The anesthesia consultant

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

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?

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:

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

For questions, contact: rjnov@yahoo.com

13 MAJOR CHANGES IN ANESTHESIOLOGY IN THE LAST TEN YEARS

10 May 201626 Oct 2018THE ANESTHESIA CONSULTANT 2 Comments

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

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Latest posts by THE ANESTHESIA CONSULTANT (see all)

WRITING MEDICAL FICTION - 6 Dec 2023
HIGH FLOW NASAL OXYGEN:AN ANESTHESIA GAME-CHANGER - 15 Nov 2023
STANFORD EMERGENCY MANUAL POCKET VERSION - 28 Sep 2023

Let’s look at 13 major changes in the last ten years of anesthesiology, and give a letter grade to mark the significance of each advance:

final_ten_year_graphic_gif

SUGAMMADEX – The long awaited reversal agent for neuromuscular paralysis reached the market in 2016, and by my review, the drug is wonderful. I’ve found sugammadex to reverse rocuronium paralysis in less than a minute in every patient who has at least one twitch from a nerve stimulator. The dose is expensive at about $100 per patient, but at this time that’s cheaper than the acquisition costs for neostigmine + glycopyrrolate. The acquisition cost of neostigmine + glycopyrrolate at our facilities exceeds $100, and this combination of drugs can take up to 9 minutes to reverse rocuronium paralysis. Sugammadex reversal can make the duration of a rocuronium motor block almost as short acting as a succinylcholine motor block, and sugammadex can also eliminate complications in the Post Anesthesia Care Unit due to residual postoperative muscle paralysis. Grade = A.

SHORTAGES OF GENERIC INTRAVENOUS DRUGS – Over the last five years we’ve seen unexpected shortages of fentanyl, morphine, propofol, ephedrine, neostigmine, glycopyrrolate, meperidine, and atropine, to name a few. These are generic drugs that formerly cost pennies per ampoule. In the current marketplace, generic manufacturers have limited the supplies and elevated the prices of these medications to exorbitant levels. I wish I’d had the foresight and the money ten years ago to invest in a factory that produced generic anesthetic drugs. Grade = F.

THE PERIOPERATIVE SURGICAL HOME – The American Society of Anesthesiologists has been pushing this excellent concept for years now—the idea being that a team of physician anesthesiologists will manage all perioperative medical care from preoperative clinic assessment through discharge, including intraoperative care, postoperative care and pain management in the PACU, the ICU, and the hospital wards. The goal is improved patient care with decreased costs. It’s not clear the idea has widespread traction as of yet, and the concept will always be at odds with the individual aspirations of internal medicine doctors, hospitalists, intensivists, surgeons, and certified nurse anesthetists, all who want to make their own management decisions, and all who desire to be paid for owning those decisions. Grade = B-.

MULTIMODAL PAIN MANAGEMENT FOLLOWING TOTAL JOINT REPLACEMENTS – The development of pain management protocols which include neuroaxial blocks, regional anesthetic blocks, local anesthetic infiltration by surgeons, oral and intravenous pain medications, have advanced the science of pain relief for total knee and total hip replacements. The cooperation between surgeons, anesthesiologists, and internal medicine specialists to develop the protocols has been outstanding, the standardized checklist care has been well accepted, and patients are benefiting. Grade = A.

ULTRASOUND GUIDED REGIONAL ANESTHESIA – Regional anesthetic blocks are not new, but visualizing the nerves via ultrasound is. The practice is becoming widespread, and the analysis of economic and quality data is ongoing. Ultrasound guided regional anesthesia is a major advance for painful orthopedic surgeries, but I worry about overuse of the technique on smaller cases for the economic benefit of the physician wielding the ultrasound probe. A second concern is the additive risk of administrating two anesthetics (regional plus general) to one patient. I’ve reviewed medical records of patients with adverse outcomes related to regional blocks, and I’m concerned ultrasound guided regional anesthesia may be creating a new paradigm of postoperative complications, e.g. prolonged nerve damage or intravascular injection of local anesthetics. In the future I look forward to seeing years of closed claims data regarding this increasing use of regional anesthesia. Grade = B.

VIDEOLARYNGOSCOPY – The invention of the GlideScope and its competitors the C-MAC, King Vision, McGrath and Airtraq videolaryngoscopes was a major advance in our ability to intubate patients with difficult airways. My need for fiberoptic intubation has plummeted since videolaryngoscopy became available. I’d recommend that everyone who attempts traditional laryngoscopy for endotracheal intubation have access to a video scope as a backup, should traditional intubation prove difficult. Grade = A.

ANESTHESIOLOGIST ASSISTANTS (AAs) – The American Society of Anesthesiologists is championing the idea of training AAs to work with physician anesthesiologists in an anesthesia care team model. A primary reason is to combat the influence and rise in numbers of Certified Registered Nurse Anesthetists (CRNAs) by inserting AAs as a substitute. Not a bad idea, but like the Perioperative Surgical Home, the concept of AAs is gaining traction slowly, and the penetration of AAs into the marketplace is minimal. To date there are only ten accredited AA education programs in the United States. Grade = B-.

CHECKLISTS – We now have pre-incision Time Outs, pre-induction Anesthesia Time Outs, and pre-regional anesthesia Block Time Outs. It’s hard to argue with these checklists. Even if 99.9% of the Time Outs change nothing, if 0.1% of the Time Outs identify a miscommunication or a laterality mistake, they are worth it. Grade = A.

ANESTHESIA ELECTRONIC MEDICAL RECORDS (EMRs)– The idea is sound. Everything in the modern world is digitalized, so why not medical records? The problem is the current product. There are multiple EMR systems, and the systems cannot communicate with each other. Can you imagine a telephone system where Sprint phones cannot communicate with AT&T phones? The current market leader for hospitals is Epic, a ponderous, expensive system that does little to make the pertinent information easier to find in medical charts. For acute care medicine such as anesthetic emergencies, the medical charting and documentation in Epic gets in the way of hands-on anesthesia care. In the past, when I administered 50 mg of rocuronium, I simply wrote “50” in the appropriate space on a piece of paper. In Epic I have to make at least 4 mouse clicks to do the same thing. This Epic entry cannot be made on a touch screen because the first rocuronium window on the touch screen is a three-millimeter-tall box, too small for a finger touch. I’d like to see Apple or Google develop better EMR software than we have at present. Perhaps the eventual winning product will be voice activated or will involve easy touch screen data entry and data access. And all EMR systems should interact with each other, so patient privacy medical information can be portable. Grade = C-.

THE ECONOMICS OF ANESTHESIA – When I began in private practice in 1986, most successful anesthesiologists joined a single-specialty anesthesia group. This group would cover a hospital or several hospitals along with nearby surgery centers and offices. The group would bill for physician services, and insurance companies would reimburse them. Each physician joining the group would endure a one or two-year tryout period, after which he or she became a partner. Incomes were proportional to the number of cases an individual attended to. The models are changing. Smaller anesthesia groups are merging into larger groups, better equipped to negotiate with healthcare insurers and ObamaCare. More and more healthcare systems are employing their own anesthesiologists. In a healthcare system, profits are pooled and shared amongst the varying specialists. This model is not objectionable. Anesthesiologists share the profits with less lucrative specialties such as internal medicine and pediatrics, but the anesthesiologists are assured a steady flow of patients from the primary care physicians and surgeons within the system. The end result is less income than in a single-specialty anesthesia group, but more security. Grade = B.

THE SPECTER OF A BAN ON BALANCE BILLING – In a perfect world all physician groups would be contracted with all health insurance companies, at a monetary rate acceptable to both sides. Unfortunately there are insurance company-physician group rifts in which an acceptable rate is not negotiated. In these instances, the physician provider for a given patient may be out of network with the patient’s insurer, not because of provider greed (as portrayed by some politicians and insurers) but because the insurance company did not offer a reasonable contracted rate. Some politicians believe physician out-of-network balance billing should be outlawed. This would give unilateral power to insurance companies. Why would an insurance company offer a reasonable rate to a physician provider group, if the insurance company can pay the physicians a low rate and the new law says the physicians have no alternative but to accept it as payment in full? The no-balance-billing politicians will portray patients as victims, but if they succeed in changing the laws, physicians will become victims. Physicians as well as consumers must unite to defeat this concept. Grade = F.

CORPORATE ANESTHESIA – National companies are buying multiple existing anesthesia groups and changing the template of our profession in America. The current physician owners of a practice can sell their group to a publically traded national company for a large upfront payoff. The future salaries of anesthesiologists of that group are then decreased, and the rest of the profit formerly garnered by the physicians goes instead to the bottom line of the national company’s shareholders. If this model becomes widespread, the profession of anesthesiology will morph into a job populated by moderately reimbursed employees. Grade = D.

INDEPENDENT PRACTICE FOR CRNAs – Anesthesiology is the practice of medicine. In a two-year training program, an ICU nurse can learn to administer propofol and sevoflurane, and how to intubate most patients, and become a CRNA. It takes a physician anesthesiologist to manage complex preoperative medical problems, intraoperative complications, and postoperative medical complications. I understand rural states such as Montana and the Dakotas cannot recruit enough physician anesthesiologists to hospitals in their smallest towns, but for states like California to legalize independent anesthesia practice for CRNAs is unconscionable. Grade = D.

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

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

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

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?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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KIRKUS REVIEW

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

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:

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

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

17 Feb 201529 Oct 2018THE ANESTHESIA CONSULTANT 1 Comment

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

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Latest posts by THE ANESTHESIA CONSULTANT (see all)

WRITING MEDICAL FICTION - 6 Dec 2023
HIGH FLOW NASAL OXYGEN:AN ANESTHESIA GAME-CHANGER - 15 Nov 2023
STANFORD EMERGENCY MANUAL POCKET VERSION - 28 Sep 2023

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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*
*
*

KIRKUS REVIEW

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

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:

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

SUCCINYLCHOLINE: VITAL DRUG OR OBSOLETE DINOSAUR?

21 Jul 201431 Oct 2018THE ANESTHESIA CONSULTANT 6 Comments

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Recent Posts

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

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Latest posts by THE ANESTHESIA CONSULTANT (see all)

WRITING MEDICAL FICTION - 6 Dec 2023
HIGH FLOW NASAL OXYGEN:AN ANESTHESIA GAME-CHANGER - 15 Nov 2023
STANFORD EMERGENCY MANUAL POCKET VERSION - 28 Sep 2023

Succinylcholine: vital drug or dinosaur? Succinylcholine (sux) has the wonderful advantage of rendering a patient paralyzed in less than a minute, and the discouraging disadvantage of a long list of side effects that make the drug problematic.

A vial of succinylcholine

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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

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

HOW TO WAKE UP PATIENTS PROMPTLY FOLLOWING GENERAL ANESTHETICS

6 Nov 201321 Dec 2022THE ANESTHESIA CONSULTANT 16 Comments

Author
Recent Posts

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

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Latest posts by THE ANESTHESIA CONSULTANT (see all)

WRITING MEDICAL FICTION - 6 Dec 2023
HIGH FLOW NASAL OXYGEN:AN ANESTHESIA GAME-CHANGER - 15 Nov 2023
STANFORD EMERGENCY MANUAL POCKET VERSION - 28 Sep 2023

Two patients arrive simultaneously in the recovery room following general endotracheal anesthetics. One patient is unresponsive and requires an oral airway to maintain adequate respiration. In the next bed, the second patient is awake, comfortable and conversant. How can this be? It occurs because different anesthetists practice differently. Some can wake up patients promptly, and some cannot.

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Does it matter if a patient wakes up promptly after general anesthesia? It does. An awake, alert patient will have minimal airway or breathing problems. When it’s time to walk away from your patient in the recovery room, you’ll worry less if your patient is already talking to you and has minimal residual effects of general anesthesia. Whether the surgery was a radical neck dissection, a carotid endarterectomy, a laparotomy, or a facelift, it’s preferable to have your patient as awake as possible in the recovery room.

What can you do to assure your patients wake up promptly? A Pubmed search will give you little guidance. There’s a paucity of data or evidence in the medical literature on how to wake patients faster. You’ll find data on ultra-short acting drugs such as propofol and remifentanil. This data helps, but the skill of waking up a patient on demand is more an art than a science. Textbooks give you little advice. Anesthesiologist’s Manual of Surgical Procedures, (4^th Edition, 2009), edited by Jaffe and Samuels, has an Appendix that lists Standard Adult Anesthetic Protocols, but there is little specific information on how to titrate the drugs to ensure a timely wakeup.

Based on 29 years of administering over 20,000 anesthetics, this is my advice on how to wake patients promptly from general anesthesia:

Propofol. Use propofol for induction of anesthesia. You may or may not choose to infuse propofol during maintenance anesthesia (e.g. at a rate of 50 mcg/kg/min) but if you do, I recommend turning off the infusion at least 10 minutes before planned wakeup. This allows adequate time for the drug to redistribute and for serum propofol levels to decrease enough to avoid residual sleepiness.
Sevoflurane. Sevoflurane is relatively insoluble and its effects wear off quickly when the drug is ventilated out of the lungs at the conclusion of surgery. I recommend a maintenance concentration of 1.5% inspired sevoflurane in most patients. I drop this concentration to 1% while the surgeon is applying the dressings. When the dressings are finished, I turn off the sevoflurane and continue ventilation to pump the sevoflurane out of the patient’s lungs and bloodstream. The expired concentration will usually drop to 0.2% within 5-10 minutes, a level at which most patients will open their eyes.
Nitrous oxide. Unless there is a contraindication (e.g. laparoscopy or thoractomy) I recommend you use 50% nitrous oxide. It’s relatively insoluble, and adding nitrous oxide will permit you to utilize less sevoflurane. I recommend turning off nitrous oxide when the surgeon is applying the dressings at the end of the case, and turning the oxygen flow rate up to 10 liters/minute while maintaining ventilation to wash out the remaining nitrous oxide.
Narcotics. Use narcotics sparingly and wisely. I see overzealous use of narcotics as a problem. Prior to inserting an endotracheal tube, it’s reasonable to administer 50 – 100 mcg of fentanyl to a healthy adult or 0 -50 mcg of fentanyl to a geriatric patient. A small dose serves to blunt the hemodynamic responses of tachycardia or hypertension associated with larynogoscopy and intubation. Bolusing 250 mcg of fentanyl prior to intubation is an unnecessary overdose. The use of ongoing doses of narcotics during an anesthetic depends on the amount of surgical stimulation and the anticipated amount of post-operative pain. You may administer intermittent increments of narcotic (I may give a 50-100 mcg dose of fentanyl every hour) but I recommend your final narcotic bolus be given no less than 30 minutes prior to the anticipated wakeup. Undesired high levels of narcotic at the conclusion of surgery contribute to oversedation and slow awakening. If your patient complains of pain at wakeup, further narcotic is titrated intravenously to control the pain. Your patient’s verbal responses are your best monitor regarding how much narcotic is needed. Your goal at wakeup should be to have adequate narcotic levels and effect, but no more narcotic than needed.
Intra-tracheal lidocaine. I recommend spraying 4 ml of 4% lidocaine into the larynx and trachea at laryngoscopy prior to inserting the endotracheal tube. I can’t cite you any data, but it’s my impression that patients demonstrate less bucking on endotracheal tubes at awakening when lidocaine was sprayed into their tracheas. Less bucking enables you to decrease anesthetic levels further while the endotracheal tube is still in situ.
Local anesthetics. Local anesthetics are your friends at the conclusion of surgery. If the surgeon is able to blunt post-operative pain with local anesthesia or if you are able to blunt post-operative pain with a neuroaxial block or a regional block, your patient will require zero or minimal intravenous narcotics, and your patient will wake up more quickly.
Muscle relaxants. Use muscle relaxants sparingly. Nothing will slow a wakeup more than a patient in whom you cannot reverse the paralysis with a standard dose of neostigmine. This necessitates a delay in extubation until muscle strength returns. Muscle relaxation is necessary when you choose to insert an endotracheal tube at the beginning of an anesthetic, but many cases do not require paralysis for the duration of the surgery. When you must administer muscle relaxation throughout surgery, use a nerve stimulator and be careful not to abolish all twitch responses. Avoid long-acting paralyzing drugs such as pancuronium, as you will have difficulty reversing the paralysis if surgery concludes soon after you’ve administered a dose. Use rocuronium instead. Avoid administering a dose of rocuronium if you believe the surgery will conclude within the next 30 minutes—it may be difficult to reverse the paralysis, and this will delay wakeup.
Laryngeal Mask Airway (LMA). When possible, substitute an LMA for an endotracheal tube. Wakeups will be smoother, muscle relaxants are unnecessary, and narcotic doses can be titrated with the aim of keeping the patient’s spontaneous respiratory rate between 15- 20 breaths per minute.
Temperature monitoring and forced air warming. Cold is an anesthetic. Strive to keep your patient normothermic by using forced air warming. If your patient’s core temperature is low, wakeup will be delayed.

10. Consider remaining in the operating room after surgery until your patient is awake enough to respond to verbal commands. This is my practice, and I recommend it for safety reasons. In the operating room you have all your airway equipment, drugs, and suction at your fingertips. If an unexpected emergence event occurs, you’re prepared. If an unexpected emergence event occurs in an obtunded patient in the recovery room, your resuscitation equipment will not be as readily available. If your patient is responsive to verbal commands in the operating room, your patient will be wakeful on arrival in the recovery room.

Is this protocol a recipe? Yes, it is. You’ll have your own recipe, and your ingredients may vary from mine. You may choose to administer desflurane instead of sevoflurane. You may choose sufentanil, morphine, or meperidine instead of fentanyl. My advice still applies. Use as little narcotic as is necessary, and try not to administer intravenous narcotic during the last 30 minutes of surgery. If you use a remifentanil infusion, taper the infusion off early enough so the patient is wakeful at the conclusion of surgery.

The principles I’ve recommended here are time-tested and practical. Follow these guidelines and you’ll experience two heartwarming scenarios from time to time: 1) Patients in the recovery room will ask you, “You mean the surgery is done already? I can’t believe it,” and 2) Recovery room nurses will ask you, “Did this patient really have a general anesthetic? She’s so awake!”

Your chest will swell with pride, and you’ll feel like an artist. Good luck.

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

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

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

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?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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KIRKUS REVIEW

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

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:

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

THE TOP TEN MOST USEFUL ADVANCES AND THE FIVE MOST OVERRATED ADVANCES AFFECTING ANESTHESIA IN THE PAST 25 YEARS

6 Feb 201312 Jul 2021THE ANESTHESIA CONSULTANT 2 Comments

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

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

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In 1986 the American Society of Anesthesiologists adopted pulse oximetry and end-tidal CO2 monitoring as standards of care. These two monitors were our specialty’s major advances in the 1980’s, and made anesthesia safer for everyone. What are the most significant advances affecting anesthesia since that time? As a clinician in private practice, I’ve personally administered over 20,000 anesthetics in the past quarter century. Based on my experience and observations, I’ve assembled my list of the Top Ten Most Useful Advances Affecting Anesthesia from 1987-2012. I’ve also assembled my list of the Five Most Overrated Advances Affecting Anesthesia from 1987-2012.

THE TOP TEN MOST USEFUL ADVANCES AFFFECTING ANESTHESIA IN THE PAST 25 YEARS (1987- 2012):

#10. The cell phone (replacing the beeper). Cell phones changed the world, and they changed anesthesia practice as well. Before the cell phone, you’d get paged while driving home and have to search to find a payphone. Cell phones allow you to be in constant contact with all the nurses and doctors involved in your patient’s care at all times. No one should carry a beeper anymore.

#9. Ultrasound use in the operating room. The ultrasound machine aids peripheral nerve blockade and catheter placement, and intravascular catheterization. Nerve block procedures used to resemble “voodoo medicine,” as physicians stuck sharp needles into tissues in search of paresthesias and nerve stimulation. Now we can see what we’re doing.

#8. The video laryngoscope. Surgeons have been using video cameras for decades. We finally caught up. Although there’s no need for a video laryngoscope on routine cases, the device is an invaluable tool for seeing around corners during difficult intubations.

#7. Rocuronium. Anesthesiologists long coveted a replacement for the side-effect-ridden depolarizing muscle relaxant succinylcholine. Rocuronium is not as rapid in onset as succinylcholine, but it is the fastest non-depolarizer in our pharmaceutical drawer. If you survey charts of private practice anesthesiologists, you’ll see rocuronium used 10:1 over any other relaxant.

#6. Zofran. The introduction of ondansetron and the 5-HT3 receptor blocking drugs gave anesthesiologists our first effective therapy to combat post-operative nausea and vomiting.

#5. The ASA Difficult Airway Algorithm. Anesthesia and critical care medicine revolve around the mantra of “Airway-Breathing-Circulation.” When the ASA published the Difficult Airway Algorithm in Anesthesiology in 1991, they validated a systematic approach to airway management and to the rescue of failed airway situations. It’s an algorithm that we’ve all committed to memory, and anesthesia practice is safer as a result.

#4. The internet. The internet changed the world, and the Internet changed anesthesia practice as well. With Internet access, clinicians are connected to all known published medical knowledge at all times. Doctors have terrific memories, but no one remembers everything. Now you can research any medical topic in seconds. Some academics opine that the use of electronic devices in the operating room is dangerous, akin to texting while driving. Monitoring an anesthetized patient is significantly different to driving a car. Much of O.R. monitoring is auditory. We listen to the oximeter beep constantly, which confirms that our patient is well oxygenated. A cacophony of alarms sound whenever vital signs vary from norms. An anesthesia professional should never let any electronic device distract him or her from vigilant monitoring of the patient.

#3. Sevoflurane. Sevo is the volatile anesthetic of choice in community private practice, and is a remarkable improvement over its predecessors. Sevoflurane is as insoluble as nitrous oxide, and its effect dissipates significantly faster than isoflurane. Sevo has a pleasant smell, and it replaced halothane for mask inductions.

#2. Propofol. Propofol is wonderful hypnotic for induction and maintenance. It produces a much faster wake-up than thiopental, and causes no nausea. Propofol makes us all look good when recovery rooms are full of wide-awake, happy patients.

#1. The Laryngeal Mask Airway. What an advance the LMA was. We used to insert endotracheal tubes for almost every general anesthesia case. Endotracheal tubes necessitated laryngoscopy, muscle relaxation, and reversal of muscle relaxation. LMA’s are now used for most extremity surgeries, many head and neck surgeries, and most ambulatory anesthetics.

THE FIVE MOST OVERRATED ADVANCES AFFECTING ANESTHESIA IN THE PAST 25 YEARS (1987-2012):

#5. Office-based general anesthesia. With the advent of propofol, every surgeon with a spare closet in their office became interested in doing surgery in that closet, and they want you to give general anesthesia there. You can refuse, but if there is money to be earned, chances are some anesthesia colleague will step forward with their service. Keeping office general anesthesia safe and at the standard of care takes careful planning regarding equipment, monitors, and emergency resuscitation protocols. Another disadvantage is the lateral spread of staffing required when an anesthesia group is forced to cover solitary cases in multiple surgical offices at 7:30 a.m. A high percentage of these remote sites will have no surgery after 11 a.m.

#4. Remifentanil. Remi was touted as the ultra-short-acting narcotic that paralleled the ultra-short hypnotic propofol. The problem is that anesthesiologists want hypnotics to wear off fast, but are less interested in narcotics that wear off and don’t provide post-operative analgesia. I see remi as a solid option for neuroanesthesia, but its usefulness in routine anesthetic cases is minimal.

#3. Desflurane. Desflurane suffers from not being as versatile a drug as sevoflurane. It’s useless for mask inductions, causes airway irritation in spontaneously breathing patients, and causes tachycardia in high doses. Stick with sevo.

#2. The BIS Monitor. Data never confirmed the value of this device to anesthesiologists, and it never gained popularity as a standard for avoiding awareness during surgery.

#1. The electronic medical record. Every facet of American society uses computers to manage information, so it was inevitable that medicine would follow. Federal law is mandating the adoption of EMRs. But while you are clicking and clicking through hundreds of Epic EMR screens at Stanford just to finish one case, anesthesiologists in surgery centers just miles away are still documenting their medical records in minimal time by filling out 2 or 3 sheets of paper per case. Today’s EMRs are primitive renditions of what will follow. I’ve heard the price tag for the current EMR at our medical center approached $500 million. How long will it take to recoup that magnitude of investment? I know the EMR has never assisted me in caring for a patient’s Airway, Breathing, or Circulation in an acute care setting. Managing difficulties with the EMR can easily distract from clinical care. Is there any data that demonstrates an EMR’s value to anesthesiologists or perioperative physicians?

Your Top Ten List and Overrated Five List will differ from mine. Feel free to communicate your opinions to me at rjnov@yahoo.com.

As we read this, hundreds of companies and individuals are working on new products. Future Top Ten lists will boast a fresh generation of inventions to aid us in taking better care of our patients.

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

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

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

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?

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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*
*
*

KIRKUS REVIEW

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

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:

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

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

31 Oct 20112 Oct 2017THE ANESTHESIA CONSULTANT 1 Comment

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Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

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WRITING MEDICAL FICTION - 6 Dec 2023
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Clinical Case for Discussion: A 3-year-old boy is eating a McDonalds Happy Meal on the lawn of the restaurant. A lawn mower approaches, and a rock is ejected from the mower, hitting the child in the eye. The boy suffers an open eye injury, and is taken to the nearest hospital. You are on call for the repair. You are an experienced practitioner, but not a pediatric anesthesia specialist. What do you do?

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

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

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

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

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

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

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

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

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

Things are different at a community hospital, where a smaller team of anesthesiologists shares night call. Unless the hospital is very large, it is uncommon to have multiple specialist anesthesiologists on call each day, e.g. one for pediatrics, one for cardiac cases, one for trauma, one for obstetrics, and one for the general OR. It is common for general anesthesia practitioners to cover many or all specialties when they are on call. If they are not comfortable with an individual case, they can seek out a better trained anesthesiologist, if one is available. The trend for having a specialist anesthesiologist for every type of case, at all hours of the night and weekend, is a difficult one to staff. The decision to care for a patient at a community hospital is a judgment as to whether standards of care can be met with the physicians who are available.

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

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KIRKUS REVIEW

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

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:

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

FACTS FOR LAYPEOPLE: DRUGS ANESTHESIOLOGISTS ADMINISTER

23 Aug 20112 Oct 2017THE ANESTHESIA CONSULTANT Leave a comment

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