tube cannot be inserted before the child turns blue, the surgeon must immediately slice into the child’s neck and insert a breathing tube through the skin. Once again, five minutes without oxygen causes irreversible brain damage. Sound scary? It is.
  3. The new graduate is on duty alone at a dental office, anesthetizing a 17-year-old male for wisdom teeth removal. After the induction of general anesthesia but before the beginning of surgery, the anesthesiologist administers a requested dose of intravenous antibiotic. Minutes later, the patient’s blood pressure drops from 120/80 to 60/30, the heart rate climbs from 80 to 160 beats per minute, and the normal lung sounds convert to tight wheezes. Hopefully the anesthesiologist will make the correct diagnosis of an anaphylactic allergic reaction—most likely due to the antibiotic. The effective treatment requires perfect management of the patient’s airway, breathing, and circulation. The specific treatment for anaphylaxis requires intravenous injection of epinephrine (adrenaline). A misdiagnosis leading to the omission of epinephrine can be fatal. If the blood pressure remains low and the lungs continue to deteriorate, there will be a lack of oxygen delivery to the brain. Once again, five minutes without oxygen causes irreversible brain damage. Sound scary? It is.

What can be done to make free-soloing safer for patients? In my opinion, the best safety ropes are these:

  1. Most hospitals have an emergency room physician on duty at all hours. These MDs are multi-talented and have the acute care skills necessary to assist an anesthesiologist in an emergency. Rather than waiting until a patient has a cardiac arrest or until an airway is lost and the patient’s brain is losing oxygen, an anesthesia professional can consult the ER doctor in advance, e.g. requesting them to assist with a difficult induction of anesthesia on a morbidly obese adult or with a child with a difficult airway.
  2. Even if no experienced anesthesiologist is present in the hospital, there is always an experienced physician anesthesiologist colleague available on the other end of a phone call. Young or inexperienced anesthesia professionals can telephone senior anesthesiologists prior to the anesthetic, whenever a situation arises in which they are doubtful, insecure, or uncomfortable. It’s difficult to admit a lack of confidence, but it’s better to do this than to review a terrible complication with the senior anesthesiologist the next day, like two firefighters gazing over the burned basement remains of a previously preserved house.
  3. Most American anesthesia training programs are now utilizing simulation training facilities to prepare residents for severe acute care scenarios. A simulator lab has a surrogate patient and a full battery of vital sign monitors under the control of a teacher. The teacher can dial in a variety of emergencies and observe the pupil’s response to the emergencies. Feedback is given afterward regarding observed errors and any needed improvements in management. If a young physician anesthesiologist has faced emergencies in the simulator, we believe the anesthesiologist will be better prepared to free-solo following their training.
  4. The Stanford Anesthesiology department authored the Stanford Cognitive Aid Emergency Manual, a booklet of itemized recipes and checklists for all common dire emergencies one might see in an operating room. A PDF of this booklet is available for free of charge download here. Using the Stanford Cognitive Aid Emergency Manual in the operating room will help prevent medical errors, even by inexperienced anesthesia professionals.
  5. Whenever possible, solo anesthesiologists should have already passed the American Board of Anesthesiologists written and oral examinations, and therefore be board-certified. It’s a fact that one can practice anesthesiology in the United States without being board certified, but the ABA oral examination forces graduates to answer difficult questions in the pressure cooker of an oral exam room. Board-certified anesthesiologists will be better prepared for the pressure cooker of an operating room emergency as well.

If you’re a patient, should you worry about your anesthetist free-soloing during your surgery?

Let me reassure you. If you’re having an elective surgery in a hospital in the daytime, there are usually multiple backup anesthesia providers to assist with any problems. But for emergencies in the middle of the night, on weekends, or at freestanding surgical facilities with only one anesthesiologist present, your anesthesia care and outcome will be solely dependent on the skills, training, and experience of the solitary individual who is attending to you.

I’ve stood at the bottom of El Capitan in Yosemite National Park and looked upward at the vertical granite face with awe. I could never climb El Capitan, with or without ropes. I respect what Alex Honnold did at the highest level. He is brave beyond measure and he was willing to put his life on the line. Anesthesiologists, particularly junior anesthesiologists, must free-solo as well. No Hollywood cameras will be rolling, but the adrenaline will be pumping through their veins just as if they themselves were climbing El Capitan.

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

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

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

Will I Have a Breathing Tube During Anesthesia?

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How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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

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

8-year-old Matadi Sela Petit, who journeyed from the Democratic Republic of Congo to Los Angeles for surgery, died at Cedars-Sinai Hospital on December 16, 2018, from what has been described as “a rare genetic reaction to the anesthesia.” Matadi was born with a cleft lip and a tumor on the left side of his face/cheek that grew into the size depicted in this photograph:

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Matadi Sela Petit

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

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

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

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

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

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

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

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

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

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DOCTOR VITA AND THE BS IN HEALTHCARE

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

Last week Lawton Burns PhD and Mark Pauly PhD of the Wharton School of Business at the University of Pennsylvania published a landmark economic article entitled, “Detecting BS in Health Care.” Yes, you did not read that wrong—the academic paper used the abbreviation “BS” to describe the bull—- in the healthcare industry.

BS in Health Care

 

As a practicing physician, I find it to be a fascinating paper, and I recommend you click on the link and read it. The authors begin with a discussion of the art and value of BS detection. They mention that Ernest Hemingway was once asked, “Is there one quality needed to be a good writer, above all others?”

Hemingway replied, “Yes, a built-in, shock-proof, crap detector.”

The authors write, “While flat-out dishonesty for short term financial gains is an obvious answer, a more common explanation is the need to say something positive when there is nothing positive to say. . . . The incentives to generate BS are not likely to diminish—if anything, rising spending and stagnant health outcomes strengthen them—so it is all the more important to have an accurate and fast way to detect and deter BS in health care.”

The authors list their Top 10 Forms of BS in Health Care. The first four forms of BS weave a common theme:

  1. Top-down solutions: High-level executives and top management in the health care industry are supposed to engineer alternative payment models, but nothing has worked to date.
  2. One-size-fits-all, off-the-shelf: Leadership of industry and government assume one solution will work for multiple organizations, without customization.
  3. Silver-bullet prescriptions: A “silver bullet” is described as something that will cure all ills, and must be implemented because it been “decided that it is good for you,” Electronic health records (EHRs) are a prime example of a silver-bullet prescription. The federal government pushed the use of EHRs, claiming the systems would reduce costs and improve quality—but Burns and Pauly argue EHRs “eventually raised costs and only mildly touched a few quality dimensions.”
  4. Follow the guru: We must follow a visionary guru with a mystical revelation about what needs to be done. The authors describe how, in health care, Harvard professor Michael Porter and former CMS (Center of Medicare and Medicaid) administrator Don Berwick launched theories based on population health, and per-capita cost, to little success.

The current U.S. healthcare market is dominated by large corporations, led by businessmen who outline a yellow brick road for physicians to lead patients along. There is minimal effective policy-making from physicians. Healthcare stocks consistently grow in value, with little relationship to an improvement in clinical care, value, or cost. The government is involved as well, as in their mandate for Electronic Health Records (EHRs), a technology change that cost a lot of money, while forging a barrier between clinicians and the patients we are trying to interview, examine, and care for.

Where will the current trends take us? Will businessmen and/or the government prescribe health care? Will more and more computers and machines dominate health care?

Self-driving cars, Siri, Alexa, automated checkouts at Safeway, and IBM’s Watson are technologic realities. Will we someday see a self-driving physician with the voice of Siri and the brains of Watson?

Call that device “Doctor Vita.”

The saga of Doctor Vita arrives in 2019 from All Things That Matter Press.

 

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

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

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Will I Be Nauseated After General Anesthesia?

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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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IS SUBLINGUAL SUFENTANIL DANGEROUS?

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

Is sublingual sufentanil dangerous? The United States Food and Drug Administration (FDA) voted to approve the narcotic sufentanil for sublingual use in November of 2018. Sublingual sufentanil is 5-10 times more potent than fentanyl, and dissolves under the tongue in seconds.

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In an era of opioid overdose crisis, we now have a new, even more potent pill form of opiate.

Opioid deaths 1999-2017Sublingual sufentanil is approved for use only in medical settings, for the treatment of moderate to severe acute pain. But it is also possible that sublingual sufentanil will become the most dangerous street opiate ever known. This column reviews the arrival of sublingual sufentanil, from the viewpoint of a practicing anesthesiology attending.

Raeford Brown, Jr., MD, chair of the Anesthetic and Analgesic Drug Products Advisory Committee, and professor of anesthesiology and pediatrics at the University of Kentucky, disagreed with the FDA approval for sublingual sufentanil, citing the drug’s risk for “diversion, abuse, and death.” He cited the possible harms of such a “dangerous” drug — estimated to be 500-600 times more potent than morphine — coming to market in a tablet form. He warned of the risks of diversion of sufentanil by anesthesiologists and other medical personnel. He was quoted, “Sufentanil is a very potent opioid that is in a preparation that will be easily divertible. In the IV formulation, it has been a drug of abuse for health care providers.”

I agree with Dr. Brown. Sublingual sufentanil raises dangerous concerns. Sublingual sufentanil has the potential become the hydrogen bomb of all opiates—the mother of all lethal street drugs.

I have extensive experience administering intravenous sufentanil to patients. Intravenous sufentanil was FDA-approved in 1984. Its original primary use was as an anesthetic for cardiac surgery. I practiced cardiac anesthesia from 1985 until 2000. In the 1980s, cardiac anesthesia was achieved by high dose narcotic techniques, specifically with high dose fentanyl (100 micrograms/kg) techniques. For a 70-kilogram patient, this required injecting 7000 micrograms of fentanyl, or 140 ml of fentanyl (nearly two and an half sixty-milliliter syringes full of fentanyl) at the time of anesthetic induction. When intravenous sufentanil was approved at the same 50 mcg/ml concentration as fentanyl, but with a potency of 10 X of fentanyl, the narcotic induction only required 14 ml of sufentanil total. I can still remember my wide-eyed professors saying, “With sufentanil, the entire cardiac anesthetic is here in one syringe.” The use of sufentanil for cardiac anesthesia faded as anesthesiologists began using lower doses of narcotic as part of early-extubation techniques in the late 1990s.

We also used intravenous sufentanil to supplement anesthesia for non-cardiac surgeries. The most common method was to dilute the sufentanil 10:1 with saline, to a concentration of 5 mcg/ml. At this concentration, sufentanil was indistinguishable from fentanyl at 50 mcg/ml. After several years it became apparent that there was no advantage of using sufentanil IV over fentanyl IV in non-cardiac anesthesia, and the administration of IV sufentanil dwindled. The intravenous sufentanil form of the drug was also approved for epidural anesthesia. Over time, the use of sufentanil for epidural anesthesia also decreased, also supplanted by fentanyl.

Just when it looked like sufentanil was a drug nobody really neededà enter AcelRx Pharmaceuticals, a San Francisco Bay Area company which manufactured and tested a sublingual sufentanil product designed to melt under a patient’s tongue. Pamela Palmer, the founder and Chief Medical Officer of AcelRx, received her MD and PhD at Stanford, and is an acquaintance of mine. Dr. Palmer is an anesthesiologist who is brilliant and well informed regarding the pharmacology of sufentanil and the use of sufentanil in anesthetic practice.

Because sufentanil is highly lipid (fat) soluble, it is quickly absorbed into the bloodstream through the mucosal lining of the mouth. AcelRx will market the drug under the name Dsuvia, in a sublingual sufentanil tablet system (SSTS) which consists of a single-dose applicator prefilled with a single 3-mm-diameter 30-mcg tablet, administered by a healthcare professional no more frequently than hourly.

sublingual sufentanil

A radio frequency identification (RFID) cartridge, requiring the patient’s thumbprint, helps reduce unauthorized dosing. The device is tethered to the patient’s bed to reduce risk of product loss. Each tablet is pre-loaded into a single-dose applicator within a pouch so it is suitable for field/trauma use. Both the fixed drug and dose and lockout time interval eliminate the end-user programming error risk associated with Patient Controlled Analgesia (PCA) intravenous narcotic pumps.

Studies documented the efficacy and safety of the SSTS in the treatment of postoperative pain in patients following open abdominal surgery compared with placebo.

SSTS was rated a success by significantly more patients when compared to intravenous PCA morphine. There was a faster onset of analgesia and both higher patient and nurse satisfaction scores with the SSTS as measured by validated questionnaires.

Dsuvia will be marketed as “postoperative, sublingual, patient controlled analgesia.” Once administered under the tongue, the sufentanil tablets typically dissolve within 5  minutes. The FDA approved the drug to be used in hospital settings only, for the treatment of moderate-to-severe acute pain, where a narcotic is needed and rapid onset is desired, but the route of administration does not require intravenous access. Typical settings would be the surgical wards after major orthopedic or general surgery procedures. The chief competition for Dsuvia will likely be Patient Controlled Analgesia (PCA) intravenous narcotic pumps, a commonly used analgesic method in which patients push a bedside button and self-administer intravenous narcotic (e.g. morphine, fentanyl, or Dilaudid) on demand through their IV line.

The most significant risk involving sublingual sufentanil is its potency, specifically its extreme potency as a respiratory depressant. The product description by AcelRx states that sufentanil has a “high therapeutic index” of 26,716. The Therapeutic Index is the ratio that compares the blood concentration at which a drug becomes toxic and the concentration at which the drug is effective. The larger the therapeutic index (TI), the safer the drug is. The TI affirms that sufentanil toxicity starts at a concentration of 26716 times its therapeutic concentration, but this ignores the risk of respiratory depression at much, much lower doses. A patient treated with an overdose of sufentanil will stop breathing at a dose only slightly greater, i.e. in the ballpark of only 2 – 4 times greater, than its therapeutic concentration. Like all opiates, sufentanil has side effects of respiratory depression, sedation, nausea and constipation. Respiratory depression is the reason why opiate overdose patients die. Opiate overdoses do not cause death because of an inherent “toxicity” of the drug concentration in the blood, but rather because of respiratory depression. People simply stop breathing.

Regarding sufentanil, the National Institute of Health website states: WARNINGS: Serious, life-threatening, or fatal respiratory depression has been reported with the use of opioids, even when used as recommended. Respiratory depression, if not immediately recognized and treated, may lead to respiratory arrest and death. Sufentanil Citrate injection should be administered only by persons specifically trained in the use of anesthetic drugs and the management of the respiratory effects of potent opioids, including respiration and cardiac resuscitation of patients in the age group being treated. Such training must include the establishment and maintenance of a patent airway and assisted ventilation. Adequate facilities should be available for postoperative monitoring and ventilation of patients administered anesthetic doses of Sufentanil Citrate Injection. It is essential that these facilities be fully equipped to handle all degrees of respiratory depression. Management of respiratory depression may include close observation, supportive measures, and use of opioid antagonists, depending on the patient’s clinical status.

There is also hope that sublingual sufentanil will have battlefield applications. A statement from FDA Commissioner Scott Gottlieg, MD on November 2, 2018 read: “(Sublingual sufentanil) has some unique features in that the drug is delivered in a stable form that makes it ideally suited for certain special circumstances where patients may not be able to swallow oral medication, and where access to intravenous pain relief is not possible. This includes potential uses on the battlefield. For this reason, the Department of Defense (DoD) worked closely with the sponsor on the development of this new medicine. This opioid formulation, along with Dsuvia’s unique delivery device, was a priority medical product for the Pentagon because it fills a specific and important, but limited, unmet medical need in treating our nation’s soldiers on the battlefield. The involvement and needs of the DoD in treating soldiers on the battlefield were discussed by the advisory committee . . . The FDA has made it a high priority to make sure our soldiers have access to treatments that meet the unique needs of the battlefield, including when intravenous administration is not possible for the treatment of acute pain related to battlefield wounds.”

In conclusion, will sublingual sufentanil be dangerous or not?

My assessment of sublingual sufentanil, based on the information above, is as follows:

  1. Sublingual sufentanil (SS) can be useful in hospitalized post-operative patients following major, painful surgeries such as orthopedic total joint replacements or intra-abdominal surgeries. SS could replace PCA intravenous morphine or fentanyl.
  2. The market share, or prevalence of SS use will largely depend on its cost versus intravenous PCA units. AcelRx will market the drug beginning in early 2019, at a wholesale price of $50 to $60 per dose. https://www.washingtonpost.com/national/health-science/fda-approves-a-powerful-new-opioid/2018/11/02/88cd27e6-deaf-11e8-85df-7a6b4d25cfbb_story.html?utm_term=.f4efacea46ad
  3. SS will not be frequently used in Post Anesthesia Care Units, Intensive Care Units, or the Emergency Department, because patients in these settings all have intravenous lines in place, and can receive traditional IV narcotics as needed. There is no need or demand for a sublingual narcotic product in these settings.
  4. If SS tablets are diverted or stolen and are taken outside of medical settings, they can cause death. Overdoses as low as two to four times a therapeutic dose could cause respiratory depression and death. If hospital personnel divert the drug for recreational use, these personnel will be at high risk for mortality.
  5. If SS ever reaches the streets as a recreational drug or heroin substitute, users will achieve opiate overdose and death at a very high rate. If anyone naively believes the drug will not reach the streets, consider that manufactured forms of all the other pill forms of opiates, i.e. Percocet, Vicodin, and Oxycodone, eventually reached the streets. What will prevent this new drug from doing the same?
  6. Efforts to educate street users regarding the dangers of this new drug will likely fail. There can be no safe use of SS outside a medical setting. People will likely overdose and die.
  7. Regarding battlefield use: In military settings where IVs are not common, the capacity to administer potent sublingual narcotic may become standard. But misuse and abuse in the military and on the battlefield are also possible. Tales of rampant drug abuse by soldiers in the Vietnam War are part of the lore of that conflict. Access to sublingual sufentanil in the military would need to be strictly confined and monitored.
  8. An added note: An intentional overdose with SS is probably an outstanding drug for physician-aided suicide.

I have no crystal ball, but the bottom line is this:

If sublingual sufentanil use is confined to acute care hospital settings, it will be useful and not dangerous. But if sublingual sufentanil reaches the streets as a drug of abuse, it will be lethal.

Time will tell which of these fates is the truth.

 

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

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FRONT OF NECK ACCESS

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

Can you perform an emergency surgical cricothyroidotomy? In the dreaded Can’t Intubate, Can’t Oxygenate (CICO) scenario, if your patient has no airway, you must immediately establish a front of neck access (FONA) to save your patient’s life.

SCALPEL, BOUGIE, TUBE APPROACH TO CRICOTHYROIDOTOMY

SCALPEL, BOUGIE, TUBE APPROACH TO CRICOTHYROIDOTOMY

This week I attended an outstanding Stanford Anesthesia Grand Rounds delivered by Drs. Jeremy Collins, Susan Galgay, and Tom Bradley. The lecture reviewed the literature regarding CICO events, and concluded that performing a surgical airway through the cricoid membrane is an essential skill for anesthesiologists.

Most anesthesia professionals have never cut into a patient’s neck, but we must own this skill if the necessity arises. I’ve done thousands of cases over 34 years. I have never performed a surgical cricothyroidotomy, but I may need to do one tomorrow. It’s essential expertise for myself and for every anesthesiologist.

As I’ve reviewed in previous columns, a lack of oxygen to the brain for five minutes can cause anoxic brain damage—a disaster all anesthesiology professionals must avoid. The specter that someday we will induce and paralyze a morbidly obese patient, and then be unable to intubate or oxygenate that patient, is in the back of the mind of every anesthesia professional. If and when this happens, we must be able to act without hesitation to oxygenate the patient via FONA.

CICO events are rare, but they do occur with a published incidence of 1 in 50,000 anesthetics, per the fourth national audit project in the United Kingdom (NAP4).  Approaches to FONA include either cannula techniques or surgical techniques, with significant differences.

Cannula Techniques:

These involve inserting a large bore IV catheter through the cricothyroid membrane. Because the lumen of a 14-gauge IV catheter is small, ventilation requires a high- pressure jet oxygen delivery system. In Duggan’s publication from 2016, the failure rate with cannula techniques was 42% in CICO emergencies. In addition, barotrauma occurred in 32% of CICO emergency procedures. Fifty-one percent of CICO emergency events managed with a FONA cannula had a complication. Several reports described trans-tracheal jet ventilation-related subcutaneous emphysema hampering subsequent attempts at surgical airway or tracheal intubation. Failure can also occur because of kinking, malposition, or displacement of the needle/cannula. The Stanford Anesthesia Grand Rounds concluded that these failure rates and complications with cannula FONA techniques were prohibitively high.

Surgical Techniques:

The cricothyroid membrane is divided by a surgical incision made with a wide scalpel (#10 scalpel). With the scalpel, bougie, tube (SBT) technique, a bougie is inserted into the trachea through the incision. A lubricated 6.0 mm cuffed endotracheal tube is advanced over the bougie into the trachea, and the bougie is removed.

There are contrasting difficult airway algorithms algorithms for different English-speaking countries around the globe. See this link for the algorithms from the United States, Australia, Canada, and United Kingdom. Each has unique recommendations for CICO emergencies.

The American Society of Anesthesiologists Difficult Airway Algorithm outlines an approach to airway management, but at the bottom right of the chart, the plan for the CICO situation is “Emergency Invasive Airway Access.” A footnote reads “invasive airway access includes surgical or percutaneous airway, jet ventilation, and retrograde intubation.” The algorithm gives no definitive choice of which technique to use. This is a shortcoming of the American algorithm. There are invasive airway options, and in an emergency there can be no wavering or doubts regarding what to do. Per the data above, percutaneous airway and jet ventilation carry high failure and complication rates. Per discussion at the Stanford Anesthesia Grand Rounds, retrograde intubation is too slow, too difficult, and should be eliminated from the recipe for emergency lifesaving treatment.

The Australian algorithm uses the Vortex approach to managing an unexpected difficult airway.

the vortex approach

THE VORTEX APPROACH

Three options (face mask, endotracheal intubation, and laryngeal mask airway) are all attempted, in any order, to establish a patent airway. If all three methods fail to establish a patent airway, this (not the occurrence of oxygen desaturation) is the trigger to establish an emergency surgical airway (ESA). ESA techniques include either cannula or scalpel cricothyroidotomy to provide a patent airway as rapidly as possible. Note that the Australian Vortex approach endorses either cannula or scalpel cricothyroidotomy, and recommends that anesthesiologists be familiar with both FONA techniques.

The conclusions reached in the Stanford Grand Rounds most closely adhered to the British algorithm, which advocates the SBT (scalpel, bougie, endotracheal tube) method to securing a surgical airway. The SBT method has been specifically endorsed in the United Kingdom Difficult Airway Society algorithm. What follows is the text from the United Kingdom Difficult Airway Society guideline for a Can’t Intubate, Can’t Oxygenate event:

 

The United Kingdom Difficult Airway Society guideline for Failed intubation, failed oxygenation in the paralyzed, anaesthetised patient:

Fig5-Failed-intubation-failed-oxygenation-in-the-paralysed-anaesthetized-patient

Author’s addendum: Many or most patients who suffer CICO events will be obese and have thick or short necks. The cricothyroid membrane may not be easily palpable. Per the text above, the United Kingdom Difficult Airway Society guidelines recommend you make an 8-10 cm vertical skin incision, caudad to cephalad, over the cricothyroid area. This type of surgical maneuver is not a routine part of anesthetic practice, and it will require both skill and courage to commit to the incision. The guidelines next ask you to use blunt dissection with the fingers of both hands to separate tissues until you can identify the larynx and palpate the cricothyroid membrane. Once the cricothyroid membrane is identified, the scalpel incision is made through the cricothyroid membrane. This technique will no doubt create bleeding in the anterior neck, and will not be easy to perform. Enlisting the surgeon’s help during the procedure is advisable. Remember that controlling bleeding is not the primary issue—the primary goal is to locate the cricothroid membrane deep to the adipose of the anterior neck.

When I was a resident I was trained to give cricothyroid injections of lidocaine or cocaine to anesthetize the lumen of the trachea prior to awake fiberoptic intubations. The anatomy of the cricothyroid membrane in most patients is easily palpable, and it can be penetrated with minimal effort or bleeding. In a morbidly obese patient, this approach will be more difficult.

 

How to train anesthesiologists to perform SBT cricothyroidotomy:

This was the subject of discussion at the end of Grand Rounds. Because of the extreme rarity of CICO events, skills will be absent, lost, or dormant for many practitioners. Practice on simulators or plastic models at 6 months intervals was recommended. Dr. Bradley explained that in one approach in Britain, a two-person team traveled from operating room to operating room to teach the SBT method. One member of the teaching team relieved the anesthesiologist from the operating room, and the second member then took the anesthesiologist a room to enjoy a pot of tea and to learn from a plastic training model of the cricothyroid membrane. The final proposals for education and re-education to retain skills at Stanford and throughout the world are challenges for the future. Note that surgeons have almost no education at cricothyroid approaches. Head and neck surgeons are trained in tracheostomy, a different procedure that likely will take too much time to perform when compared to a cricothyroidotomy. Training of surgical colleagues also needs to be addressed in the future.

 

What You Should Do Now:

  1. Familiarize yourself with the anatomy of the cricothyroid membrane on each of your patients.
  2. Have an SBT kit containing a #10 scalpel, a bougie, and a #6 cuffed endotracheal tube included with each difficult airway cart at each facility you anesthetize at.
  3. I now carry an SBT kit in my briefcase which I take with me every day at work. In the current model of private practice in California, where we work at multiple different freestanding surgery centers and surgeon offices, this is a reliable means to assure that I have FONA equipment with me wherever I anesthetize patients.
  4. Be prepared. Review and rehearse the anatomy and skills necessary to perform front of neck surgical cricothyroidotomy in seconds.
  5. Work to avoid CICO events. Evaluate each airway prior to surgery. If a significant concern exists regarding a difficult intubation, a difficult mask ventilation, or a difficult FONA, use your judgment and perform an awake intubation. Securing an airway prior to anesthesia induction is a reliable way to avoid CICO disasters.

 

Two important take-home messages from this column are:

  1. Learn the specific the SBT recipe for front of neck access.
  2. Don’t hesitate and waste seconds—it will take courage to grab that scalpel, but that’s your job and your duty to your patient.

 

For further discussion and advice on airway emergencies, see my columns on Avoiding Airway Lawsuits, Airway Disasters, and The Most Important Technical Skill For an Anesthesiologist.

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

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AUTISM AND ANESTHESIA

the anesthesia consultant

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

Anesthetizing uncooperative patients is difficult. The combination of autism and anesthesia requires careful planning.

autism and anesthesia

Children or adults with psychological, developmental, or behavioral disorders such as autism may be combative or aggressive, and may require extra measures of preanesthetic sedation or restraint. The parents/guardians and the anesthesia team need to be actively involved with forming the preoperative plan for uncooperative patients.

The incidence of autism in the United States is high—the Autism and Developmental Disabilities Monitoring (ADDM) Network of the Center for Disease Control estimates about 1 in 59 children has autism spectrum disorder (ASD).

Characteristics of autism include developmental delays of behavioral and social skills, and an inability to communicate. The symptoms of ASD stretch across a broad range from mild to incapacitating.

It’s not infrequent that autistic patients need surgery and anesthesia. Patients with autism commonly need to be sedated for routine procedures that a normal child or adult would cooperate with. Dental cases are common, and are frequently referred to a hospital because the typical care systems at an outpatient surgery center or a dental office are inadequate to complete a successful anesthetic.

The most common anesthesia induction technique in children and toddlers is an inhalation induction with sevoflurane. The routine practice of performing an inhalational sevoflurane induction on a child with autism may be impossible.

The most common anesthesia induction technique in adults involves the intravenous injection of propofol. The routine practice of starting a preoperative IV to begin anesthesia care on an adolescent or adult with autism may also be impossible.

Let’s look at an example case of an uncooperative adolescent who is adult-sized and who requires an anesthetic:

A 16-year-old, 70-kilogram male with Autistic Spectrum Disorder is scheduled for dental surgery and teeth cleaning. He is verbal with his mother, but refuses to interact with the anesthesia or nursing personnel. He refuses to change into a hospital gown, or to remove his long-sleeved sweater. He refuses to drink or swallow any premedication, he refuses an IV, and he refuses inhalation induction. The mother, who is the patient’s legal guardian, consents to surgery and anesthesia, but she is unable to convince her son to cooperate with the medical team.

What do you do?

The surgical and anesthetic team spent significant time explaining, reassuring, and coddling the patient, to no avail. They told the mother she had the choice of going home without any surgical procedure or anesthesia at all. The mother was adamant that the procedure needed to be performed. To this end, all parties agreed to the following plan:

  1. Two hospital security guards were called to the bedside in the preoperative area.
  2. The two hospital guards and the mother donned white operating room coveralls.
  3. At the mother’s consent, the guards laid the patient down on the hospital gurney, held him there, and the surgical team and the guards pushed the gurney down the hallway to the operating room (a significant distance of approximately 100 yards).
  4. Upon arrival in the operating room, one of the security guards uncovered the sweater from the patient’s arm, and the anesthesiologist injected an intramuscular mixture of 2 mg/kg ketamine, 0.2 mg/kg midazolam, and .02 mg/kg atropine into the patient’s deltoid muscle. The patient protested, and the mother reassured him.
  5. The oximeter and routine monitors were placed.
  6. Once the patient became sedated (2-4 minutes later), the mother was escorted from the room and the anesthesiologist started an IV in the patient’s arm. The patient was then preoxygenated via mask in the standard fashion, propofol 1 mg/kg and rocuronium 0.5 mg/kg were injected IV, and the trachea was intubated.
  7. The surgery proceeded as scheduled, with sevoflurane as maintenance anesthesia.
  8. At the conclusion of surgery, the patient was extubated awake and taken to the Post Anesthesia Care Unit (PACU) in stable condition. The mother was reunited with the patient there. The patient was sedate, calm, comfortable, and tolerated the PACU care well.
  9. The patient was discharged home without complications after 90 minutes in the PACU. The mother was happy with the perioperative care.

Perhaps this practice of intramuscular induction of anesthesia sounds brutal to you.

The intramuscular (IM) ketamine/midazolam/atropine induction of anesthesia as described in the case study above is effective. In our practice, the recipe is the combination of 2 mg/kg of ketamine, 0.2 mg of midazolam, and .02 mg/kg of atropine.

The ketamine concentration is 100 mg/ml. The midazolam concentration is 5 mg/ml. The total volume of the intramuscular injection in our case study patient was 140 mg ketamine (1.4 ml), 14 gm midazolam (2.8 ml), and 1.4 mg atropine (1.4 ml), for a total injectate volume of 5.6 ml. More dilute concentrations of these three drugs will necessitate too large a volume for intramuscular injection. This IM induction technique is effective in safely inducing general anesthesia without an IV within 2-4 minutes, and has been described in a previous article on dental office anesthesia.

There are more gentle approaches to an uncooperative patient—approaches which this patient would not agree to. The literature lists these options for premedication or induction of anesthesia in uncooperative patients:

  1. Intranasal premedication sedation with either 0.5 mg/kg of midazolam, or 1 microgram/kg of dexmedetomidine were found to be equally effective in sedating 20 uncooperativechildren aged 2-6 years for dental treatment visits. 0.25 mg/kg of atropine, in combination with 0.5 mg/kg of midazolam, and 1-2
  2. Oral premedication sedation with 5 mg/kg oral midazolam. Oral sedation is considered as the oldest, easiest way of administrating sedative drugs to pediatric patients. Midazolam is a well-known sedative, and we use this often in our practice if the patient will accept it. The effect initiates within 20–30 minutes of oral administration.
  3. Oral premedication with dexmedetomidine 5 mcg/kg.
  4. Oral midazolam, ibuprofen, and 6 mg/kg of ketamine. Oral ketamine of  up to 8 mg/kg has shown to effective in improving compliance during induction of anesthesia. Compared with oral midazolam, oral ketamine causes less respiratory depression. Ketamine does cause nystagmus, increased salivation, hallucinations and emergence delirium. When used alone as a premedicant ketamine has not been found to be effective. There is no significant difference between oral ketamine and oral midazolam in the postoperative recovery or hospital discharge.

Uncooperative children or adults with ASD will each have individualized needs. Patients with significant ASD may have severe objections to the doctor-patient relationship, and it can take a prolonged time to gain their trust. It’s important to discuss the perioperative anesthetic issues and the preoperative plan with a parent or guardian well in advance of the surgical date if possible. The anesthesia team can determine the simplest means of preoperative sedation/anesthesia to complete the case successfully, and the family can give input regarding previous anesthesia successes or failures. It’s optimal if the family and the MDs can agree to an appropriate approach to the anesthetic, days prior to the actual surgery.

Parents often ask about the risk of general anesthesia to the brain of their child. At present there is no documented connection between exposures to general anesthesia and the development or worsening of autistic symptoms. In a study of a birth cohort of 114,435 children from Taiwan from 2001 to 2010, 5197 children under the age of 2 years were exposed to general anesthesia and surgery. The 1 : 4 matched control group comprised 20,788 children. The results showed that neither exposure to general anesthesia and surgery before the age of 2 years age, nor the number of exposures, were associated with the development of autistic disorder. 

Do autistic patients suffer more complications from anesthesia and surgery than non-autistic patients? In a review by Arnold published in Pediatric Anesthesia in 2015, other than a significant difference in the premedication type and route (per the discussion above), children with ASD had similar perioperative experiences as non‐ASD subjects.

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

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

 

 

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

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NERVE BLOCKS AND NERVE INJURY

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

Let’s discuss an elephant in the room of operating room anesthesia–the association between peripheral nerve blocks and nerve injury.

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The use of peripheral nerve blocks has crescendoed in anesthesia practice, stimulated by the use of ultrasound-guided visualization of nerves. There are growing economic industries in ultrasound machines, ultrasound block needles, and in anesthesia personnel who bill for this additional optional procedure on orthopedic patients.

Ultrasound allows us to visualize the nerves, but there are no data demonstrating a lower neurologic complication rate with this ultrasound technique.(Liu SS, et al. A prospective, randomized controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms. Anesth Analg. 2009;109:265-271).

The incidence of nerve injury following peripheral nerve block is low, but not zero. Per Gadsden, the mechanism of permanent nerve injury is felt to be either needle trauma, or toxicity of local anesthetics. In a review article by David Hardman MD MBA, of the University of North Carolina, the incidence of permanent injury rates, as defined by a neurologic abnormality present at or beyond 12 months after the procedure, ranges from 0.029% to 0.2%. This reviewed data came from old studies, dating from 2001 – 2012. There are no more recent published studies of large populations. Multiplying this 1/3000 to 1/500 incidence by the tens of thousands of nerve blocks performed yearly leads to a significant number of permanently damaged nerves.

This is a problem.

I would never agree to have an ultrasound-guided brachial plexus, femoral or popliteal nerve block performed on me.

Why not? Because I need my hands and upper extremities to function normally in order to earn a living as an anesthesiologist. Because I’m also active in a number of sports, and I need my legs and lower extremities to function normally in order to walk, run, and function in athletics.

For me, the acceptable incidence of permanent nerve injury to my limbs is zero. The incidence of permanent nerve injury with general anesthesia should be zero. Of course, if the surgical team is negligent and positions me in a dangerous posture during general anesthesia, there could be a compression or traction nerve injury, but this is exceedingly rare in competent hands. Of course, if an orthopedic surgeon is negligent and compresses, stretches or damages a nerve, there could be nerve injury, but again this is exceedingly rare in competent hands.

If I’m wary of having a peripheral nerve block performed on myself, then I must be wary for my patients as well. Every individual needs their upper and lower extremities to function normally to perform every day tasks, to perform their jobs, or to enjoy their leisure or athletic activities.

I contend that, as of 2018, the incidence and number of permanent nerve injuries during this era of ultrasound-guided nerve blocks looms larger than any medical literature confirms. Why is this? I believe there are several reasons for the under-reporting of nerve injury following peripheral nerve blocks:

  1. Time lag in published data. The data in the medical literature regarding peripheral nerve injury following nerve block is old. In a lecture on this topic by David Hardman MD MBA at the American Society of Anesthesiologists (ASA) national convention in San Francisco, none of the data regarding nerve injury complication was more recent that 2007. Recent data is still unreported, and remains to be analyzed.
  2. Time lag in Closed Claims data. The ASA Closed Claims data always lags behind the occurrence of complications. A typical malpractice lawsuit takes a long time (e.g. 4 – 7 years) to come to a conclusion. The ASA Closed Claim database may be 10 years or more in arrears before it is finally published.
  3. Some peripheral nerve injuries never get reported to anyone. Either the patient never informs the physician, the case never gets tallied in any database, the physician never informs any quality assurance (QA) committee, or the case meets its termination in a QA committee discussion that goes no further.
  4. No one publishes case reports of their complications. Do you think an anesthesiologist is motivated to publish a case report in which they had permanent nerve injury of the brachial plexus following an interscalene nerve block for shoulder surgery? Of course not. He or she wants that case buried deeply, with as few people as possible knowing. No one publishes their dirty laundry, hence the medical literature is lacking in adverse case reports.
  5. Academic professors specializing in regional anesthesia have little interest in publicizing data that could damn or minimize the importance of their chosen subspecialty. A physician who makes his or her living performing, teaching, and writing about a hammer has a conflict of interest when it comes to speaking out on the dangers of wielding that hammer.

In my role as a peer review physician, quality assurance committee member, expert legal witness, and simply as a physician in a busy medical system, I’m aware of more than a dozen patients who already have permanent nerve injury following an ultrasound-guided peripheral nerve block. None of their case histories has been published, and none of their cases have appeared in a published series of nerve injury complications.

Is there a cover-up ongoing regarding permanent nerve injury? There is certainly no publicizing of these complications.

Let me give you an example of another anesthesia technique that was associated with permanent nerve injury: In the 1990’s we routinely used hyperbaric 5% lidocaine for spinal anesthesia. Lidocaine had the advantage of supplying short (1 – 1 ½ hour) spinal anesthesia for simple cases such as cytoscopies, urethral surgeries, perineal surgeries, and inguinal hernias. Case reports of cauda equina syndrome emerged, in which some lidocaine spinal anesthetics were associated with inflammation of the distal spinal cord (cauda equina), which caused permanent lower extremity nerve injury. Because of this risk, the use of lidocaine spinal anesthesia disappeared. The risk of nerve injury was real, and the risk was too daunting to continue using that anesthesia technique.

Expect a similar story to evolve over the coming years regarding the current burgeoning practice of peripheral nerve blockade. “Complications of Peripheral Nerve Block,” an article published in the British Journal of Anaesthesia in 2010, stated that “complications of peripheral nerve blocks are fortunately rare, but can be devastating for both the patient and the anaesthesiologist.” Indeed, for the patients whose nerve injury does not resolve it can be a tragedy.

In his lecture on nerve injury complications of peripheral nerve block delivered at the 2018 ASA national convention in San Francisco, speaker David Hardman, MD MBA told a standing room only crowd of anesthesiologists that if your patient develops a permanent nerve injury following a peripheral nerve block, “you will be sued.” Why was there a huge crowd for this particular lecture? I believe it’s because many anesthesiologists are aware of the occurrence of nerve injury, and aren’t sure what to do about the incidence of ultrasound-guided nerve blocks in their practice.

No one wants to be sued, but per the Hippocratic Oath we must first do no harm. The real crisis is not that an anesthesia provider gets sued, but that the patient will go the rest of their lives without the normal use of their arm or leg.

General anesthesia has risks. Adding a regional anesthetic to a general anesthetic adds a second set of risks. At times regional anesthesia is indicated. I still perform peripheral nerve blocks on select patients, and I believe peripheral nerve blockade still has utility in anesthesia practice. I believe ultrasound-guided peripheral nerve blocks are indicated:

  1. If the scheduled procedure will cause significant post-operative pain, e.g. a total shoulder replacement.
  2. If parenteral narcotics are unlikely to relieve the pain satisfactorily, e.g. a total shoulder replacement, or you are doing a painful procedure on a patient who consumes chronic narcotics, and who will be tolerant to narcotic analgesia.
  3. If I explain the non-zero risk of permanent nerve injury, e.g. a risk of 1 in 3000 patients, and the patient both understands this risk and consents to proceed.

Seducing a patient into accepting a peripheral nerve block by minimizing the chance of permanent nerve injury with phases such as, “nerve injury is very, very rare,” or “nerve injury is very uncommon, and it usually resolves,” is deceptive medical practice. If that patient later develops permanent nerve injury, you can expect to be sued. A 2007 survey of academic regional anesthesiologists indicated that nearly 40% of respondents did not disclose the risks of long-term and disabling neurologic injury prior to performing peripheral nerve blocks.( Brull R, et al. Disclosure of risks associated with regional anesthesia: a survey of academic regional anesthesiologists. Reg Anesth Pain Med. 2007;32:7-11)

It’s better to tell the patient the truth, and risk the following dialogue:

Anesthesiologist: “The risk of permanent nerve injury after this nerve block is very low, but it’s not zero. A ballpark incidence of the chance of permanent nerve injury to your arm (or leg) is one patient in 3,000.”

 Patient: “A one in 3000 chance that I could have permanent nerve injury? I don’t want to take that chance. Skip the block.”

Yes, you might lose the opportunity to do the block, but that’s what informed consent is all about. It’s your duty to explain the risks, the benefits, and the alternatives. In Hardman’s article, the author states that he circles the words “nerve injury” on the anesthesia consent for peripheral nerve block, and he has the patient write their initials next to it, to document that they have read it and understand the risks.

 

REFERENCES:

  1. https://www.anesthesiologynews.com/Review-Articles/Article/07-15/Nerve-Injury-After-Peripheral-Nerve-Block-nbsp-Best-Practices-and-Medical-Legal-Protection-Strategies/32991/ses=ogst
  2. Liu SS, et al. A prospective, randomized controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms. Anesth Analg. 2009;109:265-271).
  3. Brull R, et al. Disclosure of risks associated with regional anesthesia: a survey of academic regional anesthesiologists. Reg Anesth Pain Med. 2007;32:7-11.
  4.  http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1948033
  5. https://www.nysora.com/neurologic-complications-of-peripheral-nerve-blocks
  6. https://academic.oup.com/bja/article/105/suppl_1/i97/235950   

 

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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:

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ABOUT THE ANESTHESIA CONSULTANT

the anesthesia consultant

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

Greetings. My name is Dr. Richard Novak, the author of About The Anesthesia Consultant. The Anesthesia Consultant exists to increase your knowledge about anesthesia and the practice of medicine before, during, and after surgery. The Anesthesia Consultant is designed to inform and entertain both laypeople and medical specialists, and provides answers not found in traditional textbooks.

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I’m a Stanford-trained physician, double-boarded in internal medicine and anesthesiology, and I’ve personally anesthetized over 25,000 patients over 34+ years. I’m currently an Adjunct Clinical Professor in the Stanford Department of Anesthesiology, Perioperative and Pain Medicine.

I’ve learned a lot over these years, and my intent is to share my knowledge with my readers, who include anesthesia professionals and lay people. This anesthesia blog contains more than 180 distinct pages and posts, all written by me. About half the columns are directed to the general public, so that they can understand anesthesia practice and the life of an anesthesia professional. The other half are detailed, well-referenced articles aimed at physician anesthesiologists, nurse anesthetists, and anesthesia assistants the world over.

I began my writing career in 2001, when I was the Deputy Chief of Anesthesia at Stanford University Hospital. Stanford is a mixed hospital, with both full time faculty and private practice faculty. I have been in the private practice of anesthesia since 1986, and my viewpoints are unique because very few private practice physician anesthesiologists have worked in a major university hospital for over thirty years.

Private practice anesthesia differs from academic anesthesia in important ways, and I began writing monthly Deputy Chief Columns in the Stanford Anesthesiology Department newsletter in 2001, to articulate these differences.

Once the total number of columns exceeded sixty, I created The Anesthesia Consultant website in 2010 to share my writing with readers outside Stanford. I continue to write 1 – 1 columns per month, in addition to maintaining a full time job as a clinical anesthesiologist.

In 2018, The Anesthesia Consultant was rated the #7 anesthesia blog in the world by Feedspot.

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

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

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

Will I Have a Breathing Tube During Anesthesia?

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?

 

Click on the Pages of The Anesthesia Consultant for an overview of important topics, or browse through the 160+ Posts listed in the sidebar. If you don’t find the answer to your anesthesia questions, you can contact me at:

rjnov@yahoo.com.

 

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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Thanks, and good luck reading!

Richard Novak, MD

 

NEW ANESTHESIOLOGY GRADUATES NEED TO KNOW _______.

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

New anesthesiology graduates know a great deal, and yet still have a lot to learn. What do you need to know before you start your first job following anesthesia residency? You already know the basic science facts, and you’ve done three years of cases with a faculty member next to your right elbow at every crucial moment.

But are you ready to work alone?

 

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When an anesthesiologist finishes their formal training, he or she has a brain full of academic teachings, and has performed hundreds of anesthetics in a university setting while being supervised by faculty members.

Turn the page to the first weeks of an anesthesia career in a private or community practice, and the setting is different: The new graduate must work by themselves, without supervision, in a new and unfamiliar hospital, alongside surgeons and nurses they don’t know.

It’s the most difficult transition in an anesthesiologist’s career.

I learned a lot in my first year(s) in private practice. What follows are links to the columns I wrote to bolster the knowledge base of the new graduate. In essence, these are the points of wisdom I wish I’d known when I finished residency. These are the pearls not available in the standard textbooks:

 

10 WAYS PRIVATE PRACTICE ANESTHESIA DIFFERS FROM ACADEMIC ANESTHESIA

A discussion of the key differences between private practice and university anesthesia practice.

 

12 THINGS TO KNOW AS YOU NEAR THE END OF YOUR ANESTHESIA TRAINING

A summary of resources to prepare yourself to practice anesthesia outside of the academic setting.

 

AVOIDING AIRWAY DISASTERS IN ANESTHESIA

An airway disaster can cost your patient’s life, and radically alter the career of a young anesthesiologist. This column offers advice on how to stay out of an airway disaster.

 

12 TIPS ON BECOMING AN OUTSTANDING ANESTHESIOLOGIST

This column summarizes the qualities you’ll need to succeed as an anesthesiologist.

 

FIVE MINUTES . . . TO AVOID ANOXIC BRAIN INJURY

As an expert witness, I’ve seen dozens of cases of anoxic brain death cases. It only takes five minutes of botched anesthesia practice to cause anoxic brain injury, and this column offers advice on how to avoid becoming a defendant in a malpractice suit.

 

HOW TO WAKE UP PATIENTS PROMPTLY FOLLOWING GENERAL ANESTHETICS

You’ll become a better anesthesiologist over the decades. Based on my 30+ years of experience, this column give advice on how to wake patients quickly and with excellent airway maintenance.

 

10 TRENDS FOR THE FUTURE OF ANESTHESIOLOGY

What are next 30 years of your career going to look like? No one knows for sure, but this column discusses the current trends, and where they are heading.

 

ADVICE FOR PASSING THE ORAL BOARD EXAMS IN ANESTHESIOLOGY

You’ll have to pass the oral exam to become board-certified. Here I offer advice, based on decades of giving  mock oral examinations to residents at Stanford.

 

SMOOTH EMERGENCE FROM GENERAL ANESTHESIA

Smooth emergence from anesthesia is important in every case, from a craniotomy to a tonsillectomy to a facelift. I offer advice from 30+ years of experience.

 

WOULD YOU GIVE AN NFL QUARTERBACK A PERIPHERAL NERVE BLOCK?

Regional anesthesia is touted by university regional anesthetic specialists. In the community, you will have to decide how to give informed consent regarding nerve damage, and who is at prohibitive risk for any incidence of nerve damage.

 

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

In residency, you have four hands available, because your faculty member is at your assistance. In private practice, you’ll have to learn to anesthetize children by yourself. This column gives advice on solo practice of pediatric anesthesia.

 

HOW TO PREPARE TO SAFELY INDUCE GENERAL ANESTHESIA IN TWO MINUTES

You’re young, you’re green, and the surgeon is in a hurry. This column gives pearls on how to start an anesthetic as quickly and safely as possible.

 

WHAT ONE QUESTION SHOULD YOU ASK TO DETERMINE IF A PATIENT IS ACUTELY ILL?

A nurse telephones you regarding one of your patients in the Post Operative Care Unit. What one question do you ask to determine if the patient is acutely ill or not?

 

KEEPING ANESTHESIA SIMPLE: THE KISS PRINCIPLE

In university training, professors often attempt to make anesthetics interesting and unique. In private practice, a key objective is to keep anesthetics simple, i.e. following the KISS principle, or Keep It Simple Stupid.

 

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

Your work is not finished until you’ve extubated the trachea safely. What does the medical literature advise regarding the proper time and techniques regarding extubation, particularly in difficult airway patients?

 

Good luck with your first job! Keep reading, and don’t be afraid to ask your senior colleagues for advice and guidance.

ANESTHESIA EXPERT WITNESS

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

Dr. Richard Novak, an Adjunct Clinical Professor of Anesthesiology at Stanford University Medical Center, is available for anesthesia expert witness consultation.

Dr. Novak is a clinician who administers anesthesia and directs perioperative medical care at Stanford University Hospital and multiple outpatient surgery centers in and around Palo Alto, California. Dr. Novak has personally performed more than 25,000 anesthetics since 1984, and is uniquely qualified because he works in an academic medical center but is also a community private practice anesthesiologist.  In addition to providing clinical care, Dr. Novak is available for experienced medical-legal expert witness consultation, case review, or testimony in the specialties of anesthesiology and perioperative internal medicine.

Dr. Novak is board certified by both the American Board of Anesthesiology and the American Board of Internal Medicine.

CONTACT EMAIL:  RJNOV@yahoo.com

 

CURRICULUM VITAE

OFFICE ADDRESS

Associated Anesthesiologists Medical Group

2237 Alma Street

Palo Alto, California 94601

telephone (650) 323-0617

 

Education:

1972-76                        B.A., Chemistry, Magna Cum Laude, Carleton College

1976-80                        M.D., University of Chicago Pritzker School of Medicine

 

Postgraduate Education:

1980-81                        Internship in Internal Medicine, Stanford University Hospital

1981-83                        Residency in Internal Medicine, Stanford University Hospital

1984-86                        Residency in Anesthesiology, Stanford University Hospital

 

Awards and Honors:

 Phi Beta Kappa, Carleton College

AOA, University of Chicago School of Medicine

 

Professional Experience:

1983-84  Physician Specialist, Department of Internal Medicine, Stanford Emergency Room, Stanford University School of Medicine

1986   Attending Anesthesiologist, Santa Teresa Kaiser Hospital, San Jose, CA

1986-88   Attending Anesthesiologist, Washington Hospital, Fremont, California

1989 to Present    Attending Anesthesiologist, Stanford University Hospital, Associated Anesthesiologists Medical Group, Inc., Palo Alto, California

 

Medical Licensure:  California

 

Medical Staff Privileges:

Stanford University Hospital, Palo Alto, California

Plastic Surgery Center, Palo Alto, California

Menlo Park Surgical Hospital, Menlo Park, California

Waverley Surgery Center, Palo Alto, California

California Ear Institute, Palo Alto, California

 

Board Certification:

1981       Diplomate, National Board of Medical Examiners

1983       Diplomate, American Board of Internal Medicine

1987       Diplomate, American Board of Anesthesiology

 

Academic Appointments/Presentations:

1983-84    Physician Specialist, Department of Internal Medicine, Emergency Room Attending, Stanford University School of Medicine.

1988-1993    Clinical Instructor, Stanford University Department of Anesthesiology

1993- 2000    Adjunct Clinical Assistant Professor, Stanford University Department of Anesthesiology.

2000 to August 2018    Adjunct Clinical Associate Professor, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine.

September 2018 to present   Adjunct Clinical Professor, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine.

 

Teaching Experience:

1983  Instructor, Advanced Trauma Life Support, Instructor, Advanced Cardiac Life Support

1984   Lecturer, Emergency Management of Overdose,  Stanford Hospital Pharmacy Symposium

1988 to Present  Examiner, Practice Oral Board Exams, Stanford Department of Anesthesia

1992  Lecturer, Preoperative Assessment of Internal Medicine Patients,

Internal Medicine Resident  Conference, Stanford University Hospital

1993  Lecturer, Anaphylaxis on Induction of General Anesthesia,, Stanford Anesthesia Grand Rounds

1995  Lecturer, Electrolyte Disturbance during Hysteroscopy, Stanford Anesthesia Grand Rounds

2001 Lecturer, Anaphylaxis during Liposuction, Stanford Anesthesia Grand Rounds

2001 to Present  Author, Deputy Chief Column, Anesthesia Gas Pipeline, Department of Anesthesia, Stanford, CA.

2003  Lecturer, Hypovolemic Shock in Gynecologic Laparoscopy, Stanford Anesthesia Grand Rounds

2004 Lecturer, Neurologic Complications following Total Joint Replacement, Stanford Anesthesia Grand Rounds

2005 Lecturer, Preoperative Screening at an Freestanding Ambulatory Surgery Center, Stanford Anesthesia Grand Rounds

2007 Lecturer, Awareness During General Anesthesia, Stanford Anesthesia Grand Rounds

2009 Lecturer, Medical Director Management of a Freestanding Ambulatory Surgery Center, Stanford Anesthesia Grand Rounds

2011 Lecturer, Pulmonary Edema in a 3-Year-Old Following Tonsillectomy, and 75 Cases of 10-Hour Outpatient General Anesthetics for Atresia/Microtia Pediatric Surgery, Stanford Anesthesia Grand Rounds

2015 Lecturer, Pediatric Anesthesia in a Freestanding Ambulatory Surgery Center, Stanford Anesthesia Grand Rounds

2016  Invited Lecturer, The Transition From Anesthesia Residency to Community Practice, University of New Mexico, Albuquerque, New Mexico, July 14, 2016

2016  Invited Lecturer, Pediatric Anesthesia at Freestanding Ambulatory Facilities, University of New Mexico Anesthesia Grand Rounds, Albuquerque, New Mexico, July 15, 2016

2017  Lecturer, Expert Witness Testimony in Anesthesia, Stanford Anesthesia Grand Rounds

2017  Exhibit: an audio recording of The Metronome, a poem by Richard Novak MD, at the Russell Museum of Medical History and Innovation at Massachusetts General Hospital regarding perspectives on anesthesia, at Boston City Hall Plaza as part of HUBweek, Boston’s festival of innovation, October 2017.

 

Offices Held:

1991 to Present  Vice President, Associated Anesthesiologists Medical Group, Inc.

1995 to 1998   Alternate Delegate, District 4, California Society of Anesthesiologists

1996 to 2000  Medical Advisory Board, Palo Alto Surgecenter

2001-2015  Deputy Chief of Anesthesia, Stanford University Medical Center

2002-Present  Medical Director, Waverley Surgery Center, Palo Alto, California

2005-2014  Delegate, District 4, California Society of Anesthesiologists

2006-Present Expert Reviewer, Medical Board of California

 

Medical Committees:

1997 to 2009   Care Improvement QA Committee, Stanford Univ. Hospital

1998 to Present   Quality Assurance Committee, Stanford Dept. of Anesthesia

1997 to Present   Quality Assurance Committee, Associated Anesthesiologists Medical Group

1996 to 2000    Medical Advisory Board, Palo Alto Surgecenter

2002 to 2009   Stanford University Hospital Anesthesia QA Committee

2002 to Present  Chairman, Waverley Surgery Center QA Committee

 

Publications:

Novak RJ, Gaeke R, Kirsner JB. Chronic Daily Narcotic Use in Patients with Crohn’s Disease:   Gastroenterology May 1980;  78(5): Part 2, p 1331.

Novak  RJ, Hill BB, Schubart PJ, Fogarty TJ, Zarins CK.  Endovascular Aortic Aneurysm Repair in a Patient with Prohibitive Cardiopulmonary Risk:  Anesthesiology 1999;  91:  1542 – 45.

Novak RJ, Dental Anesthesia for Autistic Children, letter to the editor:   Autism Research Review International 2000, Vol 14, No. 4, page 7.

Novak RJ, The Metronome, Anesthesiology, Mind to Mind Section 2012: 117:417.

Novak RJ, Vascular Access Made Easy, Outpatient Surgery Magazine Manager’s Guide to Ambulatory Anesthesia, July 2013, pages 10-19.

Novak RJ, Lessons in Medication Labeling, Outpatient Surgery Magazine Manager’s Guide to Ambulatory Anesthesia, October 2013, pages 22-25.

Author, Deputy Chief Columns, January 2001 – 2015, Anesthesia publication Gas Pipeline, circulated internationally by the Department of Anesthesia, Stanford, CA.

Author, The Anesthesia Consultant website, http://theanesthesiaconsultant.com

Novak RJ, The Doctor and Mr. Dylan, a novel, Pegasus Books, 2014, and Montelago Press, 2017, (second edition).

Novak, RJ, Best Practices in Drug Safety, Manager’s Guide to Staff and Patient Safety Supplement to Outpatient Surgery Magazine, October 2015, pages 34-40.

Novak RJ, Book Chapter, Disorders of Potassium Balance, in Complications in                        Anesthesia, 3rd Edition, 2017, edited by Lee Fleisher and Stanley Rosenbaum,                        Elsevier Press, Philadelphia.

Novak RJ, Book Chapter: Management of Insulin Overdose; in Advanced                         Perioperative Crisis Management, 2017, edited by Matthew McEvoy                                          and Cory Furse, Oxford Press.

Novak RJ, Book Chapter, Anesthesia Considerations in Ear Reconstruction, in Modern Microtia Reconstruction: Art, Science, and New Clinical Techniques, edited by Reinisch J and Tahiri Y, Springer Press, New York, 2019.

Novak RJ, Ideas That Work: Anesthesiologists Start Their Own IVs to                                     Build Rapport With Patients, Outpatient Surgery Magazine, April 2017.

Novak RJ, Doctor Vita, a novel, All Things That Matter Press, 2019.

 

Volunteer Activities:

 1992 to 2000    Internal Medicine Physician, RotaCare Clinic of East Palo Alto

2007 to 2009     Internal Medicine Physician, Samaritan House Clinic, Redwood City

2015 to present  Editor for SafeSpace mental health non-profit organization, Menlo Park, CA

 

Professional Societies:

American Society of Anesthesiologists

California Society of Anesthesiologists

California Medical Association

Santa Clara County Medical Association

 

All expert witness testimony follows the Guidelines For ExpertWitness Qualifications and Testimony, as set forth by American Society of Anesthesiologists:

GUIDELINES FOR EXPERT WITNESS QUALIFICATIONS AND TESTIMONY (Approved by the ASA House of Delegates on October 15, 2003, and last amended on October 22, 2008) PREAMBLE The integrity of the litigation process in the United States depends in part on the honest, unbiased, responsible testimony of expert witnesses. Such testimony serves to clarify and explain technical concepts and to articulate professional standards of care. The ASA supports the concept that such expert testimony by anesthesiologists should be readily available, objective and unbiased. To limit uninformed and possibly misleading testimony, experts should be qualified for their role and should follow a clear and consistent set of ethical guidelines. A. EXPERT WITNESS QUALIFICATIONS 1. The physician (expert witness) should have a current, valid and unrestricted license to practice medicine. 2. The physician should be board certified in anesthesiology or hold an equivalent specialist qualification. 3. The physician should have been actively involved in the clinical practice of anesthesiology at the time of the event. B. EXPERT WITNESS ETHICAL GUIDELINES 1. The physician’s review of the medical facts should be truthful, thorough and impartial and should not exclude any relevant information to create a view favoring either the plaintiff or the defendant. The ultimate test for accuracy and impartiality is a willingness to prepare testimony that could be presented unchanged for use by either the plaintiff or defendant. 2. The physician’s testimony should reflect an evaluation of performance in light of generally accepted standards, reflected in relevant literature, neither condemning performance that clearly falls within generally accepted practice standards nor endorsing or condoning performance that clearly falls outside accepted medical practice. 3. The physician should make a clear distinction between medical malpractice and adverse outcomes not necessarily related to negligent practice. 4. The physician should make every effort to assess the relationship of the alleged substandard practice to the patient’s outcome. Deviation from a practice standard is not always causally related to a poor outcome. 5. The physician’s fee for expert testimony should relate to the time spent and in no circumstances should be contingent upon outcome of the claim. 6. The physician should be willing to submit such testimony for peer review.

 

 

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?

 

FIVE MINUTES . . . TO AVOID ANOXIC BRAIN INJURY

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

Anoxic brain injury. These three words make any anesthesiologist cringe. In layman’s terms, anoxic brain injury, or anoxic encephalopathy, means “the brain is deprived of oxygen.”

Five minutes stopwatch

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In an anesthetic disaster the brain can be deprived of oxygen. Without oxygen, brain cells die, and once they die they do not regenerate. If something dire goes wrong during anesthesia and surgery and the flow of oxygen to the brain is cut off, an anesthesia practitioner has about five minutes to diagnose the cause of the problem and treat it. Some brain cells start dying within five minutes after the oxygen supply disappears, and brain hypoxia can rapidly cause severe brain damage or death. (1,2)

In malpractice cases I’ve consulted on, a five-minute window is an accepted duration for low blood oxygen levels to cause permanent brain damage.

The good news is that catastrophic events causing sudden drops in oxygen levels are very rare during anesthesia. I’ve reviewed the risks of anesthesia in the 21st Century in a previous column, which I refer you to.

Miller’s Anesthesia is the premier textbook in anesthesiology. I respect Miller’s Anesthesia as an outstanding reference, but a keyword search for “anoxic encephalopathy” in Miller’s Anesthesia only links to two chapters: one on temperature regulation, and second on pediatric intensive care. The topic of anoxic encephalopathy as related to anesthesia disasters and brain death—a issue that can ruin both a patient’s life and an anesthesiologist’s career—is not specifically covered in Miller’s Anesthesia.

Anesthesiologists are human, and human error is known to seep into anesthesia care. Miller’s Anesthesia, Chapter 7 on Human Performance and Patient Safety,3 makes several statements pertinent to human error:

“. . . anesthesia professionals themselves, both as a profession and as individuals, have strengths and vulnerabilities pertaining to their work environment. The performance of human beings is incredibly flexible and powerful in some aspects but very limited in others. Humans are vulnerable to distractions, biases, and errors.”  

“The stakes are high because even for elective surgery in healthy patients, there is an ever-present and very real risk of injury, brain damage, or even death. A catastrophe is often the end result of many pathways that begin with seemingly innocuous triggering events. . . .”

“Because more than 70% of all errors in medicine can be attributed to problems with human factors rather than problems with knowledge or practical skills, the impact of human factors cannot be overestimated.

My impression, based on 34 years in an anesthesia career, is that some anesthesia practitioners perform better under pressure. Just like Joe Montana had the knack for doing the right thing on a football field when the pressure was on, and just like Sully (Chesley Sullenberger) made correct decisions when the jet engines of US Airways Flight 1549 were knocked out by collisions with birds shortly after takeoff, some anesthesia practitioners perform well under intense pressure . . . and some don’t.

Let me present two examples, inspired by real cases, of relatively healthy young patients who had unexpected hypoxic (low oxygen) episodes. These patients had drastically different outcomes due to different anesthetic care:

CASE 1.

A 40-year-old male presented for outpatient septoplasty surgery. His past medical history was positive for obesity (weight=100 kg with a BMI=32) and hypertension. His preoperative vital signs were normal with an oxygen saturation of 98%.

Anesthesia was induced with propofol 250 mg, fentanyl 100 micrograms, and rocuronium 50 mg IV. An endotracheal tube was easily placed, and breath sounds were equal bilaterally. Anesthesia was maintained with oxygen, nitrous oxide, and sevoflurane 1.5%, and incremental doses of 50 micrograms of fentanyl.

The surgery concluded 2 hours later, and the nitrous oxide and sevoflurane were discontinued. The patient began to cough, and reached up to try to pull out his endotracheal tube. The anesthesiologist decided to extubate the trachea. After extubation the patient was making respiratory efforts, but no airflow was noted. A jaw thrust attempt to break suspected laryngospasm was ineffective. The oxygen saturation dropped to 78%.

  • Succinylcholine 40 mg was administered. There was no improvement in the oxygenation or airway.
  • Two minutes later a second dose of succinylcholine 60 mg was administered. There was continued inability to move oxygen.
  • Two minutes later, a #4 LMA was placed, with continued inability to move oxygen.
  • Two minutes later the anesthesiologist attempted to reintubate the trachea. The first attempt was unsuccessful due to poor visibility. The oxygen saturation dropped to 50%.
  • Seven minutes after the initial oxygen desaturation to 78%, a second laryngoscopy using a GlideScope was successful, and a 7.0 ET tube was placed. Copious secretions were suctioned out of the ET tube. Ventilation remained difficult and peak inspiration pressures were high. The patient continued to be hypoxic. The patient’s ECG deteriorated into pulseless electrical activity (PEA), and chest compressions were initiated. Epinephrine 1 mg was administered IV twice, the peripheral pulses returned, and chest compressions were stopped.
  • Twenty minutes after the oxygen desaturation to 78%, the oxygen saturation finally rose to 94%. A chest x-ray showed pulmonary edema. The diagnosis was laryngospasm leading to negative pressure pulmonary edema. Furosemide 20 mg was administered IV. The patient remained on a ventilator in the ICU for seven days, at which time he was declared brain dead.

 

CASE 2.

A 30-year-old male was scheduled for maxillary and mandibular osteotomies for obstructive sleep apnea. He was otherwise healthy. He weighed 80 kg and had a BMI=26. His preoperative vital signs were normal.

Anesthesia was induced with propofol 250 mg and rocuronium 50 IV, and a right cuffed nasal endotracheal tube was placed. Breath sounds were bilateral and equal. Anesthesia was maintained with sevoflurane 1.5%, nitrous oxide 50%, propofol 50 mcg/kg/hr, and incremental doses of 50 mcg fentanyl. The surgery concluded 4 hours later. The surgeons wired the upper and lower teeth together. The propofol, sevoflurane, and nitrous oxide were discontinued.

The patient opened his eyes ten minutes later, and responded appropriately to conversation. The endotracheal tube was removed, and the patient’s airway was patent. He was moved to the gurney, the back of the gurney was elevated 30 degrees, and a non-rebreather mask with a 10 liters/minute flow rate of oxygen was strapped over his face. The anesthesiologist then transported the patient down the hallway to the PACU. En route the patient became more somnolent and developed upper airway obstruction resistant to jaw thrust maneuvers.

  • On arrival at the PACU the patient was nonresponsive, and his initial oxygen saturation was 75%. The anesthesiologist began mask ventilation via an Ambu bag, and the oxygen saturation rose to 90%. The patient was making ventilatory efforts without significant air movement.
  • The wires fixating the maxilla and mandible together were severed with a wire cutter.
  • The anesthesiologist attempted laryngoscopy with a Miller 2 blade, and was unable to visualize the larynx because of frothing fluid bubbling in the oropharynx. A presumptive diagnosis of negative pressure pulmonary edema was made, and a GlideScope was called for. The oxygen saturation was 88%.
  • After suctioning the frothy fluid which filled the oropharynx, a second laryngoscopy attempt with the GlideScope yielded successful placement of a 7.0 oral endotracheal tube. Pulmonary edema fluid was suctioned from the lumen of the endotracheal tube, and furosemide 20 mg was injected IV. The oxygen saturation rose to 98% on 100% oxygen.

The duration of time from when the patient’s oxygen level was discovered to be 75% until his oxygen level rose above 90% was two minutes. The duration of time from when the patient’s oxygen level was discovered to be 75% until the trachea was successfully reintubated was four minutes.

The patient remained intubated in the ICU for two nights, with diagnoses of upper airway edema post maxillary-mandibular osteotomies and negative pressure pulmonary edema. He was extubated on post-op day #3, when he successfully passed a cuff-leak test. His oxygen saturations were normal and his brain was undamaged. He walked out the hospital alive and well.

Case #1 and Case #2 were similar in that both patients were young relatively healthy men having head and neck surgery. The expected risk of serious complication for each procedure was low. The expected risk of death, or of brain death, was extremely small. Yet one man died and the other survived.

Why?

In Case #1, a case study based on a closed claim malpractice settlement, the delays in anesthesia care led to prolonged low oxygen levels, and these prolonged low oxygen levels caused anoxic brain damage. The deviations from the standard of care included:

  1. The patient was extubated too early, at a time when he was still partially anesthetized, in a transitional phase of anesthesia, and not yet awake. The safest technique for extubation is awake extubation, when the patient is an awake state of eye opening and obeying commands. Per the Difficult Airway Society Guidelines for the Management of Tracheal Extubation, an awake intubation is when “the patient’s eyes are open and the patient is responsive to commands.”4 This patient had head and neck surgery, and was at risk for post-operative airway problems. Extubating before the patient opened his eyes and obeyed verbal commands was a deviation from the standard of care.
  2. Once the patient developed post-extubation laryngospasm, the standard of care was for the anesthesiologist to act immediately to relieve airway obstruction and correct hypoxemia. Laryngospasm can lead to hypoxia, as it did in this case. The order of treatment is A-B-C, or Airway–Breathing–Circulation. When the immediate application of jaw thrust and continuous positive airway pressure via facemask was unsuccessful, and the oxygen saturation dropped into the 70’s, the standard of care was to immediately paralyze the patient with an intubating dose of succinylcholine (1 mg/kg IV) and to reinsert an endotracheal tube. Per Difficult Airway Society Guidelines for the Management of Tracheal Extubation, “If laryngospasm persists and/or oxygen saturation is falling: (administer) succinylcholine 1 mg/kg intravenously. Worsening hypoxia in the face of continuing severe laryngospasm with total cord closure . . . requires immediate treatment with intravenous succinylcholine. The rational for 1 mg/kg is to provide cord relaxation, permitting ventilation, re-oxygenation and intubation should it be necessary.”4 The entire time from the onset of laryngospasm to the successful control of the airway and ventilation of the lungs in Case #1 exceeded 20 minutes.

When a bad outcome like this occurs in a hospital or surgery center, a facility’s Quality Assurance Committee examines the details of the case—not to assign blame—but to identify flaws in patient care systems which must be improved in the future.

When a patient’s family hires a lawyer to investigate a bad outcome, the same analysis of the medical record and the medical details occurs, but the stakes are different. Physicians and facilities carry malpractice insurance with limits in the millions of dollars. If a physician or a facility is found to have performed below the standard of care, and if that negligent performance is found to have caused patient damage, they may well lose a malpractice settlement. The minute-by-minute pulse oximetry data will be scrutinized during any ensuing malpractice trial or deposition, with an aim to document how many minutes the oxygen saturation was critically low. A time frame of five minutes or greater of hypoxia in the medical record can be damning for the anesthesiologist’s case.

In the Miller’s Anesthesia chapter titled Human Performance and Patient Safety, Drs. Rall and Gaba describe 15 Key Points of Crisis Resource Management (CRM).3 Highlights of the Key Points include:

  • CRM Key Point 2. Anticipate and Plan. “Anesthesia professionals must consider the requirements of a case in advance and plan for the key milestone. They must imagine what could go wrong and plan ahead for each possible difficulty. Savvy anesthesia professionals expect the unexpected, and when it does strike, they then anticipate what could happen next and prepare for the worst.”
  • CRM Key Point 3. Call for Help Early.
  • CRM Key Point 4. Exercise Leadership and Followership With Assertiveness. “A team needs a leader. Someone has to take command, distribute tasks, collect information, and make key decisions. . . . Followers are key members of the team who listen to what the team leader says and do what is needed.”
  • CRM Key Point 8. Use All Available Information. “Information sources include those immediately at hand (the patient, monitors, the anesthesia record), secondary sources such as the patient’s chart, and external sources such as cognitive aids (see later) or even the Internet.”
  • CRM Key Point 11. Use Cognitive Aids. “Cognitive aids—such as checklists, handbooks, calculators, and advice hotlines—come in different forms but serve similar functions. They make knowledge “explicit” and “in the world” rather than only being implicit, in someone’s brain.” An example cognitive aid is the Stanford Emergency Manual, which I recommend.5

Dr. David Gaba, one of the authors of this chapter, is a longtime friend of mine and a pioneer in the fields of anesthesia simulator design and crisis management. I respect this list of 15 CRM Key Points, but I also know that when the clock is ticking on those five minutes of patient hypoxia, there is no time to think through 15 items. There is no time for any wasted effort or motions. The anesthesia provider must captain the ship and restore oxygenation without delay. The anesthesia provider needs a plan embedded in his or her brainstem that allows them to keep the patient safe.

Based on my experience as both a practicing anesthesiologist for over 30 years and an expert witness for over 15 years, when your patient’s oxygen level drops acutely, these are the things you need to DO:

  1. First off, turn your oxygen supply to 100% oxygen. Turn off all nitrous oxide or air input.
  2. Call for help.
  3. Think A-B-C, or Airway-Breathing-Circulation, in that order.
  4. Examine the patient, particularly their airway and lungs.
  5. If the patient is not already intubated, and you cannot mask ventilate the patient to a safe oxygen level, intubate the trachea immediately to deliver 100% oxygen via controlled ventilation. Use succinylcholine, the fastest emergency paralytic drug.
  6. If you cannot intubate the patient with a traditional Miller 2 or Mac 3 blade, request a GlideScope videoscope ASAP. (Have the American Society of Anesthesiologists Difficult Airway Algorithm committed to memory.)
  7. Have the Stanford Emergency Manual5 in your operating room suite, and ask a registered nurse to recite the Cognitive Aid Checklist for HYPOXEMIA to you, to make sure you haven’t missed something.
  8. If the patient is still not improving, reaffirm your assessments of A-B-C. Fix the Airway, fix the B, then fix the Circulation.
  9. Remember: ACLS (Acute Cardiac Life Support) is important, but ACLS is C, and if A and B are faulty, the cardiac care of ACLS will not save the brain.

Other advice to anesthesiologists:

  • Before a hypoxic emergency occurs in your practice, do yourself and your patients a favor by passing the American Board of Anesthesiologists oral board examination. The time spent studying for the oral boards will make you a safer and smarter anesthesiologist who is better prepared to handle emergency situations. A study in the journal Anesthesiology showed rates for death and failure to rescue from crises were greater when anesthesia care was delivered by non-board certified midcareer anesthesiologists.6 In the Stanford Department of Anesthesiology, Perioperative and Pain Medicine, we administer mock oral board examinations to the residents and fellows twice a year. Presenting an examinee with a sudden hypoxic episode is a common occurrence during the exam. If you can think well in a room in front of two examiners, you are more likely to think well in a true hypoxemic emergency when your patient’s life is at stake.
  • A second tip: If you have access to anesthesia simulator sessions, enroll yourself.

What if you’re a patient reading this? What if you’re contemplating surgery? How can you optimize your chances to avoid an anesthetic disaster?

I offer these suggestions:

  • Choose to have your surgery at a facility that is staffed with American Board of Anesthesiology board-certified physician anesthesiologists.
  • Ask a knowledgeable medical professional to recommend a specific anesthesiologist at your facility, and request that specific anesthesiologist for your care.
  • Inquire about who would manage your crisis if you have one during or after your surgery. Will your anesthesia professional be a physician anesthesiologist, a Certified Registered Nurse Anesthetist (CRNA), or an anesthesia care team made up of both? If an anesthesia care team is attending to you, how many rooms is each physician anesthesiologist supervising? How far away or how many minutes away will your physician anesthesiologist be while you are asleep?
  • In the future, quality of care data will be available on facilities and physicians, including anesthesiologists. These metrics will allow patients to compare facilities and physicians. Do your homework with whatever data is publicized. Research the facility you are about to be anesthetized in.
  • If you’re a higher risk patient, i.e. you have: significant obesity, obstructive sleep apnea, heart problems, breathing problems, age > 65, or you’re having regular dialysis, emergency surgery, abdominal surgery, chest surgery, major vascular surgery, cardiac surgery, brain surgery, regular dialysis, total joint replacement, or a surgery with a risk of high blood loss . . . be aware you’re at a higher risk, and ask more questions of your surgeon and your anesthesia provider.
  • If yours is an elective surgery, realize you have time to heed the advice in this column. Take your time to choose your surgeon, your facility, and your anesthesia provider if you can.

None of us, anesthesia providers or the families of patients, want to be sitting in a courtroom for a malpractice trial because there were five bad minutes without oxygen.

References:

  1. https://medlineplus.gov/ency/article/001435.htm
  2. https://medlineplus.gov/ency/article/000013.htm
  3. Rall M, Gaba D, et al. Human Performance and Patient Safety. Miller’s Anesthesia, Chapter 7, Eighth Edition, p 106-166.
  4. Popat M, Mitchell V, et al. Difficult Airway Society Guidelines for the management of tracheal extubation, Anaesthesia 2012, 67, 318-340.
  5. Stanford Anesthesia Cognitive Aid Group. Emergency Manual: Cognitive aids for perioperative clinical events. *Core contributors in random order: Howard SK, Chu LK, Goldhaber-Fiebert SN, Gaba DM, Harrison TK http://emergencymanual.stanford.edu/
  6. Silber JH et al. Anesthesiologist Board Certification and Patient Outcomes. Anesthesiology.2002 May;96(5):1044-52.

 

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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LETHAL EXECUTION USING FENTANYL . . . AN ANESTHESIOLOGIST’S OPINION

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

Lethal injection using fentanyl occurred for the first time in the death penalty execution of Carey Dean Moore in Nebraska August 14th, 2018.

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Per CBS News, “The Nebraska drug protocol called for an initial IV dose of diazepam, commonly known as Valium, to render the inmate unconscious, followed by the powerful synthetic opioid fentanyl, then cisatracurium besylate to induce paralysis and stop the inmate from breathing and potassium chloride to stop the heart.

Diazepam and cisatracurium also had never been used in executions before.”

From an anesthesiologist’s point of view:

  1. Valium (diazepam), an antianxiety drug, is seldom used in current surgical anesthesia practice, as it has been replaced by Versed (midazolam), which has a faster onset and causes less stinging on intravenous injection.
  2. Fentanyl, a powerful morphine-type narcotic, given in very high doses, brings on sedation, respiratory depression, and unconsciousness. The combination of Valium and high doses of fentanyl (typically 100 micrograms per kilogram) was the standard anesthetic used for open heart surgery in the 1980s. High doses of fentanyl can cause chest wall rigidity, which would add to any agonal respiratory efforts during a lethal injection, hence the necessity of a muscle relaxant (see below).
  3. Cisatracurium, a muscle relaxant or paralyzing drug, blocks all muscle movement and breathing. The paralyzing drug is used to both stop respiration and to eliminated any writhing and agonal movements during the dying movements.
  4. Potassium chloride, in high concentrations, causes the heart to fibrillate and cease beating.

Beginning in the 1970s, initial lethal injection recipes in the United States included 1) sodium thiopental (a barbiturate) to induce sleep, 2) pancuronium (a muscle relaxant) to paralyze the individual, and 3) potassium chloride to fibrillate the heart. In the 1970s-1990s, thiopental and pancuronium were commonly used anesthetic drugs. (In recent decades, propofol has replaced thiopental as the hypnotic of choice for general anesthesia for surgery, and the drugs rocuronium and vecuronium have replaced pancuronium as muscle relaxants for surgery.)

The European Union banned the export of thiopental for lethal injection in 2011, and a search for available alternate sedatives and intravenous anesthetics ensued. By 2016, more than twenty American and European pharmaceutical manufacturers had blocked the sale of their drugs for use in lethal injections, effectively making most FDA-approved unavailable for any potential lethal execution drug.1

This use of fentanyl, diazepam, and cisatracurium in Nebraska is the latest chapter in the recipe for lethal injection story. Stay tuned to see whether the manufacturers of these drugs choose to ban their sale for use in capital punishment.

For previous columns regarding lethal injection procedures, see

JANUARY 2014 LETHAL INJECTION WITH MIDAZOLAM AND HYDROMORPHONE . . AN ANESTHESIOLOGIST’S OPINION, and

APRIL 2014 LETHAL INJECTION IN OKLAHOMA . . . AN ANESTHESIOLOGIST’S VIEW.

Note: As a physician who took the Hippocratic Oath to never harm patients, I neither approve of nor would assist in any way in the lethal injection of a prisoner.

 

References:

  1. Eckholm, Erik “Pfizer Blocks the Use of Its Drugs in Executions”The New York Times. May 16, 2016.

 

 

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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WILL ATUL GAWANDE CHANGE THE FUTURE FOR ANESTHESIOLOGISTS?

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

Dr. Atul Gawande was named CEO of the new Amazon-Berkshire-JPMorgan Chase healthcare partnership. Dr. Robert Pearl wrote an original article in Forbes (June 25, 2018) titled, “Why Atul Gawande Will Soon Be the Most Feared CEO in Healthcare.” Dr. Gawande is a Professor of Surgery at Harvard/ Brigham and Women’s Hospital, and is the bestselling author of multiple nonfiction books directed at healthcare topics. Gawande also has a Masters Degree in Public Health, and with his background as a clinician, he is well poised to interpret the problems of our current healthcare system. Per Dr. Pearl, Gawande was hired by the new Amazon-Berkshire-JPMorgan Chase healthcare partnership to “disrupt the industry, to make traditional health plans obsolete, and to create a bold new future for American healthcare.” Will Gawande change the future for anesthesiologists?

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I’ve read Dr. Gawande’s books and I’ve heard him speak at Stanford. I have the highest respect for his intellect, clinical acumen, and insight. I’m intrigued and excited by what changes he might envision and enact for American healthcare. Surgical care comprises $500 billion, or 40% of healthcare dollars spent spent in America, so we can expect changes in our surgical world to be a likely source of healthcare savings.

Author Dr. Robert Pearl is the former CEO of Kaiser’s Permanente Medical Group, and brother to my Stanford University Department of Anesthesiology Chairman Ronald Pearl MD PhD. In his Forbes article, Robert Pearl lists three major reforms he anticipates Gawande will advocate for. Each reform is aimed to radically improve how care is paid for and provided—and each reform is aimed to radically alter how healthcare providers must function to survive in the future. Let’s look at these three proposed Gawande changes, and how they affect the future for anesthesiologists:

 

  1. Taking out the trash. Pearl writes, “It’s estimated that 25 percent of all U.S. healthcare spending (about $765 billion each year) is wasted. From arthroscopic knee surgeries for chronic cartilaginous injuries to chemotherapy administered in the last month of life, insurers have long reimbursed unnecessary claims and perpetuated a fee-for-service model that rewards doctors for providing more (not better) care. Dr. Gawande has witnessed the excesses of modern medical treatment first-hand, cataloging in his essays the toll wasteful care takes on patients, including his own friends and family. I believe one of his first operational goals will be to root out wasteful spending and services, not as way to ration care, but as a tool to improve clinical outcomes.”

         EFFECT ON ANESTHESIOLOGY AND PERIOPERATIVE MEDICINE: Each “unnecessary claim” that needed an anesthesiologist and every “fee-for-service” procedure that involved anesthesia care would disappear, decreasing the need for anesthesiologists and anesthesia services. This proposed elimination of wasteful spending would decrease the demand for anesthesia professionals.

 

  1. Creating a checklist. Pearl writes, “Gawande earned national acclaim with his 2009 bestseller, The Checklist Manifesto, inspiring an entire industry to double down on evidence-based medicine. From the exam room to the operating room, doctors today follow a clear set of protocols that Dr. Gawande helped establish. He’s currently focused on extending these successes to other areas, including maternity care and the treatment of patients with complex and chronic diseases. For example, the doctor has observed how the best healthcare providers can help 90 percent or more of their patients control high blood pressure. And yet the national control rate is just 55 percent. Left to their own devices, physicians prefer to follow their guts when diagnosing and treating patients. Dr. Gawande knows that, most of the time, science (not intuition) saves more lives, raises the quality of care and lowers costs.”

EFFECT ON ANESTHESIOLOGY AND PERIOPERATIVE MEDICINE: In the future, specific evidence-based protocols and algorithms could dictate anesthesia “recipes.” In the past, every anesthesia provider has had the freedom to design and carry out the pharmacology, monitoring, and perioperative care for each patient as he or she saw fit. These individual decisions were based on each physician’s training and experience. But in recent years, for example, protocols have been introduced to standardize perioperative care for total knee replacement, so that anesthetics include a spinal anesthetic, an adductor canal nerve block, and sedation or a light general anesthetic as well as multimodal analgesia with oral analgesic supplements. These total knee protocols have become standardized and accepted. What about future protocols? Can an insurer dictate what they will or will not pay for, based on their assessment of scientific evidence? This could occur if the insurer has data that the non-protocol care does nothing to improve quality, and it costs more. Let’s look at an example: There are a variety of pharmaceutical choices for the anesthesia care of a shoulder arthroscopy. An ultrasound-directed nerve block is optional. Is there evidence that the block provides safer or cheaper outcomes? If an evidence-based analysis is conducted and it shows that complications, costs, room time, and ancillary staff support are most economical with general anesthesia sans a nerve block, then that interscalene nerve block could be deemed an extraneous charge—an extraneous procedure that will not be paid for. If an anesthesiologist wanted to use the nerve block, the insurer would not reimburse those costs. Only the drug costs, procedures, and protocols approved by the insurance company would be approved. In the current fee-for-service practice, the anesthesiologist may be reimbursed $1000 for an ultrasound-directed nerve block that takes 5 minutes to perform. In the future the anesthesiologist may be doing that block without any reimbursement, yet still be responsible for any costs of that block and any risks or complications of that block. Having Amazon/Gawande dictate evidence-based protocols for postoperative care may produce cost-cutting economics, and anesthesiologists might find their hands tied to a recipe dictated from on high.

 

  1. Being human. Pearl writes, “In Being Mortal, Dr. Gawande shines an unflattering light on end-of-life care in America, revealing that treatment for our nation’s elderly is often expensive, ineffective and inhumane. He has long been an advocate for the model of clinician as counselor, not as technician, and for the power of palliative care to make end-of-life treatment more compassionate and personal. His stories about his own father and mother are moving, and underscore the emotions driving his desire to improve care for our nation’s sickest patients.”

EFFECT ON ANESTHESIOLOGY AND PERIOPERATIVE MEDICINE: All physicians have witnessed expensive and often futile end-of-life intensive care management for elderly patients. If physicians and hospitals are offered an open checkbook, they may choose to administer expensive high-tech interventions to elderly patients during their last weeks of life, including ventilator care, pressors, multiple antibiotics, blood product transfusions, and surgeries. In America we value every life as a precious resource. We value saving every life. It’s probable true that we can no longer afford to spend millions of dollars on the last weeks of each sick elderly patient’s life. It’s probably true that we need some conscience, some compassion, some judgment, and some empathy to choose who to attempt to save. Currently physicians cannot police these decisions themselves, and the government cannot set any rationing policies regarding end-of-life care. It may very well be insurance companies like Amazon/Gawande who set the incentives and disincentives directing payment or non-payment for such care. If surgeons and medical centers lose incentives to perform end-of-life surgical procedures, there will be decreased caseloads for anesthesiologists.

 

The expense of the current American healthcare system is unsustainable. Healthcare costs are 17% of the Gross National Product, and this percentage is growing every year. The cost of insuring employees is a large share of the wage and benefit expenses of every American CEO. The cost of insuring loved ones with current high-deductible insurance plans is a large share of the expense budget for every American family.

Something has to change. The driver of change may very well be the combined economic clout and intellect of: Amazon, the company that delivers UPS packages to our door 36 hours after placing an order; Warren Buffett, the world’s third richest man; J P Morgan Chase, a multi-national investment bank; and d) a talented physician/author/visionary named Atul Gawande.

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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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

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.”

am_150605_child_anesthesia_800x600

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:

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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

For questions, contact:  rjnov@yahoo.com

 

 

 

 

 

 

 

 

 

HOW NEW IS “MODERN 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

Point/Counterpoint: How new is modern anesthesia? Are modern anesthesia techniques radically different from the methods of twenty years ago? True or false?

1990s-moodboard

 

POINT: False. Twenty-first century general anesthetics are nearly identical to the anesthetic techniques of the late 1990s. Consider this list of the most commonly administered anesthetic drugs in the United States in the present day (2018):

Medication                        Year introduced

Propofol                              1989

Sevoflurane                        1995

Nitrous oxide                     1846

Fentanyl                               1959

Versed                                   1985

Rocuronium                        1994

Succinylcholine                  1952

Zofran                                  1991

Bupivicaine                          1957

 

I review hundreds of anesthesia records each year from California and multiple other regions of America. I can attest that these nine medications are still the mainstays of most anesthetics. A typical standard general anesthetic includes Versed as an anti-anxiety premed, propofol as the hypnotic, sevoflurane +/- nitrous oxide as the maintenance vapor(s), fentanyl as the narcotic, Zofran for nausea prophylaxis, rocuronium or succinylcholine for muscle paralysis, and bupivicaine injected (usually by the surgeon) for long-lasting pain relief.

How can it be that general anesthesia has ceased to evolve? In this brave new world of the Internet, iPhones, iPads, and personal computers, how could anesthesiology have stalled out with 20th-century pharmacology? My colleague Donald Stanski, MD PhD, former Chairman of Anesthesiology at Stanford and now an executive in pharmacology business, explained it to me this way: The existing anesthesia drugs are cheap and work well. The cost of research and development for each new anesthesia drug is prohibitively expensive, and for pharmaceutical companies there is no certainty that any new anesthesia drug would control a sufficient market share to make a profit.

I believe we would benefit from a new narcotic drug that would promise less side effects than the fentanyl/morphine analogues, i.e. less respiratory depression, nausea, and sedation. I believe we would benefit from a new ultra-short onset paralyzing drug without the side effects of succinylcholine, i.e. without the risks of muscle pain, hyperkalemic arrests, triggering of malignant hyperthermia, increased intracranial and intraocular pressure, or bradycardia. Someone may discover these products someday, but for the present time the older drugs enjoy the market share.

What about regional anesthesia? When a patient needs a spinal anesthetic, the recipe of bupivicaine +/- morphine is unchanged from the 1990s. When a patient needs an epidural for surgery, the recipe of bupivicaine or lidocaine +/- narcotic is unchanged from the 1990s.

What about monitors of vital signs? The standard monitoring devices of pulse oximetry, end-tidal CO2 monitoring, and other essential anesthesia vital sign monitors were developed and in use by the 1990s. I can think of no specific reason why a general anesthetic administered in 2018 would be safer than a general anesthetic administered in the 1990s.

 

COUNTERPOINT: True. Anesthesia in 2018 is markedly different from anesthesia in the 1990s. Most of the drugs in use haven’t changed, but current-day anesthesia providers practice in a cockpit surrounded by computers. Each operating room anesthesia location is the epicenter of computerized medical record-keeping machines, computerized Pyxis-style drug storage systems, computerized labeling machines, and bar-code reading billing machines. If you don’t understand how to command these high-tech devices, you’ll be unable to initiate an anesthetic at a university hospital. The adage that “the patient comes first” is sometimes lost in an array of LED displays, passwords, and keyboards.

There have been other significant changes in anesthesia practice since the year 2000:

  • The most significant advance is the video laryngoscope, a vital tool for intubating difficult airways, which has facilitated endotracheal intubation in thousands of patients where 20th-century rigid laryngoscope blades were not effective.
  • Ropivicaine was released in the year 2000, and has the distinct advantage of long-lasting local anesthetic nerve blockade with less motor block than bupivicaine.
  • Sugammadex is a remarkable advance, allowing for the reliable reversal of neuromuscular paralysis in only seconds. Sugammadex is the single most important new medication in the toolbox of the 21st-century anesthesiologist.
  • Ultrasound-guided regional anesthesia was developed in 1994, but became popular in the past ten years. Administering local anesthetic injections adjacent to major nerves grants non-narcotic pain relief to thousands of patients following orthopedic surgeries.
  • Acute pain services utilize nerve blocks and other adjuncts to relieve post-operative discomfort. Pain service teams were available only in primitive forms in the 1990s. In fact, at Stanford we changed our name from the “Department of Anesthesiology” to the “Department of Anesthesiology, Perioperative and Pain Medicine” since the turn of the millennium.

 

In closing:

At a wedding a bride is advised to wear something old, something new, something borrowed, and something blue.

In the world of anesthesia we use some things old, some things new, nothing borrowed, and . . . we make sure our patients never turn blue.   🙂

 

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:

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

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:

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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FENTANYL AND THE OPIOID CRISIS: AN ANESTHESIOLOGIST’S PERSPECTIVE

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

The United States is in the midst of an opioid epidemic. The crisis consists of two separate threats. One is the increased presence of powerful illicit street drugs such as fentanyl. The second threat is the increasing use of oral prescription painkillers like Oxycontin, Percocet, and Vicodin. This column addresses fentanyl—its medical aspects and the on-the-street abuses of this powerful narcotic.

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MEDICAL USE OF FENTANYL

I’ve administered fentanyl to over 20,000 patients in my career, and can vouch for the medical utility and import of this drug. Fentanyl is the most commonly administered narcotic during surgery in the United States. If you’ve had a surgical anesthetic, or even a colonoscopy, you’ve likely received fentanyl with few ill effects. Fentanyl is an essential ingredient in the pharmaceutical armamentarium of acute care medicine in hospitals, surgery centers, intensive care units, and emergency rooms throughout the United States. On the streets, fentanyl is killing people. In our hospitals and surgery centers, fentanyl is a useful adjunct as omnipresent as Tylenol.

Fentanyl was first synthesized by Dr. Paul Janssen of Janssen Pharmaceuticals in the 1960s, and was then introduced into anesthetic practice under the brand name Sublimaze.1 Fentanyl is a rapid-onset narcotic drug usually administered by intravenous injection. Compared to morphine, fentanyl is more lipid (fat) soluble, which means the drug crosses into the central nervous system more quickly and works faster than morphine. The termination of the effect of low doses of fentanyl results from decreased concentration, as the drug redistributes from the bloodstream to other organ tissues.

The elimination of higher doses of fentanyl from the body depends on elimination by the liver. Morphine, Demerol, and Dilaudid are other common intravenous medical narcotics, which have slower onset and longer duration of action. When injected into an intravenous line, fentanyl reaches its peak analgesic effect in minutes, significantly faster than morphine. This quicker onset makes fentanyl an easier drug for anesthesiologists to titrate to a desired effect., which makes fentanyl superior when timing for a patient’s awakening from anesthesia. As outpatient and ambulatory surgery blossomed, a short-acting narcotic such as fentanyl, which wore off promptly, became the narcotic of choice.

The most daunting feature of fentanyl is its potency. Most drugs used by anesthesiologists are in doses of milligrams (mgs) or grams (gms). Fentanyl is approximately 100 times more potent than morphine, so a typical 5 mg (5 mg = 5000 microgram) dose of morphine is equivalent to a mere 50 microgram dose of fentanyl. A typical intravenous incremental dose of fentanyl to an adult patient is a mere 50-100 micrograms. The drug is marketed as one milliliter = 50 micrograms for this reason, so 1 – 2 milliliters is an appropriate dose. This potency and the need to be packaged in micrograms is unique to fentanyl and its analogues sufentanil and remifentanil, and requires medical personnel to become comfortable with the low ranges of the appropriate microgram doses.2

Medical fentanyl can be administered in several ways:

  • Intravenous fentanyl, as described above, is the most common medical usage of the drug.
  • Rarely, fentanyl is added to the spinal fluid as part of a spinal anesthetic block prior to surgery, or to the epidural space as part of an epidural block prior to surgery or prior to labor for childbirth.
  • Transdermal drug delivery of fentanyl via an adhesive skin patch is also possible, because of the drug’s high solubility in both water and oil, low molecular weight, high potency, and its lack of skin irritation. Fentanyl transdermal patches (Durogesic or Duragesic) are useful in chronic pain management. The patches work by slowly releasing fentanyl through the skin into the bloodstream over 48 to 72 hours, allowing for long-lasting pain management. Dosage is based on the size of the patch.
  • Oral transmucosal fentanyl citrate (OTFC) is a solid dosage form of fentanyl that consists of fentanyl incorporated into a sweetened lozenge on a stick. A commercially available fentanyl product for oral administration, the fentanyl lollipop Actiq, is an application of this technology. The lollipop provides a means by which the drug can dissolve slowly in the mouth. The lollipop is only FDA approved for providing analgesia to patients with chronic pain or cancer pain, and the fentanyl lollipop is not FDA-approved for analgesia after surgery.

Narcotics suppress pain by their action in the brain and spinal cord, but they cause their adverse side effects in multiple organ systems, including the respiratory and cardiovascular systems. The principal danger from narcotics is respiratory depression. The respiratory rate is usually markedly slowed in narcotic overdose, as excessive doses of narcotics make people stop breathing. If there’s an anesthesiologist present to support a person’s breathing, respiratory depression is not a problem. On the streets, with no medical personnel present, respiratory depression from a narcotic overdose can be fatal.

The anesthesia world is well aware of the risks of fentanyl addiction. Narcotic addiction has struck down many anesthesia providers who found themselves vulnerable to sampling the potent euphoria-inducing fentanyl doses they were administering to their patients. Stanford authors described fentanyl addiction in anesthesiologists in 1980.3 More than a dozen of my personal friends and colleagues died anesthetic drug-related addiction deaths in the 1980s and 1990s.

For some of these physicians the first sign of their addiction was death by overdose. In others the addiction was uncovered, they were sent to rehabilitation programs, and they are still alive today. Anesthesiologists graduating from narcotic rehab programs are still known to have a risk to relapse. The relapse rate for anesthesiologists after drug abuse treatment is greatest in the first 5 years and decreases as time in recovery increases. The positive news is that 89% of anesthesiologists who complete treatment and commit to aftercare remain abstinent for longer than 2 years. However, death is still the primary presenting sign of relapse in opiate-addicted anesthesiologists.

 

FENTANYL AS A STREET DRUG

The current battle against fentanyl as a street drug has little or nothing to do with American medical practice. Most of the fentanyl found on the streets is not diverted from hospitals, but rather is sourced from China and Mexico. Dealers sought a narcotic product cheaper and even stronger than heroin, and that product is fentanyl. In 2016 there were more than 60,000 fatal overdoses in America. More than half were due to opioids, and the newest and most potent street narcotic was fentanyl.

Fentanyl-related overdose deaths increased nearly 600 percent from 2014 to 2016. “If anything can be likened to a weapon of mass destruction in what it can do to a community, it’s fentanyl,” said Michael Ferguson, a special agent in charge of the Drug Enforcement Administration’s New England division. “It’s manufactured death.” Illicit fentanyl is imported directly from China or Mexico, where the drug is manufactured. Dealers then mix the powder into other drugs, making for imprecise potency in sometimes-lethal doses.4 The IV street drug fentanyl is believed to be manufactured in China or Mexico, and is smuggled across the borders. Highly organized drug cartels are spreading the drug throughout the country. Its street nickname is “China White” or “China Girl,” referring at where most of the drug is thought to be coming from. The DEA estimates that drug traffickers can buy a kilogram of fentanyl powder for $3,300 and sell it on the streets for more than 300 times that, generating nearly a million dollars.5

As a street drug, fentanyl can be injected intravenously, taken orally, or snorted nasally. Each of these routes poses a threat:

  • Intravenous fentanyl as a street drug – Prior to fentanyl, heroin was the injectable street drug of choice. Because of the extremely high strength and potency of pure fentanyl powder, it’s difficult to dilute appropriately. The diluted mixture may be far too strong and, may cause respiratory depression and death. Some heroin dealers mix fentanyl powder with heroin to increase potency or compensate for low-quality heroin. Because fentanyl is more potent than heroin, the presence of even small quantities of fentanyl in injected heroin can result in respiratory depression. The fentanyl sold on the streets is likely made in a non-pharmaceutical lab, and is less pure than the medical version anesthesiologists administer. Its effect on the body can be hard to predict. Heroin and fentanyl look identical, and with drugs purchased on the street, addicts don’t know what they’re taking. An intravenous fentanyl overdose can cause a person to cease in breathing within minutes of injection, and result in death. Narcan, or naloxone, is a specific antagonist of narcotic overdose. Administration of Narcan as a fentanyl overdose antidote is a potential acute rescue remedy. 
  • Oral fentanyl as a street drug – Fentanyl is also sold as an oral street drug. Ten people died in just twelve days from fentanyl-laced pills in Sacramento County, California in March of 2016. In San Francisco, fentanyl showed up in pills labeled as Xanax, which turned out to be pure fentanyl. After 26 years in a Orange County crime lab south of Los Angeles, forensic scientist Terry Baisz said, “I was shocked the first time I tested this stuff and it came back as fentanyl. We hadn’t seen it before 2015.” Dealers were describing their pills as Xanax or Oxycodone. The tablets looked nearly identical to products manufactured by commercial pharmaceutical companies, although the pills sold on the streets contained fentanyl.6 The singer Prince’s death in 2016 was due in part to an overdose of fentanyl, likely in a pill form of counterfeit hydrocodone-acetaminophen (Vicodin) tablets.7
  • Intranasal fentanyl as a street drug – If fentanyl is supplied to the addict in powder form, and the powder is confused with cocaine and is snorted intranasallly, the addict may die. A hospital in New Haven, Connecticut treated twelve overdoses, three of them fatal, in just an eight-hour period in June 2016 among addicts who were snorting a white powder they purchased on the city’s streets. 8The powder they believed was cocaine turned out to be fentanyl. The absorption of a nasal dose of fentanyl can lead to immediate respiratory depression and death.

U.S. Surgeon General Jerome Adams, an anesthesiologist, has suggested distributing the narcotic antagonist Narcan freely, so that onlookers can quickly treat fentanyl-overdosed individuals.9 I respect Dr. Adams at the highest level, but I’m skeptical of this approach. An addict injecting fentanyl while he or she is alone is still at high risk of dying, and I’m not aware of any statistics documenting whether addicts reliably have company present while they are injecting themselves.

First response Emergency Medical Technicians should carry Narcan. Treatment of patients who are discovered comatose for unknown reasons has long included an empiric injection of Narcan to reverse possible narcotic overdose. The public needs to be aware of the existence of fentanyl powder, its ultra-high potency, and the danger of a fatal overdose immediately after the intravenous injection, oral ingestion, or intranasal inhalation of any street drug. There’s a real threat that any dose of street fentanyl can be lethal.

In our operating rooms, hospitals, surgery centers, and intensive care units, fentanyl is used safely. On the streets, fentanyl poses nothing but problems. Education, prevention, and DEA enforcement will have key roles in addressing the crisis of fentanyl in non-medical settings.

 

References:

  1. Fentanyl, Chemical and Engineering News, https://pubs.acs.org/cen/coverstory/83/8325/8325fentanyl.html
  2. Kazuhiko F, Opioid Analgesics, Miller’s Anesthesia, 8th Edition, Chapter 31, 864-914.
  3. Spiegelman WG, Saunders L, Mazze Ri, Addiction and anesthesiology, Anesthesiology 1984 Apr;60(4):335-41.
  4. Lewis N et al. Fentanyl linked to thousands of urban overdose deaths, Washington Post, August 15, 2017.
  5. https://www.washingtonpost.com/graphics/2017/national/fentanyl-overdoses/?utm_term=.8c722ada39be Nazarenus C. The opioid fentanyl: the new heroin, but deadlier. Medical Marijuana 411, May 11, 2016.
  6. https://medicalmarijuana411.com/opiod-fentanyl-new-heroin-deadlier/Sidner S. The opioid fentanyl: the new heroin, but deadlier. ClickonDetroit.com, May 10, 2016. https://www.clickondetroit.com/health/fentanyl-the-new-heroin-but-deadlier
  7. Kroll D, Prince’s Death From Fentanyl May Have Been Due To Counterfeit Generic Drugs, Pharma and Healthcare, Aug 22, 2016. https://www.forbes.com/sites/davidkroll/2016/08/22/princes-death-from-fentanyl-may-have-been-due-to-counterfeit-generic-drugs/#52096f902b17
  8. Bebinger M, Fentanyl-laced cocaine becoming a deadly problem among drug users, Health News from NPR, March 29, 2018. https://www.npr.org/sections/health-shots/2018/03/29/597717402/fentanyl-laced-cocaine-becoming-a-deadly-problem-among-drug-users
  9. Surgeon General Urges More Americans To Carry Opioid Antidote, NPR Public Health, April 5, 2018. https://www.npr.org/sections/health-shots/2018/04/05/599538089/surgeon-general-urges-more-americans-to-carry-opioid-antidote

 

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

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How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

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

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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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INTRAVENOUS ACETAMINOPHEN: AN IMPORTANT NON-OPIOID THERAPY, OR AN EXORBITANTLY PRICED VERSION OF AN OVER-THE-COUNTER MEDICATION?

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

Intravenous acetaminophen was introduced in Europe in 2002. The United States Food and Drug Administration approved IV acetaminophen (Ofirmev, Cadence Pharmaceuticals) in 2010 for management of mild to moderate pain, moderate to severe pain with adjunctive opioid analgesics, and reduction of fever.

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IV acetaminophen (Ofirmev)

 

 

Acetaminophen (Tylenol) has been available in oral and rectal forms for decades. 

tylenol-tylenol-extra-strength-500-mg-150-units

Oral acetaminophen

 

Healthcare costs continue to skyrocket in the United States. In 2016 Americans spent $435 billion on prescription drugs.1 This month the Trump administration released a 44-page blueprint for executive action on drug pricing entitled “American Patients First.” Their goal is to drive prescription drug costs down by increasing competition. At this time it’s too early to tell how effective these efforts will be.

Anesthesiologists are the only physicians who prescribe and then directly administer medications themselves. CRNAs are the only nursing professionals who prescribe and then directly administer medications themselves. Because anesthesiologists and CRNAs typically don’t pay for the medications, there can be a disconnect regarding costs and value.

If you were in charge of pharmaceutical purchasing at a hospital or an ambulatory surgery center, and you had an identical acetaminophen molecule available for either 5 cents per dose or $42 per dose, which would you choose? The answer is obvious, but as an administrator you are not prescribing the drug.

A 2014 study showed that patients who received IV acetaminophen reported superior satisfaction with pain control compared to patients who received placebo.2 In inpatient and postoperative settings, intravenous acetaminophen became a route of choice for rapid analgesia, and appeared to reduce the need for other analgesics such as opioids. Disadvantages of IV acetaminophen included the time and equipment needed for IV drug administration, as well as increased costs.

In a publication from the Canadian Journal of Hospital Pharmacy, Jibril wrote, “The study drug (acetaminophen, either oral or IV) was given when patients first awakened after surgery, and additional doses were given every 6 h until 0900 the next morning. . . . The use of opioids was significantly lower in the group receiving acetaminophen by the IV route than in the group receiving acetaminophen by the oral route (p < 0.05). However, this difference did not translate into a significant difference in rates of postoperative nausea and vomiting or any significant difference in pain scores on a 100-mm visual analogue scale (VAS) at any time. . . . A major finding of this review was the absence of strong evidence suggesting superiority of IV acetaminophen administration over oral routes. . . . IV acetaminophen may be useful for opioid-sparing in postoperative pain. To date, no strong evidence exists that IV acetaminophen should replace any form of standard care. At most, the evidence indicates that this formulation could function as an adjunctive agent in patients unable to take oral forms. . . . . In the United States, there has been great debate regarding use of this formulation, which has led many hospitals to adopt policies and procedures that restrict use for a limited period or for patients not able to take medications by mouth. These restrictions are required because of the cost of the product, in addition to other administration-related inconveniences. Canadian hospitals and formulary committees should be aware of the available efficacy and safety data if the formulation is marketed in Canada and its use becomes widespread. Given the high cost and the lack of superiority over oral forms, Canadian hospitals may need to restrict use of the IV formulation, as their US counterparts have already done.”3

In a study of IV acetaminophen use in neurosurgical ICU patients at Virginia Commonwealth University, Gretchen Brophy, PharmD, of the departments of pharmacy and neurosurgery wrote, “We and every institution I’ve spoken to have restricted its use, because we don’t have data saying it’s more effective. At $33 a dose” – recently up from $10 – “it’s harder to justify. At least in the 0-3 hour window, it didn’t have any additional benefit over oral. It might still be better at 1 hour; kinetically, that would make sense, but there’s nothing yet to say from what we did that it’s better.”4 VCU restricted intravenous acetaminophen use to one dose per patient.

Mallinckrodt purchased Cadence Pharmaceuticals in 2014, and increased the price of Ofirmev from $17.70 to $42.48 per vial. (A full case of Ofirmev includes 24 vials.) Sales increased to $71 million during their fiscal first quarter, double the amount for the same period the previous year. Hospitals noted the rise in expenses and sought alternatives such as oral acetaminophen, and the volume of sales dropped. Robert Press, chief of hospital operations at NYU Langone, which anticipated $1 million in additional costs because of Ofirmev, was quoted to say, “We found out a lot of the use was really not necessary and we found we could give alternative products.”5

Some hospitals removed Ofirmev from their formularies after the price went up. Others simply switched to alternatives such as oral acetaminophen. Others increased their budgets to cover the cost of the drug, but the net effect of Mallinckrodt’s price hike was to reduce the doses of Ofirmev prescribed. Mallinckrodt’s U.S. headquarters are located in Missouri. Senator Claire McCaskill (D-Missouri) wrote a letter to Mallinckrodt CEO Mark Trudeau demanding information about pricing and revenue numbers. In the letter she also suggested that Ofirmev, expensive as it was, might actually be saving hospitals money because of opioid-sparing. Senator McCaskill wrote, “Any obstacle to prescribing non-opioid alternatives, even those used solely in a hospital setting, is cause for concern.” It should be noted that McCaskill received $2,500 in campaign financing from Mallinckrodt during the 2016 election cycle.6

Mallinckrodt released a statement that read, “One recent analysis of health economic data on the use of Ofirmev coupled with a one-level reduction in opioid use was linked to decreasing hospital stays, potential opioid-related complications and related costs for the treatment of acute surgical pain. . . . The study showed a potential of $4.7 million in annual savings for a typical, medium-sized hospital.”6

The clinical benefit of reduced opioid consumption with Ofirmev has not been evaluated nor demonstrated in prospective, randomized controlled trials. In a review in the journal Pharmacotherapeutics, Yeh wrote, “Although use of intravenous acetaminophen has reduced other postoperative resource utilization (e.g., hospital length of stay) in some studies outside the United States in patients undergoing abdominal surgery, a full economic evaluation in the United States has yet to be undertaken.”7

The research study anesthesiologists would like to read is a prospective, randomized, double-blind trial of 1000 mg of preoperative oral acetaminophen, versus 1000 mg of IV acetaminophen administered just prior to the end of surgery. Will this research ever be performed? I hope so, but you can bet Mallinckrodt is never going to fund that study.

I repeat Jibril’s conclusion to sum up the answer to our initial question above:“An absence of strong evidence suggesting superiority of IV acetaminophen administration over oral routes. . . . To date, no strong evidence exists that IV acetaminophen should replace any form of standard care. At most, the evidence indicates that this formulation could function as an adjunctive agent in patients unable to take oral forms. . . . Therefore, on the basis of current evidence, if a patient has a functioning gastrointestinal tract and is able to take oral formulations, IV formulations are not indicated.”3

And what is the solution regarding anesthesia providers who frequently choose to prescribe IV acetaminophen despite these recommendations? The hospital I work at, Stanford University Hospital, restricts Ofirmev usage to patients who are NPO (nothing by mouth), and each Ofirmev order has a hard stop after 24 hours, eliminating further usage. The owners of the surgery center I medically direct have an even more decisive solution: Ofirmev is not on the facility formulary at all.

 

References:

  1.  Cortez J. Prescription Drug Spending Hits Record $425 Billion in U.S. Bloomberg, April 13, 2016.                                                https://www.bloomberg.com/news/articles/2016-04-14/prescription-drug-spending-hits-record-425-billion-in-u-s
  2. Apfel CC et al. Patient satisfaction with intravenous acetaminophen: a pooled analysis of five randomized, placebo-controlled studies in the acute postoperative setting. J Healthc Qual. 2014 Jan 16.
  3. Jibril F, et al. Intravenous versus Oral Acetaminophen for Pain: Systematic Review of Current Evidence to Support Clinical Decision-Making, Can J Hosp Pharm. 2015 May-Jun; 68(3): 238–247.
  4. Otto MA et al. No pain benefit found for IV acetaminophen vs. oral in the neuro ICU. Clinical Neurology News. January 30, 2015.
  5. Staton T. Price hikes aren’t always sustainable: Just ask Mallinckrodt about Ofirmev. Fierce Pharma. Oct 12, 2015. https://www.fiercepharma.com/pharma/prie-hikes-aren-t-always-sustainable-just-ask-mallinckrodt-about-ofirmev
  6. Staton T. Mallinckrodt’s pain med Ofirmev gets scrutiny in Senate—but this pricing probe has a twist. Fierce Pharma. May 30, 2017. https://www.fiercepharma.com/pharma/mallinckrodt-s-pain-med-ofirmev-gets-scrutiny-senate-but-pricing-probe-has-a-twist
  7. Yeh Y et al. Reviews of Therapeutics: Clinical and Economic Evidence for Intravenous Acetaminophen. Pharmacotherapeutics. 08 May 2012.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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LEARJET ANESTHESIA – THE EARLY DAYS OF HEART TRANSPLANTATION

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

Learjet anesthesia? Yes, anesthesia can be a glamorous specialty. During my Stanford training in 1984-1986 I flew on Learjets more times than I can count, during missions to harvest donor hearts from throughout the western United States.

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Norman Shumway MD PhD, a Stanford surgical professor and legend, invented the heart transplantation procedure and performed the first heart transplant in the USA on January 6, 1968 in operating room 13 of Stanford University Hospital. Survival rates for heart transplantation patients increased markedly in 1983 with the adoption of cyclosporine as an effective anti-rejection drug. During the 1980’s Stanford was the only prominent heart transplantation program in the western United States, and the quantity of brain dead heart donors was modest. In order to expand their volume of transplants, Stanford created a fixed-wing aircraft harvesting and transportation program to bring donor hearts to Palo Alto from distant locations.

One registered nurse had a fulltime job locating appropriate brain dead heart donors within a 60-90 minute Learjet trip from Stanford. A separate team of physicians and nurses was responsible for assembling a waitlist of prospective heart transplant recipients, and for arranging housing for them within the San Francisco Bay Area.

When Stanford learned of a brain dead donor with a normal heart at a distant location, the following choreography occurred: 1) a matching donor was identified and told to come to Stanford Medical Center immediately; 2) a team of surgeons, anesthesiologists, nurses, and a heart-lung perfusionist was paged to Stanford Medical Center immediately to prepare the recipient patient for his or her transplant surgery; and 3) a transport team of two surgeons (a chief resident in cardiac surgery and a second surgical resident), one anesthesia fellow or resident, one scrub nurse, one circulating nurse, and the nurse in charge of the transport team were all paged to the Stanford Medical Center immediately.

Note that the anesthesia transport team member was only an anesthesia fellow or a resident. The eligible residents were second-year residents (anesthesia residency training was only two years in duration during the 1980’s). As a second-year resident, I was a partially trained anesthesiologist who had done only 800-1000 anesthetics at that time, and was not yet eligible to sit for the American Board of Anesthesia exam.

An ambulance transported our team to the Moffett Field Air Force Base, 10 miles southeast of the Stanford campus, where we boarded a Learjet for the flight to the donor hospital. The donor harvesting catchment area was as far north as Seattle, as far south as Las Vegas, and as far east as Boise. We had no medical tasks to do in flight, and we spent our time looking out the windows and small talking. Upon arrival at the airport in the donor city, an ambulance transported us to the hospital.

At the hospital we proceeded to the intensive care unit where we found the donor’s brain dead body connected to a ventilator and ICU monitors. At this point my work began. Even though the patient was brain dead, it was imperative to maintain his or her vital signs and oxygenation at optimal levels to preserve the cardiac function for the eventual recipient. My first tasks were to insert an arterial line in the radial artery to monitor blood pressure, and to insert a central venous pressure catheter in the internal jugular vein to administer medication infusions as needed to decrease or increase the blood pressure during the upcoming surgery. We would then transport the patient through the hallways of this foreign hospital, accompanied by the surgeons, and directed by staff of that hospital who knew the floor plan. I’d be squeezing an Ambu bag full of oxygen to ventilate the patient, all the while vigilant of the vital signs displayed on a portable monitor during the transport.

We’d arrive in the operating room—a room we’d never seen or worked in before—and prepare the patient for surgery. My job was to connect the patient to the operating room ventilator and the standard cardiac surgery monitors: ECG, oximeter, arterial line, and central venous pressure. The manufacturers of the monitoring equipment varied from hospital to hospital, and it was not unusual for the equipment to be different than machines I’d worked with before. My next task was to prepare vasoactive drips such as nitroprusside and connect them to the central venous pressure IV line. No anesthetic drugs were used, because the donor was brain dead, but surgical stimulus always caused increases in blood pressure and heart rate. It was critical that pumping against a high resistance or pumping at a high rate not tax the donor heart. I also had to fill out a written anesthesia medical record to document what I was doing to the patient.

The scrub tech, nurse, and the two surgeons prepped and draped the patient for surgery, and the initial incision was made over the sternum. A power saw was used to cut the breastbone down the midline to enter the chest. A rib-spreader was used to widen the cavity and improve visualization. The surgeons inspected the heart in terms of its general appearance, size, contractility, and the state of the coronary arteries. Once they’d determined the heart was indeed normal, the transplant nursing coordinator made a phone call to the Stanford operating room in California to inform them it was a green light to anesthetize the heart recipient there.

In our operating room, the two surgeons clamped off the aorta and all other blood vessels leading into and out of the heart, and injected a cardioplegic solution into the coronary arteries via the root of the aorta. This solution preserved the heart function during the upcoming trip when the heart would no longer be beating. The surgeons then cut the heart out of the body, placed it in a sterile bag, and placed the bag into an Igloo chest full of ice. I turned off the ventilator, the surgeons removed their gloves and gowns, and our whole cast scurried out of the operating room with the Igloo and its precious cargo in hand.

It was always a bizarre sight to see that human carcass with an empty thorax lying on an operating room table when we left the operating room. In the later months of my Learjet experiences, a second transplant team was sometimes present to harvest the kidneys or corneas after we departed.

The original ambulance met us at the Emergency Room entrance, and we sped back to the airport Code 3 with alarms blaring. We drove onto the tarmac next to the Learjet and climbed inside. The doors closed, engines flared, and wheels up . . . we were on our way back to Palo Alto.

The flight home was relaxing. We’d spent an intense period of time at the hospital, and we had no work to do except to ride and look out the windows. Beverages and food were always supplied for the trip home. The mood was jubilant—the feeling you get with medical jobs when you realize you’ve accomplished something. We were helping the recipient patient in their journey back to health, and experiencing private jet travel at 35,000 feet at the same time.

On arrival to Moffett Field, an ambulance awaited us on the tarmac. We’d climb in and ride at top speed back to Stanford. We stopped in front of the Emergency Room, and the surgeons and the nurse coordinator ran through the doorway and up the stairs to operating room 13, where the anesthetized recipient patient lay, his or her chest open, ready to receive the new heart at once.

At this point I went home. An anesthesia resident colleague and an anesthesia faculty member were upstairs attending to the recipient. Caring for the recipient patient was their job for today—mine was finished.

How stressful was the entire journey to harvest the new heart? Pretty stressful, to be honest. At that point, I’d done less than two years of anesthesia training, and I was relatively inexperienced. During my training, a faculty member always stood right next to me during every anesthesia induction and a faculty member was immediately available at all times. On the Learjet trips I was without faculty backup for the first time. The setting at the destination hospital was always unfamiliar. The equipment on hand at the destination hospital was often unfamiliar. The cardiac chief resident surgeon was typically an intense 39-year-old who’d been training for decades and who had little interest in waiting any longer than possible while an anesthesia resident-in-training toiled to insert an arterial line and a central venous catheter. Even though the patient was brain dead, there was no tolerance for errors in ventilation or medical management, it was imperative to keep the vital signs stable throughout the donor surgical procedure, and there was time pressure to keep the process moving.

Prior to my anesthesia residency I’d completed three years as an internal medicine resident at Stanford and one year as an attending in the Emergency Room at Stanford. All my experience in internal medicine and emergency medicine was useful on those heart-harvesting trips—but I knew how lucky I was. Internal medicine residents don’t get to ride Learjets, and ER attendings don’t get to ride Learjets either.

An added motivation: We were paid $35/hour for our time, a princely sum in 1986.

Alas, none of this would happen nowadays. Currently there are hundreds of cardiac transplantation programs in the United States, and each program procures their donor hearts from close geographic proximity.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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

KIRKUS REVIEW

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

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too.

Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?”

The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

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

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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THE #7 ANESTHESIA BLOG IN THE WORLD

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

Today theanesthesiaconsultant.com was named the #7 anesthesia blog in the world by Feedspot.

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I’m grateful to Feedspot for this honor, and to my readers for making this possible.

See the link here to view the complete list of the world’s top anesthesia blogs.

Theanesthesiaconsultant.com was ranked #7, behind such high-powered professional websites such as Anesthesiology News, the Journal of the Association of Anaesthetists of Great Britain and Ireland, and Reddit Anesthesiology,

I write theanesthesiaconsultant from the unique point of view of a busy attending anesthesiologist who works in both private practice and also in an academic setting at Stanford University. After 35+ years and 25,000+ anesthetics, I’m still learning. And as I learn, I write about it.

Keep reading, and I’ll keep writing!

 

Thanks,

Richard Novak, MD

 

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?

ARE SURGERY CENTERS SAFE?

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

Are surgery centers safe? This column is in response the Kaiser Health News story “How a push to cut costs and boost profits at surgery centers led to a trail of deaths” published on USAToday.com this week. The article set off a firestorm of controversy in the surgery center industry. The Kaiser article cites anecdotal information and allegations from ongoing litigation cases of patients seemingly harmed by their care at outpatient ambulatory surgery centers.

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The quantity of ambulatory surgery centers has greatly increased over the past forty years for three primary reasons: Technologic advances made surgery easier, anesthetic care is safer, and healthcare payment policies encourage ambulatory surgery. I’ve been the Medical Director at a busy freestanding ambulatory surgery center in Northern California for a decade and a half. I’m a Stanford University-trained anesthesiologist and internist, and I’m uniquely qualified to answer the question: Are American surgery centers safe?

Yes, they are safe.

A review of the medical literature on Pubmed shows no peer-reviewed studies or data that surgery centers provide less safe care than hospitals.

Surgery and anesthesia are never 100% safe, no matter where procedures are done. There are always risks. The roles of anesthesiologists and surgeons at surgery centers are to minimize the risks.

There are four key questions regarding safe patient care at surgery centers:

  1. Is the scheduled procedure appropriate for an outpatient surgery center?
  2. Is the patient healthy enough to tolerate the scheduled procedure as an outpatient?
  3. Are the healthcare professionals at that center practicing at the standard of care?
  4. Is the surgery center accredited by an organization such as the Accreditation Association for Ambulatory Health Care (AAAHC)?

 

Question #1.

The most important screening question for a surgery center is, “What is the scheduled procedure?” Knee arthroscopies, tonsillectomies, inguinal hernia repairs, and colonoscopies are standard surgery center procedures. You cannot do large cases such as craniotomies, open heart surgeries, or an aortic vascular surgeries at a surgery center. The necessary backups of an intensive care unit, a blood bank, respiratory therapy, and a clinical laboratory are lacking. The job of a Medical Director is to survey the schedule each week, and decide if any planned cases are outside the usual comfort zone for that center. If there is any question, the Medical Director must gather more information on the procedure and the patient, usually by talking directly to the surgeon, and decide whether or not to give the case a green light. If the verdict is a red light, the surgeon needs to do the case in a hospital.

In recent years, some surgery centers have expanded their scope. Procedures such spine surgeries, total joint replacements, and bariatric surgeries are performed as ambulatory or short stay procedures at some outpatient centers. As the USAToday.com article points out, one motivation is money. A surgery center can extract well-insured cases from hospitals in order to increase profits for the surgery center. Is it better for a patient to have these procedures in a freestanding facility detached from a hospital? There is a paucity of research in peer-reviewed medical literature regarding the performance of these cases outside of hospitals. The USAToday.com article lists multiple spine surgery patients who died after surgery at an ambulatory surgery center. Medicare has only approved payment for spinal surgery at ambulatory centers since 2015. To my knowledge, no one has published the overall statistics regarding complications from spinal surgery in surgery centers and compared this to the complications from similar procedures in hospital settings.

What about the claim from the USAToday.com article that 911 calls from a surgery center are a problem? If a patient unexpectedly becomes acutely ill at a surgery center, calling 911 and transferring the patient to a hospital is routine policy and appropriate medical care.

 

Question #2.

How does a facility decide whether a patient is fit enough to undergo a given surgery at an outpatient center? At a surgery center, it’s the Medical Director’s job to screen every patient prior to scheduling. It’s the Medical Director’s job to prevent patients who are too sick from having a procedure at a surgery center. Different systems exist for preoperative assessment. Large university hospitals staff preoperative anesthesia clinics for their patients, and patients are required to physically visit the clinic to be examined and assessed prior to inpatient surgery. This system is not always practical in outpatient community medicine. Patients are usually assessed by their primary care physicians as indicated before surgery. A typical preoperative screening protocol at a surgery center is as follows: a preoperative assessment professional from the surgery center will telephone each patient several days before surgery, ask a series of pertinent screening medical questions, and fill out a standardized form. Any outlying answers are referred to the Medical Director, who decides if the patient is fit for the surgery. If the patient is too sick, the Medical Director will cancel the case, and tell the surgeon that the surgery needs to be done in a hospital.

 

Question #3.

When a complication occurs, anesthesiologists and surgeons in the operating room have a responsibility to correctly diagnose the problem and apply the correct therapy. The legal term for this is that physicians must adhere to the “standard of care.” The standard of care is defined as “what a reasonably trained physician would do in the same circumstance.” Deviating from the standard care is called negligence, and is part and parcel to medical malpractice lawsuits. If a bad outcome occurs in a surgery center because of negligence, i.e. malpractice, this is not a fault of the surgery center system. This concept is a central flaw in the USAToday.com article. The article cites multiple bad outcomes from surgery center cases, and in many of these cases the central issue seems to be negligent, below the standard of care decisions and actions by the health care professionals involved. Negligence is not specific to surgery centers.

 

Question #4.

Most surgery centers provide care to Medicare patients, and must meet standards approved by the federal government. To obtain Medicare certification, a surgery center must have an inspection conducted by a representative of an organization that the government has authorized to conduct that inspection, such as the Accreditation Association for Ambulatory Health Care (AAAHC). Inspectors will physically visit the surgery center to verify that the center meets established standards. Most surgery centers have passed such an inspection. The surgery center I work at is recertified every three years. If you’re uncertain whether your local surgery center is safe, request documentation that the facility has been certified by an organization such as AAAHC.

Nearly 60% of all surgical procedures in the United States are performed as outpatient surgery. Tens of millions of Americans receive care in ambulatory surgery centers each year. I’ve personally had two arthroscopic surgeries and three colonoscopies, and I chose to have all five procedures at a freestanding outpatient surgery center. The USAToday.com article cited anecdotal adverse outcomes from patients who were cared for at outpatient ambulatory surgery centers. Adverse outcomes will occur, but the frequency of these events (adverse events vs. total number of cases) is extraordinarily small. America’s surgery centers are by and large very safe. I reaffirm that no peer-reviewed data documents that ambulatory surgery centers are unsafe.

The key issues regarding surgery center safety will always be the four questions posed above. Is a given procedure safe and appropriate for an outpatient surgery center? Is a given patient fit enough to have their particular procedure in an outpatient surgery center? Are the healthcare professionals at that center practicing at the standard of care? And is the surgery center accredited by an organization such as the AAAHC?

In the overwhelming majority of America’s surgery centers, the answers to these three questions will be “Yes, yes, yes, and yes.”

 

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HANGOVER AFTER GENERAL ANESTHESIA

the anesthesia consultant

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

Prior to surgery your patient tells you, “I always get a hangover after general anesthesia. I sleep for hours and I’m nauseated. All my life I’ve been very sensitive to medications. I never drink alcohol, and even a ½ dose of Nyquil or cold medicine knocks me out all night.”

What do you do with this information?

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I’ve been a full time anesthesiologist for 34 years, and I’ve heard this monologue from patients countless times. My impression? The patient is always right. They’ve had the same body all their lives, and they know their reaction to central nervous system depressants. Listen to them and adjust your care.

Hangover after general anesthesia (HAGA) describes a patient who has a safe general anesthetic, but who then feels hungover, sedated, and wasted for a time period exceeding two hours afterwards. There is significant overlap between HAGA and postoperative nausea and vomiting (PONV).

The four established risk factors for PONV are: 1) the use of postoperative narcotic pain relievers, 2) female sex, 3) a non-cigarette smoker, and 4) a previous history of PONV.1 In my experience, these same four characteristics are risk factors for HAGA. Painful surgeries require more narcotics, which can lead to more nauseated patients. If the surgery isn’t painful, an anesthesia provider can work to eliminate postoperative narcotics, and minimize both PONV and HAGA.

With modern pharmacology and anesthetic techniques, HAGA should be uncommon. Propofol and sevoflurane are the mainstays of 21st century general anesthesia. Both are ultra-short acting medications that enable anesthesiologists to produce alert, awake patients within an hour of most general anesthetics.

Propofol has a quick onset and quick offset clinical effect, because the drug is highly lipid soluble and is rapidly distributed out of the bloodstream to other tissues of the body. When administration of propofol is discontinued, the initial fall in the plasma concentration is 50% due to this redistribution and 50% due to liver metabolism. The time to awakening after a 2-hour anesthetic is rapid (8-19 minutes).2 The elimination (hepatic) half-life is 3 to 12 hours, but propofol is not known to cause nausea. Hangover symptoms from propofol are rare. Sleepiness is the most common side effect, and this clears quickly.

Sevoflurane also has a quick onset and quick offset. Sevoflurane vapor is primarily eliminated via ventilation from the lungs. Because the drug has low solubility in the bloodstream, the pulmonary elimination is rapid, and only 5% of sevoflurane remains in the body to be metabolized by the liver and excreted via the kidneys. Pertinent mild side effects of sevoflurane include nausea/early 25%, vomiting/early 18%, dizziness/early 4%.3 These incidences of nausea and vomiting are higher than for propofol, so utilization of propofol over sevoflurane seems prudent for patients with a history of HAGA or PONV. However, because propofol is a sedative/hypnotic and does little to provide surgical analgesia, the addition of either a potent vapor such as sevoflurane or a narcotic is often necessary.

Over the years I’ve examined previous anesthetic records for many patients with a history of HAGA. The most common findings in these old records are relative overdoses of narcotics, be it fentanyl, Dilaudid, morphine, or any another narcotic. My impression is that some anesthesia providers rely on a set recipe for their narcotic dosing, and that they do not adequately alter or adjust this recipe for patients who are small, petite, elderly, or teetotalers. Narcotics are often indicated during surgery when surgical stimulus peaks, or near the conclusion of surgery to insure a patient has an adequate systemic narcotic effect and won’t wake up in agony. When a patient has a history of HAGA or PONV, I recommend minimizing the amount of intraoperative IV narcotics. Additional IV narcotics can be added post-extubation if the patient complains of significant pain.

Anesthesia providers typically judge anesthetic dosing depending on: a) patient weight, b) patient age, and c) the patient’s vital signs (i.e. high blood pressure and/or heart rates are treated by increasing doses of drugs, and low blood pressures are treated with decreasing drug administration).

A patient’s weight can be misleading. Multiple studies support that drug doses should be based on lean body weight (LBW) rather than their total weight.4,5 A 5-foot-6-inch obese patient may weight 200 pounds but have an estimated LBW of 150 pounds. Injected drug doses need to reduced by a factor of 150/200, or ¾.

Patients at extremes of age, e.g. geriatric or neonatal patients, can have significantly reduced requirements for injected anesthetic drugs. I refer the reader to textbook chapters on pediatric and geriatric anesthesia for evidence.

Utilizing increased anesthesia depth to treat hypertension or tachycardia is appropriate if the diagnosis is inadequate depth of anesthesia. If in your clinical assessment you’re administering an adequate level of anesthesia, then it’s appropriate to treat hypertension or tachycardia with antihypertensive agents or beta blockers rather than adding extraneous anesthetic depth or narcotics.

Is there science to confirm the existence of excessive anesthesia dosing? In a February 2018 Stanford Grand Rounds lecture, Dr. Daniel Sessler of the Cleveland Clinic presented data that hypotension is a risk factor for perioperative myocardial injury. Per Dr. Sessler’s unpublished data gleaned from electronic medical records on thousands of patients, one-third of intraoperative hypotension occurs during the time period between the induction of anesthesia and the surgical incision. During this time period, general anesthesia doses are unopposed by surgical stimulus. An inference from this data is that lesser amounts of general anesthetic drugs are required between induction and incision. Options to lower the anesthetic doses pre-incision include: a) less or no narcotic until the time of incision, b) utilizing 60% nitrous oxide without sevoflurane until incision, or c) utilizing sevoflurane without any nitrous oxide until incision. My preference is a combination of options a) and c), i.e. minimizing or avoiding narcotics until incision, and avoiding nitrous oxide until incision.

Conflicting data exist regarding redheaded patients and general anesthesia. A 2004 study of 10 redheads and 10 controls showed the inhaled desflurane requirement in redheads was significantly greater than in dark-haired women.6 This conclusion was refuted in a 2010 prospective study of 468 patients which showed no significant difference in recovery times, pain scores or quality of recovery scores in patients with red hair.7

Whenever possible it’s advisable for the surgeon to inject local anesthesia near the surgical site, or the anesthesiologist to use local anesthetic via a nerve block or a neuroaxial block to minimize postoperative pain.

Should we use intraoperative BIS monitors to guide minimalization of intraoperative anesthetics and narcotics? Although the idea is intriguing, I’m not aware of any data to support that BIS monitors provide a significant solution to the problem of intraoperative overmedication.

When a patient has a past history of HAGA or PONV, prior to surgery I discuss a metaphorical postoperative teeter-totter. On one end of the teeter-totter, the patient will have minimal postoperative pain but will be at risk for the systemic side effects of IV narcotics, namely sedation and nausea. On the opposite end of the teeter-totter, the patient will have some postoperative pain but will also benefit from lower systemic side effects of IV narcotics, namely lower levels of sedation and nausea. I tell the patient that after the surgery, in the Post Anesthesia Care Unit, they will be awake and able to make their own decisions whether they desire additional doses of intravenous narcotics or not, with the full knowledge that extra doses of narcotics may bring extra risk of sedation and nausea.

Can anything be done to predict the risk of HAGA? I attempt to identify teetotalers preoperatively. I routinely ask every patient, “Do you drink alcohol at times?” Their answers vary from, “No, I do not drink at all,” to “Yes, once or twice a month,” to “Yes, two glasses of wine every day.” It’s been my experience that patients who never drink alcohol (the most prevalent central nervous system depressant in the world) are more sensitive to anesthetic medications. It’s easy to postulate that a teetotaler’s brain is more sensitive to CNS depressants, and that their hepatic metabolism is less efficient clearing CNS depressants than a patient who ingests alcohol or other CNS depressants daily.

This column conveys what I’ve learned based on my clinical experiences over decades. When you attend to patients with a past history of hangover after general anesthesia, try the suggestions discussed above:

  1. Take a history and correctly identify patients with a past history of hangover after general anesthesia.
  2. Utilize propofol > sevoflurane for patients who are petite, who never drink alcohol, or give a history of being sensitive to CNS depressants.
  3. Administer significantly less IV narcotics to patients who are petite, who are elderly, who never drink alcohol, or give a history of being sensitive to CNS depressants.
  4. Administer intravenous doses based on lean body weight, not the actual weight, on obese patients.
  5. Administer lower doses of narcotics to patients at extremes of age, e.g. geriatric patients and the very young.
  6. Regarding intraoperative hypertension and/or tachycardia, if the anesthetic depth is already adequate, consider treating with antihypertensive medications or beta blockers rather than adding additional anesthetic.
  7. Decrease the amount of anesthesia you administer between the induction of anesthesia and surgical incision.
  8. Utilize local anesthetic/regional blocks to minimize postoperative pain as appropriate.
  9. Ask patients “Do you drink alcohol at times?” For teetotalers, utilize decreased doses, particularly decreased doses of narcotics.

These patients will likely fare better in your hands than what they’ve experienced after previous surgeries, and they will rank you above the historical control of anesthetists who’ve overdosed them in the past.

References:

  1. Apfel CC et al. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 1999 Sep;91(3):693-700.
  2. http://www.pdr.net/drug-summary/diprivan?druglabelid=1719#11
  3. http://www.pdr.net/drug-summary/Ultane-sevoflurane-32
  4. Lemmens HJ . Perioperative pharmacology in morbid obesity. Curr Opin Anaesthesiol.2010 Aug;23(4):485-91.
  5. Chassard D et al. Influence of bodycompartments on propofol induction dose in female patients. Acta Anaesthesiol Scand. 1996 Sep;40(8 Pt 1):889-91.
  6. Liem EB et al. Anesthetic requirement is increased in redheads. 2004 Aug;101(2):279-83.
  7. Myles PSBuchanan FFBain CR. The effect of hair colour on anaesthetic requirements and recovery time after surgery. Anaesth Intensive Care.2012 Jul;40(4):683-9

 

 

 

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

KIRKUS REVIEW

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

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too.

Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?”

The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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CARTOON — IS ANESTHESIA AN ART?

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

THIS ORIGINAL ANESTHESIA CARTOON WAS PUBLISHED IN THE CALIFORNIA SOCIETY OF ANESTHESIOLOGISTS BULLETIN, VOLUME 52, NUMBER 2, APRIL-JUNE 2003.

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IS ANESTHESIA AN ART OR A SCIENCE? WAS  NIETZSCHE  CORRECT THAT ‘WHAT DOES NOT KILL ME MAKES ME STRONGER?”

In 2018, anesthesiologists consider surgeons our colleagues, and we seek and expect collegial relationships with them. I’ve heard surgeons say, “The patient is moving, dammit,” but the frequency of this sort of angry retort is less now than it was in the 1980s when I began my anesthesia career.

Do anesthesiologists have surgeries which last 10 hours? Yes, we do, and that’s a long time to remain vigilant.

It’s likely that tortured artists create an abundance of wonderful art, and it’s just as true that anesthesiologists hardened by stressful cases and challenging conditions become the most skilled anesthesiologists.

You won’t see us crying, as Dr. Baker is doing in panel 4, but the anesthesiologist’s rapid heart rate and the adrenaline rush in high pressure operating room situations accompany the growth of every anesthesiologist from inexperience trainee to seasoned professional.

 

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 RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

DSC04882_edited

 

MYOCARDIAL INJURY AFTER NONCARDIAC SURGERY . . . COMMON, SILENT, AND DEADLY. WHAT CAN WE DO?

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

You’re a 55-year-old man with hypertension, scheduled for surgery for a right colon removal for colon cancer. How likely is your death within 30 days after surgery?

Higher than you would think.

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Your 30-day morality following this inpatient surgery is 1.2%. What can we do to improve myocardial injury after noncardiac surgery? Read on…

Dr. Daniel Sessler, Chairman of the Department of Outcomes Research at the Anesthesia Institute of the Cleveland Clinic, spoke at the Stanford Anesthesia Grand Rounds last week. His lecture, titled “Perioperative Myocardial Injury,” answered the questions above. Let me share what Dr. Sessler had to say:

  1. Myocardial injury after noncardiac surgery, abbreviated as MINS, is a common, silent, and deadly problem. Dr. Sessler described mortality related to surgery as the third leading cause of death in America, behind cardiovascular disease and cancer, and he cited myocardial injury as the leading cause of death after surgery.
  2. Devereaux, Sessler, and colleagues measured postoperative hsTnT (high sensitive troponin T) in 21,842 patients over the age of 45 who had inpatient noncardiac surgery at 23 medical centers in 13 countries.1 (For my nonmedical readers: hsTnT or cardiac troponin is a biomarker for acute myocardial infarction, i.e. heart attack.) Two hundred sixty-six patients died within 30 days after surgery, for an overall mortality rate of 1.2%. A total of 3904 patients had elevated hsTnT, diagnostic for MINS, for an overall incidence of tropinin elevation = 18% of the patients. Ninety-three percent of these patients had no ischemia-related symptoms, and would not have been detected without the hsTnT measurements.
  3. Puelacher published similar data in an older population (all patients over the age of 65).2 He studied postoperative hsTnT levels in 2018 consecutive inpatients and found perioperative myocardial injury (PMI) occurred in 397 (16% of the patients). Only 24 (6% of the patients) had typical chest pain, and only 72 (18% of the patients) had ischemic symptoms. The 30-day mortality was 8.9% for patients with PMI, compared to 1.5% for patients without PMI.
  4. hsTnT isn’t commonly measured in current practice, which means the majority of MINS patients go undiagnosed. Sessler recommended that all patients diagnosed with MINS be seen by a cardiologist, to consider further diagnostic or therapeutic intervention. He specifically mentioned the possibilities of statin and/or aspirin therapy, as well as smoking cessation and weight loss.
  5. Sessler suggested that a future approach to MINS detection would be to measure postoperative hsTNT for three days in every inpatient noncardiac surgery patient over 65 years old, and in those over 45 with one or more cardiovascular risk factor.
  6. What about preoperative clearance for noncardiac surgery? Sessler described exercise tolerance and the echocardiogram cardiac stress test as two inaccurate screening tools. He rated the two most effective screening tools as the Revised Cardiac Risk Index (see below), and the preoperative measurement of BNP (Brain Natriuretic Peptide).
  7. The Revised Cardiac Risk Index (RCRI) evaluates these 6 patient factors:

■ High-Risk Surgery – the following surgeries are deemed high risk for perioperative cardiac complications:

-­ Intraperitoneal

– Intrathoracic

– Suprainguinal vascular

■ History of ischemic heart disease – characterized by either a history                                     of a positive test, a diagnosed MI, current chest pain suspicion of                                                 myocardial ischemia, nitrate therapy, or evidence of                                                             pathological Q waves on electrocardiogram.

■ History of congestive heart failure – described as the presence of                                     either:

– Pulmonary edema, bilateral rales or S3 gallop;

– Paroxysmal nocturnal dyspnea;

– A CXR showing pulmonary vascular redistribution.

■ History of cerebrovascular disease – e.g. a prior TIA or stroke.

■ Pre-operative insulin treatment.

■ Pre-operative creatinine more than 2 mg/dL.

 

Positive findings of these factors define 4 classes of postoperative                                     cardiac complication percentage rates:

■ 0 factors – Class I – risk 0.4%;

■ 1 factor – Class II – risk 0.9%;

■ 2 factors – Class III – risk 6.6%;

■ 3 to 6 factors – Class IV – risk 11%. 

  1. Preoperative BNP concentration is a powerful independent predictor of perioperative cardiovascular complications.3 At best, clinicians can utilize both a low score in the preoperativeRevised Cardiac Risk Index plus a low value of the BNP or the N-terminal proB-type natriuretic peptide (NT-proBNP) plasma level.4 Sessler stated that a BNP test costs 1/20th as much as an echo stress test, and is more accurate in predicting postoperative cardiac mortality. He stated that a NT-proBNP level of < 300 ng/mL correlated well with a safe perioperative cardiovascular course.
  2. Elevated preoperative troponin or hsTnT concentrations were also significantly associated with postoperative MI and long-term mortality after noncardiac surgery.5
  3. Metoprolol, aspirin, and clonidine all failed as preoperative interventions to decrease cardiac risk. Metoprolol decreased postoperative myocardial infarction, but there were more deaths and an increased rate of stroke in the metoprolol group than in the placebo group.6 Aspirin before surgery and throughout the early postsurgical period had no significant effect on the rate of death or nonfatal myocardial infarction, and increased the risk of major bleeding.7 Low-dose clonidine did not reduce the rate death or nonfatal myocardial infarction, and increased the risk of clinically important hypotension and nonfatal cardiac arrest.8
  4. Eliminating nitrous oxide from the anesthetic regimen had no effect in decreasing myocardial injury.9
  5. Intraoperative hypotension correlated with postoperative myocardial injury. Mascha studied the time-weighted average intraoperative mean arterial pressure (TWA-MAP), and found that lower mean arterial pressure strongly correlated with mortality.10 Sessler stated that a mean blood pressure of 50 torr for even one minute was a risk factor for postoperative myocardial injury. Targeting a specific systolic blood pressure reduced the risk of postoperative organ dysfunction.11
  6. Sessler stated that 1/3 of intraoperative hypotension occurred during the time between induction of anesthesia and time of the surgical incision. By analyzing large databases from electronic anesthesia recording systems, hypotension was documented during this time period when general anesthesia lacked any surgical stimulus to keep blood pressure elevated. Sessler’s recommendation was to maintain the MAP > 65 torr throughout noncardiac surgery.
  7. The use of vasopressors to treat hypotension was safe.
  8. Tachycardia was not a risk factor. “It hardly matters,” Sessler said.
  9. Preoperative angiotensin-converting-enzyme inhibitors (ACE inhibitors), e.g. lisinopril, Lotensin, or Altace, and Angiotensin II receptor blockers (ARBs), e.g. Diovan or Cozaar, were risk factors for intraoperative hypotension and cardiovascular morbidity. Roshanov studied data from 14,687 patients aged 45 years or older for inpatient noncardiac surgery.12 Four thousand eight hundred and two of these patients were taking ACE inhibitors or ARBs preoperatively. The patients who withheld their ACE inhibitors/ARB drugs in the 24 hours before surgery were less likely to suffer the outcomes of death, stroke, or myocardial injury. The authors recommended that patients withhold these drugs for 24 hours before surgery.

 

Dr. Sessler closed his lecture with the following recommendations:

  • In the future, clinicians should measure high-sensitivity troponin (hsTnT) for three days postoperatively on inpatient surgery patients of age > 65, or patients age >45 with one cardiovascular risk factor. Elevated shTnT will identify patients who with MINS, and these MINS patients should be referred for cardiology/internal medicine follow up.
  • In the future, clinicians should screen for preoperative cardiovascular risk by a combination of the BNP and hsTnT assays prior to surgery.
  • There is no known preoperative medical prophylaxis against MINS.
  • Maintain intraoperative mean arterial pressure > 65.
  • Hold ACE inhibitors/ARBs for 24 hours prior to surgery.

One of our professors asked Dr. Sessler if the current practice at the Cleveland Clinic included measuring preoperative BNP and three-day postoperative hsTnT. Sessler’s answer was, “not yet, but we’re working on it.”

What about your practice and mine?

This is a new topic and a cutting edge issue to most anesthesiologists, with the key studies only published in the last year. I’m impressed by the MINS data, and I don’t want any patient of mine joining the MINS mortality list. I already withhold ACE inhibitors/ARBs for 24 hours preoperatively. I will continue to be vigilant to maintain MAP > 65, using vasopressors as necessary. I currently use the Revised Cardiac Risk Index as well as cardiology consultations as indicated to screen patients preoperatively. At the present time both the cardiologists and I depend on exercise tolerance history and echo treadmill tests for preoperative cardiac clearance. I expect in the near future our healthcare systems will adopt the standards of checking BNP preoperatively and hsTnT for three days postoperatively for inpatient surgery patients of age > 65, or patients age >45 who have one cardiovascular risk factor. Stay tuned for future recommendations.

References:

  1. Devereaux PJ et al. Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery. 2017Apr 25;317(16):1642-1651.
  2. Puelacher C et al. Perioperative Myocardial Injury After Noncardiac Surgery. Circulation. 2018;137, 1-12.
  3. Rodseth RN et al. The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery: B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a systematic review and individual patient data meta-analysis. J Am Coll Cardiol.2014 Jan 21;63(2):170-80.
  4. Vetrugno L et al. The Possible Use of PreoperativeNatriuretic Peptides for Discriminating Low Versus Moderate-High Surgical Risk Patient. Semin Cardiothorac Vasc Anesth. 2018 Jan 1.
  5. Nagele P et al. High-sensitivity cardiac troponin T in prediction and diagnosis of myocardial infarction and long-term mortality after noncardiac surgery. Am Heart J.2013 Aug;166(2):325-332.
  6. Devereaux PJ et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. 2008 May 31;371(9627):1839-47.
  7. Devereaux PJ et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med.2014 Apr 17;370(16):1494-503.
  8. Devereaux PJ et al. Clonidine in patients undergoing noncardiac surgery. N Engl J Med.2014 Apr 17;370(16):1504-13.
  9. Myles PS et al. The safety of addition of nitrous oxide to general anaesthesia in at-risk patients having major non-cardiac surgery (ENIGMA-II): a randomised, single-blind trial. Lancet. Volume 384, No. 9952, October 2014, 1446-1454.
  10. Mascha EJ. Intraoperative Mean Arterial Pressure Variability and 30-day Mortality in Patients Having Noncardiac Surgery. 2015 Jul;123(1):79-91.
  11. Futlier E et al. Effect of Individualized vs Standard Blood Pressure Management Strategies on Postoperative Organ Dysfunction Among High-Risk Patients Undergoing Major Surgery: A Randomized Clinical Trial. 2017Oct 10;318(14):1346-1357.
  12. Roshanov PS et al. Withholding versus Continuing Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers before Noncardiac Surgery: An Analysis of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN Prospective Cohort. 2017Jan;126(1):16-27.

 

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CARTOON FROM THE 1999 AMERICAN SOCIETY OF ANESTHESIOLOGISTS ART CONTEST

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

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The year was 1999, the technology stock market was exploding, and businessmen in Silicon Valley were getting richer by the hour. Meanwhile, back at the metaphor, anesthesiologists practiced their essential healing profession, and hoped HMOs and hospital administrators would not decrease their anesthesia quantum wage any further.

The cartoon won an Honorable Mention award at the ASA national meeting in 1999.

The original is a 24 inch X 36 inch panel which hangs in the office at my home.

Rick Novak, MD

 

P.S. I do believe it’s healthy for physicians to express themselves in print, in art, and via the spoken word.

 

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:

DSC04882_edited

 

MERITS OF PHYSICIAN ANESTHESIOLOGY

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

Some people have difficulty seeing the outstanding merits of physician anesthesiology. I understand where these opinions come from, but the phenomenon still bothers me.

white-coat-doctor-1080x663

 

Today I read a thoughtful and well-written essay in Anesthesiology News titled, Anesthesiologists-The Utility Players of the Medical Field written by anesthesiologist David Stinson MD from my native state of Minnesota. His thesis is that, like utility players on a baseball team, we are valuable but suffer an identity crisis. He writes, “Our specialty, anesthesia, has suffered an identity crisis for decades. Are we the ‘captain of the ship’ or is the surgeon? . . . It is never quite clear and the answer changes with location and context. Are we physicians or are we glorified advanced practice nurses?”

To me, the appropriate headline should read, “Anesthesiologists—the Most Valuable Players of the Medical Team.” I’d like to see an anesthesiologist saying, “I’m going to Disney World” at the end of the Super Bowl before picking up his (or her) MVP trophy.

Why would I say this? Two anecdotes will illustrate why I understand the problem. In the late 1970’s I was a third-year medical student at a prominent Midwestern medical school, where an unspoken rank system existed in the operating room. The surgical attendings were the kings, the students were the peasants, the nurses and techs were serfs, and the anesthesiologists were the whipping boys for the surgeons. I witnessed consistent verbal abuse, bullying, condescending barking commands, and lack of respect directed from surgeons toward anesthesiologists. One day I was scrubbed in as a retractor-holding medical student on a 12-hour esophagectomy, and at the conclusion of the procedure the attending surgeon removed his gloves and gown and left the room to talk to the family. Five minutes later, the patient had a cardiac arrest. The resuscitation was not successful, and the patient died. Afterward the surgeon bellowed his disapproval regarding how the anesthesia team had failed to keep the patient alive after he had spent all day “curing” the patient. It was an unforgettable experience to me, and one of the take-home messages was that I never wanted to be an anesthesiologist.

Fast-forward three years into the future, when I was an internal medicine resident at Stanford serving my medical intensive care unit rotation. The anesthesiology department ran the ICUs at Stanford during the 1980’s. The ICU attendings were charismatic, smart, decisive, impressive role models. The ICU attendings had respectful peer relationships with all the surgeons, including the private-practice cardiac surgeons whose post-operative patients were housed in the ICU. Morning rounds, evening rounds, and the eight hours in between were filled with action, procedures, upbeat emotions, and encouraging talk about the specialties of anesthesiology and critical care medicine. The Stanford anesthesia residents boasted of weekdays off after their nights on call, Learjet trips to harvest donor hearts for Dr. Norm Shumway’s cardiac transplant patients, weeklong trips to third-world countries to perform anesthetics on cleft lip and palate patients, and best of all, the excitement of inserting endotracheal tubes, arterial lines, central lines, Swan Ganz catheters, spinal and epidural needles into patients of all sizes and surgical needs. This was alluring to internal medicine residents. Each year a significant number of internal medicine residents applied for admittance to anesthesiology residencies, which is what I did. Were surgeons hollering at the anesthesiologists at Stanford? In a word . . . no. The department had the respect of the surgeons. This was the environment I grew up in, and the professional spirit we all should aspire to.

Here are 10 reasons why anesthesiologists should hold their heads high and never have a molecule of low self esteem around their medical center:

  1. All of acute care medicine is based on A-B-C, or Airway-Breathing-Circulation. Operating room medicine, intensive care medicine, emergency room medicine, trauma helicopter medicine, and battlefield medicine are all based on A-B-C, or Airway-Breathing-Circulation. Who are the experts of the A, or Airway? Anesthesiologists are the experts. There can be no acute care resuscitation without someone managing the airway, usually with an endotracheal tube. It’s true that other medical professionals have abilities to place endotracheal tubes, but none of them have the breadth of skills, techniques, and volume of attempts as anesthesiologists do. Hold your heads high. Read my column on bullying in the operating room. Don’t put up with condescending behavior from a surgeon. Surgeons know how to wield a scalpel. You know how to wield the most valuable tool of all medical equipment, the laryngoscope.78432-7985650
  2. It’s true that surgeons bring the patients to the operating room for surgery. It’s just as true that none of those patients would agree to the operations without having an anesthetic. The anesthesiologist’s role is vital.
  3. Clinic doctors are important. They manage primary care as well as outpatient specialty care. They make diagnoses and prescribe therapeutic medicines. Anesthesiologists also partake in clinic care in preoperative clinics and pain clinics. An anesthesiologist’s knowledge of internal medicine isn’t as comprehensive as a board-certified internist, but the consider the flip side: None of the internists can administer general anesthesia, regional anesthesia, or manage the A of the A-B-Cs like an anesthesiologist can. I was an internal medicine doctor who lacked these skills and then acquired them during anesthesia residency. Trust me—internists envy the skills of anesthesiologists.
  4. Anesthesiologists deal with life and death situations on a regular basis. Clinic doctors, including surgeons on their days in clinic, listen to and talk to patients. There is no peril in outpatient clinic medicine. On any given day at your job as an anesthesiologist you could be attending to a morbidly obese adult, a tiny child, a frail geriatric patient, or an emergency thoracic case. Your heart rate will climb as high as the patient’s, and you’ll manage the circumstances. Anesthesiologists are goalies at the Pearly Gates, and we should be proud of it.
  5. Physician anesthesiologists have a fascinating job. Anesthesiologists administer anesthetics to virtually every specialty: general surgery, cardiac surgery, neurosurgery, obstetrics, gynecology, otolaryngology, orthopedic surgery, podiatry, ophthalmology, plastic surgery, psychiatry for electroshock therapy, invasive radiologists, cardiologists, oral surgeons, dentists, and pediatric surgeons. The breadth of knowledge across specialties is unrivaled by any other physician.
  6. Who is the captain of the ship in the operating room? Is it the surgeon or is it the anesthesiologist? My advice is: don’t concede the role to your surgical colleague alone. He or she knows how to do the operation. You know how to do the anesthetic. It is a symbiotic relationship. Do not lay yourself down on the ground in reverence. In the words of the Eagles song “Peaceful Easy Feeling,” “she can’t take you anywhere you don’t already know how to go.” If you see and feel yourself as the servant, second in command, that’s where you’ll find yourself . . . as the servant, second in command. Step up. Be an equal. Be in control of your domain, a critical domain.
  7. Physician anesthesiologists are well paid. Per U. S. News and World Report, an anesthesiologist is the highest paying job in America. Think about that. There are 325 million people in our country, and there are thousands of different job descriptions. Your profession is the highest paid. Be proud of that.
  8. Physician anesthesiologists are in demand. As I write this in 2018, I receive multiple emails per day seeking attending anesthesiologists for jobs around the USA. If you’re willing to relocate and be mobile, you’ll find numerous suitors competing for your services as an attending anesthesiologist. Per U.S. News and World Report, the unemployment rate for anesthesiologists is a paltry 0.5%.
  9. Physician anesthesiologists help people every day. You could be selling Coca Cola or cell phones or cell phone data networks or stocks. Would you be serving humanity as well if you were working in some business job? You have the opportunity to change lives for hundreds of patients per year.
  10. Maybe you’re worried that nurse anesthetists will take your job away. I have no crystal ball to foretell the future, but consider these things: (a) Most CRNAs work in anesthesia care team models with our physician anesthesiologist colleagues, and this MD-CRNA relationship is a well accepted model of patient care that will persist into the future; (b) Physician anesthesiologists are needed for leadership roles in clinical care, administration, committees, and quality assurance; and (c) Remember that you are a physician and CRNAs are not. Keep up your skills. The large medical systems of the future will tier their anesthesia coverage. Complex cases will always require MD anesthesiologists. It’s likely that simple cases such as cataracts, lymph node biopsies, and knee arthroscopies can be safely done with CRNA anesthesia. Continue to seek out and perform difficult anesthetic cases only an MD would feel comfortable doing. If you find yourself attending to only ASA I an ASA II patients for straightforward surgeries, you may indeed find your job taken by someone with less training. Instead, step up. Be proud of your training, your unique skills, the heritage of your profession, and the esteem of your standing among your fellow physicians.

 

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FRAILTY IN 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

Recognizing frailty in anesthesia patients is critical.

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What if your patients, especially elderly patients, could enter their personal data and symptoms into an iPad app, and what if that information could help you determine if their risk for anesthesia was too great to risk having surgery? Can you imagine this? It will happen someday soon.

Webster’s Dictionary defines frailty as “the condition of being weak and delicate.”

Frailty is also a medical term with an accepted definition of “a multisystem loss of physiologic reserve that makes a person more vulnerable to disability during and after stress.”1

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The majority of frail patients are elderly. My training was in both internal medicine and anesthesiology, and the intersection of these two fields is geriatric anesthesia. I have both an interest and expertise in the evaluation and management of geriatric surgery patients. Metrics of frailty exist, and the evaluation of a patient’s frailty index will become an important part of geriatric anesthesia care.

The geriatric population is increasing in size, and the number of elderly patients undergoing surgery is increasing as well. More than half of all operations in the United States are performed on patients of ages ≥65 years, and this proportion will continue to increase.2

In the past a physician’s assessment of a patient’s frailty was an “eyeball” judgment, dependent on how robust versus how frail a patient looked, and dependent on an interpretation of the patient’s active medical problems. Medical researchers began to seek a quantitative metric for frailty, and they proposed frailty evaluation tools.

Dr. Linda Fried developed one of the first frailty indexes in 2001. She studied 5317 men and women 65 years of age or older, and tabulated their answers to questions regarding these five criteria of the Fried Frailty Index: 1,3

  1. Unintentional weight loss. The patient is asked the question, “In the last year, have you lost more than 10 lb unintentionally (i.e., not as a result of dieting or exercise)?” Patients answering “Yes” are categorized as frail by the weight loss criterion.
  2. The patient is read the following two statements: (1) I felt that everything I did was an effort; (2) I could not get going. The question is asked, “How often in the last week did you feel this way?” The patient’s response is rated as follows: 0 = rarely or none of the time (<1 day); 1 = some or little of the time (1 to 2 days); 2 = a moderate amount of the time (3 to 4 days); or 3 = most of the time.
  3. Muscle weakness. The patient is asked about weekly physical activity. Patients with low physical activity are categorized as frail by the physical activity criterion.
  4. Slowness while walking. The patient is asked to walk a short distance and timed. Patients who are slow walkers are categorized as frail by the walk time criterion.
  5. Grip strength. The patient’s grip strength is measured. Patients with decreased grip strength are categorized as frail by the grip strength criterion.

Frailty was defined as a clinical syndrome in which three or more of these five criteria were present. The overall prevalence of frailty in this age>65 patient population was 6.9%. The prevalence of frailty increased with age, and was higher in women than men. The frailty phenotype was predictive of falls, worsening mobility or disability, hospitalization, and death. Fried’s conclusion, a novel one at the time, was that “frailty was not synonymous with either comorbidity or disability, but that comorbidity was an etiologic risk factor for frailty, and disability was an outcome of frailty.”

Multiple frailty indexes have been proposed. Velanovich et al proposed a modified Frailty Index using 11 pre-operative variables:4

  1. History of diabetes
  2. Impaired functional status
  3. History of chronic obstructive pulmonary disease or pneumonia
  4. History of congestive heart failure
  5. History of MI within 6 months
  6. History of percutaneous coronary intervention
  7. Cardiac surgery or angina
  8. Antihypertensive medication use
  9. Peripheral vascular disease or rest pain
  10. Impaired sensory faculties
  11. History of transient ischemic attack or cerebrovascular accident with persistent residual deficit

This modified Frailty Index correlated positively with the 30-day morbidity and mortality among almost a million patients who underwent surgery between 2005 and 2009 across all surgical specialties.

Other researchers, using a variety of frailty scales, have found that increasing frailty correlates with poorer outcomes after surgery. Researchers at the Seoul National University Bundang Hospital enrolled 275 consecutive elderly patients (aged ≥65 years) who were undergoing intermediate-risk or high-risk elective operations.5

A comprehensive geriatric assessment (CGA) was performed before surgery. The CGA included 6 areas: burden of comorbidity, polypharmacy, physical function, psychological status, nutrition, and risk of postoperative delirium. 9.1% of the patients died during the follow-up period of 11.5-16.1 months, including 4 in-hospital deaths after surgery. 10.5% of the patients experienced at least one complication (e.g., pneumonia, delirium, or urinary tract infection) after surgery, and 8.7% required discharge to inpatient nursing facilities. This CGA frailty score predicted all-cause mortality rates more accurately than the American Society of Anesthesiologists classification. The following factors were associated with increased mortality rates: burden of comorbidity, dependence in activities of daily living, dependence in instrumental activities of daily living, dementia, risk of delirium, short midarm circumference, and malnutrition.

Why was the frailty score more predictive than the ASA score? Geriatric patients often have multiple comorbidities and physiological changes that impair their functional reserve. The assessment of frailty is used to account for these factors.

Contrast the frailty indexes described above to the American Society of Anesthesiologists preoperative assessment scores of ASA 1, 2, 3, 4 , and 5, below:6

ASA I A normal healthy patient Healthy, non-smoking, no or minimal alcohol use
ASA II A patient with mild systemic disease Mild diseases only without substantive functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, pregnancy, obesity (30 < BMI < 40), well-controlled DM/HTN, mild lung disease
ASA III A patient with severe systemic disease Substantive functional limitations; One or more moderate to severe diseases. Examples include (but not limited to): poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, premature infant PCA < 60 weeks, history (>3 months) of MI, CVA, TIA, or CAD/stents.
ASA IV A patient with severe systemic disease that is a constant threat to life Examples include (but not limited to): recent ( < 3 months) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis
ASA V A moribund patient who is not expected to survive without the operation Examples include (but not limited to): ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction

 

ASA scores are the currently accepted way physicians stratify patient surgical risk. An ASA IV patient with a severe systemic disease that is a constant threat to life will likely have a high frailty index, but the correlation is not absolute. A chronically ill, weak, elderly patient who is losing weight and is inactive may not have an obvious severe systemic disease such as coronary artery disease, cerebral vascular disease, end-stage renal disease, or sepsis, which would qualify them as ASA IV. But a chronically ill, weak, elderly patient who is losing weight and is inactive may have a very high frailty index, and may have a perioperative risk equivalent to any ASA IV patient.

Kennedy created a 30-item Frailty Index in the Canadian Multicentre Osteoporosis Study.7 Their frailty index proved to be a sensitive measure to quantify fracture risk over the next 10 years. McMaster University professors then authored the Fit-Frailty App (available at Apple or Google App Store), a smartphone/iPad app based on the 30-item Canadian Multicentre Osteoporosis Study Frailty Index from the Kennedy study. It takes only minutes for a patient to answer the questions on the app, and the app generates a frailty score, which ranges from 0 to 1.0.

The Edmonton Frail Scale (available at Apple or Google App Store) is a 9-criteria survey which quantifies a frailty score from 0–17. It’s easy to use, and takes about 2–3 minutes to complete.

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I predict you’ll see patients filling out frailty apps such as these on iPads in the future, with anesthesiologists and internal medicine doctors using the frailty score as part of their preanesthetic evaluation. You can also expect research on whether intervention or modification of frailty criteria prior to surgery results in lower postoperative complication rates. Frailty index research may lead us to stratify surgical treatments for healthier subsets of geriatric patient populations who are at a lower risk of complications, and provide guidance regarding the proper management of the more frail geriatric patients found to have a higher risk of adverse outcomes after surgery.

Fire up your iPads, download these frailty apps, and see how fit or frail your patients are right now.

References:

  1. Sieber F, Pauldine R, Geriatric Anesthesia, Miller’s Anesthesia, Chapter 80, 5th edition, 2407-2422.
  2. Etzioni  DA, et al. The aging population and its impact on the surgery workforce. Ann Surg. 2003;238(2):170-177.
  3. Fried LP et al. Frailty in Older Adults: Evidence for a Phenotype, The Journals of Gerontology: Series A, Volume 56, Issue 3, 1 March 2001, Pages M146–M157.
  4. Velanovich V, Antoine H, Swartz A, Peters D, Rubinfeld I. Accumulating deficits model of frailty and postoperative mortality and morbidity: its application to a national database. Journal of Surgical Research2013; 183: 104–10.
  5. Kim S-W et al, Multidimensional Frailty Score for the Prediction of Postoperative Mortality Risk, JAMA Surg. 2014;149(7):633-640.
  6. https://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system
  7. Kennedy CC et al, A Frailty Index predicts 10-year fracture risk in adults age 25 years and older: results from the Canadian Multicentre Osteoporosis Study (CaMos) Osteoporosis International, December 2014, Volume 25, Issue 12, pp 2825-2832.

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

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

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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?

 

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

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LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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IS YOUR GRANDFATHER TOO FRAIL FOR 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

Is your grandfather too frail for surgery? There are iPad apps to help you answer the question regarding frailty and anesthesia.

Webster’s Dictionary defines frailty as “the condition of being weak and delicate.” Frailty is also a medical term with an accepted definition of “a multisystem loss of physiologic reserve that makes a person more vulnerable to disability during and after stress.”1

1-1

The majority of frail patients are elderly. My training was in both internal medicine and anesthesiology, and the intersection of these two fields is geriatric anesthesia. Metrics of frailty exist, and the evaluation of a patient’s frailty index will become an important part of geriatric anesthesia care.

The geriatric population is increasing in size, and the number of elderly patients undergoing surgery is increasing as well. More than half of all operations in the United States are performed on patients of ages ≥65 years, and this proportion will continue to increase.2

In the past a physician’s assessment of a patient’s frailty was an “eyeball” judgment, dependent on how robust versus how frail a patient looked, and dependent on an interpretation of the patient’s active medical problems. Medical researchers began to seek a quantitative metric for frailty, and they proposed frailty evaluation tools.

Dr. Linda Fried developed one of the first frailty indexes in 2001. She studied 5317 men and women 65 years of age or older, and tabulated their answers to questions regarding these five criteria of the Fried Frailty Index: 1,3

  1. Unintentional weight loss. The patient is asked the question, “In the last year, have you lost more than 10 lb unintentionally (i.e., not as a result of dieting or exercise)?” Patients answering “Yes” are categorized as frail by the weight loss criterion.
  2. The patient is read the following two statements: (1) I felt that everything I did was an effort; (2) I could not get going. The question is asked, “How often in the last week did you feel this way?” The patient’s response is rated as follows: 0 = rarely or none of the time (<1 day); 1 = some or little of the time (1 to 2 days); 2 = a moderate amount of the time (3 to 4 days); or 3 = most of the time.
  3. Muscle weakness. The patient is asked about weekly physical activity. Patients with low physical activity are categorized as frail by the physical activity criterion.
  4. Slowness while walking. The patient is asked to walk a short distance and timed. Patients who are slow walkers are categorized as frail by the walk time criterion.
  5. Grip strength. The patient’s grip strength is measured. Patients with decreased grip strength are categorized as frail by the grip strength criterion.

Frailty was defined as a clinical syndrome in which three or more of these five criteria were present. The overall prevalence of frailty in this age>65 patient population was 6.9%. The frailty phenotype was predictive of falls, worsening mobility or disability.

Other researchers, using a variety of frailty scales, have found that increasing frailty correlates with poorer outcomes after surgery. Korean researchers enrolled 275 consecutive elderly patients (aged ≥65 years) who were undergoing intermediate-risk or high-risk elective operations.4 A comprehensive geriatric assessment (CGA) was performed before surgery. The CGA included 6 areas: the number of medical problems, the number of medications taken, physical function, psychological status, nutrition, and risk of postoperative delirium. This CGA frailty score predicted all-cause mortality rates after surgery.

McMaster University professors authored the Fit-Frailty App (available at Apple or Google App Store), a smartphone/iPad app based on the 30-item Canadian Multicentre Osteoporosis Study Frailty Index.5 It takes only minutes to answer the questions on the app, and the app generates a frailty score, which ranges from 0 to 1.0.

The Edmonton Frail Scale (available at Apple or Google App Store) is a 9-criteria iPad app survey which quantifies a frailty score from 0-17. It’s easy to use, and takes about 2–3 minutes to complete.

643x0w

In the future you’ll see patients filling out frailty apps such as these on iPads in the future, with anesthesiologists and other doctors using the frailty score as part of the pre-surgery evaluation. You can also expect research on whether intervention into or modification of these frailty criteria prior to surgery results in lower postoperative complication rates.

Fire up your iPads, download these frailty apps, and see how fit or frail your grandfather is right now.

References:

  1. Sieber F, Pauldine R, Geriatric Anesthesia, Miller’s Anesthesia, Chapter 80, 5th edition, 2407-2422.
  2. Etzioni  DA, et al. The aging population and its impact on the surgery workforce. Ann Surg. 2003;238(2):170-177.
  3. Fried LP et al. Frailty in Older Adults: Evidence for a Phenotype, The Journals of Gerontology: Series A, Volume 56, Issue 3, 1 March 2001, Pages M146–M157.
  4. Kim S-W et al, Multidimensional Frailty Score for the Prediction of Postoperative Mortality Risk, JAMA Surg. 2014;149(7):633-640.
  5. Kennedy CC et al, A Frailty Index predicts 10-year fracture risk in adults age 25 years and older: results from the Canadian Multicentre Osteoporosis Study (CaMos) Osteoporosis International, December 2014, Volume 25, Issue 12, pp 2825-2832.

 

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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WHEN SURGEONS, OR PATIENTS, TRY TO TELL THE ANESTHESIOLOGIST WHAT TO DO — 14 EXAMPLES

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

You’re a board-certified anesthesiologist. You’ve graduated from a residency program in which you learned the nuances of preoperative, intraoperative, and postoperative anesthesia practice. Yet at times, surgeons or patients will ask you to do something counter to your medical judgment.

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Individuals would never board a Boeing 787 aircraft and tell the pilot what to do, but individuals will try to influence their anesthesiologist.

Let’s look at some examples:

 

WHEN SURGEONS TRY TO TELL THE ANESTHESIOLOGIST WHAT TO DO:

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  1. “This patient’s not too sick. You’re wrong to cancel his surgery.” In an example of this scenario, an orthopedic surgeon tries to convince you that the 65-year-old obstructive sleep apnea patient with a BMI of 40 who never walks further than the distance from his couch to his kitchen table is “not that sick,” and that you should not cancel the patient’s rotator cuff repair at a freestanding outpatient surgery center. Trust your training and your intuition. You believe the patient is high risk in terms of his airway, his breathing, his cardiac status, and his potential for post-operative complications. You’re trained in perioperative medicine. The orthopedic surgeon is trained in the management of joint and bone disorders. Tell the surgeon that the patient needs to have cardiac clearance prior to any general anesthetic, and that the case needs to be done in a hospital setting rather than at a freestanding surgery center.
  2. “Just do MAC (Monitored Anesthesia Care) anesthesia for this case, but make sure he’s asleep. My patient doesn’t want to hear anything.” In an example of this scenario, a surgeon schedules an inguinal hernia repair as a MAC anesthetic. The surgeon intends to supplement your intravenous (IV) sedation with local anesthetic at the surgical site. The surgeon told the patient to expect “a twilight sleep during the surgery.” You discuss this with the surgeon, who requests you, “Just give the patient sedation with propofol.” Per the American Society of Anesthesiologists Continuum of Depth of Sedation, if a patient is unarousable even with painful stimulation, that is a general anesthetic. In contrast, if a patient shows purposeful response following repeated or painful stimulation, that is deep sedation. It’s possible to infuse propofol and keep a patient purposefully responsive, but very few of us do this. Propofol infusions are typically used to make our patients sleep, and most propofol infusions cross the American Society of Anesthesiologists line into general anesthesia. If there is a complication or a bad outcome after the surgery, and you delivered general anesthesia when the operating room schedule said MAC and your preoperative anesthesia note stated the anesthesia plan was MAC, then you’re at medical-legal risk for delivering a deeper anesthetic than what was documented on the schedule and on your anesthetic plan.
  3. “Can you do an axillary block for this finger surgery?” In an example of this scenario, the surgeon requests an axillary block for a debridement of a finger surgery. You’re comfortable placing ultrasound-assisted regional anesthetic blocks, but you’re not confident with this particular block. You discuss other options with the surgeon, and suggest he places a digital block, which is more specific and incurs less risks than the axillary block. He pushes back, wanting you to do the axillary block. But if you don’t want to do the block, you don’t have to. You’re in charge of the anesthetic. You make the decision. The case proceeds with intravenous sedation, the surgeon complies with your request and blocks the base of the finger with local anesthesia, and the patient does fine.
  4. “This patient doesn’t need an arterial line (or a central venous pressure line).” In an example of this scenario, an 70-year-old woman with aortic stenosis is about to undergo an exploratory laparotomy for a perforated bowel. You’re concerned about maintaining her cardiac output, blood pressure, and blood volume during the surgery, and decide she needs an arterial line prior to induction and an internal jugular CVP after induction. The surgeon, in a hurry to proceed with the laparotomy, tells you neither of these lines is necessary. Your answer? Because you’re the expert in perioperative medicine, you tell him you need those lines and you will put them in. If there is a death or a dire cardiovascular complication, you’ll be the physician who will face the criticism if you did not place the lines. Blaming the surgeon will not protect you.
  5. After the conclusion of a surgery, the surgeon says, “What are you waiting for? Extubate the patient. She is bucking and coughing. Extubate the patient!” In an example of this scenario, after the conclusion of a tonsillectomy, you turn off the anesthetics. The patient eventually coughs and bucks on the endotracheal tube, but has not opened her eyes. When you open her eyelids, you note that her gaze is dysconjugate. You’re concerned that if you extubate the trachea, this still-emerging patient could develop laryngospasm. The surgeon then says, “When are you going to extubate? All this coughing is raising the blood pressure, and will cause bleeding and I’ll have a complication.” What should you do? Anesthesia practice must always follow the priorities of A-B-C, or Airway-Breathing-Circulation. You’re in charge of the airway. The endotracheal tube is your friend until the patient opens her eyes, is awake and responsive, and can maintain her own airway. Take out the breathing tube when you’re ready, not when the surgeon asks you to.
  6. Near the conclusion of surgery the surgeon says, “I’d like you to please extubate this patient deep.” In an example of this scenario, a patient has just received a five-hour general anesthetic for a facelift. As in the example above, the surgeon is concerned that coughing or bucking on the endotracheal tube at emergence will elevate the blood pressure and cause increased postsurgical bleeding. What should you do? Again, follow your training and experience. Anesthesia practice must always follow the priorities of A-B-C, or Airway-Breathing-Circulation. You’re in charge of the airway. The endotracheal tube is your friend until your patient opens her eyes, is awake and responsive, and can maintain her own airway. Certain slender, healthy patients are safe to extubate deeply, but this author is unconvinced of the benefit/risk analysis of deep extubation. You may make the surgeon happy, and you may continue to have a safe airway under general anesthesia in the absence of the endotracheal tube, but what if you don’t? What if the airway is poorly maintained in this patient after this five-hour surgery, when her entire head and jaw are wrapped up in a bulky facelift dressing? My advice is to take out the breathing tube when you’re ready, not when the surgeon asks you to.
  7. “Just give the patient a little bit of anesthesia, because my procedure will only last 10 minutes.” In an example of this scenario, the surgeon requests you sedate a 210-pound woman with a Body Mass Index (BMI) = 36 for a 15-minute egg retrieval. Because of the brief and seemingly trivial nature of the procedure, the gynecologist requests an anesthetic free of any airway tubes. You assess the patient and her airway, and decide you’ll need to use a laryngeal mask airway (LMA), with an endotracheal tube ready to go if the woman’s ventilation on the LMA is suboptimal. You explain to the surgeon that you’re doing what is safe, despite the requests the surgeon made. On obese, elderly, pediatric, or sicker patients, there are simple surgeries, but there are no simple anesthetics. Rely on your experience and training, and do the anesthetic by the standard of care.
  8. “I’d like to do this procedure in my office operating room, not in a surgery center or the hospital.” In an example of this scenario, the surgeon has a patient he’d only like to operate on in his office. You’ve worked at his office before, and you know his office operating room does not have an anesthesia machine. Your technique there is limited to IV sedation without any airway tubes or ventilation. You discover that the patient is an obese 45-year-old woman with a BMI = 32, and the planned procedure is implantation of a maxillary bone graft. Your concern is that you will not be able to safely sedate or anesthetize this woman for this oral surgery without a breathing tube or an anesthesia machine. The surgeon objects, and says that the woman does not have enough money to pay for the procedure to be done at the local outpatient surgery center, and that’s why he needs to do it in the office. You stand firm, and kindly refuse to do the anesthetic in his office.

 

 

WHEN PATIENTS TRY TO TELL THE ANESTHESIOLOGIST WHAT TO DO:

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  1. “I don’t want a breathing tube into my windpipe and voice box because I’m a singer and I don’t want my voice ruined.” In an example of this scenario, a 35-year-old 250-pound man with a BMI of 34 who sings in a rock ‘n roll band is about to have a lumbar laminectomy. He does not want to be intubated. He read about anesthesia on the Internet, and he wants you to use an LMA instead of an endotracheal tube. Your response? You advise him that per your experience and training, his only safe airway management is with an endotracheal tube, not with an LMA. You tell him that yes, he will have a sore throat after surgery, and the irritation to his vocal cords may cause a temporary hoarse voice. You advise him that the duration of the hoarse voice should be no more than several days or a week or two, and that it’s rare for any voice change to be permanent. You advise him that he can consent to the endotracheal tube with these risks, or he can refuse. If he refuses the appropriate airway tube management, you will decline to give him anesthesia today.
  2. “I want to be awake for my surgery, so I can watch and talk to the surgeon.” In an example of this scenario, a 55-year-old woman scheduled for a knee arthroscopy wants to be awake for the surgery. She is visibly nervous, and tells you she wants to be awake because she is afraid of dying during a general anesthetic. You discuss the options with the patient, which include spinal anesthesia, epidural anesthesia, or regional blocks, each accompanied by intravenous sedation if necessary, which will permit her to be comfortable and awake. She declines each of these. She just wants “some medicine in the IV to take the edge off while I’m still awake, just like I did with my last colonoscopy.” You discuss with her that knee surgery is more painful than a colonoscopy. You discuss with her that she will need more anesthesia than she is requesting. You leave the bedside and talk to the surgeon about the options. The surgeon is agreeable with injecting local anesthesia into the knee, as a supplement to the intravenous sedation you will administer. The patient, the surgeon, and you all agree with this plan. You also give the patient informed consent that if she is not comfortable, she may need more anesthesia medications from you and she may have to go to sleep. Begrudgingly, she consents. Five minutes into the surgery, despite 200 micrograms of IV fentanyl, 6 milligrams of IV midazolam, and appropriate 2% lidocaine injections into the knee joint by the surgeon, the patient is uncomfortable, crying, and in a state of panic. You begin an infusion of propofol, she goes to sleep, and the ordeal is over. She awakens in the PACU without complications and without complaints. In my experience, many patients who demand or insist on being awake during surgery are patients who hope to control circumstances in the middle of surgery, rather than trusting their anesthesiologist and surgeon. Don’t be surprised if these patients wind up requiring general anesthetics. Make sure you have preoperative informed consent for general anesthesia as a back up, because it’s likely you’ll need to administer it.
  3. A patient who’s been in the PACU (Post Anesthesia Care Unit) for an hour tells you, “I want more intravenous narcotics.” In an example of this scenario, a patient who had an arthroscopic anterior cruciate ligament (ACL) reconstruction is complaining of 8/10 pain ninety minutes postoperatively. He’s received 300 micrograms of fentanyl and two Percocet in the PACU, and says he is still uncomfortable. You go to his bedside, and witness that he is in no acute distress. His vital signs are normal, with a respiratory rate of 12 breaths per minute. He refused a femoral nerve block prior to surgery. Because he’s been medicated, the option of having him sign a consent and performing a femoral nerve block now is out of the question. Your assessment is that his pain score is inflated. One man’s 8/10 may be another’s 3/10. His respiratory rate is already low normal, and he’s received the adjunct of 30 mg of IV Toradol, as well as the Percocet. At this point in my practice I have the following conversation with the patient: I tell them, “You’ve already had the standard pain-relieving medications, including the oral medication the surgeon prescribed for home use. One option now would be to hospitalize you so that you can continue to receive IV narcotics, but we don’t hospitalize healthy patients after routine ACL reconstruction. A second option is for you to stay here in the PACU and continue to receive IV narcotics, but that makes little sense because you cannot continue IV narcotics at home. So the remaining option is for you to be discharged on the oral medication Percocet that the surgeon prescribed.” There’s a point after routine outpatient surgeries where there’s no rationale for the continued administration of IV narcotics, and the patient needs to be discharged home on their oral medications.
  4. Your awake patient in the PACU says, “I’m so anxious. Can I have more of that Versed you gave me before surgery?” In an example of this scenario, a patient with chronic anxiety wakes up from an uneventful anesthetic with complaints of nervousness. The role of the PACU staff is to monitor Airway-Breathing-Circulation while tending to common postsurgical complaints such as pain and nausea until the anesthetics wear off sufficiently for discharge. In my residency, my professors taught me that benzodiazepines were valuable preoperatively but have no role in the PACU, and I still follow this principle. The PACU is a temporary destination prior to discharging a patient home or to their hospital room. Sedating these patients with Versed or any other benzodiazepine in the PACU will prolong their recovery and is not indicated. The best treatment for PACU anxiety is often to discharge the patient out of the PACU.
  5. Your next patient is a child. His parent tells you, “I want to be in the operating room when my son goes to sleep. He needs me.” In an example of this scenario, the mother of a 3-year-old patient wants to accompany her son into the operating room to emotionally support the boy during a mask induction with sevoflurane. The scheduled procedure is bilateral ear pressure-equalizing tubes surgery. This author believes that parent(s) can be a distraction during the potentially dangerous time of mask induction of anesthesia. I’ve done thousands of pediatric inductions without parental presence, and I never wished I had a layperson there at my elbow while I was trying to assure safe airway management. Letting the child watch an iPad as they separate from their parents and engage in the anesthesia induction is a modern solution to this problem.
  6. A preoperative patient with a dangerous airway problem (think ankylosing spondylitis or Treacher Collins syndrome) tells you, “I refuse to have an awake intubation. I need the general anesthesia first before you put in that breathing tube.” In an example of this scenario, an 18-year-old boy with Treacher Collins syndrome and a very abnormal airway refuses awake intubation for an emergency appendectomy. Your assessment of his airway is that you will not be able to visualize the vocal cords with either traditional laryngoscopy or video laryngoscopy. You’re uncertain you can mask ventilate the patient if he is asleep either. You tell him he can be sedated and relaxed for an awake intubation, but you cannot administer general anesthetic prior to his intubation, for safety reasons. Per a study on this very topic, you decide to use dexmedetomidine , which has minimal respiratory depression, to sedate him, and you acquire the assistance of a second anesthesiologist to monitor the patient and manage the sedation while you apply topical anesthesia to the airway and drive the fiberoptic scope. After thirty minutes of work, the two of you manage to successfully insert the endotracheal tube, and the surgery can begin.

 

The overwhelming majority of anesthesiologist-surgeon and anesthesiologist-patient interactions are positive. But when conflicts such as these examples occur, the take-home messages are:

  1. YOU ARE THE BOARD-CERTIFIED SPECIALIST IN ANESTHESIA. IT IS YOUR JOB TO MAKE THE ANESTHESIA DECISIONS.
  2. SURGEONS ARE SPECIALISTS IN SURGERY. THEY ARE NOT SPECIALISTS IN ANESTHESIA OR PERIOPERATIVE MEDICINE.
  3. YOU PAY YOUR OWN MALPRACTICE INSURANCE, AND YOU HAVE TO ANSWER TO THE CONSEQUENCES IF YOU GET SUED. IF YOU ARE SUED, THE KEY QUESTION WILL BE “DID THE ANESTHESIOLOGIST PRACTICE AT THE STANDARD OF CARE?” REPLYING THAT THE SURGEON OR THE PATIENT TALKED YOU INTO A SUB-STANDARD PRACTICE IS NO DEFENSE. IT IS YOUR JOB TO MAKE THE ANESTHESIA DECISIONS.
  4. THE CORRECT ANESTHETIC PLAN IS THE SIMPLEST ANESTHETIC PLAN THAT ALL THREE PARTIES (THE SURGEON, THE PATIENT, AND YOU) AGREE TO.

 

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

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WHAT HAPPENS TO ANESTHESIOLOGISTS WHEN THEIR HOSPITAL CLOSES?

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

America’s hospitals are in fiscal chaos. Anesthesiologists work in hospitals, and when a hospital closes, anesthesiologists lose their jobs. Sixty-seven percent of U.S. Hospitals are losing money, particularly when it comes to the treatment of Medicaid/Medicare patients.

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According to a recent study published in the journal Health Affairs, 55% of hospitals lost money on each patient they served in 2013, and one-third of hospitals had a net profit of less than $1,000 per discharged patient. Only 12 percent of the hospitals studied received net profits of more than $1,000 per patient when payments from insurers, government, and the patients themselves were included.2

An anesthesia group’s success is closely tied to the fate of their hospital. If you think hospital employment or close alignment with your hospital is your security blanket, you may be wrong. How worried should you be if your hospital doesn’t survive?

Per Forbes3 and the Harvard Business Review,4 in fiscal year 2016 the New England hospital network Partners HealthCare lost $108 million, MD Anderson in Texas lost $266 million, and the Cleveland Clinic had a 71% decrease in operating income. Fiscal problems were due to decreased income and increased expenses, including:

  • Decreased reimbursements from payers, including both the government and private insurance. Most hospitals are losing money on Medicare patients because the hospital costs exceed Medicare’s fixed, per-admission DRG payments.
  • Decreased revenues due to implementation of an electronic health record (EHR) system. According to a Deloitte Survey of US Physicians,5 70% of physicians reported that EHRs reduced their productivity, thereby raising costs. In addition, these EHR systems require high startup and maintenance costs, in the hundreds of millions.
  • The exodus of once-profitable services to outpatient venues, including the movement of surgery to physician-owned ambulatory surgery centers (ASCs). ASCs offer a significantly cheaper alternative to Medicare, private payers, and patients, and physician owners earn money for doing cases at ASCs they own. There are nearly 6,000 ASCs in the United States.
  • High costs for the construction of new hospital and clinic facilities. Hospital leaders are spending millions in capital to expand their medical campuses.
  • Escalating labor expenses for the largely unionized workforce. Nurses, janitors and other medical center employees threaten to strike at each negotiation period, and the healthcare system must face increased costs in both wages and benefits.
  • Older and sicker patients require expensive medical care. This expensive medical care includes ICU stays and expensive equipment for invasive procedures and monitoring.
  • Costly decisions to purchase multiple physician practices and to pursue physician integration, i.e. making physicians employees of the hospital system, have resulted in loses of upwards of $200,000 per physician per year, with no clear returns on the investment to the healthcare systems.4

Regarding this latter point, currently 20-30% of all practicing physicians are employed by hospitals, and a high number of physicians are controlled by hospitals through alignment relationships such as Accountable Care Organizations and foundation model medical groups. A current model is for healthcare systems to gain scale in regional markets by purchasing outside physician practices. Acquired physicians are then paid a fixed salary, and lack the incentives to produce income in their previous private practices. It becomes more attractive for many physicians to merely work an 8-hour day and go home. Productivity suffers, and the bottom line suffers for the healthcare system.4 The good old days of self-employed physicians working in private practice groups have largely given way to systems of MDs working for salaries paid by hospitals or multispecialty foundation groups.

Another current model is for hospitals to gain scale by merging with other hospitals. There were 105 hospital mergers in 2013 and 100 mergers in 2014, and 1412 hospitals have merged since 1998. Hospitals merge with the goals of attaining strength as a larger entity, eliminating competition, increasing patient revenues, and increasing profits. When large hospitals merge and when hospital systems buy increasing amounts of physician practices, the administrative costs go up.6 Stanford University Hospital, the hospital I work at, merged with the UCSF Hospitals in 1997 during a similar wave of hospital mergers. The UCSF/Stanford HealthCare union was a financial failure, with losses of $86 million in its second year. The two medical systems separated in 1999.

What about anesthesiologists in the current healthcare systems? There are 46,000 anesthesiologists in the U.S, and these anesthesiologists provide $20 billion worth of health care services each year. Half of these anesthesia providers are employed by the medical centers where they practice. Forty-two percent are local private groups, and 8 percent of anesthesiologists are operated by one of four national practice management companies.7

Anesthesia work within hospitals includes increasing numbers of older, Medicare, and Medicaid patients. Medicare pays very low anesthesia rates—less than one third of commercially insured patients—and Medicaid rates are even lower. Ambulatory Surgery Centers (ASCs) have captured many of the well-insured, healthy patients for short, predictable surgical procedures. Anesthesiologists at an ASC earn stable incomes working 7 a.m. to 3 p.m. shifts at an ASC, and anesthesia groups covet such work. Because of the lower payer mix at hospitals, many hospitals have been forced to pay yearly stipends to anesthesia groups to retain essential anesthesia coverage for operating rooms, obstetrics, and trauma services.

What happens if hospital systems, with their current financial failures as described in Forbes and the Harvard Business Review, should fail and dissolve? Expect the facilities that survive to handle care only for the sickest patients and the most complicated procedures. There will continue to be a need for anesthesia services at those facilities, and there will always be sick patients who require surgery and anesthesia care. Keep your eyes and ears open. It’s common for anesthesiologists to isolate themselves from hospital politics, but I recommend you involve yourself in your healthcare system’s workings and become knowledgeable regarding your hospital’s fiscal solvency. If your hospital system fails, you may find yourself scrambling for a job in a different hospital, a different town, or a different part of the United States. The crystal ball is cloudy regarding specifics, but some anesthesia providers will find themselves playing musical chairs because of the need to find new jobs. Healthcare attorney and former University of Southern California anesthesia faculty member Mark Weiss predicts that freestanding facilities, even mobile ones, will be the future of a large percentage of surgical care. If your practice isn’t already heavily focused on freestanding facility care, independent from hospital care, he urges you consider every opportunity to expand in that direction.6

Many hospital systems are drowning in red ink, and you can expect to see dynamic changes as a result.

Stay tuned, and stay informed.

References:

  1. Top 5 Reasons US Hospitals Are Losing Money, Behavioral Health and Medical Healthcare Solutions.
  2. Wyland M, Half of US Hospitals Lose Money on Patient Care, Non Profit Quarterly, May 3, 2016.
  3. Pearl R, Why Major Hospitals Are Losing Money By the Millions, Forbes, Nov 7, 2017.
  4. Goldsmith J, Bajner R, 5 Ways U.S. Hospitals Can Handle Loses From Medicare Patients, Harvard Business Review, Nov 10, 2017.
  5. Deloitte 2016 Survey of US Physicians, Findings on Health Information Technology and Electronic Health Records.
  6. Snowbeck C, Why Local Doctors are Selling Their Practices to National Companies, The Minneapolis Star Tribune, June 16, 2016.
  7. Weiss MF, Impending Death of Hospitals: Will Your Anesthesia Practice Survive? The Anesthesia Insider Blog, April 15, 2016.

 

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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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:

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CODE BLUE – WHEN AN ANESTHESIOLOGIST PREMATURELY DEPARTS A FREESTANDING SURGERY CENTER

the anesthesia consultant

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

Let’s look at a case study which highlights a specific risk of general anesthesia at a freestanding surgery center or a surgeon’s office operating room, when the anesthesiologist departs soon after the case is finished.

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The patient is a 66-year-old woman admitted for a facelift, neck lift, and blepharoplasties. The surgery is scheduled for 8 hours, and will be conducted in a private operating room adjacent to a plastic surgeon’s office. The patient has preoperative medical clearance from her internist. Her only medical problems are hyperlipidemia and stable asthma. She has no history of cardiac problems. Her weight is 80 kg, and her BMI=29. Her ECG and preoperative labs are normal. 

The anesthesiologist meets the patient prior to the surgery, reviews the chart, and examines the patient. The assessment is ASA II, and the plan is general endotracheal anesthesia. The anesthesiologist’s informed consent includes the common risks of sleepiness, pain, nausea, and sore throat postoperatively. He explains that the risks of serious complications related to the heart, the lungs, or the brain are not zero, but that the risks are close to zero. The patient consents.

The patient enters the operating room at 0730 hours. The anesthetic consists of midazolam 2 mg IV as a premed, induction with propofol 200 mg IV, fentanyl 100 micrograms IV, and rocuronium 40 mg IV. The trachea is intubated, and anesthesia is maintained with 1-1.5% sevoflurane, 50% nitrous oxide, a propofol infusion at 50 mcg/kg/min, and intermittent boluses of fentanyl.

The surgery concludes at 1630 hours. The surgeon wraps the face in several layers of gauze bandages, and the anesthesiologist discontinues the anesthetic drugs. The patient eventually begins bucking on the breathing tube, and the tube is removed. The anesthesiologist and the operating room nurse transport the patient to the PACU (Post Anesthesia Care Unit), where the patient is connected to the standard monitors of pulse oximetry, ECG, blood pressure, and temperature. Four liters/min of oxygen are administered intranasally. The initial vital signs are an oxygen saturation of 95%, heart rate of 90, respiratory rate of 24, and blood pressure of 140/88. 

The PACU nurse’s name is Gloria, and she is new to this surgical facility. Her last job was as a home health nurse for a registry company. The anesthesiologist has never met her before. The anesthesiologist gives a detailed sign out to the PACU nurse, transferring care to her. He orders fentanyl 50 mcg IV as needed for postoperative pain, and labetalol 10 mg IV as need to maintain the blood pressure less than 140 systolic and 90 diastolic.

Twenty minutes later, the anesthesiologist physically leaves the facility. He signs out to the plastic surgeon, who remains in his office across the hall to do paperwork.

Thirty minutes later, the anesthesiologist receives a cell phone call from the plastic surgeon. The patient is having difficulty breathing, the oxygen saturation is less than 80%, the blood pressure is elevated at 170/100, and there is a facial hematoma developing in the right cheek which is inhibiting the patient’s ability to breathe. The anesthesiologist is alarmed. He instructs the surgeon to call 911, and says he will return to the site immediately. Traffic is heavy at rush hour and it takes him 30 minutes before he arrives. The paramedics are onsite, the patient has been reintubated, and the patient is being transported to a nearby hospital. In the days that follow, the patient does not reawaken. A neurologic consult and an EEG confirm the diagnosis of anoxic brain damage.

This is every anesthesia provider’s nightmare. What went wrong?

A number of things went wrong, and the primary issue was the absence of an experienced acute care doctor on site when this patient began to decompensate. The interval history after the anesthesiologist left the facility was as follows:

The patient began to moan and complain that her face hurt. Her blood pressure increased to 165/100. The nurse treated her with two doses of 50 mcg of IV fentanyl. The patient became increasingly somnolent, began to snore and obstruct her airway, and her oxygen saturation dropped to 88%. The elevated blood pressure went untreated. The nurse turned the nasal oxygen up to 6 liters/minute and called the plastic surgeon. The plastic surgeon arrived on scene, and unsuccessfully tried to improve the patient’s airway, but the oxygen saturation dropped to 70%. The snoring first increased in amplitude and then converted to total airway obstruction. The blood pressure climbed to 165/100, and surgeon noted that the patient’s right cheek was swollen, adding to the airway obstruction. The oxygen saturation dropped further to 60%. The surgeon ordered an amp of Narcan IV to reverse the fentanyl, but neither he nor the nurse knew where the Narcan was stored. They telephoned the anesthesiologist and then they called 911. By the time the nurse found the Narcan, the oxygen saturation had been below 80% for over five minutes. She injected the Narcan IV, and the patient still did not wake up. Paramedics arrived five minutes later, and were able to intubate the trachea on the third attempt. The oxygen saturation then climbed to 100%, and they transported the patient to the hospital. 

Can this scenario occur? Yes? Have variations on this theme occurred? Yes. Based on my experience as an expert witness, expert reviewer, and quality assurance committee member for many years, this scenario is representative of several cases I’m aware of. The common thread is a perioperative patient with an airway, breathing, or circulation disaster when there was no anesthesiologist present.

An increasing number of surgeries are being conducted utilizing general anesthesia in freestanding surgery centers or physician offices. Advances in anesthesia pharmacology, monitoring, training, and pain control enable safe anesthesia care in many locations remote from an acute care hospital. Today, one of every ten surgeries is performed in a doctor’s office.

Freestanding surgery centers and office-based operating rooms are islands without intensive care units, laboratories, rapid response teams, respiratory therapy departments, arterial blood gas measurements, or emergency rooms. The reservoir for assistance when an acute complication arises isn’t deep. PACU medical care is typically safe when a physician anesthesiologist is on site and available for consultation. For the last case of each day, the anesthesiologist must utilize judgment in deciding when to leave the facility.

PACU complications are not rare. For inpatients and outpatients combined, the PACU complication rate was 24% in a prospective study of more than 18,000 consecutive admissions to the PACU. The most frequent events were nausea and vomiting (9.8%), the need for upper airway support (6.8%), and hypotension (2.7%).  From1985 to 1989, 7.1% of the 1175 anesthesia-related malpractice claims in the United States were attributed to PACU events. The most serious adverse outcomes were due to airway, respiratory, and cardiovascular complications.

In a freestanding operating room suite where general anesthesia is performed, it’s critical that before the final anesthesiologist departs, all patients must be awake with stable vital signs and free of airway, breathing, or cardiac problems. The anesthesiologist needs to evaluate when it’s safe to leave.

I’ve personally performed over 7,000 general anesthetics in freestanding surgery centers and office operating rooms. General anesthesia in freestanding facilities can be very, very safe, but the complication rate in ambulatory surgery centers is not zero. In a study by Fleisher et al, for patients > 65 years of age the incidence of death in an ambulatory surgery center was calculated to be 2.3 per 100,000 outpatient procedures. The number of patients admitted to a hospital within 7 days of outpatient surgery was 9.08 per 1000 outpatient procedures performed at a physician’s office, and 8.41 per 1000 outpatient procedures performed at an ambulatory surgery center. Advanced age, a previous inpatient hospital admission within the past 6 months, surgical location at a physician’s office or an outpatient facility, and the invasiveness of the surgery were the risk factors for an increased risk of  hospital admission or death within 7 days of surgery at an outpatient facility.

What should have happened in the case study above?

The anesthesiologist was responsible for the patient and any complications until the patient was discharged from the PACU. Every facility will typically have a policy mandating that an anesthesiologist remains on site after a general anesthetic until a patient is medically discharged. What does “medically discharged” mean? It does not mean that the anesthesiologist must stay until the patient is wheeled out the door to their ride home. Medically discharged means the patient is: 1) awake and oriented to time and place, 2) able to maintain their airway without any device or assistance, and 3) pain is reasonably controlled with oral medications, 4) nausea is reasonably controlled, 5) there is no bleeding or surgical complication, 6) the vital signs are within normal limits, and 7) an adult is present to accompany the patient home.

I’d advise this guideline: You, the anesthesiologist, should not depart until you’re able to have meaningful conversation with your final patient in the PACU, confirming that the patient is awake, free of airway or breathing problems, and appears ready to resume their recovery after the surgery center. It’s within the standard of care to sign out to the surgeon at this point, but realize that the surgeon is not an expert in airway management or acute care management. The surgeon is not a substitute for an anesthesiologist.

What about the PACU nurse in this case study? All PACU nurses are not equal. PACU nurses are required to have ACLS (Advanced Cardiac Life Support) certification, but some nurses are inexperienced and cannot manage complications they’ve never seen before. An anesthesiologist needs to have a sense for the experience and competency of the nurse before he decides to depart. If you’ve never met your PACU nurse previously, I’d recommend you query her regarding her last job(s) and her comfort zone managing an PACU patient alone.

What about CRNA (Certified Registered Nurse Anesthetist) readers of this website? A solitary freestanding operating room is not typically staffed by an anesthesia care team, which would necessitate both a CRNA and an attending physician anesthesiologist care for one patient. If the solitary freestanding operating room is located in an opt-out state and the lone anesthesia provider is a CRNA, then the discussion regarding physician anesthesiologists in the case study applies to the CRNA.

The moral of this column? Don’t get caught on the other end of a traffic snarl while the patient you just anesthetized is hypoxic in the PACU. You worked hard to keep your patient alive and safe throughout the operating room course, but your job isn’t finished until your patient is wheeled out the door to their ride home after their time in the PACU. When you’re on site at the surgery suite, your patient is safe. When you’re not on site, there are no guarantees. You pay your own malpractice insurance, and I know you want to avoid a bad outcome for both your patient’s wellbeing and for your own.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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THE MINI-COG: COGNITIVE IMPAIRMENT AND SURGICAL OUTCOME

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

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